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News Archive - Progress Newsletter Summer 2000 Online

Advances in Breast Cancer

by Kathryn A. Carolin, M.D. and Helen A. Pass, M.D.

There is good news in the fight against breast cancer. Death rates from the disease, which strikes about 180,000 American women each year, continue to decline. The greatest reductions have been among younger and white women, with more modest declines among African Americans and women ages 65 and older. This progress is due to improvements in prevention, early detection and diagnosis, and treatment. Following are highlights of advances made on these fronts during the last year.

Prevention

As data from large clinical studies have become available, the idea of chemoprevention -- using drugs to prevent cancer -- is becoming a reality. Results from the Breast Cancer Prevention Trial, a study designed to see if the anti-estrogen drug tamoxifen could prevent breast cancer in women who were at an increased risk of developing the disease, showed an almost 50-percent reduction in invasive breast cancer in women who took tamoxifen compared to women who did not. Prevention, in this case however, did not come without a price. Study participants over age 50 suffered more side effects, including endometrial (uterine) cancer, as well as blood clots in the leg veins or lungs. A new trial, the Breast Cancer Prevention Trial 2 (STAR), is evaluating the utility of a newer anti-estrogen medication (Raloxifene), with hopefully fewer side effects as compared to tamoxifen. Consul-tation with physicians familiar with these studies can help determine if your risk of developing breast cancer is significant enough to warrant consideration of the use of these medications.

Early Detection and Diagnosis

Thanks to mammography, the majority of breast cancers are now diagnosed while the cancer is in an early, more curable stage. Guidelines developed by the National Com-prehensive Cancer Network (NCCN), a group of the country's leading cancer centers including the University of Michigan, recommend women receive a baseline mammogram at the age of 40 and be screened yearly thereafter.

More options than ever before are available to help physicians diagnose breast cancer, and the trend has been to use less-invasive measures for the diagnosis and treatment of breast cancer. Mammogram-guided stereotactic fine needle and core biopsies have become the standard of care. Mammogram-guided large and skinny needle biopsies can be performed on most abnormalities. Use of this technology can avoid surgery to make a diagnosis in most cases. This results in less scarring, avoidance of anesthesia and faster recovery, and therefore is felt to be the optimal method of diagnosing breast abnormalities.

Treatment

Treatment for breast cancer is constantly evolving. The most significant change in surgery has been the use of sentinel lymph node mapping in women with breast cancer. By visually tracing a special blue dye, as well as using a hand-held Geiger counter to trace radioactivity injected near the cancer, the surgeon is able to pinpoint the lymph node(s) to which a tumor drains. This allows removal of fewer lymph nodes than in a standard operation and thus a lower risk of side effects (especially arm swelling), and allows treatment as an outpatient and faster recovery for women in whom this can be performed. Less-invasive surgical treatment is also now possible in some women with larger cancers. In the past, these patients were treated surgically with the complete removal of the breast (a mastectomy).

Currently, in select patients, chemotherapy can be given in an attempt to shrink the tumor. If an adequate reduction in size is achieved with chemotherapy, a lumpectomy may be possible. Whereas surgery has become less invasive, the use of chemotherapy and radiation has become more aggressive and intervention is now recommended earlier.

Guidelines for giving chemotherapy after surgery (also know as adjuvant therapy) also have changed. Regardless of menopausal status, women with tumors bigger than 1 centimeter should be counseled about receiving chemo-therapy. In patients with metastatic breast cancer whose tumor has the Her-2 Neu tumor marker found on the surface of some breast cancer cells, treatment with a monoclonal antibody known as Herceptin can shrink tumors without significant side effects. For women with more aggressive cancers, the combination of two separate chemotherapy regimens, given sequentially, has been demonstrated to improve survival over the use of either regimen alone.

Similarly, the recommendations for the initiation of radiation therapy have been expanded. While all breast cancer patients treated surgically with lumpectomy received radiation, there is now an endorsement of greater use of radiation after mastectomy. Newer studies have shown that in certain patients, especially those with cancer in their lymph nodes, there may be a survival benefit to post-mastectomy radiation.

In the near future, advances in imaging techniques such as PET (Positron Emission Tomography) scans may make removal of axillary lymph nodes unnecessary in the vast majority of patients. Chemotherapy regimens will become more targeted and specific with tailored dosing regimens. On the horizon is the prospect that some cancers may be treated without surgery but with the placement of instruments into the breast that can cause tumor destruction perhaps without scarring.

We eagerly anticipate the development and maturation of new breast cancer therapies and strive to continue to make advances against this all-too-common disease.

 

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