Understanding Breast Cancer Treatment Options & Care Goals

Laura Beth Ezzell:

What are the goals of treatment and how they vary by type and stage?

Dr. Daniel Silbiger:

Sure. It’s a long answer to the question, but let’s simplify it first to localized, so if this is a curative intention breast cancer, or if it is one that has, unfortunately, spread to other parts of the body. Not merely to the localized axel area, that’s still a curative setting. But what if it has spread to other parts? So, let’s start with the localized setting. Our hope and prayer is that we do go for cure. Those staging, that’s called stage I, II, or III breast cancers. And our hope with combining surgery, radiation, and systemic treatments like chemotherapies, estrogen blocking therapies, we’re hoping to come up with a definitive plan for patients.

If it is an estrogen hormone-positive breast cancer, these involve, beyond the surgery/radiation, these involve upwards of 10 years for some patients of estrogen-blocking therapies. I tell patients we’re not trying to give more treatments just to give more side effects, no, we’re giving more treatments to give longevity and survival because that’s what some of the studies have suggested to us that longer duration treatment may be important. If, for instance, though we’re looking at the hormone-negative, HER2-negative, triple-negative type of breast cancer, those are cancers that do traditionally involve chemotherapy, perhaps other immunotherapies to awaken the immune system. But the flip side is that those are shorter courses of therapy, six months to one year, and after we’re done with those therapies some of those folks are no longer in need of more systemic therapies. So, it contrasts.

And then, of course, the last point of stage IV, which is, unfortunately, incurable breast cancers that have spread to other parts of the body, we are then in those discussions focusing on long-term systemic treatments to shrink the cancer and minimize chances of it spreading to other parts of the body. I’m hopeful that that helps to lay the foundation for our discussion.

Laura Beth Ezzell:

No, I thought that was really well done. So, thank you for that, doctor. Can you provide an overview of the currently available treatment options? Let’s start with surgery here. When is this necessary?

Dr. Daniel Silbiger:

Yeah. So, surgery is usually a cornerstone to any locally or locally advanced disease, so stage I, II, or III. The order of events – I don’t want to confuse or overwhelm, it can be a little bit tricky. But in general, for most, certainly traditional hormone-positive cancers, we do start with surgery. And the surgery though has evolved for the better. It used to be, not that long ago, a few decades back that we were doing radical, aggressive mastectomies and full dissections on all our patients; that is now a rarity.

We now really focus on really trying to minimize toxicity or side effects from surgery. And so, a lot of folks are able to do breast conservation lumpectomies and that is accompanied with what’s called a sentinel lymph node biopsy, which spares aggressive dissection of the armpit area to avoid lymphedema and swelling. I want to share with the program too, is that we now are even in some cases omitting lymph node sampling in some of the smaller hormone-positive tumors even in patients that are in their 50s to 70s that are postmenopausal. And this is what is important, to be at an institute where we’re keeping up with the guidelines and the studies. So, we really are deescalating surgeries when appropriate as well for patients.

And it’s exciting to share, here at the clinic we’re even doing some endoscopic mastectomies and so forth for folks to minimize time and the surgical incisions as well. So, lots of stuff is evolving in this area of surgery. I’ll start with those points for us.

Laura Beth Ezzell:

No, no. I appreciate you starting there. So, what are the other treatment classes for breast cancer care?

Dr. Daniel Silbiger:

Sure. So, beyond surgery then of course we have radiation therapy, lots of progress here too. And I really think this is important because many institutions are not keeping up with some of the newer radiation schedules and protocols. There are options for partial breast radiation in some cases, especially for smaller tumors, hormone-positive. You can see schedules that are five sessions of treatment alone now, daily for a week, once a week for five weeks. It used to be that everyone was getting five, six weeks of radiation treatment.

So, I think it’s really important to have these good discussions with radiation oncology about what’s the right thing for me? It’s not a one size fits all of doing whole breast and complex five, six weeks of radiation anymore. The other category, of course, are some of the medicines I had been talking about, so hormone endocrine therapies, estrogen-lowering therapies for patients. This can range from, in postmenopausal women receiving medicines called aromatase inhibitors like anastrozole (Arimidex), letrozole (Femara), or tamoxifen’s (Nolvadex) another class of medicines. For some of our patients that are still menstruating, we have perhaps some opportunity to do ovary suppression when it’s appropriate with more aggressive hormone-positive tumors or lymph node-involved tumors. And so, that’s an important class of medications that provides a cornerstone of our systemic therapy. And then, of course, I’ve mentioned the one that I know brings a lot of anxiety to our patients, chemotherapy.

And chemotherapy has evolved tremendously. I’m fortunate that my mom is a retired oncology nurse, and she was giving chemotherapy for many years. And I’m proud to share that she has seen tremendous improvements in how we give chemotherapy now. Supportive medicines, nausea support medicines, we have tremendous changes in our regimen now that make them much more tolerable. And I tell patients it’s not one size fits all, we look into other health issues, age, and we balance out the type of cancer they have, and we really tailor that to then the aggression of chemotherapy strategy we have for them.