New options in breast cancer treatment: What you need to know

Breast cancer is the second leading cause of cancer death in women, exceeded only by lung cancer. The chance that breast cancer will be responsible for a woman's death is about 1 in 36. Death rates from breast cancer have been declining since about 1989, with larger decreases in women younger than 50. These decreases are believed to be the result of earlier detection through screening and increased awareness, as well as improved treatment.

There are more than 2.8 million breast cancer survivors in the United States.

SOURCE: AMERICAN CANCER SOCIETY

SHARE YOUR STORIES:

Are you facing a breast cancer diagnosis? Are you a survivor? We want to hear from you. Please tell us what has helped you through a diagnosis and treatment? Your advice can help inspire others who are currently facing this journey. Please write to use at life@coxinc.com. Please include your first and last name, hometown and a daytime phone number. Your answers will be considered for publication in our annual Pink Paper edition on Oct. 18.

In October, when the world suddenly turns pink, wading through all of the breast cancer information can be overwhelming.

Today, we take a closer look at some of the latest developments in breast cancer treatment to help spread awareness of this disease.

LYMPHEDEMA SURGERY

Up to 40 percent of breast cancer patients who’ve had lymph nodes removed from their armpit — along with follow-up radiation and chemo — will experience lymphedema of the arm as a side effect: arms that feel extremely heavy, swelling and clothes that don’t fit.

The standard treatment for the condition involves exercise, manual lymphatic drainage by a certified lymphedema therapist, and compression therapy. But a new surgical option has been shown to relieve symptoms in those getting only partial relief.

“The bulk of what I do is for people who have lymphedema and have been working with therapists for months — or years — and have plateaued and are having a hard time,” said Dr. Roman Skoracki, a plastic and reconstructive surgeon who has become known for two innovative surgical techniques. He says those who’ve suffered from lymphedema for years are also suffering psychologically.

One of those was Jeff Howie, a breast cancer survivor and lymphedema patient from Houston who calls the surgery a “life changer.”

“I had to spend about two hours a day taking care of it,” he explains. “If you don’t take care of it, there’s the distinct possibility that you may have a fatal disease as a result. I’d actually thought about having my left arm amputated because the routine was such a drag.”

Surgery solved the problem: Since the day after the surgery, Howie hasn’t had to do a thing to seek relief.

How it occurs

The disease is an imbalance of the production of lymph fluid and its clearance — the clearance can't keep up with the production. Lymphovenous bypass and vascularized lymph node transfer are microsurgical procedures that involve re-routing lymphatic channels to allow for proper draining of fluids.

Skoracki says the condition is often under-diagnosed so he’s also working to identify those at highest risk for developing it and addressing the problem before it becomes severe.

“The onset may not be immediate. Of those that will develop lymphedema, 90 percent will have it within three years of their cancer therapy, but in a small amount of patients, it may occur years later.”

Skoracki has been offering the bypasses for the past eight years — first at Houston’s MD Anderson Cancer Center, where Howie was treated, and currently at The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital.

The bypass surgery typically takes about four to five hours and requires an overnight stay in the hospital. Skoracki said the procedure is technically demanding, as the entire procedure — including the initial skin incision — is performed under the operating microscope and the channels that are repaired are less than 1 millimeter in diameter.

TARGETED RADIATION

The goal in radiation these days is to develop techniques that offer more targeted treatment to the cancer and reduce exposure to healthy tissue and organs.

One of the experts in the field is Dr. Julia White, who has served as chair of the Breast Cancer Committee for the Radiation Therapy Oncology Group (RTOG) since 2007. This group receives National Cancer Institute funding to conduct clinical trials, so in this role, White oversees all of the breast radiation clinical trials.

White, director of breast oncology at The OSUCCC — James and Stefanie Spielman Comprehensive Breast Center, explains that a procedure called accelerated partial breast irradition, (APBI), can make a difference to those women who have gone through menopause, are in their 50s and have a cancer that is small. If their lymph nodes are free of cancer, and if they have the type of cancer that is responsive to estrogen and progesteran and are intending to take their oral hormone treatment for five to 10 years, she says APBI may be an option.

“These women are ideal to have accelerated partial breast irradition,” she explained. “Normally they would have the entire breast radiated in 16 to 25 treatments given five days a week, plus additional radiation delivered to the surgical site for another five to seven treatments.”

She said the new treatment — which focuses on the surgical spot rather than the entire breast — is possible because there now is a much better understanding of how breast cancer behaves.

“We understand biologically that some breast cancers have different patterns of recurrence and response, so the idea of APBI is to identify the cancers that — if they are going to recur — recur in exactly the same surgical spot.”

In those cases, White explained, you are really not gaining anything by radiating the entire breast. Because the clinical trials on the new option have not yet been reported, White said doctors have a sense of who it is safe for but aren’t yet certain whether it is an option for everyone who has had a lumpectomy.

Though there has been much confusion on the subject, White said it has now been shown that the recurrence of cancer and the survival rate is the same whether patients have a breast removal (mastectomy) or a lumpectomy and radiation.

“So for some women, we now say that you’re still a good candidate for lump and radiation, but we may only need to treat the highest risk zone.”

She said this new treatment for those with Stage 1 breast cancer and clean lymph nodes, involves less burdensome side effects and only 6-10 radiation treatments on five to eight days.

Intraoperative radiation

“If a patient has a lumpectomy, we can decide to give one large treatment to the lump cavity immediately after the lump has been removed and prior to the skin being closed, while the patient is still on the operating room table,” White explains.

This treatment option, which takes two to three hours to complete, has been given to women who qualify for the past eight to 10 years, typically older women whose nodes are negative going into surgery and have a small tumor.

“You’re taking an additional risk here, but it’s very convenient,” White said, adding the advantage of APBI is that it is given after the surgery is already known to have been successful.

“There is an 80-85 percent chance that we are right, and the pathology will eventually confirm it,” she explains, “but when when we give the radiation interoperatively — during the initial surgery — we don’t yet have the pathology report.”

Clinical trials over the next four years, she said, will confirm whether the interoperative radiation leads to results as good as APBI.

NEWER DRUGS

Much of the big news in breast cancer treatment involves drugs that are designed to fit specific types of breast cancer.

“We now recognize that one size doesn’t fit all when it comes to breast cancer treatment, and that there are in fact several different types of breast cancer,” says Dr. Dennis Citrin, a medical oncologist who practices at the Cancer Treatment Centers of America in Zion, Ill.

Citrin, author of “Knowledge is Power: What Every Woman Should Know About Breast Cancer,” said the biology of the particular disease to a great extent determines the type of drug treatment that will be offered. Breast cancer is now known to be one of three different types: In hormone-sensitive breast cancer, hormone or endocrine therapy is used to minimize the stimulation of growth of breast cancer cells by the female sex hormone estrogen.

For the Her2/neu form — an aggressive cancer with a previously poor prognosis — at least five new drugs now target the Her2 pathway and have “completely turned around” the prognosis, Citrin said. In triple negative breast cancer, where targeted agents don’t work, chemotherapy drugs are traditionally used.

“The traditional targeted agents that we use in hormone sensitive and Her2 positive disease don’t work for triple negative breast cancer,” explained Citrin. “But we are now identifying newer cellular targets in triple negative disease that we can target with specific drugs. And that’s what genomic testing is about.

A case in point

One of the women whose life has been extended by the new drugs is Diane Butler-Hughes of Brookville, Ohio, who is profiled in Citrin’s book.

She first noticed a thickening in her right breast in 1998 when she was 38 years old. Two years later she was diagnosed with Stage III, ER-Positive, PR-Positive, invasive lobular breast cancer. Citrin said that form of estrogen-sensitive breast cancer is often difficult to detect on a mammogram. Her mammogram was normal just two weeks before her mastectomy.

Four years after surgery, chemotherapy, radiation and hormone treatment, Butler-Hughes was found to have a spot on her spine. But Citrin said although she has widespread cancer in her body, a variety of new estrogen blockers have kept his patient alive for 11 years.

“Diane has done well and now we are using newly developed drugs that reinforce the effect of the hormone treatment and restore a sensitivity to hormone treatment when it’s no longer effective,” he explained. “Lately she has been running into trouble, so we have started her on a new medication that hasn’t had a chance to kick in. We are hopeful that this new treatment will achieve another remission.”

A patient’s perspective

Butler Hughes has been living with Stage 4 cancer for the past 10 years.

“I had no idea that I would live this long,” she admits, adding that some of the chemotherapies and hormone therapies that she has been on for the past six years were not available when she was diagnosed 14 years ago.

“In 2012, when I learned that a chemotherapy I had been on stopped working, Dr. Citrin presented me with a new plan to start a new drug combination (Afinitor and Aromasin) that had just finished its run in clinical trials for the treatment of advanced breast cancer,” she says. “He was hoping that it would buy me an extra two years of life.”

That treatment worked for 28 months. When it stopped working recently, Butler-Hughes started on a series of hormone therapy injections.

“Dr. Citrin told me a few years back that I’ll need to be on treatment for the rest of my life,” she said. “The cancer treatments that I have received in the past few years have definitely extended my life. I’m not going to sugarcoat it — I’ve had many side effects, some very severe and too numerous to count.

“But with new cancer treatments on the horizon becoming available, I remain hopeful. The cancer may seem to have a mind of its own right now and wants to take over — but I’m not willing to let that happen.”