There’s more than one route that draws people to City of Hope’s High-Risk Breast Clinic.
Some have “Stage 0” tumors that pose no immediate threat but could lead to a more serious diagnosis later. Some face elevated risk after surviving cancer. Others have watched family members fight the disease and want to know about their own chances of developing breast cancer.
No matter what brings them to the clinic, all can expect to find caring providers applying the latest knowledge to quantify individual risk and tailor plans that catch tumors early — when treatment is likeliest to succeed — or stop cancer before it starts.
Founded in 2017, the High-Risk Breast Clinic brings together experts in oncology and clinical cancer genetics committed to not only helping patients but also expanding their options. Indeed, weaving research into the clinic’s activities is a longtime priority for founding co-directors Lisa Yee, M.D., professor of surgery, and Victoria Seewaldt, M.D., the Ruth Ziegler Chair in Population Sciences.
“The way forward is through clinical trials,” Dr. Yee said. “We want our patients to have access to new ways of managing their risk, so our goal has been to build a robust portfolio of research studies.”
The High-Risk Breast Clinic is primarily headquartered at City of Hope | South Pasadena, but also provides services at the main campus in Duarte, City of Hope Orange County Lennar Foundation Cancer Center and community practice sites in the South Bay and Mission Hills — enabling more Southern California patients to seek care closer to home.
From Assessment to Planning
Calculations of a patient’s risk derive from myriad sources, including personal, medical and family history, as well as no-cost genetic testing through City of Hope’s Center for Precision Medicine. The specific results determine potential next steps.
For instance, a mutation to the BRCA1 or BRCA2 gene can boost someone’s lifetime risk of breast cancer from 12% to 60%. For a patient approaching midlife, surgery to remove the breasts could be an option to consider. A younger patient with the same finding might defer surgery for the future and opt for twice-yearly imaging, alternating mammograms and magnetic resonance imaging, plus regular doctor’s exams.
Another patient with noninvasive breast cancer might be presented with the choice of removing the lump and a course of preventive radiotherapy, or lowering risk by as much as half with an estrogen-blocking medicine, such as tamoxifen. Because obesity after menopause is a risk factor, Dr. Yee also emphasizes lifestyle interventions, such as diet and exercise, when appropriate.
“It’s easier to make healthy choices a part of your life now, rather than adding them on when you’re in trouble,” she said. “It’s never overnight, but by raising diet quality and incrementally increasing physical activity, hopefully patients will keep healthy going forward.”
The clinic’s customized approach is vital to serving patients, according to medical oncologist Leah Naghi, M.D. — at once a recent addition to the High-Risk Breast Clinic and a familiar face who completed her fellowship training at City of Hope®.
“Precision and personalized care is compassionate care,” said Dr. Naghi, an assistant clinical professor of medical oncology and therapeutics research with expertise in clinical cancer genetics. “You’re not just being fit into this box or that box. You are an individual, and we are going to care for you as best as possible.”
Some of the strongest preventive measures carry long-term implications. Removing a patient’s breasts often comes with body image issues, even when ameliorated with increasingly advanced reconstruction techniques. And some women shy away from anti-estrogen treatment because it can have menopause-like side effects. Such weighty decisions require thoughtful deliberation. So patients’ interface with the High-Risk Breast Clinic takes the form of an ongoing conversation over multiple counseling visits.
For Dr. Yee, clarity is key.
“Navigating breast cancer risk is very personal,” she said. “I want patients to understand the science of what I’m recommending they do. We talk about side effects and make it personal to them, so they fully understand their choices.”
Serving high-risk patients who have seen cancer play out in their families over and over is particularly meaningful for Dr. Naghi, who found her calling in medicine through an early interest in genetics.
“It makes a huge difference in their lives to keep them from reliving the trauma of their families’ past,” she said. “Helping people in this way has always been a goal for me.”
Advancing Clinical Care for Those at Risk
Dr. Yee has a long history of working with patients at elevated risk for breast cancer, having launched a high-risk clinic in 1995 at her previous academic home, The Ohio State University. As the field has grown and evolved over the decades, so has her resolve to push it forward with research.
“Our hope is to keep refining our understanding of risk,” Dr. Yee said. “I’m really big on seeing if we can find a better way than what we currently offer patients.”
Clinical trials at the clinic have covered the gamut, from looking at reducing breast cancer risk to improving monitoring to exploring new biochemical markers for risk.
One trial currently enrolling at City of Hope tests a new intervention for noninvasive tumors. Multi-institutional studies further along or recently closed have examined surveillance versus surgery for Stage 0 breast cancers, drug treatment for metabolic disease as a way to reduce risk in obese premenopausal patients, and immunotherapy as a potential alternative to mastectomy for those with BRCA mutations.
“That’s fairly exciting,” Dr. Yee said, “for a gene mutation carrier to have another option.”
Expanding the benefits of surveillance and prevention is also a passion for Dr. Yee. Upcoming studies will address factors that can keep subpopulations, including Asians and Latinos, from accessing prevention or early detection to counteract factors that magnify risk. The focus is on breaking down barriers, increasing understanding and meeting people where they are.
“We need to address risk in a diverse population,” she said. “City of Hope has the ability, and certainly the locations, to help a lot of people manage increased risk for breast cancer. And hopefully, we can prevent it.”