Breast Cancer Treatments Offer Patients Many Options

Even though American women are far more likely to die of cardiovascular disease than of all forms of cancer, breast cancer remains the illness many women fear most. Breast cancer is now the most common cancer in American women, according to the National Cancer Institute (NCI), well ahead of the next two cancers, lung and colorectal. An estimated 211,240 new cases of breast cancer will be diagnosed in 2005, and 40,400 Americans - nearly all of them women - will die of the disease this year.

The good news is that most breast cancers today are diagnosed early, when they are most treatable, says Alonzo Walker, MD, Chief, Division of General Surgery and Professor of Surgery at the Medical College of Wisconsin. A surgical oncologist, Dr. Walker is also Medical Director of the Froedtert & The Medical College Breast Care Center.

Dr. Walker credits mammograms with helping to find more breast cancers early. He estimates that 60% to 65% of women diagnosed with breast cancer today have early-stage cancers. "But," he adds, "being a referral center, we also see more advanced-stage cancers."

Team Effort Includes the Patient
At Froedtert & The Medical College, every breast cancer patient's diagnosis and treatment regimen is discussed at a weekly Breast Conference by a multidisciplinary team of on-site physicians - surgeons, radiation oncologists, medical oncologists, pathologists, physical medicine and rehabilitation specialists and plastic surgeons - as well as nurse practitioners and clinical research associates, and nurse navigators who work with patients, coordinating their appointments and scheduling treatments. Medical students and residents also attend the conferences.

Patients are always part of the treatment decision, Dr. Walker says. In some cases, they may select among several treatment options, depending on their personal situations. And because the Medical College is a research institution, many new therapies are available through clinical trials to carefully selected patients.

Although no breast cancer patient's case is "typical," Dr. Walker says small, local cancers usually are amenable to lumpectomies - removal of the tumor and its surrounding margin of normal tissue - rather than mastectomy, which removes the entire breast. Whether lumpectomy or mastectomy, patients with invasive cancers undergo a node-mapping procedure, in which a few lymph nodes are removed and examined to determine whether the cancer has spread to the lymph nodes in the armpit. In most cases, a lumpectomy is followed by radiation to prevent a recurrence. In some cases, patients also receive a course of chemotherapy or hormone therapy, he says.

As recently as 30 years ago, American physicians routinely performed a surgery called radical mastectomy on all patients diagnosed with breast cancer. This surgery - which involved removal of the entire breast, underlying muscles and all lymph glands in the axilla, or armpit - was performed regardless of the stage of the cancer. Reconstructive surgery was not widely performed.

'Patient-Friendly' Therapy
"Today's breast-conserving therapy is much more comfortable for the patient. There's less lymphedema (swelling due to pooling of fluids), less chance of a loss of sensation and a shorter recovery time," Dr. Walker says. "Even in cases where it's necessary to remove all the lymph nodes, surgeons strive to spare the nerves and blood vessels in the area so there is no functional disability and the patient regains full range of motion. It's much more patient-friendly."

The survival rate for lumpectomy and radiation is the same as for mastectomy in women with invasive and noninvasive cancer. Lumpectomy does spare the appearance of the breast. But some women find it inconvenient to undergo the standard radiation therapy for six weeks, five days a week. Thus, some patients choose mastectomy over lumpectomy and radiation, to eliminate the need for radiation. Their decision to undergo total mastectomy might also be influenced by the knowledge that breast reconstruction can often take place during the same procedure as the mastectomy. Reconstruction can use tissue from the patient's own body or an artificial implant.

In some cases, a mastectomy is recommended in women with other serious medical conditions, or when extensive cancer is found in the breast. It's also used when patients have undergone previous radiation to the breast or chest wall.

Staging Dictates Treatment
Staging refers to the process of determining how far the cancer has progressed at diagnosis. The stage is a major factor in treatment options. Patients treated at Froedtert & The Medical College receive a "Treatment Guidelines" booklet that includes "Decision Trees" developed by the National Comprehensive Cancer Network, an alliance of leading cancer centers, to help patients make informed decisions about their therapeutic options. It discusses stages in detail and describes evaluation, treatments, risk reduction, and follow-up.

In breast cancer, stages can range from 0, where the cancer is small and confined to the lobules, or milk producing parts of the breast, to Stage 4, where the cancer has spread to other organs, such as bone, lung, liver or brain. Stage 0, for instance, may require minimal treatment, but observation and careful follow-up is recommended. With Stage 4 cancer, more aggressive hormone therapy or chemotherapy are recommended.

New Treatment Options
As a research institution, the Medical College of Wisconsin is conducting clinical trials of many new therapies for treating breast cancer, Dr. Walker says. These include:

Surgical approaches: The Froedtert & The Medical College Breast Surgery Program is considering participation in a clinical trial testing a minimally invasive technique called ablation that destroys tumors with freezing (called cryosurgery). The technique is currently being used in tumors of the liver and prostate gland. "Its application to breast cancer therapy is in a very early stage of research," Dr. Walker says, "and not currently open to patients."

Radiation: Dr. Walker says research is underway to test whether radiation targeted just to the tumor and surrounding tissue can yield the same success as whole breast irradiation, the method currently used over six weeks to prevent recurrence. Called "accelerated partial breast irradiation," the procedure, if successful, would limit the exposure of healthy tissue to radiation. This study is open to carefully selected patients who meet strict research guidelines.

Drug therapy: Researchers are examining the efficacy of two drugs, Herceptin and a class of drugs called aromatase inhibitors, in treating invasive breast cancers. The National Cancer Institute describes Herceptin (or trastuzumab) as a monoclonal antibody, a class of drugs made in the laboratory. It is formulated to attack cancer cells that overexpress, or make too much of, a protein called HER-2, found on the surface of cancer cells. Approximately 25% to 30% of breast cancers overexpress HER-2. These tumors tend to grow faster and are generally more likely to recur than tumors that do not overproduce HER-2. Herceptin slows or stops the growth of these cells, and Dr. Walker calls the findings so far "encouraging."

Aromatase inhibitors, like the drug tamoxifen, inhibit estrogen. Tamoxifen, which blocks the estrogen receptor, is primarily prescribed for premenopausal women, Dr. Walker says, and aromatase inhibitors, which block estrogen production, are used predominantly on postmenopausal patients.

Prevention: Another Medical College study, recently closed to new patients, is titled STAR, for the Study of Tamoxifen and Raloxifene. Its purpose is comparing tamoxifen with raloxifene, another hormone-restricting drug, for their efficacy in preventing the recurrence of breast cancer. Results are being evaluated.

Dr. Walker believes the best choice women can make for breast health is prevention. "I encourage women to get regular mammograms and perform breast self-exams." He means all women. Although some breast cancer is inherited from parents, 90% to 95% of cases do not have a hereditary link.

Barbara Abel
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.