by David Tatman
Over the last decade, a number of factors have led to improved outcomes for patients who receive a diagnosis of breast cancer. These improved outcomes have been related to better treatments using chemotherapy, immunotherapy, radiation therapy, and surgery. Screening technology and techniques have also improved, and the number of women who receive a screening has increased, leading to earlier disease detection. This combination of better treatment options and improved screening has had a significant impact on survival for women with breast cancer.
A few key statistics to consider:
- In the U.S., nearly 270,000 new cases of breast cancer were diagnosed in 2018, which accounted for 30% of all cancer diagnoses in women.
- In Iowa, 2,400 new cases were diagnosed in 2018.
- Less than 5% of all cases were diagnosed in women age 40 and below.
- The cumulative risk of an American woman getting breast cancer is 12.8%, meaning one out of eight women will receive this diagnosis at some point during her life.
Early Detection Is Key
Medical experts have engaged in considerable debate as to the recommended age to start mammograms and the frequency at which they should be received. This has occurred because over-diagnosis carries certain risks, as does under-diagnosis. Recently the U.S. Preventative Services Task Force (USPSTF), which has generally given relatively conservative recommendations for screening, issued an expansion of screening for BRCA1/2 genes in certain women, based on medical history and ancestral descent. While the USPSTF recommendations can be confusing, especially for women with complex medical histories, the American Cancer Society’s (ACS) recommendation for women with average risk is relatively straightforward: yearly mammograms should begin at age 45 and can change to every other year at age 55. ACS also advocates for women having a choice to begin at age 40 if they desire. In addition to standard mammograms, the benefits of early detection have been augmented by better screening of dense breast tissue with newer modalities, such as tomosynthesis, and the use of digital mammography and ultrasound. Iowa has been a leader in the U.S. in adopting policy that mandates providers inform women that they have dense breast tissue so they can request one of these newer modalities.
One local effort to improve early detection has been the Swipe for a Cure Program. This program, created with funds initially donated by Dubuque Bank & Trust and in partnership with Crescent Community Health Center and MercyOne Dubuque, provides mammograms for women who can neither afford a mammogram nor qualify for other programs (e.g., Medicaid, VNA, etc.). Any patient who cannot afford a mammogram can make an appointment at Crescent to be evaluated for the need for services. The staff at Crescent then recommend patients for the program and write orders for their mammogram. Although the initial program was created by DB&T, other community partners have made donations to keep the program going.
Recent clinical trials have shown that, in some cases, less surgery can benefit patients. For example, one trial found that in women who are undergoing breast-conservation therapy (i.e., a lumpectomy plus radiation), additional risk of axillary node removal may be avoided if there is little disease present in her lymph nodes. Another trial has shown that axillary node removal may be avoided in some cases when neoadjuvant chemotherapy (i.e., chemo before the main chemo) is given, even when the axillary nodes were positive at diagnosis.
Perhaps no treatment improvements have been more profound over the last decade than the explosion of targeted therapy. The use of biological markers has allowed cancer cells to be targeted by drugs that are very specific to only the cancer cells, therefore sparing healthy cells. This often leads to a more effective treatment and often is much better tolerated by patients since they have fewer side effects. Newer drugs, such as pertuzumab and trastuzumab, are good examples of drugs that specifically target HER2 positive invasive breast cancer.
Recent advances in radiation therapy have focused largely on techniques to spare healthy tissue that surrounds the field of the tumor being treated. Clinical trials have found that in certain cases a patient can receive much higher doses of radiation in fewer treatments without compromising effectiveness, which is much more convenient for patients. New techniques, such as deep inspiration breath hold, have been utilized to more safely deliver a dose of radiation. The imaging of tumors has also improved over the last decade. Software is now routinely used that is able to fuse images of tumors, for example from CT, MRI, or PET, giving the providers a much more detailed composite image of the tumor they are treating.
Cancer in the Future
Over the next decade, cancer care will continue to rapidly advance. The aging of our population and rising obesity rates will unfortunately have a negative impact on breast cancer rates. There will no doubt be many more advances in targeted and immunotherapy because we have just begun to understand how the immune system modulates cancer, and how we can harness the immune system to cure or even prevent cancer. The use of big data in cancer research is making it feasible to understand which factors are more important in improving treatment outcomes. Better screening methods will become available and early detection will become the norm. The use of artificial intelligence and machine learning could have a transformative impact on breast cancer screening. Policy shifts will also play a role in cancer care.
Over the next couple years, as we move away from a fee for service reimbursement model to a quality-based model, an even greater emphasis will be on patient-centered care. This will mean that patients will become more engaged in their treatment decisions and will be partners with their providers, both working in concert to achieve optimal outcomes. Improved outcomes will best be accomplished with a comprehensive and integrated approach to cancer care.
Editors note: David Tatman is executive director of the MercyOne Dubuque Cancer Center.