In Health: Breast Cancer - Better Ways To Detect And Treat


Dr. Rebecca Viscusi

Dr. Pavani Chalasani

Dr. Michele Ley

Mary Verplank R.N.

October is Breast Cancer Awareness Month, and we interviewed local experts to discover the latest developments in tests and treatments.
By Elena Acoba | Photography by James Patrick

In Pima County, an estimated 550 women were newly diagnosed with breast cancer in 2016. But the word from local physicians is that there’s good news on several fronts.
Many more women are surviving breast cancer. The average survival rate is 85 percent, but can be as high as 99 percent, says breast surgical oncologist Michele Ley, M.D., director of Tucson Medical Center’s Breast Health Program. “Twenty to thirty years ago, these
numbers used to be 70 to 80 percent,”
she says.
In Pima County, the number of annual diagnoses has gone up since 2010, but the trend for mortality rates is falling.
It all starts with early diagnosis, explains Dr. Ley.
One reason for earlier detection is the effort to find women with a high risk of getting the disease. Another is improved screening equipment.
“We’re better able to cure the cancers, and the treatments can be less invasive and more precise when the cancers are smaller,” she says.
The wide range of treatment options makes fighting breast cancer less daunting than in the past, says Rebecca Viscusi, M.D., a breast surgeon with Arizona Cancer Center.
“We now have more options in terms of how we treat breast cancer, and really focus on individualizing treatment based on the patient, her disease characteristics and her social situation and personal beliefs,” she says.
Today’s breast cancer patient also benefits from a team approach. Health professionals along the spectrum of services — imagers, breast surgeons, pathologists, oncologists, plastic surgeons, nurse counselors and more — work together to customize treatment and reconstruction. No longer are women handed from one specialist to another to deal with each issue in isolation. That leads to cure, remission and better cosmetic results for the vast majority of patients.
Diagnosis
The best diagnosis is one that is avoided. That’s what high-risk clinics at Tucson Medical Center (TMC) and Arizona Cancer Center (ACC) hope to accomplish.
A lot of research has gone into the role that genetics plays in breast cancer. Actress Angelina Jolie’s decision to remove her breasts in 2013 to avoid cancer was based on information that a mutation of the BRCA1 gene greatly increases the chance of getting the disease.
Research has found other gene mutations, including BRCA2, that could lead to breast cancer.
As costs for genetic testing have come down, more clinics and physicians are ordering them. The results can help you to start a discussion with your doctor.
High-risk is explored well beyond genetic testing, says ACC’s Pavani Chalasani, M.D. Her many positions include medical oncologist with the Breast Cancer Multidisiplinary Clinic and principal investigator for several clinical trials.
There is much information to be gleaned from the breast cancer experience of other family members. Was that person male or female? Immediate or extended family member? Diagnosed at an early or late age? “There are a lot of nuances to this,” Dr. Chalasani says.
Once a person is identified with a high breast cancer risk, TMC and ACC help plan a schedule of enhanced screening using mammography, MRIs and other methods. They help a patient make decisions on preventive surgery, as well as provide information on nutrition and other lifestyle changes that reduce cancer risk.
“Our primary goal is to prevent these patients, and possibly their family members, from ever having cancer,” notes Stephanie Boreale, senior director of ambulatory services at TMC.
For women with average or low risk, standard mammography techniques have been improved to better detect early cancer. Three-dimensional mammograms, now considered the standard of care by many physicians, reveal more detail and spot cancers that are too small to show up in two-dimensional scans.
MRIs, biopsies and hormone receptor tests can further pinpoint a diagnosis.
Treatment
At ACC and TMC, once a woman receives a breast cancer diagnosis, a team of health professionals and others help to create a plan of attack.
In weekly meetings, all of the health professionals, not just a patient’s specific doctors, gather to discuss courses of action.
That means that more than one surgeon, more than one oncologist and so on, are looking at each case. “Treatment is not a single-doctor approach anymore,” says Dr. Chalasani.
These meetings allow specialists to share what they know about new treatments, what they’ve seen or read about as effective therapies, and their expertise to answer tough questions about a specific patient.
“We collaborate by discussing options, timelines and ensure the whole care team is knowledgeable about the next steps,” says Mary Verplank, R.N., a nurse navigator at TMC. She puts together a multidisciplinary team of specialists to facilitate care of the patient. The same collaboration occurs at ACC.
TMC also can tap into the expertise of the Mayo Clinic in Phoenix, where doctors may be consulted about specific patients. Two years ago, TMC and Mayo agreed to collaborate on more challenging cases and make use of recent ongoing research.
A nurse navigator at TMC or a patient navigator at ACC is assigned to each patient. The navigator helps answer questions, arranges appointments and tests, coordinates care and provides service referrals to help resolve non-medical issues such as finances, counseling and transportation.
“Patients find the results reassuring that we are all in agreement and are offering them the best care,” says Dr. Ley.
Much of breast cancer treatment depends on several tests and procedures that help pinpoint the cancer’s location. These methods help reduce the amount of surgery, radiation, chemotherapy or hormone therapy that’s needed to fight the disease. Here’s a sample of what’s available from ACC and TMC.
HER2/neu testing tells an oncologist whether a patient needs chemotherapy. It can take up to 10 days for results,
but TMC’s on-site lab reduces that wait to four days.
Radar localization uses a reflector embedded in the breast to help a surgeon find a small cancer. Think of it like a microchip in a pet, explains Dr. Ley. The reflector can be embedded up to a month before surgery. A more common locator requires a wire to be inserted partially into the breast only a few hours before surgery.
Using the radar procedure “saves the patient a trip to the imaging center on the day of the surgery,” says Dr. Viscusi. In June she became the first surgeon in the Tucson area to use this procedure. TMC plans on incorporating it by the end of the year.
Lymphoseek radioactive tracer helps surgeons find cancerous lymph nodes in the armpit. Compared to previous procedures, this “is more accurate and faster,” according to Dr. Ley.
BIOZORB is a coil with metallic markers on it. It’s placed in the cavity following surgery where the cancerous tumor was located. It shows where future radiation is to be targeted.
Intraoperative ultrasound in the operating room helps surgeons more accurately remove a tumor as well as the healthy tissue around it — called the margin — to make sure all of the cancer has been excised.
Partial breast radiation eliminates the need for multi-week radiation treatment of the whole breast. A catheter leading into the cavity of the removed tumor feeds radiation seeds into the site for five days. ACC is in a trial to administer a single dose of seeds during surgery, further reducing the time of treatment.
Clinical trials by Dr. Chalasani’s research team (up to 15 trials at any one time) involve breast cancer. Some allow all subjects to get drugs or therapies that already have led to better outcomes.
TMC also is able to tap into the research efforts at the Mayo Clinic to offer clinical trial enrollment for local patients.
Reconstruction
Oncoplastic surgery combines cancer surgery with plastic surgery to help preserve the look of the breast after treatment. Combining surgeries can reduce the number of operations.
Because of these new techniques, plastic surgeons often are part of the treatment team. “Having them on board right away is important,” Dr. Chalasani observes. They can suggest when reconstruction should occur on the treatment timeline and recommend the best techniques based on what the patient needs or wants.
Disfigurement is a big concern for women with breast cancer. “They’re worried about what they will look like when all is said and done,” says Dr. Viscusi.
“With immediate reconstruction, the patients have better psychological outcomes,” adds Dr. Ley.
Hidden scar techniques utilize small incisions in places that will hide a scar and preserve much of the healthy breast tissue.
Skin sparing and nipple sparing in a mastectomy (removal of the whole breast) leaves intact as much of the breast skin as possible.
Immediate reconstruction involves a plastic surgeon inserting temporary tissue expanders or permanent implants at the time of the mastectomy.
Breast reduction or lift can be done right after a lumpectomy (removal of a tumor) because diseased tissue already has been removed.
Surgical Recovery
TMC has a program that helps patients safely recover from pain even before they’re out of surgery. Hospital surgeons work with anesthesiologists and pharmacists on pain management. The Enhanced Recovery After Surgery (ERAS) program aims to reduce the need for opiods and avoid dependence on pain medications.
ACC provides services for patients who suffer painful swelling in the arm where cancerous lymph nodes are removed. Called lymphedema, the long-term condition also can affect shoulder movement. The center has a lymphedema therapist who can provide treatment and discuss ways to prevent the condition.
Additionally, ACC has classes that prepare patients for chemotherapy and radiation.
Support
Abreast cancer diagnosis is scary. Uncertainty abounds about physical and mental health, lifestyle changes, financial stability and more.
From diagnosis to recovery, ACC and TMC provide services to help patients and their families navigate the changes they face.
TMC has support groups and a yoga class specifically for breast cancer patients. Its Live Well series covers nutrition, psychological health, social issues and therapeutic movement.
Oncology social workers in ACC’s “Supportive Care for Healing” counsel patients, run support groups, help families cope with changing responsibilities and aid patients in adjusting to life after treatment.
The program also includes services for nutritional counseling, acupuncture, massage, reiki, shiatsu and reflexology. Classes include qi gong, tai chi and yoga.
These are more than indulgences after going through a tough medical situation. Dr. Chalasani says that depression, pain, vaginal dryness and other side effects of continued treatment can affect patients’ final outcomes. “A lot of things are interconnected. We want to treat our patients so that cancer never comes back, ever.” TL