Technical Advances and Efforts to Bridge Care Gaps Take Center Stage During Breast Cancer Awareness Month

Sheldon M. Feldman, MD

Breast cancer care for African American women often diverges from that of their White counterparts due to differences in disease biology, resulting in younger diagnoses and more aggressive disease presentations in this underserved patient population, Sheldon M. Feldman, MD, shared in an interview with OncLive^®.

Feldman, who is the chief of the Division of Breast Surgery and Breast Surgical Oncology, the director of Breast Cancer Services, and a professor in the Department of Surgery at Montefiore Einstein, in Bronx, New York, went on to explain that awareness of treatment-associated toxicities or potential complications is critical for optimizing therapies among underserved populations.

In the interview, Feldman expanded on the importance of addressing disparities in breast cancer care, efforts to promote healthy lifestyles and reduce recurrence risk for breast cancer survivors, and the impact of advancements with surgical and reconstruction technologies on outcomes and quality of life (QOL) for patients.

Feldman highlighted this topic and others like it in another interview with OncLive during Breast Cancer Awareness Month.

OncLive: Why is it important to recognize racial disparities in breast cancer, and how can treatment-related toxicities be mitigated in underserved patient populations?

Feldman: The biology of the cancer, the genetics of the individual, and the particular characteristics of different racial subgroups are very important [in breast cancer]. We're beginning to understand that. For example, we know that the age of diagnosis is often younger for African American women. More of [these patients] are diagnosed with triple–negative breast cancer, which is in many ways the most difficult type to treat. This is because there's no target that has been defined. It's not estrogen-sensitive, it's not progesterone receptor–sensitive, and it's not HER2 overexpressed. There is no specific target that's treated.

With the recognition that African American women are more likely to be diagnosed at a younger age with a more serious type of breast cancer, there has been [a push] towards recommending screening for African American women—particularly those with a family history—at a younger age. That will be very, very helpful. Supplemental screening for young women, which is used for all ethnicities of women with dense breast tissue, including ultrasound and MRI, are also very important.

The other thing that's been recognized now is some of the complications related to treatment with chemotherapy can be worse for African American women. One complication is neuropathy from a [taxane]-based chemotherapy, which is a dreaded complication. There are several different types of taxanes, including paclitaxel and docetaxel, which are commonly used. Recent studies have shown that docetaxel may have a lower incidence of neuropathy for African American women than the other drug.

There has also been more evidence that [modifying] dosing schedules, in terms of the way the medicine is given, may be [an area of opportunity] in reducing neuropathy risk. That's important, because this is a dreadful complication that patients can develop and seems to be more prevalent. A study has been [recently] done on [this topic], showing that the genetics behind the subgroup of patients who are more likely to develop neuropathy is well established. Drawing from the anti-HER2 groups, we hope that there will be a medical approach to preventing neuropathy in the subgroup that's identified as being at higher risk. That's extremely promising.

What factors should be prioritized in post-treatment care to improve long-term QOL for patients and reduce the risk of disease recurrence?

Patients are so overwhelmed with their initial diagnosis, but somewhere in the process, we begin to talk about what their options are. This [can include] surgery, radiation, chemotherapy, and other medicines, including antibodies. Those are all things that we are [administering] to patients. However, we know that the immune system is incredibly important and that the patient can do things to help strengthen their own immune system in survivorship, to reduce their chance of recurrence; these studies now are getting quite mature.

It is a very teachable moment when someone is diagnosed with cancer because they're thinking in front of their brain, ‘I'm going to die, what can I do? I want to make changes.’ [Patients] may not be eating well, are overweight, don't exercise, or they're under a lot of stress. These are the things that we know we all should do to stay healthy. This is an opportunity to improve their health and wellness, so we try to help patients navigate that, to manage changes to their lifestyle.

More recent studies have shown that exercise is medicine. Irregular aerobic exercise and strength training is medicine, and as effective as some of the drugs in preventing recurrence. Therefore, we’ve developed programs to help patients implement these changes into their lifestyle so that they can be not just survivors but exceed their health goals prior to diagnosis and be in a healthier place than they were before in spite of their cancer diagnosis. This is so important for many patients. Although it's so much easier to take a pill than to exercise for 45 minutes, 5 days a week, when someone's ready to make changes in their life because they're frightened about a cancer diagnosis, it's an opportunity to help patients achieve that.

How have technical advancements and an increased focus on quality of life in breast cancer care impacted your practice as a surgical oncologist?

The good news is that with early diagnosis, we can save the breast for most women. [It is important] to perform a precise lumpectomy procedure so that we can get clean margins; there's more and more technology now that helps us achieve clear margins by carefully localizing the site of the tumor. Surgeons need help identify that site. There's also some newer technology for magnetic seeds or radioactive seeds. There is a lot of technology in this space now, but the bottom line is that they all help surgeons. As a surgeon, it helps me when I do an operation in terms of removing the right amount of tissue.

[This technology] also helps patients who need to have reconstructive surgery done. If they're going to have a mastectomy and they're going to have new fatty tissue brought in to replace their breast, that's what we call flap procedures. This technology has also been very helpful. We have SPY technology using indocyanine green, which allows us to identify the blood supply to the flap that's brought in. When the reconstruction is done, we can have assurance that the tissue that has been brought in to replace the breast that's been removed will be healthy and viable. These technical advances are important.

The other thing that I've been involved with and interested in is avoiding surgical complications, particularly those related to lymphedema. We've helped to advance techniques to minimize the number of lymph nodes removed and maintain the normal lymphatic anatomy so patients don't experience swollen arms. This technology, called bioimpedance spectroscopy, helps to identify any swelling of the arm extremely early. It is a platform that allows us to measure the arm volume preoperatively, so that if patients begin to develop any swelling of the arm, even before we can see it, it can be identified by this noninvasive technology. [This allows] us to treat the patient before they even develop lymphedema.

All of these quality-of-life [focuses] and technical advances add up to improve outcomes for patients and make their experience better. There have been a lot of advances across the board and in every aspect of care, but there's still a lot to do. We still have patients who don't do well, who don't have the targets to treat, who are not diagnosed early.

Getting back to Breast Cancer Awareness Month, early diagnosis is everything. It makes options easier for patients, makes outcome better, and helps patients overcome the fear of being screened, so that if a problem is found, [they will understand] that if it's found early, they will be successfully treated. They will be okay and likely not have to go through major treatments.