Breast Cancer - How the War Is Being Won

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SPECIAL TO THE NEWS HERALD

Breast cancer is a major killer of women in the United States and worldwide. For a woman, the fear of breast cancer is multi-layered-a loss of body image and sexuality, the fear of treatment and its side effects, and ultimately, the threat the disease poses to her survival.

The incidence of breast cancer has continued to rise in recent decades, possibly in part because of better detection.  Statistics show that breast cancer affects one in nine American women at some time in life, but there is much hope for the present and future, since treatment options are increasing. As medical researchers learn more about the disease, they are developing treatments and drugs that zero in on cancer-causing cells while leaving healthy tissue unharmed.

 The Disease and Its Standard Treatments

Breast cancer is not a single disease but a group of malignancies that affect different breast tissues in different ways. As scientists learn about specific types of breast cancer and how to interrupt tumor growth, treatment plans have become more individualized. Important variables in treatment planning include the size, stage and location of the tumor; the estrogen and progesterone receptor profile; whether cancer has spread to the lymph nodes or beyond; a woman's age; and, most recently, the genetic makeup of tumor cells.

Surgery to remove the primary tumor remains a standard treatment option. Lumpectomy, the removal of only the tumor and a margin of tissue around it, accounts for the majority of breast cancer surgeries. Lumpectomy is usually followed by radiation therapy to ensure that no stray cancer cells still remain.

Extensive research now shows that lumpectomy plus radiation is as effective as total mastectomy for localized tumors.

Mastectomy is still recommended in some instances: when the tumor is very large, has more than one focal point or when there is a high risk of a new tumor in the breast. Some women who are eligible for lumpectomy choose to have a mastectomy to alleviate their fears of recurrence.

 New Techniques Offer Hope

At Blue Ridge HealthCare’s Cancer Care Center at Valdese Hospital cutting-edge technology is being used to minimize radiation exposure to skin and healthy tissues by means of advanced treatment planning and IMRT.

IMRT is a mode of high-precision radiotherapy that delivers precise radiation doses to a malignant tumor or specific areas where cancer cell may have spread. The radiation dose is designed to conform to the three-dimensional shape of the tumor or area of treatment by modulating - or controlling-the intensity of the radiation beam.  In this way it can focus a higher radiation dose to the cancerous area while minimizing radiation exposure of surrounding normal tissues.

While IMRT represents the best radiation treatment option available at present, a number of new techniques under investigation promise to further ease the side effects associated with radiation after lumpectomy.

Partial breast radiation is currently being investigated in trials. One technique that has shown promise is Mammosite radiation therapy. After the lumpectomy is performed, a catheter is inserted into the cavity created by the removal of the tumor. This catheter delivers radiation to the tumor bed over a five-day period.

This means that only the area immediately around the lumpectomy site receives radiation, sparing skin and other healthy breast tissue. The targeted radiation is delivered over only five days, rather than the six-week schedule associated with standard radiation therapy.

Although it's still under investigation the fact that treatment is over sooner and reduces the possibility of damage to other tissue raises hope that Mammosite may one day be a preferred treatment option for breast cancer patients.

Another technique being investigated as an alternative to lumpectomy is radiofrequency ablation. In this procedure, a surgeon inserts a needle into the tumor and kills it with radiofrequency - a form of heat. The advantage of this technique, which is still at an early trial stage, is that no incision is required.

New Drugs Changing Treatment

In recent years, women who are past menopause and have hormone-receptor-positive breast cancer have been treated with surgery, usually followed by radiation, then with five years of therapy with the drug tamoxifen to prevent recurrence. Tamoxifen blocks estrogen receptors in the breast and stops tumor growth. Two decades ago, tamoxifen therapy represented a major breakthrough in breast cancer therapy.

Recently a new class of drugs known as aromatase inhibitors have been added as a supplement to tamoxifen. Studies now show that aromatase inhibitors may be just as effective without taxoxifen.

One recently released study of the aromatase inhibitor letrozole found that it improved survival when compared with tamoxifen.

Blue Ridge HealthCare’s Cancer Care Center Medical Director, Dr. Carolyn Mook has been using aromatase inhibitors to treat her patients for quite some time. “We use aromatase inhibitors extensively in postmenopausal women,” Mook said. “They are drugs that lower the body’s estrogen production and deprive the estrogen receptor, keeping certain cancers in remission. We use it both in postmenopausal women who have recurrent disease, and also as adjuvant therapy in women who have estrogen receptor positive early stage breast cancer.”

Both tamoxifen and the aromatase inhibitors have side effects, which may affect the decision about which drug would be the best choice for a specific woman.

Recent trials have generated considerable excitement about a new drug, Herceptin, that some claim is the best new drug for breast cancer treatment since tamoxifen.

Again, Dr Mook commented that she’s been using this drug as well for several years. “Herceptin is a monoclonal antibody that’s directed at a gene called HER2/neu,” Mook said.

Cancer cells have unique markers or antigens on their surface. A monoclonal antibody is an antibody that is specifically engineered to attach itself to the surface of a cancer cell. They can be designed to actively destroy the cell or to carry a toxin to the cancer that will ultimately cause it to die.

Mook explained, “About 30 percent of women over-express the HER2/neu gene. In those women Herceptin is effective – in some cases administered alone, but more importantly along with chemotherapy. We’ve been giving it to women who have recurrent breast cancer for quite some time,”

She went on to explain that this past spring data became available that showed Herceptin to be effective in adjuvant therapy. Adjuvant therapy is chemotherapy that is administered after surgery to prevent a recurrence.

“It’s a preventative therapy,” Mook said. “Most women who have breast cancer - even early-stage breast cancer will get some form of adjuvant therapy.

Researchers who followed more than 6,500 women with early stage breast cancer for three years found that those treated with Herceptin had their risk of relapse cut in half.

Not every woman with breast cancer will be a candidate for Herceptin therapy. It’s effective only for breast cancer patients whose tumors express too much of the HER2 protein.

Dr. Mook was also excited drugs just released that use unique methods to halt tumors.

“The latest big news I can share is that we’re using treatments that affect vascular proliferation of tumors,” she said. “They help to block the tumor from making new blood vessels, which ultimately keeps the tumor from growing.”

Mook said the drugs are called VEGF inhibitors, and there are several different ones in use at Blue Ridge HealthCare, including Avastin, Erbitux, and Tarceva.

The second largest employer in Burke County, Blue Ridge HealthCare serves a four-county area and includes Grace and Valdese hospitals, Blue Ridge Home HealthCare, Grace Heights and College Pines Health & Rehabilitation Centers, Grace Ridge Retirement Community, Phifer Wellness Center and a number of physician practices.Breast cancer poses a serious threat, but women have the knowledge and tools to mitigate that threat. Regular mammography screening can help ensure that when breast cancer does develop, it is detected early, when treatment can be most effective. More effective treatment options now and in the near future have led medical experts to predict that by 2010 mortality in middle age from breast cancer will be just half of what it was in 1980. It's a battle that's slowly being won.