Select breast cancer patients who after undergoing chemotherapy as their first line of treatment show no residual cancer – a state known as pathologic complete response (pCR) – may be able to avoid follow-up breast and lymph node surgery, according to an MD Anderson study. The study identifies patients known as “exceptional responders” who are at lowest risk for local metastases and therefore are candidates for less invasive treatments.
Henry Kuerer, M.D., Ph.D., professor of Breast Surgical Oncology, is principal investigator of the study that enrolled 527 women diagnosed with triple negative and HER-2 positive breast cancers. All the participants received neoadjuvant chemotherapy, in which chemo was their initial treatment, followed by standard breast and lymph node surgery. Clinical staging was determined prior to chemo by core biopsy or fine-needle aspiration, followed by clinical exam, mammography, and ultrasound of the breast and lymph nodes.
Kuerer set out to identify which patients in the group could have safely avoided surgery. To do so, he first needed to identify those who achieved a pCR following neoadjuvant chemo.
Kuerer had recently completed a trial investigating the utility of image-guided biopsies to predict breast pCR. The preliminary results of that study revealed the technique to have 100 percent accuracy and 100 percent predictive value for determining residual disease following neoadjuvant chemo.
“By doing the same image-guided needle biopsies after neoadjuvant chemo that we do at time of diagnosis, our preliminary research revealed we can accurately predict which women will have a complete response,” said Kuerer.
The current study tested
participants using this technique, and showed that patients
achieving a breast pCR were seven times less likely to have residual
cancer in the lymph nodes
“Based upon these findings, we anticipate women with initial lymph node-negative disease may avoid breast and lymph node surgery if they achieve a pCR after neoadjuvant chemo and move on to standard radiotherapy,” said Audree Tadros, M.D., fellow in Breast Surgical Oncology and the study’s lead author.
Read more about this study in MD Anderson’s newsroom.
Linda Phetphongsy is still trying to adjust to life with breast implants, though she welcomes the peace of mind they bring her.
“I feel great, and I don’t have to worry as much about getting breast cancer,” she says.
The 32-year-old mother of two underwent a double mastectomy and breast reconstruction last year after learning that she has a BRCA1 gene mutation, which puts her at increased risk for breast cancer and ovarian cancer.
Linda inherited the BRCA1 gene mutation from her mother, who had cancer three times -- breast cancer in 2003, ovarian cancer in 2013, followed by an ovarian cancer recurrence in 2014. Her mom died of ovarian cancer in May 2016.
“We lost my mom to cancer when she was in her late 50s, and I don’t want that to happen to my kids,” she says.
Taking control of a BRCA1 mutation
When Linda’s mom died, she’d already begun talking with Nicole Fleming, M.D., her mother’s doctor at MD Anderson in Sugar Land, about what she could do to reduce her own chances of developing breast and ovarian cancers. Fleming recommended a double mastectomy and eventually a hysterectomy.
Linda quickly scheduled up an appointment with breast surgeon Makesha Miggins, M.D., to learn more about her options.
“I decided to go ahead and do a mastectomy first after speaking with Dr. Miggins,” she says. “My mother had just passed, so at the time, it felt right. I wanted to do everything I can do to avoid getting cancer.”
In August 2016, Linda underwent a double mastectomy. During the six-hour surgery, Miggins removed nearly all of Linda’s breast tissue while Victor Hassid, M.D., inserted a tissue expander to keep her skin stretched until breast reconstruction surgery.
“The pain didn’t last as long as I thought it would. I pretty much expected the worst because I watched so many YouTube videos, but it wasn’t as bad as I expected it to be,” she says.
Four months later, Linda had her breast reconstruction surgery. Hassid replaced the tissue expander with breast implants then added a little bit of fat from Linda’s belly to fill out extra space in her left breast.
Life after a double mastectomy
Though she’s completely recovered from the three-hour surgery, Linda’s not yet fully used to her implants.
“I still don’t feel like they’re my breasts,” she says. “I have no feeling in the middle part of my breasts, and they definitely look different. My nipples get hard by themselves, and I won’t even be cold. I’m still getting used to wearing a bra.”
But she’s grateful for the support she received from her care team.
“Dr. Miggins and Dr. Hassid did an excellent job, and their team -- they’re awesome,” she says. “They were just so caring. They walked me through the entire process and they explained everything to me. They took all my concerns into consideration.”
Next up: a hysterectomy
Linda’s only halfway done with her cancer prevention journey. She plans to undergo a hysterectomy within the next two years. She says people often ask her why she’s decided to take such radical measures if she’s never been diagnosed with cancer.
Her response is simple: “It’s different when you have children. I want to be at their wedding, walk them down the aisle,” she says. “We kind of lost out on that with my mother. I don’t want my children to have to deal with that.”
Request an appointment at MD Anderson online or by calling 1-877-632-6789.
BY Jacqueline Mason
A cadre of elite surgeons is making a mark as pioneering researchers at MD Anderson. In the operating room, they’re not just excising tumors, they’re testing innovative therapies to stop cancer in its tracks.
The surgeons you’re about to meet have dedicated their careers to curing and preventing cancer, often through less-invasive procedures. Curiosity spurs their motivation: Can doing less to patients — or something dramatically different — allow doctors to manage their disease and return them to a reasonable quality of life?
To get answers, their patients have enrolled in clinical trials that unfold in the operating room and are often over in just minutes or hours.
Breast cancer patients with dense breast tissue have almost a two-fold increased risk of developing disease in the other breast, according to new research from MD Anderson Cancer.
The study, published in the journal Cancer, is among the first to find the association between breast density (BD) and what is known as contralateral breast cancer (CBC). Dense breasts have a lot more fibrous connective tissue and glandular tissue and little fatty tissue.
According to study author Isabelle Bedrosian, M.D., a big challenge in the management of this patient population, especially as they are making surgical decisions, is trying to counsel women appropriately on their risk of developing breast cancer in the other breast.
“We know there are a number of well-established influences for developing both primary and secondary breast cancers, such as BRCA mutations, family history and the tumor’s estrogen receptor status,” explained Bedrosian, a professor of Breast Surgical Oncology. “We also know density is a risk factor for the development of primary breast cancer. However, no one has closely looked at it as a risk factor for developing contralateral disease.”
The estimated 10-year risk for women with breast cancer off developing CBC can be as low as 2%, and as high 40%, said Bedrosian. The dramatic range is mostly due to the variability of risk factors across the patient population, she explained.
For the retrospective, case-controlled study, the researchers identified 680 stage I, II and III breast cancer patients, all treated at MD Anderson between 1997 and 2012. BRCA patients were excluded from the study, given their known increased risk of CBC.
Women with an additional diagnosis of metachronous CBC – defined as breast cancer in the opposite breast diagnosed more than six months after the initial diagnosis – were the “cases,” and patients who had not developed CBC were the “controls.” Cases and controls were matched on a 1-2 ratio based on a number of factors, including age, year of diagnosis and hormone receptor status.
Of the selected patients, 229 were cases and 451 were controls. The MD Anderson researchers categorized each patient’s breast density by mammogram reading, assessed at the time of first diagnosis, as “nondense” or “dense,” using the categorizations from the American College of Radiology.
Among the cases, 39.3% were classified as having nondense breast tissue and 60.7% as having dense breast tissue, compared to 48.3% and 51.7%, respectively, in the controls.
After adjusting for known breast cancer risk factors, the researchers found almost a two-fold increased risk of developing CBC in breast cancer survivors with dense breasts.
Read more about this study in MD Anderson’s Newsroom.
The first national review of breast-conserving therapy (BCT) shows that over the last 13 years, rates of this treatment for early-stage breast cancer have increased at a steady pace. However, the review also highlights demographic factors that impact whether or not a patient will have access to BCT. MD Anderson researchers found that disparities related to age, treatment facility type and geographic region, are declining. But they also identified several socioeconomic factors including health insurance coverage, income and travel distance to treatment centers as barriers to BCT.
Published online in JAMA Surgery, the researchers used the National Cancer Data Base (NCDB) to examine the surgical choices of women with stage T1 or T2 breast cancer treated between 1998 and 2011. The NCDB is a nationwide oncology outcomes database that includes approximately 70% of all newly diagnosed cases of cancer in the U.S. Of the nearly 728,000 women included in the analysis, the percentage undergoing BCT increased from 54.3% in 1998 to 59.7% in 2006, and then remained relatively constant, landing at 60.1% in 2011.
However, the rates of BCT — also called lumpectomy — varied based on patient demographics, including insurance status and income, and treating facility variables such as facility type, location and travel distance for the patient.
“Looking at the big picture, strides have been made to reduce disparities in the use of this very effective treatment for women with early-stage breast cancer. But despite significant progress by the medical community, there are significant pockets of women where this therapy is underutilized,” said principal investigator Isabelle Bedrosian, M.D., associate professor of Surgical Oncology and medical director of the Nellie B. Connally Breast Center at MD Anderson. “The socioeconomic barriers are unlikely to be erased without health policy changes.”
Elaborating on the findings, she added that lower rates of BCT among women who live farthest from treatment facilities may be attributed to patients’ ability or willingness to travel for daily radiation therapy, a standard follow-up to lumpectomy. This may also account for lower rates of BCT in the South, where women often have disproportionately greater travel distances to treatment facilities. Income and insurance status also play a significant role in surgical choice, as a woman from a low-income family may be unable to commit to the length of time needed for the weeks of radiotherapy.
Most women with breast cancer have some type of surgery to remove the tumor, usually opting for BCT or mastectomy. With BCT, only the part of the breast containing the cancer and some surrounding tissue are removed. The National Institutes of Health issued a consensus statement in 1990 in support of BCT that led to a substantial decline in mastectomy rates and widespread acceptance of BCT as an appropriate and effective treatment for early-stage breast cancer. However, in the past decade, technical advances and other societal changes — including genetic testing for BRCA1 and BRCA2 mutations, advances in reconstruction techniques, breast magnetic resonance imaging and contralateral prophylactic mastectomy — have garnered increased patient interest.
According to Dr. Bedrosian, this study confirms that the majority of women are choosing BCT, a “reassuring finding that patients and physicians recognize that this less invasive therapy is a good course of treatment for early-stage breast cancer.” However, she added, “These data also demonstrate the breadth of the socioeconomic factors that need to be considered to adequately address the disparate use of BCT across demographic groups.”
Read the full press release on the MD Anderson website.