Multidisciplinary Breast Cancer Symposium, 9/14/19; Henry Ford Health System, Detroit

A summary of some key points, by Patricia Anstett, medical writer

Mammography

1. Women should request a 3-D mammogram, also called digital breast tomosynthesis or DBT, because it’s better than standard film-screen mammogram, particularly for women with so-called dense, or less fatty breasts. A traditional mammogram usually takes two X-ray images of the breast: one image from the top to bottom and another from side to side. DBT mammography takes multiple X-ray images of the breast from multiple angles that help a radiologist see tiny details.
2. Most women can handle the information doctors provide about a woman’s risk and treatment choices for breast cancer. Doctors need to improve how they deliver these messages and choices.

Dr. Jennifer Plichta, Duke Health

Genetic Screening

• 90% of women with BRCA mutations are not tested for genetic risks, and 95% of people with mutations for Lynch Syndrome, a type of colon cancer, aren’t tested. That means too many people lose the chance to prevent cancer or find it early.
• Medical centers are moving towards offering earlier genetic screening before a cancer diagnosis, then offering counseling about a woman’s risks and choices afterwards. There are many reasons for the change, including a shortage of genetic counselors. Top genetic experts say that identifying women as carriers of genetic mutations after they have been diagnosed with breast cancer is a failure of cancer prevention.
• 2.1 million U.S. women have been tested for genetic cancer risks; 13 million need testing, and another 1 million to 1.8 million need retesting because they were tested with what is not outdated techniques.
• Costs of genetic testing has plummeted and is cheap, compared to a decade ago.
• A few medical centers have begun studies to conduct genetic testing of children at birth for a range of diseases, including cancer.
• Breast cancer is caused by a number of gene mutations, not just BRCA1 and BRCA2. Each gene brings different cancer risks. Information about the variance in these risks is at www.ask2me.org
• What’s coming: testing for as any as 20,000 genes, for more than cancer.

Dr. Kevin Hughes, Massachusetts General Hospital

Ductal Carcinoma in Situ

1. An estimated 60,000 American women are diagnosed each year with DCIS, an early tumor that increasingly is under debate as to whether it should be described as cancer or a possible precursor. Its diagnosis has increased with mammography improvements.
2. Treatment decisions for women with DCIS are among the most difficult doctors discuss with patients because it’s still unclear which tumors may be aggressive, requiring surgery and other treatments, and which ones can be monitored without surgery or treated with breast-conserving options. The question is, which ones will progress and when? Studies vary from 14% to 53% in assessing which DCIS cases won’t progress.
3. Most U.S. women with DCIS now get surgery and radiation; some with estrogen-positive tumors also have chemotherapy to reduce the risk of recurrence.
4. Nearly all women diagnosed with DCIS don’t die of breast cancer. 
5. Over-treating DCIS may cause physical and mental disaffects and may affect a woman’s sexual well-being. Those issues have raised discussion about whether some women can be followed with active surveillance, including mammograms and MRIs.
6. Factors that affect treatment decisions for DCIS include the size of the tumor; surgical margins; pathology reports and a patient’s age.
7. New computer tools are improving a doctor’s ability to assess and score a DCIS tumor for its likelihood to progress. However, these tools “aren’t yet perfect” to determine who needs surgery or radiation. Ongoing studies hope to provide better insights.

Dr. Emilia Diego, University of Pittsburgh Medical Center

Pre-Surgery Drug Options

1. Chemotherapy and endocrine therapy may be offered women with more aggressive risks to down-size a tumor, allowing a woman to have breast-sparing surgery, and possibly lower the chance her tumor will progress. The largest study to date shows no survival advantage of these options though they did allow seven percent of women to have a lumpectomy instead of a mastectomy.
2. So-called adjuvant therapy with the drug tamoxifen or an aromatase inhibitor, a class of medicines that help reduce estrogen levels in the body, has proven as effective as chemotherapy’s response rates, while improving surgery options with fewer side effects.
3. Studies undergo should help doctors sort out whether a woman can use less toxic hormonal options with similar benefits to chemotherapy.

Dr. Haythem Ali, Henry Ford Cancer Institute

Axillary Dissection Decisions

• Medical centers are working to study which breast cancer patients need more than a biopsy of a single sentinel node to find whether cancer has spread. Studies show 50-70% of women have no other tumors outside the breast other than a single node.
• Removal of more than one lymph node can cause serious medical problems afterwards, including lymphedema, a swollen chest and arm problem; tingling, burning of numbness in the skin; and shoulder problems.
• New computer models are helping doctors assess whether a woman needs more than a sentinel node biopsy if she has had chemotherapy or endocrine therapy prior to surgery, to help reduce surgery complications in some women.

Theresa Schwartz, St. Louis University Hospital

Gene Profiling

• There’s a new era in medicine to de-escalate or downsize breast cancer treatment because options may cause serious health and financial issues for patients and add significant health care costs.
• Cancer teams are using new computer tools to calculate which tumors are most likely to cause a late recurrence of breast cancer, which can reoccur as many as two decades later after an initial diagnosis.

Tatiana Prowell, Johns Hopkins Medicine

Surgery for Lymphedema Prevention

• 3-5 million breast cancer patients in the U.S. have lymphedema, an often-debilitating swollen arm and chest condition following breast cancer surgery, particularly after surgery to remove more than one lymph node. Risk factors include age over 25; obesity; post-operative radiation; and wound and drainage issues from surgery.
• Some medical teams now offer surgery that connects lymphatic vessels in the chest and arm to veins in the arm, a type of bypass process performed by some microvascular plastic surgeons. The technique is challenging to perform; remains under study; and may not be a good choice for all patients with lymphedema with various medical issues.

Dr. Dunya Atisha, Henry Ford Cancer Institute

Radiation for Advanced Breast Cancer

• Radiation for breast cancer patients with 1-3 positive lymph nodes is under study and increasingly will benefit from computer models sorting out which women will benefit most.

Dr. Eleanor Walker, Henry Ford Cancer Institute

Fertility issues

• Of the 1 in 8 women to be diagnosed in her lifetime in the U.S. with breast cancer, 3% are between 25 and 35, prime child-bearing ages. Half want to have children after a breast cancer diagnosis but only 1 in 10 do.
• Chemotherapy may cause temporary or permanent loss of ovarian function, affecting a woman’s ability to have a baby. A woman’s age and type of chemotherapy are factors in her ability to have a baby. Women should discuss with reproductive endocrinologists which drugs affect their risk of having a baby later.
• Most women resume menstrual periods within six months of chemotherapy. If a woman hasn’t started having periods 12 months after chemotherapy, it’s unlikely she will, affecting her chance to have a child.
• Top medical centers now offer breast cancer patients several options to preserve eggs prior to chemotherapy or surgery, but choices vary greatly in cost and insurance coverage.
• Women can assess their chance of getting pregnant or having a child, as well as find help with other questions, through the Society of Assisted Reproductive Technology, www.sart.org.
• Some medical centers are willing to perform assisted reproductive techniques within six months of a woman’s surgery or chemotherapy, not the 24 months that remain standard in most places.
• Some studies suggest some breast cancer patients can delay chemotherapy for two years so they can have a baby.

Dr. Monique Swain, Henry Ford Cancer Institute