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The New Reality of Breast Cancer

by Erica Bauwens

Advances in South Jersey medical research, detection and radiation technologies are making a once-ominous diagnosis easier to fight than ever.

October has become synonymous with breast cancer awareness, but for South Jersey patients, survivors, family members and medical experts, the disease is on their mind every day. It’s a cancer that is known by many, largely because it affects such a huge percentage of women across the United States—about 12 percent of women, or 1 in 8, according to BreastCancer.org. And while the Ardmore, Pa.-based nonprofit estimates that 231,840 new cases of invasive breast cancer will be diagnosed in 2015, the numbers for survival and treatment have changed dramatically for the better.

Incidence rates have dropped from 2000, the first drop in decades, and death rates have also gone down for all patients, but particularly for patients over the age of 50. Those advancements are thanks largely in part to work being done right here in our backyard. Focusing on earlier detection, more patient-friendly treatment, and genetic testing and education tools, fighting this disease has come a long way.

A clear diagnosis
With breast cancer remaining one of the most common diagnoses for women in the country, area medical providers are crafting treatment centers that cover everything from diagnosis to post-treatment.

There’s the Janet Knowles Breast Cancer Center, a massive center based out of the MD Anderson Cancer Center at Cooper in Camden. The Janet Knowles Center, which opened its base location in May, also has outposts in Willingboro and Voorhees with one central goal:
“The goal is to have a multidisciplinary setting, so [patients] can see an oncologist, plastic surgeon and physician in one setting,” says Dr. Kristin Brill, program director for the center. With eight exam centers, chemotherapy space, plastic surgeons, genetic counselors, nutritionists and behavioral health specialists all on site—as well as a gift shop with jewelry and gifts for browsing—it really is a one-stop spot. “They’re getting information from their specialists and formulate a plan and can get feedback at that time. It’s a nice opportunity for the physicians to collaborate and it enhances patient care.”

The same is happening with Lourdes Health System’s Burlington women’s center. The state-of-the-art space has a dedicated focus on imaging, which is the most important piece of the puzzle when it comes to detection. New to imaging is a 3D mam­mography unit, also known as tomosynthesis. According to Lourdes’ Chair of Radiology and Nuclear Medicine Dr. Kathleen Greatrex, it’s a game changer.

“The FDA approved 3D mammography in 2011, and it’s a method of imaging the breast in three dimensions,” explains Greatrex. “The slices are 1 millimeter thick, and basically these multiple images are reconstructed into a three dimensional data set. [Experts] found that, overall, the sensitivity for picking up cancers increased with the use of breast tomosynthesis, which is really important. These increased specificity by 10 percent and the recall rate—having a patient in to rescan—decreased by 43 percent.”

While still new, tomosynthesis can be a very valuable tool for all varieties of women. “It’s proven to be very, very helpful in allowing us to look at the breast in a way that mammography doesn’t give us,” says Greatrex. “We’ve changed a 2D view into a three dimensional view. So we can differentiate between normal, asymmetric breast tissue and the potential for an underlying mass.”

This is particularly helpful for women with dense breast tissue, which has increased risk of breast cancer due to scans that are hard to read. When done in conjunction with ultrasounds, the results for women mean less wait time and less frequent scans. “Breast density does play a risk factor for breast cancer,” continues Greatrex.

“Breast cancer increases if your breast density is significant. That’s because we are looking through a snow storm, a dense cloud of tissue. It’s hard to see calcium, or masses. An ultrasound will allow us to pick up tumors or calcium in a way that mammography normally doesn’t. This new technology means we might not need a patient to come back in three months or so, which alleviates the stress and psychological stress factor that women may face if they think they have to come back in three months.”

More advanced diagnosis techniques include molecular imaging, optical imaging and contrast-enhanced mammography. According to Dr. Catherine Piccoli of South Jersey Radiology—who specializes in breast imaging and diagnostic radiology—these up- and-coming methods of detection could reshape the future of breast cancer diagnosis.

“Nuclear imaging of the breast is a generic term that covers different types of scans including positron-emission mammography (PEM), breast specific gamma imaging (BSGI) and molecular breast imaging (MBI),” explains Piccoli, who says that radiation dose is the primary concern in these treatments.

“Contrast-enhanced mammography uses an iodinated contrast agent and low radiation dose to produce images similar to mammography as well as contrast- enhanced images that show vascularized lesions,” she continues. “This technique appears to be fairly sensitive and specific for cancer detection, but it is in its infancy and far more data is needed before its usefulness is known.”

Tackling treatment
The treatment options available for women have also come a long way, with a focus on making treatment easier—and oftentimes faster—on the patient.

Dr. Generosa Grana, director of the MD Anderson Cancer Center at Cooper, says that treatment for breast cancer can be divided into three areas of advancement: surgical, radiation and systematic advances. “When we see a patient our job is not to just talk about standard treatment but to lay out what else is new and what else is available for the patient,” she says.

The new goal for physicians is a tailored form of treatment, to address each patient’s individual needs. Surgery remains the first way to tackle a tumor, but the standard double mastectomy has come a long way. “In surgical we are doing a lot of breast conservation. Across the country a lot of women are choosing to have bilateral mastectomy, but our surgeons spend a lot of time making sure women are aware of their options. If that’s what you choose, the key is having excellent plastic surgery,” says Grana. “Reconstructive options can be tailored to a patient’s age and stage and other problems they might have, or their goal.”

With clinical trials offered across the country through MD Anderson, Cooper has also found new advances in radiation that make the entire process somewhat easier on the patient’s body. “Over the last couple of years the treatment plan has changed to using shorter courses of therapy. Instead of six weeks, some women are offered four weeks,” says Grana. The newest option is the SAVI treatment, a five-day plan offered in Camden that addresses only certain kinds of cancer.

Chemotherapy—which is notorious for its difficult and lengthy side effects—has evolved as well. “In general there are more options based on tumor types,” says Brill. “We’ve learned more about appropriate dosages. And a big change has been targeted therapy, like herceptin for HER2-positive cancers. It’s a chemotherapy that’s meant to treat that specific tumor. They’re a little different because they’re not the common chemotherapy and they channel just the specific tumor as opposed to the entire body, which is what results in the nausea, hair loss, etc., that is associated with traditional chemotherapy.”

“The prognosis has gotten easier to deal with, especially because there are so many resources,” says Grana. “For the physician it hasn’t gotten easier, if anything it’s gotten more complex. Now we have many options and a good physician goes over every option.”

For Brill and the Janet Knowles Cancer Center, that also means providing a comfortable setting for women who spend so much time fighting the disease. “For our patients it’s a comfortable place to sit and wait with family. There are a lot programs available and the shop is a neat concept because people find little things that are really inspirational in there,” she says. “And our infusion center for chemotherapy has individual cubbies, separated out areas with seating for family members, big windows and TVs. There are also a couple of rooms that are more isolated and a little bit closed off for people who really value their privacy.”

Education and testing
One of the biggest areas of cancer advancement is far and wide genetic testing. Testing for genetic mutations that contribute to cancer diagnosis came to light in 2013, when celebrity Angelina Jolie went public with her preventative double mastectomy after discovering that she carried the BRCA1 gene, which increased her risk of breast cancer by 87 percent.

Since then, the BRCA1 and BRCA2 genes have become the basis of testing done across the country—and largely in our area—that has unearthed dozens of new genetic abnormalities that can also link a family’s genetics to certain cancers.

“The most common genes for which testing is performed are BRCA1, BRCA2, and PALB2,” explains Piccoli. “Other less common genetic mutations have also been associated with breast cancer risk and testing for many of these abnormalities has become available.”

“Prior to two years ago we knew about the BRCA 1 or BRCA2 genes. Those were the two genes we could test for,” says Grana. “Often we could find something but there would be women with a long history of breast or ovarian cancer and we couldn’t find anything. Over the last two years we have found over 25 genes that contribute to breast cancer risk.”

Karen Swenson, RN, OCN, is the clinical trial coordinator for the Kennedy Telegenetics Screening Program, working alongside principal investigator Dr. Trina Poretta. The program— created in collaboration with the University of Pennsylvania—is designed to find more genetic strains in our area, and is open to all.

“The technology has advanced for different genes, not for the BRCA gene in particular. They can find out if they have a history of cancer if they have that mutation,” says Swenson. “If they have that mutation, that can benefit research and their family members.”

Swenson says the trial provides patients with a family history of cancers with screening options, video counseling and a full genetic test that will determine their risks. “A lot of people were tested a long time ago and we didn’t have access to the full panel that we have now, but there’s a panel of many, many mutations that we’ve found. And a lot of people’s family history will change since the last time you were tested.”

And while genetic testing can help give some people an idea of what their future holds, Piccoli stresses that only about 10 percent of breast cancers are associated with genetic inheritance, so regular screenings are still important.

The future of breast cancer
With all the changes on the horizon and advancements in technology, one large question still remains: Are we closer to the cure?

“I think the goal is not finding a full cure, but changing breast cancer from spreading—and changing the outcome of what used to be stage 4 or non-treatable breast cancer,” says Brill. “The ultimate step is seeing permanent remission or a permanent cure for stage 4.”

Brill says that she sees a bright future for all areas of treatment and therapy techniques. “I think we’ll see more development in targeted therapies and techniques like immunotherapy. We’ll find that our therapies are less toxic and radiation is minimized. Surgery is going the same direction, where less is more. We’re finding the threshold for that minimum amount of invasive surgery or morbidities.”

Her colleague, Grana, agrees. “I foresee—in the next five years—that our surgical treatment may become less aggressive,” she says. “There’s a debate about managing non-invasive breast cancer and that some of those cases may be able to avoid radiation. We may be able to do less. I think our genetics are only going to improve and we can understand a risk better.”

Greatrex—who lost her mother to breast cancer while she was in medical school—says that, no matter what lies ahead, the answer to a healthy present is in the hands of the patient. “A monthly breast exam should begin after the age of 20. Nobody knows our body better than ourselves, and if you don’t know how to conduct a self exam your doctor can help explain how to do it. Follow up with a clinical breast exam every three years between the ages 20 and 39. Then get a clinical breast exam and a 3D mammogram every year after the age of 40.

“Just get a 3D mammogram. I can’t stress it enough,” she continues. “There’s no other modality that has come close to replacing it as a means of which to diagnose breast cancer at a stage and a size which can be treated. If we can diagnose it at that stage, it’s a cure.”

Published (and copyrighted) in Suburban Family Magazine, Volume 6, Issue 8 (October, 2015).
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