Written records and drawings found from about 3,500 years ago show that breast cancer affected people all the way back to ancient times. Today, patients who are diagnosed with breast cancer early may have treatment and procedure options available to them that weren’t available even 40 years ago. We spoke with specialists at the Tufts MC Breast Health Center about the changes in breast cancer care, advances made, challenges that remain and what’s on the horizon.
There have been numerous significant advances in the diagnosis and treatment of breast cancer over the last 40 years. However, according to the Centers for Disease Control and Prevention, after skin cancers, breast cancer is the most common cancer in women in the United States. The average risk of a woman developing breast cancer in her lifetime is about 12%, or a 1 in 8 chance.
Survival rates improving but populations at risk
The good news from a report released by the American Cancer Society in 2017 is that survival rates are improving. The number of women who died from breast cancer from 1992-2017 was down about 40%. However, that same report found that black women are 42% more likely to die from the disease than white women.
It’s the most common cause of death from cancer among Hispanic women, and the second most common cause of death from cancer among white, black, Asian/Pacific Islander, and American Indian/Alaska Native women according to the Centers for Disease Control and Prevention.
“Improvements in early detection with mammography and in breast cancer treatments are major contributors to the overall decline in mortality rates,” says Roger Graham, MD, Chief of the Division of General Surgery, Chief of Surgical Oncology and Director of the Breast Health Center at Tufts MC. “What’s also obvious is that, unfortunately, not everyone is benefitting due to a variety of complex factors.”
A separate study of Asian-Americans conducted over a 25-year period and released last year showed a significant increase in breast cancer incidences among this population, although Japanese Americans appear to be relatively spared. The authors of the report point to the need for greater access to care, including mammography screenings, and further research to identify risk factors in specific populations.
Screening guidelines for breast health
Experts agree that all women should get routine screenings for breast cancer. While not all breast cancers will be found early and some that are found will not have a good prognosis, mammography screening, or mammograms, is still the most effective method of early breast cancer detection for women. However, guidelines about when to actually begin mammography screening differ.
“Recommendations for breast cancer screening guidelines have changed and continue to evolve as we learn more about the disease, and certainly since we started using the first generation of mammography equipment to help detect breast cancer in the 1970s,”says Shital S. Makim, MD, Chief of Breast Imaging at Tufts MC. “We understand this may be confusing for patients, our advice is it’s critical that women have regular examinations by their medical providers.”
The breast health experts at Tufts MC follow the American College of Radiology guidelines. The American College of Radiology recommends annual mammography screening starting at age 40 for women of average risk of developing breast cancer.
Dr. Makim says, “Women at a higher risk of developing breast cancer should be sure to discuss with their provider when the ‘right time’ is to begin regular screening and how often to be screened.”
Men can get, it, too
Although much less common than in women, we know now that men can get breast cancer, too. About 1 in 1000 men will develop breast cancer during their lifetime, which is about 1 percent the rate in women.
Breast cancer in men is too often discovered at a later stage because they don’t recognize the symptoms, primarily a lump or mass in the breast. And, there aren’t any current screening recommendations for men. Ultrasound and mammography are usually only done if a lump is found.
Anyone who notices anything unusual about their breasts should contact their medical provider right away.
Family risk factors and genetic counseling
In the mid-90s, scientists at the National Institutes of Health identified mutations (alterations or changes) in certain common genes that everyone has, and that they were linked to an increased risk of developing breast cancer. These genes are referred to as the BRCA1 and BRCA2 genes.
After this discovery, genetic testing became available as an option to determine who is a carrier of the BRCA1 and BRCA2 gene mutations and other genetic mutations that place patients at higher risk for breast cancer. Medical providers and genetic counselors are trained in interpreting genetic test results and options and in explaining what they could actually mean for patients and their families. The test requires providing a saliva or blood sample that is then analyzed in a laboratory to determine if a mutation is present in a gene of importance.
According to breastcancer.org, about 5 to 10 percent of breast cancers are thought to be hereditary, caused by abnormal genes passed from parent to child. Among Jewish women and men of Ashkenazi decent, or whose ancestors are from central or Eastern Europe, about 1 in 40 are carriers of the BRCA gene mutation.
“We work closely with our Genetics Risk Assessment Program, and refer women who are diagnosed with breast cancer under age 50 or have a strong family history of breast cancer or ovarian cancer, for a consultation with a genetics counselor,” says Cate Mullen, RN, MSN, AOSCNS, Nurse Coordinator at the Breast Health Center at Tufts MC. “Before the appointment, we explain the reasons why we think it could be beneficial to meet, what to expect during the meeting and issues to think about.”
Improvements in the patient’s experience
Many health care organizations have made great efforts to improve the overall experience for patients. Cate is part of the team at Tufts MC that provides support and education to patients and their families or caregivers throughout their treatment plan. This includes helping to facilitate a support group for women to discuss common concerns and questions, practice skills to help cope with treatment and share their feelings.
Cate says, “Going through cancer is a very challenging experience for people. It’s really important that the health care team work closely with each patient to explain the treatment options and to formulate the best care plan for the individual.”
Another improvement is the convenience of having all the specialists in one location. The Breast Health Center at Tufts MC was one of the very first multidisciplinary breast health centers in the country when they opened their doors 40 years ago.
“When the center was started in 1978, it was unheard of to have all the specialists under one roof, and in some places it still is,” explains John Erban, MD, Clinical Director of the Tufts Medical Center Cancer Center. “Dr. Doug Marchant, founder, and the experts at Tufts Medical Center realized from the beginning the benefits for patients, as well as providers, to have all the experts in one convenient place. This model helps seamlessly to coordinate care and decision making and improves communication between the providers, patients, families and caregivers.”
Advances in surgical care and excellent outcomes
If a patient is diagnosed with breast cancer and requires surgery, she might be a candidate for oncoplastic surgery, a technique that eliminates the breast tumor and reconstructs the breast all in one procedure. Non-oncoplastic breast cancer surgeries with reconstruction typically require at least two procedures.
Tufts MC Breast Surgical Oncologist, Abhishek Chatterjee, MD, MBA, is one of approximately 20 doctors nationwide who is board certified in plastic surgery and fellowship trained in breast surgery oncology. He says the ideal candidate for this surgery should have enough breast tissue (usually found in moderate to large breasts) to allow for taking away more tissue than a typical lumpectomy - also referred to as “breast conserving surgery."
During oncoplastic surgery, a larger portion of the breast is often removed and the breast is immediately reconstructed. Women who have smaller breasts or a cancer that takes up substantial breast volume might consider other treatment options with their medical provider, including a mastectomy (removal of the entire breast), usually followed by another surgery to reconstruct the breast at a later date.
Oncoplastic surgery also has greater success in removing all the cancer in the breast than other procedures.
“Breast cancer patients who undergo traditional simple lumpectomy operations, or breast conserving surgery, might require additional operations to remove all the cancer,” explains Dr. Chatterjee. “Another advantage of oncoplastic surgery is that it allows us to conserve a patient’s breast but minimizes the chances of leaving some of the cancer because we remove more of the tissue.”
During breast cancer surgery, when surgeons remove the cancer they also remove what they believe to be healthy tissue surrounding the cancer to help ensure they have removed all of it. This tissue is called the "surgical margin" or just "margin". It is examined by a pathologist during or after a surgery to determine if there is cancer in that specific area.
After oncoplastic surgery, Dr. Chatterjee says that 9 out of 10 times a patient is cancer free at her margins. He points out that these are some of the lowest positive margin rates in the region.
“For the first time we have a breast cancer surgery that removes the cancer and also improves the aesthetic outcome of the patient,” explains Dr. Chatterjee. “And, instead of two surgeries, the patient undergoes one.”
Tamoxifen and other important treatments
The hormone therapy drug Tamoxifen is the oldest and most important medication in the history of treating breast cancer. Tamoxifen and aromatase inhibitors, another class of drug, are now approved to treat millions of women and men diagnosed with hormone-receptor-positive breast cancer, a specific type of cancer.
“We’ve also seen their success in preventing breast cancer in certain high risk patients,” says Dr. Erban. “However, patients should understand the potential side effects as well as the benefits for all medications and discuss each thoroughly with their breast oncologist.”
Breast cancer patients may also benefit from additional treatments such as chemotherapy and novel targeted therapies or immunotherapies that are in clinical trials or under development at Tufts MC and other institutions.
Scientists are still exploring how immunotherapeutic drugs can stimulate the patient’s own immune system to attack breast cancer cells. A study recently released by the National Cancer Institute showed promising results with a new form of immunotherapy to treat breast cancer that didn’t respond to all other treatments.
Researchers are also helping us understand more about the long term effects of breast cancer treatment. At Tufts MC, researchers in the cardio-oncology program and survivorship program are finding out further information to better understand, treat and prevent complications of therapy for breast cancer.
While there is nothing that absolutely prevents breast cancer from developing there are things that can be done to lower your risk. Have regular examinations by your medical provider and speak about potential lifestyle related breast cancer risk factors you can control such as diet and exercise.
If you would like to make an appointment for a breast cancer screening, would like information on breast cancer prevention or are living with a breast cancer diagnosis and would like to speak with one of the Breast Health Center specialists at Tufts MC, please call 617-636-5757.