BURLINGTON — At the Women’s Health and Cancer Conference, one workshop gave a behind-the-scenes look at breast cancer diagnosis, treatment, and care from the perspectives of the different doctors involved on a breast cancer team.
The speakers at the Oct. 4 workshop included a breast surgeon, a radiation oncologist, a medical oncologist, a radiologist, and a pathologist. The team walked through the timeline of a patient with breast cancer, how they diagnosed the cancer, and what their roles as doctors were through treatment.
Radiologist Erin Tsai spoke about her primary role in diagnosing breast cancer through images. As a radiologist, Tsai interacts frequently with patients to conduct screenings, mammograms, MRIs, and ultrasounds. The patient that the team discussed was diagnosed through screening, meaning that during the patient’s annual mammograms, the radiologist detected an abnormality. The patient’s masses were visible via imaging, but Tsai also emphasized how comparing yearly exam results was important in judging its irregularity.
Since she detected a mass, Tsai said the next step was to go immediately to ultrasound which would give a better picture of the inside of the breast. She also noted that ultrasounds are cheaper and more comfortable for the patient. Affirming that the mass was highly suspicious, Tsai said that the next step was to perform a biopsy and send samples of the mass to the pathologist to study and diagnose.
A “big key,” she said, was how the mass did not appear to respect tissue plains of the breast. This characteristic, among others, implied that the mass was highly suspicious.
Uyen Phyong Vietje, a pathologist, emphasized this point as well. She described her job as “intimately familiar with tissues,” as her work on the team is to study tissue samples and diagnose the cancer. Vietje noted how, in a magnified image of the sample, the cells stuck together but did not form any architecture. They clearly had “no respect for surrounding tissue,” she said, indicating that this sort of haphazard array of cells—structureless with no awareness of surrounding tissue—was evidence of an invasive malignant cancer.
Vietje also noted that the patient was Estrogen receptor (ER) and Progesterone receptor (PR) positive. ER and PR are two types of breast cancer that are fueled by hormones, estrogen and progesterone. Knowing the type of breast cancer can help in shaping what treatment looks like.
What are the different types of breast cancer?
According to the Mayo Clinic, there are four main groups used to categorize breast cancer, including: luminal A, luminal B, HER2 positive, and triple-negative. Luminal A, the first group, includes tumors that are ER and PR positive, but negative for HER2. This means that the tumor is fueled by estrogen and progesterone hormones in the body and can often be treated with chemotherapy and hormone therapy.
Luminal B includes tumors that are ER positive, PR negative, and HER2 positive. HER2 positive means that the cancer cells have an excess of a certain growth factor protein--HER2 for short. Luminal B treatment often includes chemotherapy, hormone therapy, and treatment targeted directly at HER2.
HER2 positive is negative for ER and PR hormones. According to Mayo, this strain of breast cancer is often more aggressive than other types, however prognosis is actually quite good. Treatment often includes chemotherapy and treatment targeted directly at HER2.
Triple-negative breast cancer is negative for ER, PR, and HER2. This type of breast cancer is one of the most difficult to treat, since typical treatments like hormone therapy or drugs that target the first three groups are ineffective. In this case, chemotherapy is frequently used. According to John Hopkins Medicine, triple-negative occurs in 10 to 20 percent of diagnosed breast cancers and is more likely to spread and recur than other forms of breast cancer.
As a breast surgeon, Mary Stanley is often the first person to participate in treatment. According to her, surgery is often the first step when tumors are small and there is uncertainty about whether chemotherapy is required. Stanley stated that often, if a tumor is large, the team plans to do chemo first to shrink the tumor and then proceed with surgery.
In the case of this patient, Stanley performed a lumpectomy to remove only the mass. Another surgical option is mastectomy, which removes the whole breast including the mass. According to Stanley, the choice between a lumpectomy and mastectomy are personal to each patient, and the difference in survival is often similar, although lumpectomies can leave the door open for cancer to recur.
Once the lumpectomy was conducted, Stanley sent the tissue to Vietje in pathology again where she measured the tumor size and scored it on a scale. This information helps oncologists in determining post-surgical treatment.
After surgery often comes chemotherapy and radiation.
Medical oncologist Hibba Rehman participates in chemotherapy and hormone treatment. “Decades ago, everyone would get chemotherapy because we didn’t know how tumors would behave,” she said. “Now we have a test to determine how tumors will behave. Certain markers tell us whether tumor cells will develop more rapidly.”
Patients with ER and PR positive breast cancer are considered low-risk and often receive hormone treatment. Patients with a higher risk type of breast cancer, like HER2 positive or triple negative, often need chemotherapy. According to Rehman, the patient had a high risk of recurrence, not only in the breast, but anywhere else in the body. “[There was] a small risk of tumor cells breaking off and going into blood circulation. That is why systemic treatment is so important, why chemo is so important,” she said.
As a radiation oncologist, Ruth Heimann also works with patients to advise whether someone is a candidate for radiation. In the case of a lumpectomy, Heimann examines the margins of the cancer and Vietje’s measurements of the tumor to decide whether radiation is necessary.
“Margins are exceedingly important because they decrease the chance of cancer returning in the breast,” she said. “Now we know that radiation can take care of the surrounding possible disease in the breast without performing a mastectomy.” If the patient is young, Heimann said that radiation often takes about six weeks, followed by chemotherapy. Older patients often have a slightly shorter radiation, about four and a half weeks.
“It’s like a job,” she said—patients receive radiation daily, five days a week. Without radiation, patients who have lumpectomies have a higher chance of recurrence. According to Heimann, with radiation treatment, there is less than a five percent chance of recurrence.
Ultimately, the patient underwent a lumpectomy, four cycles of chemotherapy, hormonal treatment, and finally radiation.