By John Ostapowicz
YOUNGSTOWN, Ohio – October is Breast Cancer Awareness Month, and local doctors are stressing the importance of yearly mammograms and genetic testing to identify early warning signs.
According to the American Cancer Society, the median age at the time of breast cancer diagnosis in women is 63. About one in 10 women diagnosed with breast cancer are younger than 45.
Dr. Peggy Rosenzweig, associate director for Community Outreach and Engagement at UPMC Hillman Cancer Center and a professor at the University of Pittsburgh, says mammography can save lives by detecting tumors that are too small to be felt during a self-examination.
“The reason it saves lives is because cancer will grow and grow and grow, and eventually it will get out of the breast and sort of go somewhere else in the body. And if you can get the cancer before it leaves the breast, then you have a much better chance of not dying from breast cancer,” Rosenzweig says.
Rosenzweig also said women who feel something unusual in their breast should undergo an ultrasound, which may help detect an issue, along with a mammogram.
One way to identify breast cancer risk is to trace family health history. Rosenzweig says women should ask about the health histories of family members, including mothers, aunts, grandmothers and great-grandmothers, especially if they have been diagnosed with cancer.
Dr. William Spielvogel, a medical oncologist at UPMC Horizon – Shenango Valley in Farrell, Pa.,, says it’s important for women to get the proper screenings for breast cancer. The recommendation about when to begin screening has changed with some doctors recommending mammograms at age 50, while others say 45.
The U.S. Preventive Services Task Force recommends that women receive mammograms every other year from age 40 to 74.
Spielvogel also says breast cancer can develop after 75, and continues to recommend mammograms and treatment for these older patients.
Hospitals, health care professionals and social media messaging encourage women to get screened, and Spielvogel says the continued advocacy has made advanced cases of breast cancer less common.
“Almost everyone knows you should get it now,” Spielvogel says. “It’s kind of rare for me to have a woman come in with a big breast cancer and it’s spread throughout her body because women know that you’re supposed to go get your mammograms.”
EVOLVING OPTIONS
Over the years, treatment options have evolved such as advances in oral medications and surgical procedures. Mercy Health’s Joanie Abdu Comprehensive Breast Care Center in Youngstown, has introduced the availability of an endoscopic nipple-sparing mastectomy. The procedure is performed through a small incision that is minimally invasive.
Dr. Nicole Reyes, a breast surgical oncologist at Abdu, says E-NSM is a good fit for patients with early stage or those looking to reduce the risk of breast cancer. Whether E-NSM can be considered for a patient depends on the anatomy and other distinctive factors rather than relying solely on the stage of cancer.
“From an anatomy standpoint, indications to do or to not do this surgery or contra indications would be the same as a traditional nipple sparing mastectomy,” Reyes said. “If the tumor is a little bit more advanced, and it’s, lets say, involves the skin or the nipple, those patients wouldn’t be a good candidate for the surgery because we would have to remove either the skin or the nipple.”
E-NSM is the first procedure of its kind that saves the breast envelope, which includes the skin, the nipple and the areola.
The procedure has only been available for five years and was mainly practiced in parts of Asia before its introduction to the U.S. Reyes says she learned of it through a course at Northwestern University in Chicago where it was taught by a surgeon who spent time in Portugal and Spain.
Before the introduction of E-NSM in mid-August, mastectomies were traditionally completed through a large, open incision measuring about 7 centimeters. With the new technique, the incision length has been reduced to 3 centimeters.
“The endoscopic nipple-sparing mastectomy is using minimally invasive techniques, and essentially doing the nipple sparing mastectomy with laparoscopic instruments,” Reyes says. “I use a very small incision – it’s about 3 centimeters. I hide it under the arm and I remove all of the breast tissue from that incision.”
The recovery from E-NSM is quicker than most breast cancer procedures. Since the incision is smaller, patients heal quicker.
NEWER TREATMENTS
Treatment options for breast cancer include surgery and chemotherapy. Spielvogel says most patients he sees undergo surgery first, unless the cancer has spread to multiple lymph nodes.
“The standard person who comes in, surgery first, and then there’s the lumpectomy version or total mastectomy,” Spielvogel says. “They take the whole breast off, and studies show that you don’t have to take the whole breast off in most cases, but some women want to do that. But doing a lumpectomy and taking lymph nodes out of the armpit have been shown to be equal,” Spielvogel says.
Surgeons will present patients with options between a lumpectomy and a mastectomy. If the breast is spared, Spielvogel says radiation therapy will have to be administered in order to reduce the risk of the cancer returning to the same area.
Oral medications are increasingly being used to treat breast cancer and help prevent it from returning. Many forms of breast cancer are hormone receptor-positive, meaning the cancer cells use hormones such as estrogen to grow. Following surgery, women with hormone receptor-positive breast cancer may be prescribed oral hormonal therapy for five to 10 years.
Although the endocrine hormonal blockers have been used for several years, there is a new category of mediations called CDK4/6 inhibitors. Those inhibitors have expanded treatment options for patients with hormone receptor-positive breast cancer.
The new medications block two main proteins: cyclin-dependent kinase four and cyclin-dependent kinase six. Both proteins are essential to helping cancer cells progress through the cell-division cycle.
Rosenzweig says the concern for patients with metastatic breast cancer is that there were few treatment options once the disease reached Stage Four. She said the worry has changed over time with the introduction of newer treatments, including the CDK4/6 inhibitors.
“Those CDK4/6 inhibitors, which actually work at a cellular level, so they’re not killing cells, they change cells – the activity of the cells – that they’re not able to make the cancer,” Rosenzweig said. “Those have really changed everything in terms of Stage Four breast cancer, so that’s really exciting.”
There are other drugs that work in certain high-risk, early-stage hormone receptor-positive and HER2-negative breast cancers. Rosenzweig said new medications have been added to the treatment options to help patients in the early stages of breast cancer as well.
“The oral drugs make things very easy, so you don’t have to sit in a chemo room and get chemo. Some of the HER2 drugs can be given by a shot – an injection – rather than sitting in a chair and getting an infusion. So those things make people’s lives just easier. They don’t have to really spend so much time in the cancer center,” Rosenzweig says.
THERAPY TIME
The amount of time patients spend receiving chemotherapy and radiation therapy is another area of breast cancer treatment that has drastically changed over the years.
“When I started 20 years ago, women would come in and usually get a month of radiation to pretty much all breast cancers and now they can get away with just five days,” Spielvogel says. “We’ll put them on what’s called endocrine therapy, where we do some hormone blockade. Basically an estrogen blocker to try and prevent…”
The way radiation is administered has also changed, with advances in technology allowing some patients to receive fewer treatments while achieving similar outcomes if the treatments were longer. Depending on the stage of cancer, radiation that was required for several weeks is now delivered in a shorter time frame.
“It always used to be six weeks that you had to get radiation, then 20 days of radiation, and now it’s down to sometimes very few days where women actually have to come in and get the radiation,” Rosenzweig said. “That again lets people get back to living their lives and sort of putting their breast cancer diagnosis behind them.”
Rosenzweig says studies conducted through the National Surgical Adjuvant Breast and Bowel Project, based in Pittsburgh, confirmed that removing a section of the breast where the cancer formed, followed by radiation, could be an alternative to undergoing a mastectomy to treat breast cancer.
The issue in the past was that removing several lymph nodes caused a woman’s arm to swell. Today, surgeons remove one to two lymph nodes and check them for cancer to limit the risk of long-term complications.
“[Surgeons] try to remove just one or two lymph nodes and check it for cancer, and if those are negative, they don’t have to take any more lymph nodes,” Rosenzweig says. “The surgical techniques have been perfected, so there’s less long-term problems associated with breast cancer surgery.”
MEN’S TREATMENT
Breast cancer can also develop in men. According to the ACS, it’s estimated that around 2,670 men will be diagnosed this year with invasive breast cancer, with the average age at the time of diagnosis between the ages of 60 and 70 years old.
Because it’s rare for men to develop breast cancer, Spielvogel says men are not routinely screened. He says men who carry the BRCA gene are recommended to receive mammograms.
“If they’re a carrier of that, we do recommend that men get mammograms, and men can get mammograms too,” Spielvogel said. “Mammograms aren’t universally required, but they can be considered starting at age 50 or 10 years before the earliest male breast cancer. I do breast exams… I only have one or two men who have a BRCA carry, but I usually will say, ‘Why don’t you just get a mammogram?’”
Although there are no single causes linked directly to breast cancer, Rosenzweig says alcohol consumption, more specifically binge drinking, is a contributing risk factor.
“We really don’t think about binge drinking as it is… having four or more drinks in a night is binge drinking and that’s news to a lot of college students,” Rosenzweig says. “That’s associated with breast cancer incidents. Perhaps it’s not the drink every day, but more that big hit of alcohol at different times.”
