November 11, 2015 | by Cary A. Presant, M.D.
City of Hope's Cary A. Presant, M.D., likes what he sees when he looks back at treatment advances in breast cancer during the past year. A renowned hematologist and medical oncologist, Presant gives his take on recent changes in screening recommendations, chemotherapy regimens and preventative hormonal therapy.
The year 2015 has been a stellar one in advancing care for breast cancer. Here are some of the biggest changes I think have changed the care we all provide.
This has become the year of personalized screening schedules and techniques.
According to The American Cancer Society’s update guidelines, for women with no increased risk, standard mammograms are now recommended every year between the ages of 45 and 54, and then every two years between the ages of 55 and 75, and beyond if they have a life expectancy of 10 years or more.
For women of higher risk, however, annual mammography remains recommended starting at age 40. Who are these women? Those with a family history of breast or ovarian cancer, or with a BRCA 1 or 2 mutation; women with prior benign biopsies; women who are overweight or obese; women who have taken postmenopausal hormone replacement therapy; women who have an alcohol intake of one or more drinks daily; those who smoke; women with any symptoms in the breast; women who do not exercise or who have a high-fat diet; women who bore their first child after age 35, or who have never given birth; and women who have a cancer phobia and thus seek additional screening, despite the increased likelihood of false positive findings that might warrant needle biopsies.
Women with dense breasts should be considered for ultrasound or breast MRI, and tomosynthesis (3-D digital mammography) can be considered in place of standard mammography because of likely higher true positives and fewer false positives.
In hormonal therapy, adjuvant tamoxifen is now recommended for 10 years rather than for five.
In women with ductal carcinoma in situ (DCIS), adjuvant therapy includes aromatase inhibitors as well as tamoxifen. Prevention with hormones now includes tamoxifen, raloxifene and aromatase inhibitors. For therapy of recurrent or metastatic disease, exemestane is now routinely given with everolimus (Afinitor), and letrozole is routinely given with palbociclib (Ibrance). Initial hormonal therapy can now use injectable faslodex instead of aromatase inhibitors with better compliance. With the increasing cost of medical care, noncompliance with oral medications is an increasing problem that we all need to help manage.
Chemotherapy has also been changing.
Adjuvant docetaxel cyclophosphamide has increasingly been replacing doxorubicin, cyclophosphamide plus paclitaxel. This has led a drop in heart problems and fewer cases of myelodysplastic syndrome or leukemia.
Neoadjuvant therapy before surgery has also become more common.
For advanced disease, single-agent chemotherapy has been more frequent than combination chemotherapy. Women with oligometastatic disease (four or fewer metastatic sites) have been considered for aggressive therapy of all metastases with radiation, surgery, hormonal therapy and chemotherapy, with “cures” in 10 to 20 percent of patients. Her2 positive patients can now receive trastuzumab as well as pertuzumab, lapatnib and ado-trastuzumab emtansine (Kadcyla).
Physicians are more aware of the need for genomic screening of patients and family members susceptible for BRCA 1 and 2 abnormalities, a well as other recently-identified gene mutations (CHEK2, PALB2, PTEN, TP53, CDH1 and others).
These can be ordered together as a panel known as Myriad’s MyRisk test. And while hereditary breast-ovarian cancer syndrome now includes a higher risk for pancreatic cancer, tumor incidence can be reduced by prophylactic oophorectomy, as well as optional prophylactic mastectomy, a treatment chosen by actress Angelina Jolie. Testing has also become more accepted by patients.
Breast cancer has never been more preventable, treatable and curable. Stay tuned for more advances in 2016.
Read more by Presant on the Huffington Post.
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