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Breast Cancer Breakthroughs

Doctors offer promising news from the front lines

By Judith Cookis Rubens Photo by Brett Mountain

Breast cancer remains a scary, real health threat. But today, thanks to better screening tools, refined surgical techniques, and targeted drug and hormone therapies, a cancer diagnosis isn’t so grim. Breast cancer death rates have fallen in the past 20 years, a fact experts link to earlier diagnoses and a move away from one-size-fits-all treatments. “The whole trend now is to do less surgery and more individualized treatment,” says Cheryl Wesen, M.D., a breast surgeon and director of breast care services for St. John Health Systems. Here are some of the latest breakthroughs in the ongoing battle against breast cancer and in reconstructive treatment.

Accurate detection

Doctors usually screen for breast cancer using mammography, which picks up about 80% to 90% of tumors in women without symptoms, the American Cancer Society says. But mammography is advancing. More imaging centers are switching from film to digital mammography technology. Radiologists can enlarge suspicious areas on an electronic image more easily, and new computer-assisted diagnosis software flags trouble spots for doctors to re-check.

In early 2007, the ACS recommended annual MRIs (magnetic resonance imaging) plus mammograms for women 30 and older who are at high risk of developing breast cancer (those who have a strong family history of breast or ovarian cancer or who have been treated with radiation for Hodgkin’s disease).

Some studies have shown breast MRIs are better at finding small aggressive tumors in women with dense breasts. The downside? They pick up so much that they cause false positives. “It’s not the right test for every woman to have,” says Wesen.

Treatment advances

Identifying genetic predisposition for breast cancer by screening for the BRCA1 and BRCA2 genes was the big news of the last decade. Now scientists also better understand breast tumors at the molecular level and how hormone receptors work inside those cells.

"We’re improving our ability to do good molecular diagnosis so we know exactly which drugs to use in which setting," says Stephen Ethier, Ph.D., deputy director andassociate center director for basic science at the Barbara Ann Karmanos Cancer Institute in Detroit. About 60% to 65% of patients have estrogen-receptor positive tumors, meaning anti-estrogen drugs such as tamoxifen can sometimes stop tumor growth, Ethier says. But for post-menopausal women with early-stage breast cancer, tamoxifen is no longer the gold standard. The latest results of several international trials showed that for these women, aromatase inhibitors, a new class of drugs that prevent cells from actually making estrogen, worked better than tamoxifen. Ethier says there is still some debate over which drugs are best.

For another one-quarter of patients with HER-2 positive tumors –– an aggressive, fast-growing type – the drug of choice to slow recurrence has been trastuzumab (brand name Herceptin), an intravenous drug that didn’t work for everyone. A nextgeneration pill called lapatinib (brand name Tykerb) looks more potent in clinical testing, Ethier says. It still attacks the HER-2 protein, but in a different way. “There are more of these kinds of new drugs to come,” Ethier adds.

There are advances in radiation, too, such as new techniques in partial breast irradiation for women with early cancer. Instead of Monday through Friday treatments over six weeks, some new protocols deliver the same radiation dose in one to two weeks, Ethier says.

Also making news is the pricey genetic test Oncotype DX, which aims to tell women with early-stage cancer whether it will recur and whether they would benefit from intense chemotherapy.

"Three of four patients with zero positive lymph nodes are cured with surgery and radiation. Only one in four will recur with aggressive disease later on. The question is, ‘How do you tell who’s who?’ " Ethier says. "This is a test that could not have even been imagined 10 to 15 years ago, let alone done."

Building a better breast

Someday, experts say, we won’t need to talk about radical or total mastectomy. Until then, for those considering reconstruction, there are new types of silicone gel implants that offer a natural softness and shape, and are less likely to leak outside the pocket where the implant is placed, should the implant rupture, says Edwin G. Wilkins, M.D., a plastic surgeon specializing in mastectomy reconstruction at the University of Michigan Health System in Ann Arbor.

"The newest generation of gels aren’t the liquid silicone that people remember," Wilkins says.

About half of Wilkins’ patients choose implants during reconstruction, but the other half choose to rebuild the breast using their own tissue. The standard TRAM flap surgery, which uses pieces of abdominal wall muscle, left women with reduced sit-up power. Newer techniques – known as DIEP or GAP flap surgeries – use lower abdominal skin and fat or buttock skin and fat, but no muscle, to build the new breast.

"Moving tissue without sacrificing muscle is the new frontier," Wilkins says.

More survivors

One in eight women will be diagnosed with breast cancer during her lifetime. That’s the bad news: The lifetime risk has gradually increased over the past 30 years, in part due to longer life expectancies. But the good news is many women are also surviving longer with cancer. The all-important fiveyear survival rate for breast cancers diagnosed from 1996-2003 was 88.6%, up from 86% between 1992-97, the National Cancer Institute reports.

"Finding a cure for breast cancer is everybody’s primary goal," says U of M’s Wilkins.