What’s on the horizon for breast cancer?
By Dr. Nimmi Kapoor
Research in breast cancer is very fast-paced with an emphasis on earlier detection and easier treatment regimens that minimize harm to patients. I make it a priority to “stay on-top” of the latest and best advances in these aspects of breast health and cancer care so I can give my patients the best advice.
Detecting breast cancer involves at least two aspects of science and technology: having the best equipment for screening and knowing who needs to be screened. The revolution in breast cancer screening equipment has already made a big impact on early cancer detection. Dedicated breast MRI has been the most sensitive method of detecting breast cancer for the past decade, however is still costly and, for some, like me, claustrophobic. 3D-mammography, or tomosynthesis, has proved to decrease call-backs (that awful phone call where they tell you they aren’t sure they found something, so they need to do some more testing) and it has a higher rate of detecting cancer. Tomo, as many call it, is better than a regular mammogram and is starting to get covered by insurance more regularly. Coming-up, I think we will hear more about molecular breast imaging which is kind-of going to be in the middle of 3D mammography and breast MRI in ability to detect cancer at it’s earliest stage.
Figuring out who, and when, to be screened is another challenge. Recently, the USPSTF and ACS both changed guidelines for screening to suggest that average risk women should be screened at age 50 instead of age 40. The real challenge is understanding who is average and who may have a higher risk. We offer a sophisticated “Risk Assessment” program that takes into account personal and family history risk factors to give each woman personalized guidelines for screening. For some women, this screening will involve genetic testing to identify a hereditary risk. Genes, such as BRCA1 and BRCA2, are well-known to increase the risk of breast cancer over 50%, however we now know of over 30 genes that can be implicated in cancer development that can be inherited. Multi-gene panel testing has now become part of standardized genetic testing for people who meet appropriate testing criteria.
As a surgeon, I have watched the history of breast cancer treatment expand and then condense to now eliminate some of the basic treatment regimens we used to apply to all patients. Not everyone needs a mastectomy, or an axillary lymph node dissection, or radiation, or chemotherapy. We have entered the era of “tumor genomics” to understand tumor biology so well that we can predict which tumors are more likely to recur and which are more likely to benefit from chemotherapy. There are now research trials that randomize patients with Stage 0 breast cancer (DCIS) to no surgery and Tamoxifen only, with close observation of course. Tumor immunology will also be up-and-coming as we learn to create individualized targets for each person’s cancer.
In all, I am still glad I chose to become a breast surgeon as all of these changes are fascinating and are sure to bring about improvements in care and longevity for today’s thrivers and tomorrow’s patients.