By Dwain Hebda
There was a time when cancer was so feared and considered so lethal, it was taboo to talk about, as if the very mention of the word would summon the scourge down upon one’s home and family. Thankfully, times have changed.
After decades of research and billions of dollars ($6 billion to be precise, annually), science appears to be turning the tide against many types of cancer, including its autumnal headliner, breast cancer.
“It is the most exciting time to be involved in cancer research and drug developments and the development of new therapies for breast cancer and all cancers,” says Dr. J. Thaddeus Beck, medical oncologist and medical director of Highlands Oncology Group in Rogers and Fayetteville. “If you look at age adjusted breast cancer mortality in the United States, it’s falling year over year because of these advances in treatment. That decline in mortality is expected to continue and hopefully accelerate.”
In fact, mortality rates due to breast cancer have been on the decline since 1989, according to the National Breast Cancer Coalition, dropping 27 percent between 1990 and 2005. Breastcancer.org also reports cancer incidence rates in the U.S. began to decline in 2000 after 20 years of increases, dropping seven percent between 2002 and 2003 alone.
While breast cancer is hardly a rarity – currently, 1 in 8 women will develop invasive breast cancer over the course of her lifetime – there’s clearly reason for optimism, particularly for a longtime physician such as Beck.
“The technology that’s being studied in our clinic today is amazing,” he says. “There’s been advancements in endocrine therapy, advances in chemotherapy and chemotherapy delivering systems where you can deliver chemo with a monoclonal antibody directly to the tumor without having to expose the rest of the body to side effects.”
At every stage of the cancer continuum – from screening and diagnosis to wider treatment options such as expanded medications and surgical techniques to post-treatment support – breast cancer medicine has become more sophisticated and more coordinated than at any time in history.
Dr. Jim Hagans, a surgeon with The Surgical Clinic in Little Rock, says the team approach to treatment is one of the most effective trends in the way care is delivered to patients.
“When I came here from Dallas, I met with a bunch of people, at my request,” he says. “If I don’t have these certain people, I can’t do what I do successfully and that means a good pathologist, a good plastic surgeon, a good oncologist, a good radiation oncologist, all of us. Nowadays, that also means genetic counselors, nutritionists, all of these people who play a role. You can’t do one without the others.”
Patients are also better informed of options, Hagan says, which helps further stimulate meaningful dialogue between the medical team, the patient and their family surrounding treatment options and prognosis.
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“In my opinion, knowledge is power, so I never mind people looking things up or Googling or trying to educate themselves,” he says. “Most of my patients are sent to me by referral from very educated physicians and a lot of the patients I see have read and have good questions and they’re very educated. I’d say that’s been the case for the past 10 years or so.
“A lot patients in the past would come in and say, ‘Just tell me what to do.’ But nowadays it’s more of a big discussion where we sit down and discuss a lot of parameters.”
Treatment teams’ rosters of professionals have branched out considerably over previous eras. Today, physicians have a much better understanding of the importance of post-treatment resources, those things that address the patient’s new normal and what happens next from a physical, psychological or even spiritual perspective.
“We always say that a cancer diagnosis is a dual one,” says Dr. Diane Wilder, medical oncologist with CARTI in Little Rock. “For the science part, this is what this will looks like, this is what we’re going to do to treat it. But equally important as the physical part is the relational, the spiritual, the emotional. It’s a 50/50 journey.”
“If there are things going on in the family, those relationship issues come to the table,” she adds. “All of a sudden people get a diagnosis and they stop and they think, ‘OK, how have I lived my life and what do I want to do?’ We get many people who say, ‘What about diet? What about exercise?’ The American Society of Clinical Oncology has now said, across the board, diet and exercise matter as far as prevention, during treatment and even after treatment, to reduce the risk of cancer coming back. We know those are all huge things.”
As a result of this, certain medical specialties that a patient used to have to seek out on their own are now being given a seat at the table from the get-go. This provides a patient with the resources and guidance to help live a life of which cancer is a part, but not the only part.
“You’ve got to get out. You’ve got to be able to be with people when you want to. You’ve got to be aware of people who want to help,” Wilder says. “We help navigate people through what’s out there because they’re vulnerable and they get afraid.”
Fueling these strategies is a robust stream of information, much of it made possible by the development of genetic testing. Such testing analyzes an individual’s DNA, looking for certain markers that indicate a person’s relative chances of developing a disease.
Genetic testing gained worldwide attention five years ago when actress Angelina Jolie announced she carried a gene which put her at significantly greater cancer risk. As a result, she elected to undergo a preventative double mastectomy and have her ovaries removed, a decision that stirred debate among medical ethicists and patients’ rights advocates. It also set a precedent for women in similar situations to follow.
“(Jolie) had the BRCA 1 mutation – there’s BRCA 1 and 2, and they present a couple of things that someone has to worry about,” says Dr. Tonya Martin-Dunlap of Arkansas Breast Surgery in Little Rock. “They’re at increased risk for breast cancer, somewhere between 60 and 80 percent risk, and they’re also at increased risk for ovarian cancer.”
As in Jolie’s case, physicians such as Martin-Dunlap can now leverage the new medical technology to help women make a better informed, if no less painful decision. These new tools have resonated throughout the country, including here in Little Rock.
“It’s becoming more common and more understood that we need to do genetic testing on more and more people,” she says. “What I do is, there’s a calculator that Stanford University puts out where I can plug in their age, what their mutation is and I can run through scenarios.
“It shows in a graph their risk of getting breast cancer, getting ovarian cancer, dying of ovarian cancer, dying of breast cancer,” she adds. “Patients can see how those numbers change with each action. In that way, they can make an educated decision of whether to do the surgery or accept whatever that risk number is.”
Another major advancement has been the understanding genetics has given scientists about the specific types of tumors that exist, insights which have helped doctors vary the mode and methodology of treatment accordingly.
“If we have a woman who has a breast cancer, we send that particular slide of her cancer to a company and they have a genetic assay looking at the genes. They’ve worked this out over time and can give a score to that particular cancer,” says Dr. Michael Stanton, general surgeon at Conway Regional Health System.
“It gives you an idea of how aggressive the cancer is, and that information is very helpful for the medical oncologist to determine whether this woman should be treated with chemotherapy or not.”
Stanton said this new understanding allows physicians to be much more strategic in their treatment, with a better grasp of when or if to apply chemo, radiation and surgery, in what order and at what timing intervals.
“In the past when, we didn’t have that. It was just almost a shotgun approach,” he says. “You just said, ‘We don’t know if they need it, but we don’t want to take a chance that they might need it and we’re not giving it.’ So a lot cases where we used chemotherapy in the past might not have to get chemotherapy now. They may be able to get just hormone-blocking treatment and so forth. All of that’s just happened within the last few years.”
Another significant advancement has been in screening technology. The latest mammogram machines are capable of 3D imagery, known as tomography, which gives medical professionals a much clearer image from which to work.
“In my 17 years in this field, we’ve gone from film screening with darkroom processing to computer radiography,” says Wayne Harris, director of imaging for Jefferson Regional Medical Center in Pine Bluff. “We’ve also transitioned in my time to DR, digital radiography. Those advancements have been phenomenal.”
Combined with analytical software, radiologists are now able to analyze images that were once highly problematic, such as women with dense breast tissue or other hidden issues.
“With the 2D image of the breast, you may have normal tissue that’s overlying abnormal tissue so it’s actually hard to see if something may be underneath,” he says. “With the 3D component, the system pivots seven degrees to each side of the patient and as it’s doing that, it’s taking a series of images. When that transfers over to the computer system for the radiologist to read, we’re able to scroll through that series of images that uncovers problems under the normal tissue.”
While Harris says most patients are better educated on the need for regular mammograms (recommended annually starting at age 40 for normal risk; earlier and more often for higher risk factors) recent debate in the medical community has muddied the waters. In recent years, conflicting information has been released over what age to start mammograms or how frequently they should be performed.
“It definitely adds confusion to the patient,” says Dr. Holly Gonzales of St. Bernards Medical Center in Jonesboro. “They’re not sure which source to listen to, especially when a task force of the federal government recommends going every two years.”
Gonzales is unmoved by these reports, insisting that annual mammograms are still unequivocally the way to go.
“There are multiple large studies that demonstrate the benefits of annual screenings,” she says. “The American College of Radiology and the Breast Imaging Society both still back an annual mammogram.
“This is the most important thing that a woman can do for breast health. It’s the primary tool that we use to detect the really early cancers, so we can treat them before they’ve had time to grow.”
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It’s hard to predict what the future will look like in this field, given that many longtime physicians admit they couldn’t envision the current state of medical technology just 10 or 15 years ago. But as hopeful as experts are in this area of medicine, the fact there are still 41,000 breast cancer deaths annually in the U.S. underscores that challenges do remain.
“There’s still a lot of things that we can do to help increase accessibility,” says Dr. Daniela Ochoa, breast surgeon and director of the Diseases of the Breast Fellowship Program at UAMS. “I think a lot of our areas for improvement include patient access. To that end there’s things that we try to do to make things more easily available to patients. We have our Mammovan which is our mobile mammography unit that goes to areas of the state that do not otherwise have digital mammography available to them.”
Ochoa also notes cancer medications and techniques must to continue to evolve, thereby improving patient tolerance and comfort without sacrificing results.
“We also have other treatments and options as far as surgical procedures that are aimed at decreasing the morbidity of the treatments,” she says. “We tell patients the cure should not be worse than the disease, so part of what we strive for is trying to cure patients of breast cancer while not inflicting more harm with our treatments.
“We have options for breast conservation, what patients commonly refer to as a lumpectomy, where we save the breast tissue,” she adds. “Not everything has to be a mastectomy, necessarily.”
There are more than 3 million breast cancer survivors in the U.S. and for many, surgery is a central part of treatment, including both remedial and reconstructive procedures. According to plasticsurgery.org, the number of breast reconstruction procedures has increased nearly 40 percent between 2000 and 2016, which have made cosmetic surgeons a routine part of a patient’s medical team.
“I think women want to be able to take control of their body,” says Dr. Michael Spann of Little Rock Plastic Surgery. “Removing the breast and failing to reconstruct in some ways feels to patients that cancer has won. I think it becomes a ‘I’m going to be whole again and this is how I become that way,’ kind of thing.”
As with other medical specialties, Spann has an array of new techniques at his disposal in performing reconstructive procedures, from nipple-saving surgical methods to performing reconstruction at the same time as other surgeries.
“The reason we do that is, I have the full intention of bringing you out of that surgery as you went in and thus minimize the psychological impact of having breast cancer,” he says. “If we can do that, I find patients doing really well from the standpoint of the psychology of breast cancer because they never see themselves without.
“I always tell them, this is not a cosmetic procedure, but I’ll be damned if I’m not going to try to get the best cosmetic result out of it,” he adds. “If I’m successful, they look in the mirror and they never see that it was there. The stigma of cancer is gone.”
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