Pittsburgh Post-Gazette - Women's Health
‘It’s really dramatic how far things have come’: Major advances in breast cancer care
It didn’t seem like it at the time. But when Adam Brufsky started his career at the University of Pittsburgh in the 1990s, breast cancer treatment was just getting started. “Things are far different than they used to be,” Brufsky, medical director of the UPMC Magee-Women’s Cancer Program, said. “It’s really dramatic how far things have come.”
Numerous scientific advances have revolutionized care for breast cancer patients, leading to better prognoses and a better quality of life during treatment.
One study released this summer with data from more than 500,000 British women found that those diagnosed with early invasive breast cancer today are around two-thirds less likely to die from the disease within the first five years than they were in the 1990s.
One of the major changes in breast cancer care is taking a “less is more” approach.
“We wanted to cure it, we wanted to do the most, so we hit it with everything,” said Janette Gomez, lead physician for Allegheny Health Network’s high-risk breast cancer clinic. “Over time, we realized we can do a little less, to do what we need to without going overboard. It has had a major impact on quality of life.”
Some of that trend started in Pittsburgh back in the 1970s, when Pitt researcher Bernie Fisher discovered that simple mastectomies were just as effective as the much more severe radical mastectomies, which removed part of the chest wall.
In a sense, that approach has continued — to find ways to be surgically conservative without compromising patient outcomes. Instead of sampling all of the lymph nodes in the armpit, doctors can now just biopsy a sentinel lymph node, said Gomez, reducing the risk of patients developing a swelling complication called lymphedema.
A long-lasting dye technology newly available in the last few years allows the lymph nodes to be spared entirely for some patients who undergo a mastectomy with early stage cancer.
Instead of doing surgery immediately, some patients are also opting to treat the cancer with chemotherapy, immunotherapy or endocrine therapy first, she said — hoping to reduce the size of the tumor so that the surgery can be less extensive, such as a lumpectomy instead of a mastectomy.
“In the last five to 10 years, we’ve been focusing a lot on reducing the side effects of our treatments,” said Gomez. “We obviously want to find the disease and cure it sooner, but our patients are living a very long time, so let’s try to decrease the side effects.”
In terms of reducing the side effects of treatment such as chemotherapy, there are new techniques to determine when it is necessary.
Genomic tests analyze as many as 70 genes in cancer cells to determine the likelihood of the cancer coming back, and the benefit to the patient of undergoing chemotherapy. One recent study from the University of Pittsburgh found that treatments such as sentinel lymph node biopsies and radiation may do more harm than good in treating breast cancer in women over 70.
“We can take a little bit less of an aggressive approach and the survival will be the same,” said Brufsky.
The improved prognosis for breast cancer patients is due in large part to scientific advances in cancer treatment, which have come rapidly over the last several decades. When Brufsky began his career, the primary treatment was a birth control pill turned hormone blocker called Tamoxifen, used to treat breast cancer that feeds on estrogen.
“Really, all we had when we started was Tamoxifen,” he said. “That’s all. We didn’t have a lot.”
Today, there are numerous medications, most of them highly tailored to specific stages and genetic profiles of what researchers now know are distinct types of breast cancer.
Early in his career, Brufsky remembers seeing breast cancer patients who would come in and just wouldn’t respond to treatments. Those patients — now known to be among the 20% with an overexpression of the HER2 protein — were recognized in the 1990s and eventually treated with an antibody called Herceptin that triggers the immune system to fight cancer cells.
Clinical trials have shown Herceptin to cut cancer recurrence in half and reduce mortality by 30%.
Additionally, combining treatments such as Herceptin with chemotherapy has been “basically the magic bullet” for some women, said Brufsky. “Women who normally would have their cancer progress within six months to a year now can go a year and a half, two years without the cancer progressing.”
Other therapies, such as CDK4/6 inhibitors, which affect proteins that control how quickly cancer cells grow and divide, “completely changed the face of” treatment for advanced hormone receptor positive breast cancer, he said, noting increased life expectancy for those cancer patients.
And while breast cancer is treated much better than it used to be, it is also discovered much more quickly. Mammograms are now digital and can see in three dimensions, and doctors are beginning to use artificial intelligence for quick analysis.
Most of the breast cancer Gomez treats is now found via mammogram, she said, before a lump is even palpable.
One of the newest recommendations in terms of screening is that women with dense breast tissue receive MRIs in addition to mammograms, said Sarwat Ahmad, of St. Clair Medical Group Breast & General Surgery. Dense breast tissue is correlated with an increased risk of breast cancer and makes breast cancer more difficult to detect on a mammogram.
“Even when I started training, we did not talk about dense breast tissue at all,” she said. “Within the last 10 years, the data has gotten stronger.”
On the horizon for breast cancer care are numerous other developments in screening, treatment and research, such as vaccine trials, including one helmed by a Pitt professor; further genetic screening; and increased research on less aggressive treatments.
“We’re just trying to turn this into something you can live with for a long time,” said Brufsky, “and eventually die of something else.”