Breast Cancer Treatment Update

Beth Baughman DuPree, MD, FACS

From initial screening and diagnosis to reconstructive surgery and survivorship, breast cancer patients have many options when it comes to their care. However, navigating the system can be complex, and as a result, patients may not be receiving the best possible care available to them. For example, in a recent study by Alderman et al,¹ 70% of general surgeons did not discuss reconstructive surgery options with breast cancer patients.

“I think we need to raise the bar,” said Beth Baughman DuPree, MD, FACS, medical director of the breast health program at Holy Redeemer Hospital in Pennsylvania.

At NCONN 2011, DuPree spoke to oncology nurses about prevention, detection, diagnosis, treatment, and survivorship pertaining to breast cancer patients and how much the field has changed based on clinical trials and an increased knowledge base. “I want our nurses who are in the forefront of this cancer process to be able to help educate their patients on what their choices are all along the way,” said DuPree.

To emphasize her point, DuPree noted that many surgeons nationwide still use radical breast surgeries similar to those developed by William Stewart Halsted in the late nineteenth century, physically disfiguring patients for life while not guaranteeing a complete disease remission. She said that surgeries have become far less invasive and reconstructive surgeries—from nipple-sparing mastectomies to silicone implants— have drastically improved a patient’s self-image after treatment.

TABLE 1. Survival Outcomes of the Z11 Study

Median Follow-Up Years: 6.3

DFS

OS

SN alone

83.9 (80.2—87.9%)

92.5 (90—95.1%)

ALND

82.2 (78.3—86.3%)

91.8 (89.1-94.5%)

HR

0.82 (0.58—1.17)

0.79 (.56—1.1)

ALND indicates axillary lymph node dissection; DFS, disease-free survival; HR, hazard ratio; OS, overall survival; SLND, sentinel lymph node dissection. [Adapted from Giuliano et al. JAMA. 2011;305(6):569-575]

Z11 Trial: Some Patients Need Less Surgery

DuPree said that performing more surgery might not always be the best option for the patient, as clinical trials are starting to reveal. She pointed to the Z11 study,² in which the survival of patients with 1 or 2 cancerous sentinel lymph nodes was not affected by whether or not they had a sentinel lymph node dissection alone or axillary lymph node dissection (TABLE).

In the Zll trial, “Less surgery did not cause less survival,” DuPree said. However, DuPree added that this only applied to patients who had been tested mammographically, ultrasonographically, and had palpably negative axilla. “We really need to make sure we are putting the appropriate patients into that subgroup [of patients who do not require axillary lymph node dissection].”

Nurses Perspective

Jenna Lewis, RN, MN, OCN® Cancer Nurse Navigator Franciscan Health System St. Anthony Hospital Gig Harbor, Washington

One of the highlights of the NCONN conference was Dr DuPree’s breast care update. She covered topics from the history of breast care, to where we are today and important studies/trials that have influenced today’s breast care. She then went into specifics on prevention, screening, genetic risk assessment, and surgical intervention. She wrapped up her talk by explaining the recent paradigm shift in breast care and outlining how that shift allows for early detection, better screening tools, and minimally invasive diagnostic biopsies, just to name a few of her points.

I am not a specific breast care nurse navigator, but I am a general oncology nurse navigator so I do work with breast patients as part of my practice. It was very beneficial to have Dr DuPree present such a thorough and comprehensive update on breast care. For me it was an opportunity to learn a lot at once and not have to go back and put different pieces of the puzzle together—very valuable for a navigator who navigates many different disease types.

Breast Screening Update

DuPree also provided an update on diagnostic techniques. After the United States Preventive Services Task Force made a controversial recommendation that women aged 40 to 49 years not receive regular mammograms, additional studies have actually confirmed the effectiveness of screening at these early ages. DuPree said that women should consider getting an annual mammogram performed starting at age 40.

MRIs offer an additional screening option for women who are BRCA1 or BRCA2 positive, have a history of atypical ductal hyperplasia or lobular carcinoma in situ, have a personal history with breast cancer, or have a family history of breast cancer with >20% risk of developing the disease.

DuPree also explained newer diagnostic techniques that utilize advances in stereotactic imaging, including MRI-assisted and ultrasoundguided biopsies. The ultrasound-guided biopsies provide images in real time and are minimally invasive without exposing the patient to radiation. MRI-guided biopsies are able to rule out multifocal disease, as well as evaluate the extent of the disease. Positron emission mammography is also being explored as a highly sensitive test that may eventually be used for breast cancer screening.

Breast Screening Update

DuPree also discussed the benefits of an integrative approach for both cancer prevention and an improved quality of life during survivorship. She described several studies that have suggested the anti-cancer benefits of a high-fiber, low-fat diet; anti-cancer foods, such as certain spices, mushrooms, vegetables, and chocolate; and omega-3 fatty acids.

Regarding survivorship, DuPree said services such as massages and spiritual counseling can help turn “survivors” into “thrivers.” She described “thrivorship” as “When cancer’s not the first and last thing you think about every morning and when you find positives in your life after the cancer, and you’re living your life, and you’re living in the moment, that’s when you’re thriving, because you’re no longer defined by your cancer experience.”

References

1. Alderman AK, Hawley ST, Waljee J, et al. Understanding the impact of breast reconstruction on the surgical decision-making process for breast cancer. Cancer. 2008;112(3):489-494.
2. Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305(6):569-575.