Breast cancer afflicts up to 1 million people worldwide annually, including 230,000 cases in the United States.
Tragically, up to 40,000 deaths occur each year in our country due to breast cancer, which remains the number one cause of overall mortality in women between ages 40 and 49.
Film star Angelina Jolie chose to undergo prophylactic bilateral mastectomies upon learning that she was at high risk of the disease due to an inherited gene mutation called BRCA1, which is also linked to ovarian cancer.
Genetic screening tools that identify those at risk for cancer are emerging, and playing a larger role in prevention of cancer. For example, I gather that Angelina Jolie is now considering further surgery to prevent ovarian cancer also linked to the BRCA1 gene. Preventing cancer is an optimal strategy. But how about patients who are diagnosed with breast cancer? What can we offer them?
Treatment of breast cancer requires a multidisciplinary approach. A primary care physician will coordinate care with other specialists. Oncologists, radiologists and surgeons play pivotal roles. About 5 percent of patients will be diagnosed with disease that is widespread, a condition referred to as “de novo metastatic” disease.
Some patients present with localized disease, but subsequently develop recurrences that may metastasize. A large part of the initial evaluation of a cancer patient involves an effort to achieve diagnostic precision with respect to tumor size, microscopic characteristics of the tumor and more arcane characteristics, including presence or absence of estrogen or progesterone receptors.
If a cancer is staged in a manner that suggests localized disease with limited potential for spread, so-called “breast-conserving” treatments might be an option. In patients with larger tumors with more ominous pathological characteristics, mastectomy may be necessary.
Oncologists are experts at “staging” cancers and recommending the best treatments. Chemotherapy, radiation treatments, surgical reconstruction and treatment of depression may all play a role.
The American Society of Clinical Oncology recommends discussion of risks versus benefits of specific therapies. For example, chemotherapy may adversely impact fertility in patients of child-bearing age. Treatment must be tailored to achieve maximum benefits with the fewest possible side effects.
Since some tumors appear to be stimulated by hormones such as estrogen, some medications block receptors of these naturally occurring bodily compounds. Examples of estrogen-receptor modulators include tamoxifen, and newer agents called aromatase-inhibitors are broadening the therapeutic options with respect to this class of drugs. Clinical trials demonstrate decreases in cancer recurrence in selected patients treated with these medications.
Metastatic disease is more challenging to treat, although chemotherapeutic agents have been employed that may markedly improve survival. Treatment of breast cancer consists of more than just eradicating the disease. For example, we have agents that stimulate white blood cell production, red blood cell production, and we can treat complications of the disease, including infections and pain.
Palliative care remains a cornerstone of assisting patients and families struggling with this condition. There is more to practicing medicine than curing diseases, and management of breast cancer may require sensitivity to a wide array of psychosocial dynamics.
Every patient is unique. Although widespread breast cancer may decrease median survival rates to months or years in some patients, others soldier on for many years with the assistance of active treatment interventions.
We do not entirely understand the way the body’s immune system may resist recurrences of cancer. Moreover, the National Institutes of Health continues to sponsor clinical trials designed to improve treatments for cancer.
Many malignancies that were previously fatal, including a number of leukemias and lymphomas, are now curable in some cases. Therefore, I remain optimistic that we will continue to make strides in treating breast cancer.
Scott T. Anderson, M.D., Ph.D. ([email protected]) is clinical professor of medicine, UC Davis. This column is informational, and does not constitute medical advice.