Groundbreaking research and the newest technology have improved the chances of early detection, diagnosis and optimal treatment.
Annual mammograms are encouraged for women over the age of 45 and at least every other year after the age of 55, depending on your medical history. What many health providers aren’t telling you is that, between each regular mammogram, great strides are being made in research and detection. So, your experience may change the next time you show up for an exam.
It’s good news, although it may not seem that way at first. After my most recent mammogram, I received the dreaded callback. It had happened a couple of times before. My mother, aunt and oldest sister had been diagnosed with and survived breast cancer. In all three cases, the cancer had been in the early stages. Still, the prospect of the annual mammogram filled me with terror.
I have dense breasts, making it more difficult for mammograms to detect a possible tumor. With past mammogram callbacks, it was usually a quick retake and then I was sent home. Once, several years ago after a routine physical exam, my physician recommended a needle biopsy which fortunately proved to be benign. Again, I was sent home with a clean bill of health.
This latest callback wasn’t so quick. I was shuttled back and forth between what’s commonly known as 2D and 3D mammography. Then I was given an ultrasound, which seemed to take forever. While the nurses and technicians tried to reassure me, I called my daughter in Chicago, becoming exponentially more unhinged after each procedure. But after several hours of testing, I was sent home. All is OK, until the next time.
Digital breast tomosynthesis, also known as three-dimensional or 3D mammography, is a relatively new technology that experts are using more often. The 3D technology creates an image of the breast in three dimensions as opposed to standard digital mammography, which is only in two dimensions. Because it’s new technology, though, your insurance plan may not cover it, so be sure to check before scheduling a mammogram.
“Tomosynthesis allows us to better evaluate the breast tissue, especially in patients with denser breast tissue, and also has been proven to decrease the chance of a woman being called back for more imaging by 40 percent,” explains Dr. Amy Kerger, a radiologist with the OSU The James Comprehensive Cancer Center and Solove Research Institute.
Breast cancer science has changed drastically in recent years, I have since learned after talking with Kerger, and others including oncologist Dr. Maryam Lustberg, medical director of survivorship for The James and breast cancer survivorship for the Stefanie Spielman Comprehensive Breast Center.
Limiting Alcohol and other Preventative Measures
“In addition to improved treatments that we offer, we also take a holistic, preventative view,” says Lustberg. “How can we improve overall health by managing diet, exercise and physical and emotional well-being and limiting alcohol intake?”
Women can be proactive in their fight against cancer by increasing physical activity and optimizing weight management. Recent data “suggests that any drinking can elevate risk, so I recommend trying to avoid daily drinking and just save it for social occasions,” adds Lustberg.
In Central Ohio, the Stefanie Spielman Comprehensive Breast Center at the OSU-CCC includes nurse practitioners, certified genetic counselors, physicians and other specially trained healthcare providers that offer care and support from an initial screening to post-reconstructive surgery follow-up, if surgery is required. Among the services available are clinical trials, which may provide treatment options not normally available through other channels.
“Because we are specialists in this field, we know what places a patient at increased risk and what additional tools we need to use to better screen those at higher risk for breast cancer,” says Kerger.
Breast cancer specialists across the region are focused on the newest research that can assist in the most accurate diagnosis of each person’s cancer. Some of the latest breakthroughs include: Genetic detection of risk factors.
In the past, the standard protocol for genetic testing of inherited susceptibility had been the detection of the BRCA1 and BRCA2 gene mutation. But now specialists can look deeper into an individual’s genetic make-up.
“We have as many as 20 different genes that we can look at,” says Lustberg. These may include, among others, high- and moderate-risk genes such as TP53 and PTEN as well as the rarer genetic variants PALB2, CHEK2 and ATM. Test results “should be interpreted using the expertise of a genetic counselor,” she adds.
Classifying Different Types of Cancer
People may be familiar with the various stages of breast cancer, ranging from the extremely localized in situ Stage 0 to Stage IV, in which the cancer has metastasized to other parts of the body.
More recent research has shown “we now know that all breast cancers are not the same even in two women with the same stage of cancer,” says Dr. Bhuvaneswari Ramaswamy, an oncologist and researcher at the Stefanie Spielman center. Cancers have been narrowed down to three main types, based on tissue characteristics. Along with various medications, treatment may include chemotherapy, radiation or surgery—or a combination of more than one. The three types of breast cancers include:
Hormone Receptor-Positive Breast Cancer. This describes about 80 percent of all breast cancers and basically means that the cancers feed on the hormones of estrogen and/or progesterone. Such cancers often respond best to hormone therapy and—depending upon the age of the woman, stage of the cancer and other factors—medications such as tamoxifen, aromatase inhibitors and/or the CDK 4/6 inhibitors.
HER2-Positive Breast Cancer. In about 20 percent of breast cancers, the cells make too much HER2, a protein. Although this is the most aggressive and fast-growing cancer, “researchers have developed very specific drugs that go after the protein,” says Lustberg. This advancement has revolutionized treatment and made it much more targeted. Medications may include the drug trastuzumab (commonly known as Herceptin), lapatinib, ado-trastuzumab emtansine and others.
Triple-Negative Breast Cancer. This less-common type of breast cancer is often associated with the gene BRCA1 and doesn’t fall into either of the above categories. Although it generally responds well to chemotherapy after surgery, it can have a higher chance of recurrence. While no targeted therapies have yet been FDA approved to help prevent its return, “among the several exciting immunotherapy trials at OSU and elsewhere is one focusing on treating multiple cancer types, including triple-negative,” says Lustberg. Recently, the first results of a successful immunotherapy trial were reported for this type of cancer.
Better Targeted Treatments
Because no two cancers are alike, medications and treatments for all types of breast cancers have improved and are better targeted to the person involved. “This is pretty much across the board,” says surgical oncologist Dr. Natalie Jones, program director of OhioHealth Breast Cancer Services. “Along with improvements in chemotherapy resulting in fewer side effects, radiation used to take 6 weeks or so. Today it’s only 3-4 weeks, which lessens side effects there as well.”
Less invasive lumpectomies, along with breast and lymph node conservation, result in fewer complications and lower risk of lymphedema, which is swelling that occurs in an arm or leg caused by a blockage in the lymphatic system.
Updates in Reconstructive Surgery
While much research is done in the prevention, detection and treatment of breast cancer, additional advancements are being made in the field of reconstructive surgery. These include:
Oncoplastic surgery. While reconstruction is not usually needed for women with early-stage lumpectomies or partial mastectomies, recent developments in plastic surgery techniques can reshape the breast at the time of cancer surgery, according to the website for the National Cancer Institute. This oncoplastic surgery is far less invasive and “may use local tissue rearrangement, reconstruction through breast reduction surgery, or transfer of tissue flaps,” the site explains.
Autologous fat grafting. Mainly used to correct deformities and asymmetries that may appear after breast reconstruction but sometimes used for reconstruction itself, this relatively new technique “involves the transfer of fat tissue from one part of the body (usually the thighs, abdomen, or buttocks) to the reconstructed breast,” explains the NCI site.
Alloplastic implants. These implants can be filled with either a saline solution, which is most commonly used, or silicone gel. The implant may be put in the space where breast tissue was removed or behind the chest muscles. The FDA’s recently approved “Gummy Bear” implants consist of a thick, highly cohesive silicone gel, providing a more natural appearance than other implants.
Often, an implant is done in a two-stage, or delayed, reconstruction where the surgeon implants a tissue expander to prepare space for breast implants. While this previously required multiple trips to the doctor over several months to receive saline injections to stretch the tissue of the chest wall, the new AeroForm Tissue Expander, a sterile implant with an outer silicone shell and a remote dosage controller, allows the patient to expand the device slowly, up to three times a day.
“Patients are often discouraged by the prospect of multiple visits to the doctor for expansion,” says Dr. Jason Lichten, of Central Ohio Plastic Surgery of Columbus, Lancaster and Central Ohio. “With the Aeroform, there are no needles, fewer visits and my patients feel more in control of their breast reconstruction.” The use of the Aeroform also reduces the time it takes to expand the tissue by over half, from 46 to 21 days.
Breast Prostheses. Instead of an implant, some women opt for an artificial breast form usually custom-designed to fit their shape, commonly known as a prosthesis (or prostheses, if there are two). These can be made from silicone gel, foam or polyfill and provide a similar weight and feel to a natural breast.
These breast forms may adhere directly to the chest area or fit into special bra pockets. One company, Nearly You, offers almost 90 sizes and shapes along with bras, underwear, swimwear and other accessories.
Upper Arlington’s Over My Head Boutique specializes in hair alternatives, post-breast surgical products and other, related merchandise. It also offers in-house technology “to digitally scan the patient’s chest wall to custom-produce [a] breast prosthesis to fit like a puzzle piece,” explains owner and certified mastectomy fitter Bethany Golden. “This produces the most lifelike and medical grade silicone prostheses.”