Transcription:
The Latest Advancements in Treatment Options for Breast Cancer

Melanie Cole (Host):  In recent years, there have been so many advances in the treatment of breast cancer that looking at treatment can feel very overwhelming. My guest today is Dr. Dortha Chu. She’s a breast surgeon and a member of the medical staff at Henry Mayo Newhall Hospital. Dr. Chu, are there different types of breast cancer? If a woman gets that diagnosis, is she told what specific type she has?

Dortha Chu, MD (Guest):  Yes, and thank you so much for having me on. Yes, there are absolutely different types of breast cancers. Some are more common than others. And some are easier to treat than others. We usually can tell which type based on the biopsy sample that is obtained at the initial diagnosis. And from there, we can talk about various options for treatment and what would be best for each type of cancer.

Melanie:  So, do you stage breast cancer?

Dr. Chu:  Yes, we do. Although these days, honestly, the staging isn’t nearly as important as it was in previous years. In previous times, before we had some of our current technology, staging was very important because it determined what kind of treatment you received. These days, as long as you do not have widespread disease, pretty much everyone gets the same options in terms of treatment, we just tailor it to the individual patient and her needs.

Melanie:  Thank you for clarifying that. So, what are some of the options? Speak about some of the different types of treatment, because women hear so many things these days Dr. Chu. They hear about radiation and chemo, which they have heard about for years but now we hear about hormone therapy and targeted therapy and immunotherapy and complement, I mean it can be dizzying. So, speak about some of the most common starting with maybe surgery or chemotherapy and then move on to some of the newer treatments.

Dr. Chu:  Sure. I’d be happy to. It is very overwhelming because of the fact that we now have so many effective lines of treatment and by determining what type of cancer you have, we can then pick which particular therapies would apply to you. But starting with surgery, it’s a very good place to start. Because that is basically what I do most of the time. There’s basically two types of surgery when you break it down. One is a lumpectomy where we only remove a small piece of the breast that includes the cancer, but we get to conserve the breast and the other option is a mastectomy where we remove all of the breast tissue. You do not need to have a mastectomy every time in order to achieve optimum cure. You can achieve that with a lumpectomy, with the right circumstances.

The lumpectomy itself these days we can also perform using techniques that allow us to conserve and preserve the breast contour so that there is minimal disruption to the size and shape of the breast, up to a certain extent. You can lose up to about a quarter of the breast and we can still make it look almost the same as if you never had surgery. So, it certainly can be a very good option to preserve cosmetics.

A mastectomy would be an option for those who may have a larger cancer or may have a genetic risk for cancer or their overall risk is higher and saving the breast may present additional risk. In that case, removing of the breast tissue completely, does significantly decrease your risk of either recurring breast cancer or a new cancer not quite to zero percent. There is no such thing as zero percent, but we do get awfully close to that. There are different techniques now for removing the breast. We can do it a preserve the skin, for better reconstruction and in some cases, we can preserve the nipple as well for reconstruction. It does give the breast a little bit more of a natural shape with reconstruction, but all of these options should be discussed with your breast surgeon and with your plastic surgeon in order to achieve the best combination that is suited for your size of breasts and shape of breasts.

Melanie:  You mentioned reconstruction and sometimes that can happen during the mastectomy and there can multiple doctors. So, speak about that for the women that are concerned that it takes a long time to go through reconstruction after mastectomy.

Dr. Chu:  Sure. There are also multiple options for doing reconstruction. Again, breaking it down into simple terms, one is using your own body tissue where we take skin and fat from somewhere in the body, move it into the chest area and basically sculpt a breast so to speak out of your own body tissue. The other option is using implants of various types. The body tissue option will restore the breast immediately and we can often perform that with the mastectomy at the same time. However, it does involve a very extensive surgery and much longer recovery time because now we are talking about multiple incisions and a very lengthy procedure as far as anesthetics is concerned. So, that’s a challenge for a lot of patients to go through and again, the recovery time can be substantial.

The other option is using implants and yes, under certain circumstances, we may even be able to put the implant in immediately after mastectomy during the same procedure and again achieve good cosmesis that way. But most of the time, we do have to use tissue expanders first and this allows us to be able to expand the skin and sometimes some muscle again depending on the patient’s body type, in order to create a space large enough to place the size of implant that the patient wants. There is more control typically over size and shape with an implant option, but it does take longer time. You have to go through a period of time where the skin and or muscle gets expanded. That could happen over weeks or months before the final implant is actually placed. On the other hand, each procedure in this case is much smaller even though it does take longer. The surgeries are shorter. There is somewhat less recovery time with the surgery, but the timing involved in terms of actually achieving what you want physically does take longer.

So, those are options that I always explore with my patient and the plastic surgeon who performs that portion of the procedure. And we coordinate it together. There are times when we cannot do the reconstruction at the exact same time as the mastectomy. For example, if a patient needs radiation or we are not sure the patient might need additional therapy; sometimes it’s better not to do the reconstruction right away, see how things heal up and then proceed later on. So, there are multiple ways that we can approach it and all of those ways could potentially give you a very good result. But it needs to be a coordinated effort between your breast surgeon and the plastic surgeon, typically.

Melanie:  So, now on to some of the other modalities that you might look at, chemotherapy, radiation and the others.

Dr. Chu:  Exactly. These days, surgery alone is typically not enough for us to achieve complete cure. Because we know that there may be microscopic disease that’s left behind even with a mastectomy because cancers can hide, so to speak. And we can only physically remove what we can see or touch or visualize under imaging. So, there is always the concern over residual microscopic disease that may be trying to hide somewhere in the body and that’s where these other therapies come into play. Radiation is typically used as a combination therapy with a lumpectomy and that’s where we achieve the same level of cure as compared to a mastectomy. In other words, a lumpectomy with radiation afterwards will give you the same rate of cure as a mastectomy under most cases. And even sometimes with the mastectomy we also have to do radiation although most of the time with the mastectomy we do not have to do radiation.

So, again, radiation is one of those treatments that is dependent upon some other options that you may choose.  And it also depends on extent of disease. Radiation typically is done as a 10-15-minute procedure, five days a week between four to six weeks. That’s the standard therapy. There are ways to modify that again depending on your specific cancer and the size and degree of disease; where we can either do lesser time or we can concentrate and focus the radiation in such a way that you do not have to spend that much time again, typically over four to six weeks to receive the full benefit of radiation. If you have a very, very small tumor, and you are at an institution where they have some of the more advanced technologies available, you may have some other options for radiation as well.

There is an option called intraoperative radiotherapy or IORT that is in the news recently and it’s a wonderful technique where we actually only have to give a single dose of radiation at the time of surgery. However, techniques like this, are very limited in terms of its scope. The tumor has to be very, very small or else the amount of radiation that you receive will not be adequate to prevent the removal of all of the residual microscopic disease. Plus, it has to be in an institution that has this technology available and currently this technology is still very expensive and it’s not widely available and so you need to be at an institution where this is offered. Again, most patients are probably not going to be a candidate for this technique because of the size of their actual cancer. But these are some of the things that are being developed in the hopes that as we continue to refine the technology, we hopefully will be able to offer it to more and more women and shorten their need for extensive therapy.

Chemotherapy is the other sort of branch of therapy that I like to think of as really a broader term as medical therapy. We used to think chemotherapy was the only option and this is medicine that is given through the vein and the idea is that this is a technique that allows us to deliver life saving medication throughout the entire body so that if there is microscopic or even visible disease elsewhere in the body, the medication will get to it in a way that surgery cannot or radiation cannot. For example, I cannot remove the liver if the cancer is in the liver. So, there are times when surgery and radiation are not going to be an option for the patient but using medication, we can get treatment right to where the cancer is and be able to eradicate it that way. Traditional chemotherapy can be very difficult. This is when you think of patients losing their hair, not feeling so well etc. These days though, most of the medications have been vastly improved and symptoms are much less common, although I have to admit, losing your hair is still pretty standard, but a lot of the other side effects that you think about with chemotherapy are actually less common these days because of some of the advances we have made.

But in addition to chemotherapy which is again more of a medication based we actually now have alternatives, an additional therapy that is very exciting and very effective. The second most common treatment that we use is with hormone therapy. Most breast cancers, not all, but most breast cancers have what we call excess estrogen or progesterone hormone receptors on their surface. I call these little antennae that the cancer can use in order to help it grow and it recognizes the female hormones estrogen and progesterone but what we have found is that if can block that signal, block that antennae so to speak, it often makes the cancer very weak and it cannot grow and, in many cases, even die. And this we can achieve with pills. And these are little pills that you take once a day and it basically blocks that hormone antennae by mimicking the appearance of a hormone, but doesn’t have the same effect, in fact it has like I said the opposite effect of a regular hormone. It causes the cancer to slow down and even die. Most of the time, side effects are very minimal if anything they mimic menopause symptoms like hot flashes and sometimes muscle fatigue, most of the time, even those symptoms go away after a month or so of therapy.

So, patients can tolerate it very well and it’s just a little pill that you take every day. We do recommend it typically for five years, if you can tolerate it and we have found that this addition for hormones that have these receptors can be very effective in both preventing the cancer from recurring as well as prevent any future cancers from developing. So, these the two most common versions of therapy that we use now in terms of medications that we deliver. And this is regardless of what kind of surgery or radiation that you may have because this gets throughout as I mentioned, the entire body regardless of again, what we can do locally with surgery and radiation.

There are some very exciting things on the frontier in the field of medical therapy. One of them is immunotherapy that has gained a lot of current attention and I’m very excited by it as a lot of my colleagues are in this field. Unfortunately, it’s not quite ready yet for breast cancer. Immunotherapy has been shown to be very effective in other cancers such as lung and they are now being looked at as it applies to breast, so we are very hopeful that it will prove to be just as effective in breast cancer. But currently, it’s still considered experimental and we don’t know yet the exact benefit of these immunotherapies that are currently available. So, but these are things that we are constantly looking at as new ways to manipulate the body’s own defenses to be able to destroy breast cancer cells and create the less side effects as possible, so the patient can tolerate therapy better.

So, it really is very dependent on the conversation between you and your breast surgeon, breast oncologist, medical oncologist, radiation oncologist, plastic surgeon. There’s a whole team of doctors that you will need to help you as you decipher all of these different treatment plans and determine what is right for you. It is never something that we want you to make on your own. We want to help you and we want to help the individual patient figure out what pieces would work best for their cancer.

Melanie:  Wow. Dr. Chu, what an amazing explanation of all of the different treatments and as we said right at the beginning, it can be absolutely so confusing, and you have cleared it up so beautifully for us. Thank you so much for giving us a lesson in all of those treatments that are out there, and we can hear your passion. Thank you so much for being with us today and clearing some of this up and explaining it so very well. You’re listening to It’s Your Health Radio with Henry Mayo Newhall Hospital. For more information, please visit www.henrymayo.com that’s www.henrymayo.com . This is Melanie Cole. Thanks so much for tuning in.