9 Issues Clinicians Are Talking About in Breast Cancer Care

**Note: This blog was written by Elissa Bantug of the Kimmel Cancer Center's Breast Cancer Program.

On March 7-8, 2013, over two hundred physicians, nurses, and other healthcare providers from around the region attended the Seventh Bi-Annual Johns Hopkins Breast Cancer Conference to discuss the latest trends in research and clinical care.  Due to improved therapies, better screening processes, and enhanced multi-modality approaches, breast cancer survivors have seen a reduction in morbidity and mortality.  Conference speakers are world-renowned experts in the fields of surgical oncology, reconstructive surgery, pathology, radiology, medical oncology, radiation oncology, genetics, immunology, palliative care, social media, healthcare quality, and survivorship.  This multidisciplinary approach highlighted some of the many ways breast cancer care is improving in the U.S.  Below is some of what was discussed:

1)     Neoadjuvant Care.  Medical oncologist Dr. Karen Smith presented research indicating that neoadjuvant chemotherapy (chemotherapy before surgery) may improve surgical outcomes in patients who have certain kinds of tumors, such as those that are locally advanced and/or poorly differentiated.  Factors that may determine whether a patient is a good candidate for neoadjuvant treatment include age, grade, stage, t-score, and tumor subtype (e.g. triple negative disease).  Although long-term outcomes seem to be similar whether chemotherapy is given before or after surgery, neoadjuvant treatment may also provide clues about how certain populations respond to specific drugs or drug combinations.

2)     Tomosynthesis. Dr. Susan Harvey, Johns Hopkins Director of Breast Imaging, discussed tomosynthesis (often referred to as 3D mammography), a technology that combines the use of traditional digital mammography with 3D capabilities. Benefits of 3D mammography include a reduction in unnecessary repeat imaging, a 20-40 percent decrease in false positives and a 40 percent increase in the detection of invasive cancers.

3)     Genetic testing. Medical oncologist Dr. Deborah Armstrong provided an overview of genetic testing for breast cancer.  Approximately 10-20 percent of breast cancers are familial (running in the family) and 5-10 percent of all breast cancers are hereditary (associated with a known gene mutation such as BRCA 1 and BRCA 2).  Gene mutations can be passed down from either the mother’s or father’s side of the family, and may put affected women at a 50-85 percent lifetime risk of breast cancer and a 10-45 percent risk of ovarian cancer.  Factors that increase the likelihood of carrying one of these mutations include:

• Multiple cases of breast cancer in a family
• Early age of diagnosis (<50)
• A family history of ovarian cancer
• Breast and ovarian cancer in the same patient
• Bilateral breast cancer
• Ashkenazi Jewish descent
• Male breast cancer

With the complexities of genetic testing, it is strongly advised that patients seek genetic counseling to understand result implications.  Expanded genetic testing is now becoming available however testing may yield results for which clinical significance and recommendations are currently unclear.

4)     Chemoprevention-Dr. Kala Visvanathan, medical oncologist and director of the Clinical Cancer Genetics & Prevention Service at the Sidney Kimmel Comprehensive Cancer Center, discussed breast cancer chemoprevention.  She advocated the use of currently underutilized prevention modalities and advised that providers discuss options with all patients who may be at high risk, including patients with a strong family history, atypical ductal hyperplasia (ADH), and lobular carcinoma in-situ.  It has been reported that taking chemoprevention drugs classified as selective estrogen receptor modulators (SERMs), such as tamoxifen and raloxifene, can strongly reduce the chances of estrogen-positive breast cancer in very high risk individuals.  More evidence is needed to better predict those most at risk for developing breast cancer and which may be good candidates for chemoprevention drugs.  Currently, there are very limited prevention options for women who may be at risk for estrogen-receptor negative disease.

5)     HER2 Guidelines-Medical oncologist Dr. Antonio Wolff discussed expanding systemic therapy options for HER2‐positive breast cancer. It is estimated that 15-20 percent of all breast cancers overexpress HER2.  These tumors tend to behave more aggressively.  Dr. Wolff acknowledged that beginning in the late 1980’s HER-2 positivity use to be perceived as a poor predictive marker.  In 1998, the drug trastuzumab was shown to improve overall survival in the metastatic setting.  By 2005, adjuvant trials began reporting very positive results.  Today with the use of targeted therapies, HER-2 positivity is often viewed with good predictive outcomes.  Targeted therapies can be very effective in treating patients with HER2-positive disease; however, not all patients with this overexpression respond to targeted therapy.  Data suggests that it is more likely for a patient to have a late recurrence with ER positive HER2-postive disease than with ER negative HER positive disease.  Historically, there was vast variability in HER2 testing, making the test unreliable in some circumstances. Now that HER2 testing quality has improved, heterogeneity has become a big concern. Research is underway to determine which patients have resistant disease and might require more therapy; if models can improve HER2 targeting strategies; and which patients have sensitive disease and require less therapy.

6)     Hormonal Therapy-Medical oncologist and co-director of the Johns Hopkins Breast Cancer Program, Dr. Vered Stearns, reviewed the current guidelines for hormonal therapy for patients with estrogen or progesterone- receptive breast cancers (ER+/PR+).  For premenopausal women with hormone positive disease, a daily oral medication called tamoxifen is prescribed for 5-10 years after the completion of initial therapy.  Although extended benefit has been demonstrated for 10 years of tamoxifen by multiple clinical trials, quality of life factors and individual risk musk be factored into this decision.  Data from the Oxford Overview indicates that five years of tamoxifen can reduce the risk of a recurrence by 40 percent.  Some very young premenopausal women with ER+ disease may also be advised to undergo ovarian suppression.  Research is underway to determine if ovarian suppression alone is as effective as chemotherapy in these young patients.

Data suggests that five years of an aromatase inhibitor (AI) may be better for postmenopausal women with ER+/PR+ disease. Sometimes, postmenopausal women with ER+/PR+ disease may be prescribed tamoxifen for a few years and then switched to an aromatase inhibitor to extend the total number of years of endocrine therapy.  Patients on AI’s often complain of significant side effects, and one study presented showed that 30-40 percent of patients discontinued AI use prematurely due to side effects.  Dr. Stearns recommends  NSAIDs, Vitamin D, antidepressants, yoga, exercise, and acupuncture to cope with some of these issues.

7)     Special Needs of Young Breast Cancer Patients.  Beth Thompson, nurse navigator/educator for the Johns Hopkins LiveWell Center for Young Women with Breast Cancer discussed the unique needs of the young breast cancer patient.  It is estimated that 12 percent of all breast cancers occur in women under 45, accounting for over 2,500 deaths annually in the United States.  Ms. Thompson presented research showing that these women have more aggressive breast cancers, have an increased risk of recurrence, and tend to have worse outcomes. They also show higher levels of emotional distress and due to their age, often balance newer careers, school, body image issues, sexual side-effects, fertility, and dating.  Specific age-appropriate resources are needed to tackle some of these complexities.

8)     Social media and oncology care.  Dr. Robert Miller, medical oncologist and the Johns Hopkins Kimmel Cancer Center’s Chief Information Officer, presented data on the use of social media.  He stated, “social media is user-generated content that is shared over the internet via technologies that promotes engagement, sharing, and collaboration.”  Dr. Miller offered three uses of social media for medical providers: to treat, teach, and learn.  Treating includes engaging with patients about their care.  Teaching allows providers to gain up-to-date and credible education.  Learning encourages professionals to share medical information and knowledge.  Although teaching and learning are preferable methods of social media, it is not recommended that providers use this technology to treat patients.  Dr. Miller offers the following advice when clinicians use social media:

• Don’t be anonymous
• Make thoughtful choices about what you are creating for the world to see
• Everyone is watching
• Developing trust in your online community takes time
• Maintain a healthy skepticism

He proposes that medical professionals start by watching first (often called lurking).  This includes reading blogs, watching twitter feeds, listening to podcasts, and subscribing to RSS feeds for journals and news sites.  When joining twitter, Dr. Miller suggests you pick a short but descriptive twitter handle.  “Follow” people who share your similar interests and pay attention to twitter suggestions.  Finally, patience is required.  Allow time for you to gain comfortable and watch your social media contacts grow.

9)     Palliative Care-Dr. Tom Smith, medical oncologist and director of Palliative Care for Johns Hopkins Medicine discussed the importance of palliative care.  He presented research to indicate that palliative care has better patient satisfaction, higher quality of life, improved symptom control, and reduced depression and anxiety, all at a reduced cost when compared to usual care.  This is evidenced by more at-home hospice, fewer hospitalizations, fewer days in the intensive care unit, less chemotherapy/tests/imaging, and fewer treatment-related complications.  Dr. Smith advocated that almost all patients want honest information about prognosis, treatment options, and trajectory of disease progression.  Discussions about palliative care should be the standard of care and should occur before patients become too sick to make informed decisions.