One of the fears of having breast cancer is the anticipation of pain and suffering such as what a person has seen someone else experience. Yet, in the last five to ten years advances in early detection, minimally invasive surgeries, and improved methods of radiation treatments and chemotherapies have made it possible to have a very different course for the disease, especially if it is found early.
"All the way from surgery to radiation oncology to chemotherapy the changes have been incredible." (Medical Oncologist Ronald Harris) "I think in a lot of ways the focus of breast cancer has become how much benefit are we going to get from that therapy and is it truly advantageous to give it or receive it."
"Cancers are very unique and they behave differently. That’s why we don’t have only one kind of chemotherapy regime," (genetic counselor Luba Djurdjinovic). "And usually as a cancer progresses and becomes more disorganized it takes on new characteristics and it’s those characteristics that either make it responsive to the chemotherapy or not. So that’s why the earlier that you can find a cancer, the more likely it’s going to respond to the traditional therapies."
Dr. Ronald Harris is a medical oncologist at Broome Oncology in Johnson City, New York.
"In early stage disease when a woman has a tumor that is say one centimeter or two centimeters the decision of whether or not to give chemotherapy is based on estrogen receptors expressed by the tumor, HER2/neu status of the tumor, and prognostic factors such as the grade of the tumor."
And what is meant by HER2/neu?
"HER2/neu is part of a group of receptors on cells called tyrosine kinase receptors and they stimulate pathways in the cells that do multiple things, one of which is programmed cell death. All cells in the body die at a certain interval; they grow, they reproduce, and they die. Breast cancer cells and cancer cells in general become immortal. They turn off some of those programmed cell death or apoptotic pathways. HER2/neu receptor stimulates production of a protein and the drug Herceptin is a targeted therapy against that protein. What it does is it causes the cells that have turned off the pathway to turn the pathway back on."
And so it causes them to die off.
"It causes them to die off."
"Estrogen receptor positive; that means that the tumor is partly fueled by estrogen and that’s true I think for about 70% of women and about 80% of men," (male breast cancer survivor Bob Ritter).
"What that means is that it can be treated with drugs that block estrogen. Drugs like Tamoxifen work for men. There are newer drugs called aromatase inhibitors that also block estrogen, so it gives doctors one more tool to use."
"I think the discovery of Tamoxifen and Herceptin has changed the way we treat breast cancer and has given women a lot of hope for long lives surviving the breast cancer." (Susan Kost, Director of the Breast Care Center at Wilson Hospital in Binghamton, New York.) "Nationally we’ve noticed that there may be a reason why women are underusing mammography services because when they went off estrogen replacement, hormone therapy, women may think, OK, now I’m safe; I don’t have to worry about breast cancer. And while we’ve seen some encouraging signs that’s improved the deaths to breast cancer women still should realize that isn’t the whole story."
"If a woman has a breast cancer and it’s a high-risk breast cancer, doing an MRI of the breast and the opposite breast can indeed pick up more breast cancers that would have been missed otherwise. So, finding additional lesions which would affect surgery and possibly treatment down the road becomes very important. So I think in that way the advances of treatment are linked to the advances of detection.
Could you talk a little bit about what kinds of new medications are out to help lessen the side effects of chemotherapy?
"That’s an area that has truly improved greatly over the last few years. The anti-emetics or anti-nausea drugs have increased. They’ve discovered much more precisely the mechanism of nausea due to chemotherapy and in such have been able to develop drugs which target those specific receptors. Currently I will tell you that the days of a patient receiving chemotherapy with, unfortunately, a bin in their lap have passed. Most patients, if they do indeed develop nausea, we have a series of drugs that we can go through and usually by the time we get to the end of the list we’ve been able to control that. So, in that respect, nausea has become a controllable side effect."
Is the chemotherapy used today different, really, from what was used five years ago?
"For the standard chemotherapy given in the adjuvent setting or after surgery those drugs are mainly the same that we use, although we use them differently. Something called dose-dense chemotherapy has come around and what we’ve discovered is that the time interval and the intensity of chemotherapy can indeed change prognosis and change outcome. So, routinely dose-dense chemotherapy is given in a two-week fashion rather than a three-week fashion, which is advantageous in a lot of ways. First of all, patients tend to tolerate that regimen a little bit better. You use growth-factor supports, drugs like Neulasta and Erythropoetin or Procrit; patients are done with chemotherapy sooner which is a big factor, especially when you’re dealing with a young person or someone who’s working. There are many drugs that have come around the corner in the last five years, mainly used in metastatic breast cancer; drugs such as Abraxane, or targeted therapies like Herceptin, a new drug called Tykerb… and even a drug called Avastin which has been notable for colon cancer. These therapies are really, I think, the future direction."
What is different about those particular drugs?
"Those are targeted molecules. Now targeted molecules have become I think of the future of oncology. We are discovering pathways that cancer cells become immortal and affecting those pathways with a targeted therapy causes less side effects, less toxicity generally because standard chemotherapy does not differentiate cancer cells from normal cells."
And these are drugs that are on the market right now and available?
"Yes. There are three drugs currently that are used in breast cancer."
You mentioned growth factors earlier. What are they, and what do they do?
"When I speak about growth factors generally there are two classes that are used most commonly. One helps your white blood cells grow; so it stimulates your bone marrow stem cells to produce more white blood cells so the time period that your white blood cell count is low is lessened because specific white blood cells called neutrophils are ones that are likened to the marines of our blood–they go in first and they are your first line of defense against infection. Unfortunately, chemotherapy does decrease those white blood cells. And the second is Erythropoetin which stimulates precursor red blood cells so that you make more red blood cells to lessen the time that you are anemic. "
"A lot of people in the field will say that breast cancers that are found very small, less than a centimeter, are curable breast cancers. In other words, we catch them early; we’re able to treat them early, and again, depending on what their pathology shows, either through surgery, lumpectomy, mastectomy, possibly radiation, possibly chemo, possibly adjuvent therapies like Tamoxifen, we can cure women. If women wait and don’t get yearly screening mammography or don’t get clinical breast exams by their provider, and they’re getting older and they’re not doing these tests when we do finally find their cancers through a lump it may be now over a centimeter; it may have spread to the lymph nodes, making it more challenging for us to treat and causing her to definitely have surgery, radiation, and chemotherapy and then impacting her recurrence rate. So, I think the biggest message for women is that we do have the tools to prevent and cure breast cancer by finding it early."
Series produced by WSKG’s Kathleen Cook, with funding provided by a grant from the Susan G. Komen Foundation.