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December 2018

How Far We've Come: Twenty Year of Breast Cancer Treatment.

I recently attended the 20th annual Lynn Sage Breast Cancer conference in Chicago. Twenty years! There has been remarkable progress in the treatment of this disease. 

What struck me the most is how breast cancer treatment has moved on from a paternalistic, "doctor knows best," attitude to doctors asking, "how can we do the least amount of treatment with the maximum chance of cure and the fewest side effects?"

We haven't seen this attitude shift in other cancers, and a lot of it is due to activism of the breast cancer/survivor community, advocating for change, and helping that change to happen by raising money for research and participating in clinical research trials. 

This activism has paid off. Not too long ago, treating breast cancer meant throwing the book at you -- surgery, chemotherapy and radiation, followed by years of pills and debilitating residual effects. We now understand that different subtypes of breast cancer needed different drugs and hormones, so treatment will be the minimum amount, tailored to target the subtypes. Research in surgery, radiation, and supportive care has continued to improve these procedures and decrease side effects. Improvement in imaging has provided better, more accurate screening for early detection, and options for women with difficult-to-image and "dense" breasts. And genetics research has helped us to find more breast cancer subtypes and how to improve survival in these groups. 

It's hard to cover a 4-day meeting in a short article like this, but I hope that I captured some of the exciting at this Here are a few highlights presented at the conference.

Reducing side effects from treatment has been an important area of research--it's made life bearable for breast cancer survivors who are anxious to get back to their normal lives. For example:

            -Hair loss results from many chemotherapy drugs, and while these drugs may be necessary, the result can be devastating for a woman who is still trying to cope with the loss of her self-image after removal of part of her breast.  New methods of scalp-cooling are being tested to reduce hair loss, with surprisingly good results for some women.

            -Lymphedema is a persistent swelling of the arm resulting from surgery in axilla (armpit), and for some it can incapacitating and unsightly. Surgeons are exploring methods to prevent or treat lymphedema using microsurgery on the lymph vessels of the arm. 

Perhaps the single biggest improvement in breast cancer survival has been the widespread adoption of regular mammograms, because breast cancer caught early has a 99% chance of survival. But mammograms can miss up to 10% of cancers. And some women have breasts that just don't image well.

For some, MRI may be a better choice than mammogram. MRI imaging uses magnetic resonance instead of radiation, and can give a more detailed or complementary image of the breast.  A lot of research has now shown that MRI is helpful to elucidate a questionable mammogram result, or to image a very dense or fibrous breast--particularly a problem in some high risk women.  But the procedure is expense and insurance doesn't cover its routine use. However, I am optimistic that the breast cancer advocacy groups will lobby strongly to get insurers to start covering the procedure.

For many years, there were no new breakthroughs in treatments--until recently. Two relatively new treatments have been found promising for advanced cancer, and for some hard-to-treat subtypes, particularly "triple-negative" breast cancer. Treatment which uses the body's own immune system--immunotherapy--given dramatic results in some cases, and methods are now being developed to determine which patients will benefit from it. For some, it may even help to bypass chemotherapy completely!  Another class of drugs called "PARP inhibitors" are now being used to treat triple-negative breast cancers, and those that arise in women carrying the BRCA breast cancer gene.  As these treatments become fully integrated into medical practice I suspect we will see even better survival results in breast cancer.