The Right Questions The New Answers: Advancements in breast cancer research and treatment

Local oncologists are eagerly awaiting the imminent arrival of a MammoSite device for use in some women undergoing a lumpectomy. This internal radiation therapy delivery system — a spherical balloon catheter inserted into the cavity created by surgical removal of the breast tumor — is an option for breast conservation therapy. During a five-day course of therapy a tiny radioactive seed attached to a wire is inserted into the balloon delivering predetermined levels of radiation under precise computer control to the targeted tissue surrounding the cavity. No source of radiation remains in the woman’s body between treatments or after the final procedure.

“Radiation takes place for five days in one week rather than once a day for 25 or 30 treatments ” says Dr. Patrick Maguire of the Zimmer Cancer Center and New Hanover Radiation Oncology Center. This type of treatment partial breast irradiation (PBI) minimizes the amount of radiation to the healthy portion of the breast tissue.

“The preliminary data shows that the local recurrence rate is going to be as good as whole-breast radiation ” says Dr. Weinberg. “But we do not have the five-year data on that. The jury is still not quite in yet on that.”

And on the national scene just in are results from the STAR (Study of tamoxifen and raloxifene) trial a massive breast cancer trial which began in 1999 throughout North America. The results released in June of this year provide a very exciting piece of the puzzle in the fight against breast cancer. The NSABBP (National Surgical Adjuvant Breast and Bowel Project) study examined the effects of tamoxifen and raloxifene on prevention of cancer in postmenopausal women at high risk of breast cancer (examples of women at high risk are women who have precancerous changes on a biopsy or close family members with breast cancer).

The study concludes that raloxifene is as effective as tamoxifen in reducing the risk of invasive breast cancer with fewer side effects including risk of stroke. Although the FDA has not yet approved raloxifene for use in cancer its approval is imminent.

“Thus while not all high risk women choose to take a medication for prevention nor are all women candidates for this strategy both of these agents give us options for prevention of breast cancer ” says Dr. Kenneth Kotz oncologist at Hanover Medical Specialists.

Some Wilmington-area physicians don’t need a national study to make a change. Less than a year ago Dr. Weinberg’s patients had to travel to Chapel Hill Duke or East Carolina University for genetics counseling. Now Dr. Weinberg does this work in her office. Women with a strong family history of breast cancer and a physician’s referral are candidates for genetics counseling. The procedure is straightforward enough with a simple blood withdrawal. More important is what women do with this information.

“A lot of women don’t want to know. They think they are tempting fate with this information but doctors are becoming more aware that you need to look into a patient’s family history because that can drastically alter the type of treatment she is going to receive ” says Dr. Weinberg. “If you test positive for mutation there is up to an
80 percent chance of developing breast cancer in your lifetime and a very high risk of developing one on the other side. So a lot of those women may choose a bilateral mastectomy and a lot of them will end up choosing bilateral oophorectomy (removal of the ovaries) as there is up to a 40 percent chance of ovarian cancer too.”

Detection is also making advances in the form of digital mammograms. A 2005 study of more than 40 000 women shows digital mammograms to be more accurate than traditional film-based X-rays in diagnosing breast cancer in women under 50. Though Dr. Etta Pisano director of the Biomedical Research Imaging Center at the University of North Carolina in Chapel Hill writes that this doesn’t mean women should “rush out to get a digital.”

Additionally new computer software has revolutionized the way information gets to the patient. Dr. Kotz uses Web-based programs to illustrate to his patients how the cure rate changes with or without chemotherapy. “For many patients the fear of chemotherapy could be balanced by a better understanding of the benefits of chemotherapy ” says Dr. Kotz.

Using these programs the oncologist enters the patient’s age and other information about her health and her particular breast cancer. “An interesting feature of these programs is their ability to show in numerical fashion how a patient’s age and other medical problems affect the decision-making process. For example a person with a serious heart condition may decide against chemotherapy to help cure her breast cancer if her chance of dying from heart disease and old age significantly outweighs the danger from the cancer.”

According to Dr. Cyrus Kotwall director of the Zimmer Cancer Center at New Hanover Regional Medical Center chemotherapy itself is being examined under a microscope. A trial launched in May 2006 TAILORx — the Trial Assigning IndividuaLized Options for Treatment (Rx) — will examine whether genes that are frequently associated with the risk of recurrence if and when found in women with early-stage breast cancer can be used to assign patients to the most appropriate and effective treatment. Sponsored by the National Cancer Institute it is one of the first trials to examine a methodology for personalizing cancer treatment. The trial will enroll more than 10 000 women at 900 sites in the United States and Canada.

“This trial will help us tailor who we give therapy to ” says Dr. Kotwall. Chemotherapy doesn’t benefit every woman in the same way. This trial aims to find out who benefits and who may not. TAILORx may spare women the morbidity and costs of chemotherapy if it does not substantially benefit them.

Other researchers are reviewing an entirely different method of treatment from chemotherapy. They are looking at ways to attack the blood vessels that feed the cancer. One such drug bevacizumab is already on the market and approved by the FDA for colon and lung cancer. “Although not approved for breast cancer ” says Dr. Kotz “it is anticipated that this drug will be used with increasing frequency for breast cancer treatment in the future.”

The final piece to the puzzle is in the area of breast reconstruction. Plastic surgeons in Wilmington have been making huge strides in this area over the past year.

One of these important strides is the release of permanent silicone implants to the general public says Dr. Charles Kays of Wilmington Plastic Surgery. “Prior to six to seven months ago they were available as part of a study.”

The silicone is softer has a more natural feel and ripples less than saline implants he adds. The silicone is now made of a cohesive gel. “If you chopped it (the implant) in half with a big meat cleaver and you held it up ” says Dr. Kays “the gel would not leak out of the implant.” This solves the earlier problems of silicone leaking into the breast tissue or outside of the implant.

Many women are still choosing reconstruction flaps rather than implants. The newest of these techniques DIEP (deep inferior epigastric perforator) flap surgery is being done at large university medical centers like Duke due to the requirement for a large team of doctors to work on the microsurgery. The DIEP flap uses skin fat and blood vessels rather than muscle to recreate the breast.