PROFESSOR ANN O’DOHERTY, DR JENNIFER WESTRUP, DR LISA PRIOR, DR REEM SALMAN and DR ALINA MIHAI tell us how evolving techniques and new therapies are helping keep pace with the disease …
Breast cancer will affect more than 3,000 people in Ireland this year. Most will be women, but a small percentage of breast cancer diagnoses will occur in men. The good news is that screening and improved treatments have resulted in better survival. At diagnosis, 80 per cent of breast cancers will be treated with the intent to cure. The treatment of breast cancer is becoming ever more individualised – with regard to surgery and post-operative, hormonal and other drug treatments. Patients are encouraged to become well-informed about their disease and to participate in treatment decisions: what a woman chooses may depend on such factors as her age, personal circumstances, professional concerns and risk tolerance. Screening is vital for early detection; prevention may be possible, with simple lifestyle changes you can implement now. Five Irish-based experts bring us up to date …
Professor Ann O’Doherty, National Clinical Director of BreastCheck, Consultant Radiologist at St Vincent’s Hospital, explains how the National Screening Service works:
THE NATIONAL SCREENING SERVICE
The National Screening Service is for healthy women between 50 and 69. Women are invited every two years for a screening mammogram. There are 22 mobile vans and four static units providing this service across the country. This service is for healthy women who do not have symptoms. The aim of the programme is to reduce the number of women dying from breast cancer by 20 per cent. Unfortunately, mammography does not detect all cancer so it is important that women with symptoms consult their GP even if they have had a normal mammogram. Individual women with family history may benefit from earlier and more regular screening.
There are also eight Symptomatic Services where women with symptoms are referred by their GP. The Symptomatic Service is a multidisciplinary service where women are offered a range of investigations and clinical examination. Referrals from GPs are triaged by the hospital into routine or urgent appointments. Urgent appointments are usually offered within two weeks.
Mammography is the best test for detection of breast cancer in the screening setting. It is usually offered in the Symptomatic Service to women over 35. Ultrasound is a useful test for a specific symptom. It has a lower cancer detection rate than mammography and so it is less useful in screening. Women with high-risk symptoms who are over 35 (lump, skin dimpling or retraction, bloody nipple discharge, inflammation of the skin) are usually offered both mammography and ultrasound; the addition of ultrasound to examine a specific area of the breast adds to the sensitivity of the imaging evaluation. Women under 35 who require imaging are usually offered ultrasound alone. Women who attend the Symptomatic Service have clinical examinations and imaging; if an abnormality is found the woman will have a biopsy, usually image-guided. A multidisciplinary team of radiologists, pathologists and surgeons meet to discuss the result of each patient who has a biopsy.
Magnetic Resonance Imaging (MRI) of the breasts is a very high-tech, expensive investigation but picks up a lot of other abnormalities that may not be significant. It is usually reserved for women with a very strong family history or in certain types of cancer, to determine the best type of surgery.
A positive recent advance in breast imaging is Tomomammography, where multiple X-rays are taken in very thin sections of each breast. This technique is used in the screening service in women who are recalled from their first mammogram for further evaluation. It is also used in the investigation of women with high-risk symptoms.
The most exciting development in breast cancer is the use of targeted treatments in medical oncology which are contributing to the improvement in survival. Each individual woman’s tumour is examined for specific receptors that drive an individual patient’s breast cancer. If these receptors are present they can be targeted by specific drugs – this “bench-to-bedside” management of most cancers is leading to better survival. There have also been advances in surgical and radiation oncology which result in less extensive treatments, with excellent results.
Breast screening ceased in March 2020 due to Covid-19 because of the risk to healthy women, combined with the need to preserve healthcare resources. During March-September, screening services provided access to urgent symptomatic women. Many women were diagnosed with breast cancer during this period. There is now a significant backlog of breast screening which is now returning to maximum possible activity but not at the pre-pandemic rate. The screening service is very conscious of the many women who have not been screened and is doing everything possible to maximise its capacity.
A recent advance in breast imagine is Tomomammography, where multiple X-rays are taken in very thin sections of each breast.
Dr Jennifer Westrup is the Director of Oncology and a Consultant Medical Oncologist at Beacon Hospital. Along with her colleagues Dr Lisa Prior, Consultant Medical Oncologist, Dr Reem Salman, Consultant Breast Surgeon, and Dr Alina Mihai, Consultant Radiation Oncologist, she explains the advances in therapies available to Irish women …
Breast surgery has evolved over the years from an approach of removing the entire breast and lymph nodes under the arm, to a more modern approach of considering breast conservation wherever surgically possible. This means that instead of completely removing the breast (mastectomy), breast surgeons now consider less invasive surgeries such as wide local excisions and lumpectomies with a directed sampling of lymph nodes under the arm. In many women, a breast-conserving surgery is as effective a cancer treatment as a mastectomy when combined with radiotherapy. For patients with early-stage breast cancers, minimally invasive surgery allows patients to heal quicker, have smaller scars, maintain a better range of motion of the upper body, have fewer issues with lymphoedema, and retain their body image.
Some patients will require a mastectomy or a double mastectomy due to their tumour characteristics and/or their family history risk. The decision on what type of surgery is appropriate for each patient is highly individual and is made with the patient, the breast surgeon and the multidisciplinary team to ensure that the best cancer treatment is offered. For every patient undergoing breast surgery, we recommend post-operative physiotherapy. Upper arm movement and strength is an important part of maintaining independence as we age, and physio-directed exercises will help.
Reconstructive surgery following cancer treatment is an option that many patients consider. As oncologists, we encourage patients to have a thorough conversation with the breast surgeon about their options. Reconstructive surgery may include implants or native tissue taken from the tummy or the back. There are instances where immediate reconstruction is possible, and for many women it is a real benefit to recover from cancer surgery with breast reconstruction already done. However, all breast multidisciplinary teams focus first on fully treating the cancer. This may mean that additional cancer treatment is required after surgery and that reconstruction should be considered only after all treatment is completed. This is called “delayed reconstruction”.
We inform patients that reconstruction is available, but can be completed well after the initial treatment. In fact, for many patients, a delayed reconstruction allows for full cancer treatment up front and for the patient to regain their fitness prior to undergoing another surgical procedure. We encourage all women to continue to revisit this discussion as they may wish to make room in their lives to plan for additional surgeries, or they may find that another procedure may be more than they can manage in the year following diagnosis.
Systemic therapies are drugs that travel through the bloodstream to target cancer cells in multiple locations throughout the body. They are important in preventing cancer recurrence in patients who have undergone curative breast surgery. They are also used to shrink or control tumours in patients with metastatic or advanced breast cancer (cancer that has spread from the breast to other parts of the body). Treatment decisions are always individualised and require close collaboration between the oncologist and patient to ensure it is both effective and tolerable. Factors that should be considered include age, menopause status, health conditions, stage of breast cancer and of course the personal circumstances and wishes of the patient. Therapy regimens are also tailored to the three main breast cancer types: hormone-receptor-positive (the most common type), HER2-positive and triple-negative breast cancer.
Traditionally, systemic therapies used in breast cancer included chemotherapy and oral endocrine therapy (drugs that reduce the level of oestrogen in the body to stop hormone positive breast cancer cells growing). They remain relevant today and still form an important part of many patients’ treatment plans. However, the field of cancer research is constantly evolving and newer treatments such as “targeted therapies” and “immunotherapy” have revolutionised cancer care.
“Targeted therapies” refers to treatments that block a specific gene or protein on a cancer cell that is responsible for cell growth or survival. One of the earliest success stories was the development of a targeted drug called Trastuzumab (Herceptin) which blocked this HER2 protein (overproduced by 20 per cent of breast cancers). This, along with more recent HER2-blocking drugs such as Pertuzumab transformed HER2-positive breast cancer from one of the most aggressive cancers to one that is very treatable today. More recent advances include the introduction of CDK4/6 inhibitors such as Palbociclib, which blocks CDK4 and CDK6 proteins on hormone-receptor-positive breast cancer cells. Other “smart” drugs include “antibody drug-conjugates” which consist of an antibody joined to a chemotherapy drug. The antibody component attaches to a specific protein on the lining of the cancer cell, allowing chemotherapy to be delivered directly to it. Examples of these agents include Trastuzumab-Emtansine for HER2-positive breast cancer and Sacituzumab-Govotecan for triple-negative breast cancer.
Immunotherapy works differently to chemotherapy and targeted therapies in that it harnesses the patient’s own immune system to recognise and kill cancer cells. It is very commonly used in patients with metastatic melanoma, lung cancer and kidney cancer. The immunotherapy drug Atezolizumab has also been found to be effective in combination with chemotherapy for certain types of advanced triple-negative breast cancer. Atezolizumab blocks a protein called PD-L1 which normally puts a brake on the immune system. By removing this brake, it can allow the immune system to mount a strong response against tumour cells.
None of these treatment advances would be possible without the thousands of brave patients who enrol on clinical trials worldwide with the aim of transforming the future of breast cancer care. Cancer Trials Ireland is one of the leading national cancer research trial organisations and allows Irish patients to access new practice-changing drugs. Since its establishment in 1996, more than 15,000 patients in Ireland have participated in over 350 clinical trials. They, along with other Irish breast cancer research groups and charities, have been instrumental in allowing patients with breast cancer to live longer and enhance their quality of life. Cancer Trials Ireland is partly funded by the Health Research Board (HRB), the Irish Cancer Society and St Luke’s Institute for Cancer Research Cancer. Due to Covid-19 restrictions, certain fundraising events held by cancer charities such as the Irish Cancer Society have been cancelled. Participation in virtual events and continued donations are important through the pandemic to ensure Irish breast cancer patients continue to benefit from research and access to clinical trials.
Advances in technology allow not only a more precise delivery of radiotherapy, but also a reduction of certain risks.
Radiotherapy uses controlled doses of radiation to kill cancer cells. Radiation therapy is an effective way to reduce the risk of breast cancer recurring after surgery, with or without chemotherapy, and it is commonly used to ease symptoms related to the spread of cancer to other parts of the body.
In patients with early stage breast cancer, radiotherapy is used as an adjuvant to surgery in patients who undergo breast-conserving surgery (lumpectomy). In these patients, addition of radiotherapy to the whole breast significantly reduces the risk of recurrence in the breast. For decades, the treatment was delivered as one session a day, five times per week, for five-six weeks (this is called standard fractionated radiotherapy). However, strong evidence from well-conducted studies in Canada, the US and the UK showed that the duration of the treatment could be reduced to three-four weeks (one session per day, five times a week, 15-16 treatments in total) without impacting negatively on the outcomes of the patients. This type of radiation (called hypo-fractionated) became the new standard of care for patients with early stage breast cancer who underwent breast-conserving surgery, with or without chemotherapy.
Newly published long-term data from a study in the UK now suggests that five sessions of radiotherapy over one week is not inferior to three weeks’ radiotherapy – it does not compromise the control of the tumour in the breast, and it is safe in term of normal tissue side effects.
For some women with early-stage breast cancer, partial-breast radiation may be an option. This type of radiation therapy is directed to the area around where the tumour was removed. It can be delivered either internally (using radioactive needles or seeds) or externally with X-rays (photons) or protons. The treatment schedules are usually short (such as one to two treatments a day over three to five days).
Advances in technology allow not only a more precise delivery of radiotherapy, but also a reduction of certain risks associated with radiotherapy to the breast. For example, in large-breasted patients, use of a special radiation technique, Intensity Modulated Radiotherapy (IMRT) homogenises the radiation dose within the breast and reduces the risk of significant skin reactions. Currently available technology allows treatment only when patient is holding her breath for 20-30 seconds at a time. This allows sparing of the heart (in patients with left breast cancer) or liver (in right breast cancer), reducing the risk of injury to the heart and liver.
In a cohort of patients with limited cancer spread (called “oligometastatic”), use of a special radiation technique called radiosurgery (when used to treat limited spread to the brain) or stereotactic ablative radiotherapy (when used to treat limited spread outside the brain) has shown promising results in controlling the limited spread of disease, increasing the time until the cancer progresses further, and increasing the survival of these patients (when used in addition to the standard therapies). In addition, in patients who undergo several types of chemotherapy or other systemic treatments, the radiation treatments can delay the need for other systemic therapies.
In patients who present with symptomatic spread of their cancer to the other organs, radiotherapy eases these symptoms. For example, in patients with pain caused by spread to the bones, radiotherapy is extremely efficient in controlling the pain in more than 80 per cent of patients.
MENOPAUSE AND ENDOCRINE THERAPY
We often are asked by GPs if it is safe to prescribe Hormone Replacement Therapy (HRT) for women who are going through menopause and are affected by symptoms such as night sweats, hot flushes, and vaginal dryness. For women who have been diagnosed with hormone-receptor-positive breast cancer, we do not recommend HRT use.
However, for women with no personal or family history of breast cancer, there is a causal relationship between the use of HRT and breast cancer, but the risk is low. The controversy about HRT dates back to the publication of a report from the Women’s Health Initiative nearly 20 years ago. This study looked at over 16,000 women and considered the health benefits and risks in post-menopausal women who take HRT. The results of this trial have been updated since the original publication in 2002. In summary, there is a small increase in the risk of breast cancer in women who use HRT. The risk is increased in women who use a combined estrogen-progestin therapy.
Conversely, the risk of breast cancer is slightly decreased in women who use unopposed estrogen therapy for a short time (unopposed estrogen is prescribed for women who have had a hysterectomy).
Overall, a limited course of HRT may be an option for healthy symptomatic women who are under the age of 60, are within ten years of menopause, do not have a history of breast cancer and have no other contraindications – blood clots, stroke, liver disease or heart disease.
PREVENTING BREAST CANCER
“What can I do?” This is the most common question we are asked by women who are concerned about breast cancer. First, it is important to be breast aware, and to have regular mammograms after the age of 50. Second, it is important to know your family history. Up to ten per cent of breast cancer diagnoses are thought to be hereditary and may be passed on from a parent. If you have a strong family history, talk to your doctor. The most important lifestyle changes you can make are to exercise more, maintain a lean body weight, and consume less alcohol. You can lower your risk of breast cancer by almost 30 per cent if you exercise ten-20 hours per week. A review of statistics from the UK reveals that breast cancer generally affects 23 women out of 1,000 in the 50-59-year-old age group. The use of HRT increases the number to 27 per 1,000 (an additional four cases). Obesity increases the risk to 47 per 1,000 (an extra 24 cases). Alcohol intake increases the risk to 28 per 1,000 (an additional five cases). Exercise reduces the risk to 16 per 1,000.
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