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When Eileen Epstein was diagnosed with a common type of non-invasive breast cancer in 2002, her treatment plan was straightforward. She underwent a lumpectomy, in which the cancerous tissue and a small margin of healthy tissue was surgically removed, followed by six weeks of radiation therapy.
The treatment was a success: aside from some fatigue caused by the radiation, she had no adverse side effects and was cancer-free until last year, when a checkup revealed a small, invasive tumor in the other breast. As before, she received a lumpectomy and a cycle of radiation therapy. She also began taking an aromatase inhibitor, a targeted drug designed to arrest any rogue cancer cells that may have remained in her system.
From the time of her first diagnosis through both courses of treatment at Dana-Farber, Epstein, who lives with her husband, Mark, in Portsmouth, R.I., made a point of not becoming anxious about her future. "When I know I'm in good hands, I don't worry," says Epstein, the mother of three grown children.
Epstein's treatment is the product of countless advances in the medicines, surgical procedures, and radiation techniques used to treat breast cancer – all of them spurred by a better understanding of the basic biology of the disease, and an emphasis on precision. A generation earlier, the course of her treatment, and of her life afterward, would likely have been quite different.
J. Dirk Iglehart, MD, director of the Susan F. Smith Center for Women's Cancers at Dana-Farber, vividly recalls the standard approach when he entered the field in the 1970s.
"If a patient came into the clinic with a breast lump, she'd be admitted to the hospital where she'd sign a consent form permitting the surgeon to do a radical mastectomy if the lump was found to be cancerous," he reflects.
"She would wake up from anesthesia to find her breast and part of her chest wall had been removed. The complications – musculoskeletal damage, painful buildups of lymph fluid in nearby tissues, restrictions on movement – could be severe."
The reason for such disfiguring procedures was not just an excess of caution against cancer spread, but a fundamentally mistaken understanding of the nature of breast cancer, Dr. Iglehart continues.
"Back then, we were taught that breast cancer begins in the breast and spreads through the lymph nodes to the rest of the body. Now, we know this is not true. Tumors that arise in the breast may spread to the lymph nodes, but they may also spread through the bloodstream, both routes, or not at all. The key is to determine which type of breast cancer a woman has – by looking at the genetic make-up of the tumor cells and other factors – and treat it accordingly."
The trend away from near-universal mastectomies began with demands from patients for less-deforming procedures, and accelerated with scientific discoveries that changed scientists' understanding of how breast cancer cells behave.
Physicians began studying breast-conserving techniques in the 1980s to see if they were advisable for some patients. When clinical trials showed that lumpectomy followed by precision radiation therapy was just as effective against breast tumors as mastectomy, a critical corner was turned.
Today, Dr. Iglehart notes, most operations for breast tumors are done on an outpatient basis, with patients going home within hours of the procedure. He estimates that he does a tenth as many mastectomies today as when he began his career.
The shift toward conservation is also evident in surgical approaches to the lymph nodes leading from the breast. Instead of removing nearly all of the nodes under the arm and near the collarbone – as was once routine – surgeons now check a few lymph nodes closest to the tumor for cancer cells.
If these "sentinel" nodes are clear, the cancer is unlikely to have entered the lymph system, and no further nodes are removed.
Even if cancer cells are found in the sentinel nodes, additional nodes are no longer automatically removed. Depending on the patient and the type of breast cancer involved, doctors may recommend another treatment – hormonal therapy, chemotherapy, or radiation therapy – that is equally or more effective, but far more sparing of a patient's tissue.
"The fact that we no longer routinely remove lymph nodes from the underarm area is one of the most notable improvements in breast cancer surgery in the past 15 to 20 years," says Eric Winer, MD, the director of the Breast Oncology Center at Dana-Farber. "Recent studies have shown the advantages, in many cases, of treatments that involve less surgery in these patients."
As Dr. Winer notes, the removal of these nodes can produce significant physical problems. The most common is lymphedema, an accumulation of lymph fluid that leads to swelling in the arm, hand, chest, or back. The result can be throbbing pain and restricted motion in the arm and shoulder.
Other advances have made it possible for women who might otherwise need a mastectomy to receive a lumpectomy, instead.
"There are now pre-treatment options that can shrink tumors in some women prior to surgery, so a more limited procedure can be performed," Dr. Winer explains. Improved imaging technologies help physicians determine which patients are the best candidates for conservative surgeries.
The most surprising aspect of these changes is that tissue-sparing procedures can increase not only the quality but also the length of patients' lives.
Much of the improvement in breast cancer survival rates in the past 35 years is due to earlier detection of the disease, better systemic agents and combinations, and targeted drugs that single out cancer cells for destruction.
But advances in the "local" management of breast cancer – treatments directed within the breast itself – have played a critical role as well. In this respect, it's fair to say that a minimalist approach with respect to surgery and radiation have had a maximal effect.
Indeed, radiation therapy has followed the same trajectory as surgery over the past decade, evolving a more limited, tissue-preserving approach and healthier, longer-living patients.
Jay Harris, MD, chair of Radiation Oncology at Dana-Farber, points to several areas where precision techniques are yielding improved results. New types of imaging provide crisper, more detailed pictures of breast tumors, enabling surgeons and radiation therapists to target breast tumors more accurately and cause as little damage to surrounding tissue as possible. Imaging also helps guide daily treatment to ensure greater accuracy.
In addition, system-wide adjuvant therapy – chemotherapy and hormonal therapy that reduce the chances that a cancer will recur at distant sites – interacts in beneficial ways with radiation therapy.
One study found that patients who underwent surgery for a particular type of breast cancer and then received radiation and adjuvant chemotherapy had a cancer-recurrence rate of only 3 percent, compared to 10 percent in patients who didn't receive chemotherapy – a two-thirds reduction.
Recent news is even better. "For many years, it had been thought that lumpectomy followed by radiation therapy reduced the chances of local recurrence but would have no effect on how long patients survive," Dr. Harris states.
"But a meta-analysis – a study that analyzed the combined results of many other studies – showed that radiation therapy after surgery results in a major improvement in long-term survival rates. For every four local recurrences avoided, there is one additional survivor five years after treatment."
Along with improved efficiency has come a renewed emphasis on safety. "Some of these advances have come from improvements in radiation therapy equipment and software, which enable us to provide an optimal dose to the treatment area while avoiding nearby, healthy tissue," Dr. Harris observes.
A new technique for sparing normal tissue is as low-tech as can be imagined. Traditional approaches to irradiating breast tumors have sometimes resulted in cardiac problems because of radiation penetrating to the heart. Doctors have known for years that holding one's breath causes the heart to become narrower.
Dr. Harris wrote the first paper suggesting that having patients hold a deep breath while receiving radiation therapy could greatly reduce the amount of radiation reaching the heart.
Today, the "deep inspiration breath-hold" technique is standard practice around the world. At Dana-Farber, technicians use a sophisticated imaging system to ensure patients' breath holds are consistent during each treatment.
Turning Point 2012