Experts: So much more to do in breast cancer research

Published: April 29, 2014 By: Tiffany Wilson
Shahla Masood, M.D.

AMELIA ISLAND—Are some women having their breasts removed unnecessarily while others are dying of cancers that could have been eliminated? Are there better ways to find and treat breast cancer?

Some of the greatest minds in breast cancer research explored the most important questions in their field when they came together for the 19th Annual Multidisciplinary Symposium on Breast Disease on Amelia Island Feb. 13-16, 2014.

The University of Florida Continuing Medical Education symposium featured a unique mix of breast cancer specialties, with surgeons, pathologists, radiologists and other experts sharing the latest news and research in their disciplines. During their presentations, speakers made it clear that future research is key to resolve the problems in their field.

Treating breast cancer subtypes to avoid overtreatment.

“Breast cancer is not a single disease. It is a family of diseases, and there is very clear evidence of a correlation between the subtype and the clinical outcome of the patient,” said course director Shahala Masood, MD, professor and chair of pathology at University of Florida College of Medicine – Jacksonville and medical director of the UF Health Breast Center – Jacksonville.

Masood, who has hosted the symposium every year since its inception, said some breast cancers could be better managed were there more research into the therapies that best suit those specific subtypes. Some subtypes – such as low-grade ductal carcinoma in situ (DCIS), a type of early tumor confined to a milk duct – should stop being labeled cancer altogether to help patients understand it is not as threatening as other forms, she told the audience.

“The word ‘cancer’ leads to fear, anxiety and unbelievable overtreatment,” she said. Since the common belief is that cancer is deadly, the term should only be applied to the forms of cancer that are deadly, she reasoned.

Laura Esserman, MD, MBA, a University of California, San Francisco, professor of surgery and director of the UCSF Carol Franc Buck Breast Care Center, explained it this way: If aggressive forms of breast cancer, like those resulting from BRCA1 gene mutations, are considered murderers, “lazy” lesions like low-grade DCIS should be considered shoplifters. They’re risk factors to monitor rather than a reason to undergo immediate treatment.

“There’s not one shred of evidence that shows you’re going to harm somebody by waiting (to remove it),” she said.

Both Masood and Esserman said if the medical community would recognize that low-grade DCIS does not always evolve into cancer, it could avoid a great deal of stress and unnecessary treatment for patients. But they agreed it will take more research to prove that.

“This is going to take a long time. It’s not the kind of thing we can do very quickly,” Masood said. “But let’s get over the dark ages and look at the tools that we have today.”

Overdiagnosis and decreased screening

Esserman was part of a panel commissioned by the U.S. National Cancer Institute to look into whether patients are being overdiagnosed with cancer.

The panel concluded that conditions that are cancerous or precancerous, but unlikely to cause harm if left untreated, were commonly being treated as if they were more aggressive forms of cancer. They recommended coming up with a new term for such conditions, such as IDLE (indolent lesion of epithelial origin).

Esserman said as many as 30 percent of screen-detected breast cancers may actually be “ultra-low risk” based on their molecular profile, according to a study she was part of in 2011. She said future research could help physicians pinpoint which patients need more aggressive screening due to their risk of having an aggressive form of cancer, and which may need little if any screening.

On the other side of the issue, though, one speaker criticized current research on overdiagnosis that has led to a call for less breast cancer screenings.

“If you believe there’s no benefit from screening more frequently, you’d have to believe that cancer doesn’t grow over time,” said Stephen Feig, MD, a professor of radiology from the University of California Irvine School of Medicine.

He said physicians are finding cancer earlier, which means short-term studies show an increase in cases. But they don’t show mortality rates several years after patients are diagnosed. In one study, he noted, the follow-up was less than two-and-a-half years after the patients were diagnosed.

“That’s incredible. If you want to study whether there’s overdiagnosis, you need to follow patients for at least 10 to 14 years,” he said. “If you take that lead time into account, estimates for overdiagnosis are much, much lower.”

He pointed to the much longer, 30-year SCRY Study from Sweden’s Umeå University that showed no evidence of overdiagnosis, but rather a 26 percent drop in mortality with increased screening.

Finding a better way to screen

The importance of screening may become clearer as the quality of the screenings, themselves, continues to improve.

In the future, traditional, 2-D mammograms will most likely play less of a role as 3-D tomosynthesis images become more common, said Laurie Fajardo, MD, MBA, a University of Iowa professor of radiology. The high-tech images show a clearer picture of suspicious spots in the breast.

She said preliminary studies show that tomo machines help eliminate false positives – spots that turn out to be an “architectural distortion” rather than a cancerous lump. The advanced 3-D cameras are also finding more genuine cancerous lumps that weren’t visible in 2-D images.

“It maximizes the information you get while minimizing the dose (of radiation),” Fajardo said. “Tomo is a great game changer for us.”

When breast cancer spreads

Despite the strides researchers have made in breast cancer screening and treatment, outcomes are still very poor for patients whose cancer spreads to other organs.

Only one in five of those patients survives five years or longer, and only one in 50 is “cured,” or disease-free for more than five years, said Paul Okunieff, MD, UF chair of radiation oncology and director of the UF Health Cancer Center in Gainesville.

But that could change. Okunieff’s team is pursuing funding to demonstrate that using 3-D imaging and ablative radiation therapy (removal of the tissue) could achieve high cure rates – more than 50 percent – without significant treatment side effects.

In a pilot study in 2001, even before they had the added benefit of 3-D imaging, Okunieff’s team found that more than a third of a group of 39 patients with breast cancers that had spread (metastasized) remained disease-free for an average of eight years. And nearly half – 47 percent – are still alive.

“The defining question at this point in the game is not whether a subset of women who are curable after being diagnosed with metastatic breast cancer exists, but rather how many women can be cured, and how do we identify them when they are still in a curable state?” Okunieff said.

Regional node management through radiation therapy

Another speaker, Bruce Haffty, MD, called for more research on the effects of using radiation therapy rather than surgery when breast cancer spreads to the lymph nodes.

A study set to be released this year shows that radiation therapy could be preferable because it appears to be equally successful in eliminating cancer and less likely to cause lymphedema, said Haffty, who is professor and chair of radiation oncology at Robert Wood Johnson Medical School and New Jersey Medical School and associate director of the Rutgers Cancer Institute of New Jersey.

The clinical trial, the European Organization for Research and Treatment of Cancer’s AMAROS (After Mapping of the Axilla: Radiotherapy or Surgery?), showed that the number of patients with lymphedema was 13 percent lower in those who underwent radiotherapy instead of surgery.

Haffty said there is still debate over the survival benefits of using radiation for patients with only three or fewer cancerous lymph nodes.

“We need to determine which of them benefit and which do not,” he said.

More work also needs to be done to find a way to reduce the effect of radiation therapy on the heart and lungs, he said. Proton therapy – which can be limited to a more specific area – may be an avenue to explore. Another researcher said her team did a study that found radiation administered in the prone (facedown) position instead of supine (face up) gave more protection to the heart and lungs.

The study showed a 99 percent survival rate after five years, said Silvia Formenti, MD, professor and chair of the department of radiation oncology at New York University Clinical Cancer Center.  

An annual event

In spite of a snowstorm that cancelled flights across the United States, hundreds of participants turned out for the Multidisciplinary Symposium on Breast Disease.

“This is a unique collaboration we have,” said speaker James Grotting, MD, of Grotting Plastic Surgery in Birmingham, Alabama. “It’s one of the few times we’re able to come together and hear what’s going on in each of our fields.”

Masood said the symposium was one of the world’s first breast cancer symposiums to bring together so many disciplines. Attracting national and international experts, the symposium has been held both in the U.S. and abroad in locations including Rome, Paris, Cairo and Saudi Arabia.
Shahla Masood, M.D.

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