Breast cancer is a devastating diagnosis, and for women can strike at their identity as well as their health. But ongoing advances – in traditional and other treatments – have resulted in better outcomes and reduced trauma.
New, targeted biopharmaceutical drugs that work differently from chemotherapy – and are sometimes able to be delivered in tablet form – may offer greater hope to breast cancer patients, according to Dr. Deena Mary Atieh Graham, an oncologist from Hackensack Meridian Health’s the John Theurer Cancer Center at Hackensack University Medical Center.
“Two new ones are Tucatinib [sold under the brand name Tukysa], which is available as a pill, and Trodelvy, which is delivered intravenously,” she said. “They can be used in the treatment of HER2-Positive, and Triple Negative Breast Cancer, respectively, which are particularly aggressive forms of breast cancer that may otherwise spread to the brain or other areas of the body.”
Graham
Medical professionals are also using genetic testing and other targeted therapies that help them to deploy “tailored therapy,” she added. “In some cases, a simple blood test can enable the detection of specific mutations in the cancer, and we can then use medications that will assist in the overall treatment.”
Some recently issued studies may lead to “hormone booster therapies that could prevent cancer’s re-occurrence,” Graham noted. “Aromatase inhibitors and CDK4/6 inhibitors [a class of drugs that target enzymes called CDK4 and CDK6 in an attempt to interrupt the growth of cancer cells] show promise in treating advanced cancer, and may even prevent its development. These drugs are in clinical trials, but not have not yet been formally approved by the FDA.”
Even with these and other bio-medical advances, “there are still roles for chemotherapy and radiation,” said Graham. “But now we have the option of tailoring therapies so we know which individuals will benefit the most from particular treatments, and whether the benefits justify the risk and toxicity.”
That’s reinforced by a multidisciplinary approach that Hackensack Meridian Health, along with many other health care institutions, employs. “In addition to a specialist like myself, we typically bring in a radiologist, surgeons, pathologist, clinical geneticist, a molecular pathologist, nurses, a nutritionist and a social worker,” Graham explained. “Those efforts are complemented by patient-centered chemotherapy and nutrition classes – even during the pandemic – to help patients improve their own care.”
Modified approaches
Traditional radiation therapy has been used post-surgery for breast cancer patients since the 1960s and 1970s when a breast-conserving surgery, lumpectomy, became widely accepted, noted Dr. Peter Wu, a radiation oncologist at Holy Name Medical Center. “Radiation is the standard of care for a partial mastectomy,” he said. “It can reduce the chance of a re-occurrence of the tumor, and it also reduces life-ending complications [associated with heart and other problems].”
Previously, radiation doses were based on the amount of tissue, “regardless of the individual patient,” he added. “But now, advanced imaging techniques allow us to better target the treatment and also customize the dosage. There may be fewer side effects and in some cases, treatment may take as little as five days, instead of the traditional six weeks.”
Post-surgical reconstruction is also a big part of the overall treatment, Wu added. “Communication between radiation oncologist and the plastic surgeon is important, and is something we’ve pursued at Holy Name,” he said. “We’re also examining ways to reduce the physical side effects of breast cancer surgery, with the goal of helping women to feel and look the same after treatment.”
One such advance involves an alternative to tattoos that were traditionally inked on a breast cancer patient as a way to provide better alignment for radiation therapy. Instead, some health care project a non-permanent light grid on the patient’s skin, said Dr. Mona Karim, vice chair, Department of Radiation Oncology at Atlantic Health System’s Morristown Medical Center. “Right now we just have this at MMC, but we’re planning on expanding it to other facilities,” she added.
Schmader
Another advance, genetic testing, enables medical professionals to examine multiple issues—and can help inform surgical decisions, reducing future risk while enhancing targeted chemotherapy treatments — according to Amanda Schmader, a genetic counselor at the AtlantiCare Cancer Care Institute, a Fox chase Cancer Center partner. “Results may be returned in as fast as a week, and the test itself is simple: it can be done with a blood sample, or by having the patient spit in a tube.”
Someone who has a cancer diagnosis – or who has a family history of cancer – should get tested for their own health safety, and any genetic marker could serve as an early warning for their siblings and other family members, she added. “We’re continuing to advance knowledge, and the biggest thing is to get people to be more proactive.”
A team approach
When it comes to breast cancer evaluation and treatment, medical centers have removed the silos that used to divide specialists. “We present at a multidisciplinary tumor board, where surgeons, med oncologists, radiation oncologists, plastic surgeons, nurses and others will discuss options and preliminary management,” said Dr. Bruce Haffty, chair of radiation oncology and chief of staff at the Rutgers Cancer Institute of New Jersey. “It’s an opportunity to discuss pros and cons of certain approaches, and get an appropriate consensus, and the ‘one-stop’ nature of a multidisciplinary approach is also more convenient for the patient.”
That’s also a standard approach at Hackensack Medical Health, according to Dr. Deena Mary Atieh Graham, an oncologist at the John Theurer Cancer Center at Hackensack University Medical Center. “In addition to a specialist like myself, we typically bring in a radiologist, surgeons, pathologist, clinical geneticist, a molecular pathologist, nurses, a nutritionist and a social worker,” she said. “Those efforts are complemented by patient-centered chemotherapy and nutrition classes – even during the pandemic – to help patients improve their own care.”
And at all Atlantic Health System’s facilities, “we utilize a multidisciplinary approach to breast cancer treatment,” Dr. Mona Karim, vice chair, Department of Radiation Oncology at Morristown Medical Center. “Professionals from a variety of specialties get together to discuss timing, mammograms and other screenings, and other issues. It’s part of the art of medicine.”
Medical device advances are also improving outcomes, noted Dr. James Wurzer, medical director, Oncology Program and Division of Radiation Oncology at AtlantiCare Cancer Care Institute. “During radiation treatment, an optical surface monitoring system (OSMS) can track the motion of the patient’s chest wall,” he said. “This is important because as the patient breathes, the targeted area of the breast moves, and we want to limit the tissue that’s exposed to the radiation.”
An OSMS system can be programmed to automatically shut down the radiation “if the patient moves too, like if they cough or otherwise shift position by more than a certain amount,” he added. “AtlantiCare is also a pioneer in the use of Accelerated Partial Breast Irradiation therapy, where the surgeon will place catheters inside a breast, so the oncologist can radiate the tumor bed from the inside. Besides potentially being a faster treatment, after a lumpectomy it can reduce the risk of reoccurrence.”
Other advances include biodegradable markers that are implanted during breast surgery – and dissolve withing six months – that enables medical professionals to accurately track a tumor bed during radiation treatment. “That’s vital to target the dosage and limit the amount of other tissue that’s being exposed,” Wurzer said. “There are so many new tools being developed, with the goal of achieving better outcomes and maximizing patients’ quality of life.”
At Saint Barnabas Medical Center, an RWJBarnabas Health facility, “we use evidenced based-medicine to individualize cancer care for our patients,” noted Dr. Alison Grann, chairman Radiation Oncology at The Cancer Center at Saint Barnabas. “With the improvement of technology, the ability to better target cancerous cells and minimize radiation to surrounding healthy tissue, the radiation therapy treatment course for many breast cancer patients has declined from six weeks to three to four weeks. At SBMC, we were the first hospital in the state to introduce prone positioning in which, patients lay on a specially designed table that positions the breast away from the body limiting exposure to surrounding organs and tissues.”
The Cancer Center also uses VisionRT, a tool that tracks the surface of the skin in real time to measure breathing. “VisionRT employs a special light tracking device with a 3D camera, and it will only deliver radiation if the patient’s breathing is such that the heart stays out of the radiation field,” she added. “But cancer care is no longer one size fits all. Depending on the specifics of the diagnosis, the location of the cancer, the extent of the disease, the type of surgery selected, the individual’s genetics and the patient’s age, radiation treatment may or may not be recommended. Using the latest advancements and research, we offer a variety of ways to treat people with breast cancer and avoid as many side effects as possible.”
