Breast cancer and fear go hand in hand. Both the disease and its treatment can be frightening and overwhelming. But thanks to pioneering research and the tireless work of dedicated health professionals, hospitals and medical centers across the nation—some right here in Chicago—are slowly but steadily replacing that fear with hope.
The challenges, of course, are many. Breast cancer treatment can be particularly tricky for patients who find themselves moving from specialist to specialist, gathering details about their diagnosis and treatment and then trying to fit together the pieces on their own. That’s what makes today’s dedicated breast cancer centers so important. Specialized divisions such as the Breast Cancer Center at the University of Chicago (U of C) Medical Center allow multiple sectors to work in tandem: radiologists with images from mammograms, ultrasounds and MRIs; pathologists with biopsy results; medical oncologists with recommendations for chemotherapy; research personnel with information on clinical trials; and surgeons, plastic surgeons and radiation therapists. At the Center, the group meets weekly to look at all aspects of diagnosis and treatment. “The plans are individualized because each patient is different,” says surgeon Dr. Nora Jaskowiak, the head of the Breast Cancer Center.
Innovations in treatment
Breast cancer treatment is constantly evolving. Dr. Jaskowiak points out that in the past, most programs started with surgery followed by any necessary chemotherapy or radiation, but today, that order is often reversed, especially for particular tumor types. “If we give chemotherapy or hormonal treatment upfront, we can shrink a tumor a great deal. Depending on what regimen we’re using, we can even make tumors completely go away,” Dr. Jaskowiak explains. “A patient who might be thought to require a mastectomy initially may be able to have a lumpectomy, or a person who could have a lumpectomy initially might need a less cosmetically deforming procedure.”
Undergoing chemotherapy before surgery is also favored because a shrinking tumor lets the patient know the treatment is working. “The idea of chemotherapy is to kill any cells that might have escaped and gone somewhere else in the body,” Dr. Jaskowiak explains. “But we know that when the primary tumor or the lymph nodes respond to the chemotherapy, any microscopic disease elsewhere will respond also.”
Other advancements continue to improve treatment quality. Dr. Jaskowiak considers a procedure that entails a biopsy of the sentinel lymph node, the first lymph node to which cancer from the primary tumor is likely to spread, to be a revolutionary advancement. “We used to take out all of a patient’s lymph nodes if she had invasive breast cancer, but now, in the vast majority of patients, we only have to remove two or three. If the sentinel node is negative, we don’t have to remove all of them,” she says. “As a result, many fewer patients have swollen arms, lymphedema, nerve problems or range-of-motion problems. More than 80 percent of my breast cancer patients are getting sentinel node biopsies, and very few of those need all the lymph nodes removed.”
Improvements have also been made in the ways that radiation is given to breast cancer patients after surgery. In the past, a patient was placed on her back for the treatment, which meant that her breasts would fall to the side. The radiation then risked damaging surrounding tissue, the chest wall and even the heart. To efficiently and accurately pinpoint the targeted area, a patient at the Breast Center is placed face down on a special table with her breast falling away from her body through an opening. The Center even makes a mold of her body to keep her in precisely the same position for each session. What’s more, because a tumor moves when the patient breathes, an imaging system called respiratory gating, measures the patient’s breathing pattern to deliver radiation only at the times in the cycle when the tumor is in the best position. The Breast Center also uses a complex computer-based program called intensity-modulated radiation therapy that maximizes the radiation to the targeted area and minimizes the dose to surrounding tissues.
Research, clinical trials and the path ahead
Medical research is a critical component of understanding, preventing, diagnosing and treating breast cancer. At Loyola University Health System, researchers are performing several clinical trials to test new breast cancer drugs.
“We have developed a greater knowledge about the subtypes of breast cancer, which is no longer considered one disease. Drugs are being developed that target more specifically the characteristics of each patient’s tumor,” explains Dr. Kathy S. Albain, professor of medicine at the Loyola University of Chicago Cardinal Bernardin Cancer Center. For example, a drug called T-DM1 is being tested in patients with advanced HER2-positive breast cancer, an aggressive form of the disease. “In earlier studies, T-DM1 has shown a lot of promise. I see the day when patients with advanced disease, who in the past died in the first year or two after diagnosis, will be living with the disease and have a good quality of life for many, many years,” Dr. Albain says. Loyola is also part of a clinical trial involving a class of experimental drugs called PARP inhibitors, which target an aggressive cancer subgroup called triple negative.
Another trial at Loyola is studying the pathways of breast cancer stem cells (not to be confused with stem cell research on embryos). “A cancer is felt to become immortal by using its own stem cells. Lo and behold, it appears that our standard chemotherapy drugs kill the daughters and sons of these stem cells but do not eradicate the stem cell itself, which is probably why our treatments in advanced disease work for a while, but then the disease breaks open again,” Dr. Albain explains. “We have a trial here to inhibit the stem cell with another class of drugs called Notch inhibitors.”
The U of C Medical Center is involved in an array of research projects that examine breast cancer from a variety of perspectives. The U of C Research Center received a five-year SPORE (Specialized Programs of Research Excellence) grant to fund four projects focusing on women who have a high risk of developing breast cancer at a young age. The grant also includes funding in the crucial task of recruiting and training the up-and-coming generation of breast cancer researchers.
Research has also contributed to a better understanding of the biology of breast cancer, thus improving treatment of the disease. The team at the Chicago Cancer Genome Project is collaborating with physicians at the U of C Medical Center to map the genetic makeup of samples from 1,000 tumors including those from consenting breast cancer patients. In doing so, they hope to find new ways of diagnosing the disease and designing individualized treatments tailored to the characteristics of each tumor.
Geoffrey Greene, the vice chair of The Ben May Department of Cancer Research at the U of C, is doing work in the field of genomics as well as conducting research to find more beneficial ways to prevent and treat breast cancers that are stimulated by estrogen. He is also exploring the potential of green tea to prevent or reduce the risk of breast cancer and limit the growth of tumors. Initial results on mice were promising; soon, he will start conducting trials, leading to a pilot trial on patients at the Breast Cancer Center who are interested in adding capsules of decaffeinated green tea extract to their treatment.
“There is increasing emphasis on prevention research here at the university as well as elsewhere,” Greene says. “[There is] research on including natural products that are very practical, such as foods or food supplements that might reduce the risk or possibly even slow the progression of breast cancer in some cases. We have learned a lot about how to reduce the risk of recurrence, and we expect more breakthroughs using genomic approaches. As a consequence, we will be seeing more and more personalized medicine that is based on the gene signature profile of a tumor, as well as on an individual’s normal DNA, which will determine the likelihood of doing well on a particular therapy with minimal side effects.”
Loyola is currently participating in a national trial of a new test based on 21 genes from tumors in women who have been diagnosed with estrogen-receptor-positive breast cancer that has not yet spread to the lymph nodes. Researchers hope the test will accurately predict whether a women will benefit from chemotherapy. “Women who have very low recurrence scores have zero benefit from chemotherapy, so we know that their treatment needs to be endocrine-based. This is a huge advance,” Dr. Albain says.
Thanks to results like these, there is reason to optimistic about the future of breast cancer treatment. “Surgery used to be ‘the queen’of breast cancer, but we’re definitely in an era now where understanding the biology of tumors is at the forefront. I think that some time in the future, breast cancer surgeons are going to be an endangered species. And that will be great for patients,” Dr. Jaskowiak says.
The road that led to today’s diverse developments in preventing, diagnosing and treating breast cancer has been long, and the journey ahead is likely to be similarly enduring. But as the medical field increases its arsenal of innovations and advancements, patients and doctors alike are well-armed for a healthy and successful future.
(Reprinted from Chicago Health: Top Doctors & Hospitals, November 2010)
Published in Chicago Health Winter 2010