Modern breast cancer therapies are highly tailored to each patient’s needs, with doctors aiming to maximize the effectiveness of treatment while minimizing its impact on her quality of life and future health. BC The Mag spoke with Leslie Montgomery, MD, who leads the Division of Breast Surgery at Hackensack University Medical Center, to talk about the options available to women diagnosed with breast cancer today.
Q. What can a woman do to ensure that she has the best chance of beating breast cancer, if it is diagnosed?
A. Breast cancer is most treatable when it is found early, so it’s important to keep up with breast screening through regular mammography. Our team advises a woman to have her first screening mammogram at age 40 and to continue having a mammogram each year afterward. If she has a higher risk of cancer due to her personal or family medical history, she may be advised to begin screening sooner.
At our center, we use 3D mammography (Tomosynthesis) for all patients who come to us for breast screening. It is better than regular 2D mammography for detecting breast cancer, especially for women with dense breasts, and it produces fewer false positives (breast findings that turn out to be benign). After a screening mammogram, some women may also have breast ultrasound or MRI. Women should speak with their doctors to learn what screening is best for them.
Q. If breast cancer is found, what are the options for surgery?
A. Your breast surgeon will discuss which procedures are best for you, taking the stage, size, location, and biology of your tumor, as well as your personal preferences, breast size, and other factors into account. Most early-stage breast tumors can be removed through lumpectomy, where we remove the tumor but leave the remainder of the breast. We take an “oncoplastic” approach, taking out the tumor while preserving the look of the breast as much as possible.
Q. What if I need a mastectomy?
A. Mastectomy involves removal of all of the breast tissue, not just the tumor. Women who need a mastectomy and who want breast reconstruction can have both procedures done at the same time or have the reconstruction later. With skin-sparing mastectomy, the inner breast tissue is removed, but the skin is left intact before breast reconstruction. Some women having skin-sparing mastectomy are also candidates for nipple-sparing mastectomy depending on the location of the cancer, the size and shape of the breast, and the location of the nipple. Reconstruction can be done using tissue from another part of the body or implants. If you are considering breast reconstruction, your plastic surgeon will discuss the best options with you.
Q. When is radiation therapy needed?
A. Most women who have a lumpectomy have radiation therapy to the breast afterward. There are many types. The most common is external beam radiation, in which beams of radiation are directed to the breast from a machine outside the woman’s body. With a technique called “intensity-modulated radiation therapy,” radiation of various intensities, shaped to the contours of the lumpectomy cavity, is directed from different angles to target possible cancerous tissue while sparing normal tissue as much as possible. Most women are candidates for “hypofractionated” radiation therapy, where higher doses of radiation are given over fewer weeks. Patients appreciate the convenience of this approach.
At our center, we give external beam radiation therapy in the prone position – where the woman lies face down on a table with the treated breast falling through an opening – whenever we can. This allows us to direct radiation to that breast while sparing the lungs and heart, reducing the risk of side effects later in her life.
Q. Can I receive radiation therapy on the same day as my breast surgery and be done with treatment?
A. Intraoperative radiation therapy (IORT) for breast cancer involves the delivery of a single low dose of radiation to the cavity remaining in the breast after lumpectomy, while the patient is still in the operating room. This treatment has been publicized for its convenience and lower cost, compared with standard breast cancer radiation therapy. However, doctors have many concerns regarding the design of the study that supports the use of IORT, the interpretation of its results, the way the radiation is delivered into the lumpectomy cavity, and the effectiveness of the treatment – among other issues. For example, current IORT methods use a round applicator and assume that the cavity remaining after lumpectomy is also evenly round. But in reality, most lumpectomy cavities are not perfect spheres.
My team does not believe there is sufficient evidence to use IORT, and we do not offer it at Hackensack University Medical Center. However, we are conducting a clinical trial assessing a new approach to same-day treatment for women ages 45 and older with early-stage breast cancer. The therapy is given using a balloon applicator and is tailored to the contours of the lumpectomy cavity. Doctors use CT imaging to “sculpt” the radiation dose away from the heart, skin, and ribs. Patients have a lumpectomy in an operating room, and the radiation therapy applicator is placed in the lumpectomy cavity. After the anesthesia has worn off, patients then go to a special room in the Department of Radiation Oncology to receive a single dose of radiation therapy. We hope that this new approach can overcome the deficiencies of existing IORT systems while still offering same-day benefits to patients.
Q. What if I need chemotherapy or hormonal therapy for breast cancer?
A. A discussion with a medical oncologist can help you understand if you need chemotherapy, hormonal therapy, and/or a targeted anticancer drug as part of your breast cancer care. This decision is based on a number of factors, including your tumor’s size, stage, biology, and likelihood of coming back. State-of-the-art technology is now available to better define how and when to use chemotherapy appropriately. This helps to ensure patients get the treatment they need while avoiding therapies (and their side effects) that are not likely to be effective. For patients with advanced cancers, we are also exploring the use of “next generation gene sequencing,” a novel tool which can help us identify new molecules driving cancer growth. This technique could yield new treatment possibilities that are more targeted and effective than existing therapies.
With over 200 dedicated professionals, Hackensack University Medical Center has built the largest program in New Jersey focused on breast cancer – offering comprehensive services from screening and diagnosis through treatment, support, and survivorship. For more information, visit jtcancercenter.org. To make an appointment, call 1-844-HMH-WELL.