Treating breast cancer: Progress, challenges
October is National Breast Cancer Awareness Month. Christopher Friese, the Elizabeth Tone Hosmer Professor at the U-M School of Nursing and a researcher at U-M’s Rogel Cancer Center, discusses precision medicine in breast cancer treatment, self-exams and common concerns about breast cancer treatment.
What are the most common questions/concerns you hear from women who’ve been diagnosed with breast cancer?
Friese: One common question is, “What kind of surgery should I have?” Women with breast cancer often have a choice of removing the cancerous tissue (lumpectomy) or removing the breast (mastectomy). Some women opt to have both breasts removed (bilateral mastectomy). Women who have their breast removed also have options for reconstruction.
For many women, the surgery chosen has no bearing on their ultimate breast cancer outcome, but may impact appearance, comfort,and quality of life. It’s important for women to ask their doctors about the expected complications, any pain concerns or impact on function, and for certain women, if one surgical procedure is preferred over another to control the cancer.
Another common concern is whether the woman will have to quit her job or reduce her activities. The answer is not necessarily. Depending on the treatment plan, there may be times when reducing work hours will help with energy levels and also help women complete their cancer treatment. I encourage women to talk with their health care team about their concerns for maintaining work or favorite activities. We know light-to-moderate exercise (like brisk walking) is very helpful to reduce fatigue. Some patients benefit from physical and/or occupational therapists to keep them strong during treatment.
In the past, a breast cancer diagnosis automatically led to chemotherapy and a mastectomy. The trend now is toward more conservative treatment and tailoring treatment to the individual using precision medicine. Can you talk about that shift and a few of the recent advances in breast cancer treatment?
Friese: We have marveled at the number of cancer treatments that are newly available for many cancers. What may be underlooked is the recent work to help identify which patients don’t need aggressive treatments. The TailoRx study, published in June 2018, showed that by testing breast cancer tissue for a number of genes associated with riskier cancer, chemotherapy can be skipped safely for a large number of women at average risk, who can instead take endocrine therapy, which is a pill and has fewer side effects. This is an early win for the precision health movement.
My surgeon colleagues are also exploring whether fewer lymph nodes need to be removed during routine breast cancer surgery. By removing fewer lymph nodes, women may experience less arm swelling and pain. Women also face many options to remove cancerous breast tissue, from a lumpectomy to a mastectomy. Assessing risk factors, discussing patient preferences and better imaging studies can help women personalize their decision for breast surgery.
Of course, it is important to for women to have a good understanding of their breast cancer and their personal risk factors for the cancer to return, to make informed choices about their surgery and chemotherapy treatment.
What is precision medicine and how is it used in the context of treating breast cancer?
Friese: Very simply, precision medicine brings together all the information we have—about the patient, about their tumor—and applies that information to form treatment recommendations based on that information. We may look at family history, specific genes or proteins on the tumor, other blood tests and advanced imaging (like CT Scans, PET Scans, MRIs) to help us form a treatment plan.
An early example of precision medicine in breast cancer was testing the tumor for estrogen or progesterone receptors. When a tumor has these receptors, we can give endocrine therapy (a pill) that helps reduce the chance of breast cancer returning.
By knowing whether the tumor expresses the HER2/neu gene, we can decide whether or not to use a drug that targets that particular gene. HER2/neu-positive tumors used to be among the most fatal breast cancers and now there are several drugs that target that gene.
More recently, we can use a variety of recurrence score assays that look for the presence of multiple genes known to increase the chances for breast cancer to return. Women with high recurrence scores are more likely to benefit from chemotherapy. We can also suggest to women with low or intermediate risk scores that they can safely skip chemotherapy, absent of other risk factors.
In a recent survey that our team at the Rogel Cancer Center conducted of over 3,000 women with breast cancer, many of whom were eligible for this test, one in four women tested didn’t know whether they had the test or not, and 40 percent didn’t know their results and weren’t able to tell us if they were low, medium or high risk. This information is important, so they understand their breast cancer course and whether they would benefit or not from certain treatments.
We did find that doctors used the test results almost always as we would expect. What we think would be helpful is if patients had a better understanding of these tests in the long run so they can be partners in the decision making. There’s a group of women where it might be up to them, and if they don’t have full information about this test, or their images or their lymph nodes, they aren’t as able to participate in that conversation and let doctors know what matters most to them.
What is the prevailing thinking on self-breast exams? Are they helpful? There’s confusion around this topic among women.
Friese: I can understand why women are confused. The cancer community has been conflicted on this topic. However, since 2009, the United States Preventive Services Task Force has recommended against clinicians teaching patients to perform self-breast examination for routine screening, based on the available research evidence.
The Task Force recommends—and I do as well—that women be aware of their bodies and note any changes they see or feel to their routine health care provider. The current guidelines suggest a screening mammogram for breast cancer every other year, starting at age 50. This recommendation applies to women without any risk factors for breast cancer. If risk factors are present (strong family history of cancer, known carriers of the BRCA gene mutation, history of chest radiation), women should discuss their breast cancer screening options with their routine health care provider.
Can you talk a little about your latest research?
Friese: My team is excited to help reduce the burden of cancer that patients and loved ones experience. Our research is very much aligned to the Moonshot Goals, outlined by the National Cancer Institute. First, we are nearing completion of a study that examines how doctors, nurses and other clinicians treating cancer patients communicate with each other and use the electronic health record to manage patient side effects after chemotherapy treatment.
We have learned that in some cases, more technology doesn’t always link to safer care. Second, we have launched a chemotherapy safety boot camp for oncology nurses and pharmacists to apply the findings from our research program to patients treated in community settings. It’s really exciting to have the opportunity to share our research results with front-line clinicians to improve care for patients at the Rogel Cancer Center and beyond.
Friese is also a professor at the U-M School of Public Health, director of the Center for Improving Patient and Population Health and a member of U-M’s Institute for Healthcare Policy & Innovation.