Over the past few decades, changes in the treatment of breast cancer amount to a revolution in patient care. And it’s not over yet. There was a time when the standard approach was a radicalmastectomy, which involved removal of not just the breast, but all the lymph nodes in the armpit and underlying muscles in the chest wall. This approach has been replaced by less extensive surgery that, through decades of clinical trials, has proved to be equally effective at treating patients, as well as safer and less disfiguring. Even simple mastectomies, in which most nodes and the muscles were left intact, have become far less common. Dr. J. Dirk Iglehart, director of the Susan F. Smith Center for Women’s Cancers at Dana-Farber Cancer Institute in Boston, estimated that he now performs a tenth of the number of mastectomies than when he entered the field in the 1970s.
Currently, most women with early-stage breast cancer have alumpectomy; only the tumor and a small margin of surrounding normal tissue are removed, along with a few lymph nodes. Patients then receive localized radiation therapy and often drug therapy to head off a recurrence.
Even though this approach is less aggressive, breast cancer death rates have dropped steadily since 1990, a combined result of earlier diagnosis and medical therapies developed largely through a major national investment in cancer research, according to Dr. Clifford A. Hudis, chief of breast cancer medicine service at Memorial Sloan Kettering Cancer Center in New York.
“Treatment today is getting much more individualized,” Dr. Hudis said. Depending on the molecular nature of a woman’s tumor, postoperative hormonal or other drug treatments are routinely prescribed to prevent or delay a recurrence of disease.
Still, with nearly 40,000 breast cancer deaths annually in this country, more needs to be done.
Instead of waiting for cancer to recur in certain high-risk patients, scientists are now developing techniques to outsmart the cancer cell’s aggressive tactics by prompting the patient’s immune system to launch a continuous attack that keeps the disease at bay indefinitely.
Even lumpectomy could eventually become a thing of the past if these techniques achieve their early promise.
Another nonsurgical approach under study involves destroying the tumor by freezing it with an ice probe, but leaving it in place so that the immune system can be trained to attack it, Dr. Hudis said. The patient then would be given an immune stimulant to help overcome the molecular obstacles that had kept the immune system from recognizing the cancer as foreign tissue. When tumors are more advanced at diagnosis, it is already sometimes possible to minimize the extent of surgery without compromising a woman’s chances of disease-free survival.
Fran Saunders, 63, is one of the estimated 232,500 American women who will this year learn they have invasive breast cancer. The tumor, which she noticed herself after skipping mammogramsfor a few years, is confined to the breast region, but too large for a lumpectomy.
So Ms. Saunders, an administrative assistant from Brooklyn, is now undergoing 20 weeks of chemotherapy at New York University Langone Medical Center to shrink her tumor, after which surgical options will be discussed with her doctor.
“The size of the tumor and presence of positive nodes may not matter as much as we thought,” said Dr. Deborah M. Axelrod, a surgeon who directs breast cancer programs at the center. “It’s not even true that if the cancer is metastatic, it’s curtains.”
Tests are being developed to help doctors predict an individual patient’s response to various therapies, Dr. Axelrod said.
Patients are encouraged to become well-informed about their disease and possible therapies and to participate in treatment decisions. What a woman chooses may depend on such factors as her age, values, personal circumstances, professional concerns and risk tolerance.
“There’s no right or wrong decision, as long as patients are well-informed and choose what is best for them,” said Dr. Jennifer K. Litton, a surgical oncologist at M.D. Anderson Cancer Center in Houston. “The old days of paternalistic medicine are gone.”
Also gone is the simplistic notion that cancer is a disease of abnormal cell division, said Dr. Larry Norton, deputy physician-in-chief for breast cancer programs at Memorial Sloan Kettering. “It’s a disease of abnormal relationships between the cancer cell and other cells in its environment.”
This new perspective “is leading to changes in treatment,” he said. For example, current surgery for breast cancer involves removing only a few lymph nodes for testing, which avoids complications like a chronically swollen arm.
“We know that in many cases we’re leaving behind nodes that contain cancer cells, but it doesn’t hurt the patient to leave them there,” Dr. Norton said.
“Cancer cells require other cells in their vicinity to help them grow,” he added. “Understanding how the cells communicate is opening new opportunities to keep cancer cells from forming a tumor. It’s not true that if there’s one cancer cell left it will definitely grow and cause trouble.”
Knowing that the effectiveness of treatment is reduced once cancer has metastasized — that is, spread to other regions of the body — researchers are now testing creative ways to prevent such recurrences. One, a specially designed vaccine called NeuVax, is in the final stage of multinational clinical tests under the direction of Dr. Elizabeth A. Mittendorf, a surgical oncologist at M.D. Anderson.
The vaccine is made from a peptide, a small piece of a cancer protein, that is combined with an immune stimulant. Early results suggest that the vaccine can reduce the risk of recurrence by 50 percent among breast cancer patients whose tumors produce low levels of the protein HER2, a marker for more aggressive breast cancer.
Without the vaccine, such patients have a 20 percent chance of a recurrence, Dr. Mittendorf said. Rather than waiting to see if a patient’s cancer comes back, the vaccine is given at the time of initial treatment, when few if any cancer cells are present, she explained.
Changes have already taken place in postoperative radiation for breast cancer that reduce side effects and minimize potential long-term damage to organs under the breast. After surgery to remove the tumor, the breast may be only partly irradiated. Radiation can be focused on the cancerous area using a more intense but shorter course of treatment, Dr. Axelrod said.
And while chemotherapy is anything but pleasant, measures ranging from anti-nausea medication to massage are now commonly used to minimize patient discomfort