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Changing Paradigms in Breast Cancer Treatment

Join us as Dr. Joshua Hawkins discusses the latest advancements in breast cancer treatment. Discover how personalized care and innovative therapies are changing breast cancer care, offering hope and better outcomes for patients.

Changing Paradigms in Breast Cancer Treatment
Featuring:
Joshua Hawkins, MD, FACS

Joshua Hawkins, MD, FACS, practices General Surgery at Skagit Regional Health. He obtained his BS in Biochemistry from the University of Washington.

Transcription:

 Disclaimer: This podcast is for informational purposes only and is not intended to be used as personalized medical advice.


Cheryl Martin (Host): There's some good news in the fight against breast cancer. And here to discuss the latest changes in breast cancer treatment is Dr. Joshua Hawkins, a general surgeon here at Skagit Regional Health.


This is be Well with Skagit Regional Health. I'm Cheryl Martin. Dr. Hawkins, so glad to have you on to talk about advancements in breast cancer treatment. But first, I'd love for you to share what led you to specialize or have special interest in breast cancer surgery.


Dr. Joshua Hawkins: I became interested in breast cancer surgery in the first year or two of my practice as I discovered that doing breast cancer care allowed me to deliver a high patient impact to my patient population, in that the impact of doing cancer surgery is great and often curative and makes a fantastic both health and emotional impact on the patient.


Host: So, how would you say the field has changed since you began your practice?


Dr. Joshua Hawkins: This is an exciting time in breast cancer care because the care delivery has become much more specialized and personalized recently. So, 10 to 15 years ago, breast cancer care was much more algorithmic with fairly standard treatment patterns that were applied to broad patient groups. And over the past five years, there have been numerous advances leading from several publications that have allowed for great personalization of breast cancer care.


Host: Talk about those significant advancements in breast cancer treatment that we should know about today.


Dr. Joshua Hawkins: There are several important updates. And one of those is that not all patients require radiation treatment after lumpectomy surgery. And more and more patients are able to safely omit radiation therapy, and this is important for our patients as well as our referring providers for educating our patients that, if radiation therapy is a major concern about even seeking care for their cancer, that they need to know that not all patients require radiation anymore and can safely omit that based on current literature guidelines.


Host: And what are the factors determining that, those who can omit radiation treatment? Are there certain categories for that?


Dr. Joshua Hawkins: There are. And those categories have been expanding each year. But to start with, one of the larger studies demonstrated that in patients who were older than 65 years old and had a tumor that was three centimeters or smaller and was hormone receptor positive, and those patients received hormonal therapy in the adjuvant setting, meaning after surgery, that they had equivalent survival and equivalent rates of recurrence even when they omitted radiation therapy.


There have been several studies that have expanded upon that since then, including one that is ongoing and will likely be published later this year or next year, which extends that age category down to age 50, and that would be slightly smaller tumors, meaning two centimeters or smaller. And those who had a test after surgery called oncotype, which determines their likelihood of needing chemotherapy, if their oncotype score was less than 18 and they met those other criteria, that they could safely omit radiation therapy.


Host: That's great to know. Any other significant advancements in breast cancer treatment you want to talk about today?


Dr. Joshua Hawkins: I do. The other major change has been with omission of axillary surgery in some patients. And the major practice-changing publication that was published in 2023 was called the SOUND trial. And that demonstrated that for, many patients, again with smaller tumors, they studied patients with tumors up to 2 centimeters in size and found that if they had an ultrasound before surgery that showed no evidence of axillary disease, meaning breast cancer spread to the lymph nodes, that they could safely omit axillary surgery, meaning removal of lymph nodes from the axilla, as long as those patients again received hormonal therapy after surgery, and sometimes received radiation therapy.


The bottom line from that study was that we primarily use the decision from axillary surgery to decide if a patient needs chemotherapy after surgery, and we have other ways of determining that now, specifically in the oncotype study that I mentioned in relation to breast radiation. That same information is, again, guiding our decisions after surgery about chemotherapy. And so, in many patients, they no longer need to have lymph node removal as part of their breast cancer surgery, and this has important implications for their recovery and overall risk of long-term effects from breast cancer surgery, such as lymphedema.


Host: I understand that surgery isn't always a first step anymore. So, what factors determine a treatment course?


Dr. Joshua Hawkins: Increasingly, patients have chemotherapy prior to surgery, and that overall treatment approach is called neoadjuvant therapy. And when I started in breast cancer care, that was available but not very commonly applied. And in current practice, nearly one-third of breast cancer patients undergo chemotherapy as their initial treatment followed by surgery later and usually, quite a few months later, five to six months later. And that approach has led to better outcomes for patients, most specifically in improved survival in some patients, but also in improved ability to do breast-conserving surgery, meaning lumpectomy surgery, avoiding mastectomy when it can be avoided, potentially avoiding more extensive lymph node dissections, when they can be avoided, which leads to risk of lymphedema.


And so, many patients are now treated with that approach. But most specifically, that would be strongly considered for patients who have what we call triple-negative breast cancer, which means breast cancers that are negative for estrogen receptors, progesterone receptors, and a receptor called HER2. So if the breast cancer is negative for all three of those markers, it's called triple-negative breast cancer, and many of those patients are treated with neoadjuvant therapy prior to surgery. We would also commonly use that approach for breast cancers that are HER2 positive.


Host: How has the shift toward less invasive surgeries impacted recovery and outcomes for patients?


Dr. Joshua Hawkins: Specifically, with the omission of axillary surgery, this has led to decreased lymphedema rates, and lymphedema can be a chronic and very debilitating condition for the patient. And lymphedema rates have been shown to be lowered from approximately 5% after axillary sentinel node biopsy down to 1.8% with no axillary surgery. And similarly, there are effects on restricted arm and shoulder movement that can occur after axillary surgery. So, omission of axillary surgery has led to decreased lymphedema and improved range of motion with the arm.


On the topic of neoadjuvant therapy, one of the major benefits for the patient there is to potentially be able to avoid mastectomy. And so, many patients have a larger tumor size at initial diagnosis. And if they have one of those tumor types that responds well to chemotherapy and has successful shrinkage of the tumor with chemotherapy, they may become a candidate for having a successful lumpectomy rather than mastectomy. And mastectomy carries with it, of course, long-term implications for body image and is a much more significant surgery and longer recovery. And so, we are always motivated when we can to conserve the breast and be able to offer lumpectomy. And so, neoadjuvant therapy has been an important tool there to provide patients with options.


Host: Dr. Hawkins, what does a team-based approach to care look like? And why is it important in breast cancer treatment?


Dr. Joshua Hawkins: I believe that multidisciplinary care for breast cancer treatment is critical. Here at Skagit Regional Health, we have a weekly meeting called our Breast Tumor Board, which is a multidisciplinary meeting. It consists of surgeons, medical oncologists, radiation oncologists, pathology, radiology, research coordinator, pharmacist, multiple other people. And we discuss all of our patients both at their initial diagnosis and after surgery. And studies have shown that providing multidisciplinary care in this fashion will actually impact treatment decisions approximately 15% of the time. Meaning that if a patient just saw a surgeon and then proceeded with their breast cancer care and saw the other specialist later, their overall treatment would be different 15% of the time than if we do it how we do at Skagit Regional Health with multidisciplinary visits at the get go, at the initiation of their diagnosis, which will result in different care and optimal care for the patient when you involve a team approach.


Host: So, what are you most hopeful about when you look at the future of breast cancer care?


Dr. Joshua Hawkins: This is an exciting time to be a part of the breast cancer care delivery team. There are so many more options for patients. And we are better able to tailor our treatment plan for the patient's specific disease stage, their individual life wishes. And that results in increased ability to do breast-conserving surgery, options for avoiding axillary surgery, which can cause long-term disability, options for avoiding radiation therapy in appropriate patients, and further tailoring their care for better outcomes and increased survival.


Host: Now, before we wrap up our conversation, what should we know or do to be more proactive when it comes to our breast health?


Dr. Joshua Hawkins: For proactive breast health, the story has not changed dramatically in recent years. And I will echo thoughts that have been shared for a long time from breast cancer providers, and that is I will reinforce the importance of mammography and breast self-exam.


Host: That's it in a nutshell then. Dr. Joshua Hawkins, thank you so much for educating us on some of the key advancements in treating breast cancer. Very informative. Thank you.


Dr. Joshua Hawkins: Thank you.


Host: To learn more, visit skagitregionalhealth.org. If you found this podcast helpful, please share it on your social media and be sure to check out our entire podcast library for other topics of interest to you. Thanks for listening to Be Well with Skagit Regional Health.