Targeting and Fighting Breast Cancer in Its Many Forms.

After skin cancer, breast cancer is the most common cancer in women; only lung cancer is deadlier. This serious disease will affect over 275,000 American women this year alone. Of those, 42,000 will not survive—and that’s why it’s so important for women over 40 to have regular mammograms.

But there’s good news, too. The outlook for recovery from breast cancer is far brighter than it was in decades past. Each year, science and medicine make new discoveries and refine treatments.

Breast cancer spans a spectrum of diseases that target breast tissue and it’s important that we understand their biology and behavior.

This form of cancer can be the result of many factors. Genetic factors trigger about 5%–10% of all instances, but most cases affect women with no genetic predisposition. Also among the risk factors are use of alcohol, obesity and increased breast density.

But for most women diagnosed, their breast cancer is not the direct result of a lifestyle choice. Unlike most cancers, even tobacco use isn’t directly implicated, although smoking is still a very bad idea as it complicates treatment and recovery.

The Genetic Connection

Certain women are genetically predisposed to breast cancer, and genetic counseling is an important part of the MedStar Health breast cancer program. Red-flag risk factors include: any breast cancer diagnosis under age 50, a diagnosis of triple-negative breast cancer for a patient under age 60, a strong family history (a mother or sister with breast cancer), and cancer found in both breasts.

The most commonly implicated genes are mutations in two specific genes, abbreviated as BRCA1 and BRCA2. A mutation can increase a woman’s lifetime risk of breast cancer up to 50% over women without the mutation.

The BRCA mutation also increases the risk of ovarian and other types of cancer. It is often the culprit in cases of male breast cancer and, depending on the mutation, could also increase the risk of prostate cancer.

Genetic screening gives us the information we need to make decisions about treatment—for example, preventative surgery (especially after childbearing years) or an increase in breast screening, sometimes with MRI to complement mammogram and ultrasound. And screening can protect the entire family, since sisters, daughters and mothers may also be at risk.

Breast Cancer Types

Our first line of defense is understanding the nature of the cancer and matching it to the best evidence-based treatment. The more we know, the better the outcome.

Just 25 years ago, treatment was limited, and breast cancer was much less survivable. Today, with new medicines targeting specific cancer cells, the majority of women are diagnosed with early stage breast cancer.

• Estrogen and Progesterone Receptor Status (ER+/PR+): In ER positive (ER+), the most common type of breast cancer, the tumor’s growth is fueled by estrogen. It is less aggressive than other types. We tend to treat it long-term, and anti-estrogen medications can help prevent recurrence. Since ER+ often responds well to estrogen suppression, many women with this cancer may not need chemotherapy.
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  Similarly, some tumors grow in the presence of progesterone (PR+), and these likewise respond to hormone therapy.
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  An ER negative (ER-) tumor does not depend on estrogen and, because it doesn’t respond to anti-estrogen therapy, it calls for more aggressive treatment.

• HER2 Status: HER2 is a normal protein that helps regulate how breast cells grow, divide and repair. But too much HER2 may promote breast cancer growth.
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  HER2-positive tumors can be aggressive, but we have a variety of advanced therapies to target the HER2 protein. It is an area of very active research, and two new medications were approved by the FDA this year and have become available for use. The prognosis for HER2-positive tumors is good, especially when caught early—another compelling reason to stick to your mammogram schedule.

• Triple Negative: When a tumor grows without any help from estrogen, progesterone or HER2, it’s the most aggressive form of breast cancer, known as triple negative. This diagnosis typically requires a full range of treatment—including chemotherapy—to afford the best odds of more cancer-free years.

In Situ or Invasive

Within the breast tissue is a network of lobes, lobules and ducts that produce and transport milk after childbirth. Breast cancer most typically occurs in either the milk duct or in a lobule, one of the glands that produce milk.

When the cancer is isolated to a duct or lobule, it’s considered in situ, meaning “in its original place.” In situ cancers are not life-threatening, but their presence can increase the risk of developing a more invasive form of breast cancer over time.

Invasive, or infiltrating, ductal carcinoma begins in the milk duct. It’s described as invasive because it has infiltrated surrounding breast tissue. More rarely, tumors can appear in the lobule, and this is known as lobular breast cancer.

Proteins Are Key

For all types of breast cancer, we’re interested in the proteins which the cancer cells produce. The protein expression helps us classify the cancer and deliver a treatment protocol that will produce optimum results.

In years past, breast cancer was breast cancer—we didn’t have the tools to differentiate one type from another. Today, we target and isolate tumor cells much more accurately. We make decisions about medication, surgery, radiation and chemotherapy based not just on the size and location of the tumor, but on its specific biology.

Genomic testing is on the leading edge of breast cancer diagnoses. It enables us to analyze the tumor’s entire genome, the entirety of its genetic code, not just one or two isolated genes within it. Years ago, tumor size was the prime indicator. With advanced genomics, we are given an increasingly clearer view into the internal mechanism of the cancer cells. That is a much more reliable pathway to a cure.

The Path to Treatment

Most women are directed to see an oncologist after a screening mammogram uncovers a suspicious mass, or when a lump or bump is found during self-examination. Of course, it’s not always cancer. A variety of benign breast diseases, including unusual calcification or evidence of fibrocystic disease, can also spur a doctor visit.

It’s typical for the patient to then return for additional imaging studies. If the mass remains suspicious, we’ll do a needle biopsy, the most reliable way to get a sample of the abnormal cells for lab studies. The biopsy is done on an outpatient basis. The test is quick, using local anesthesia to numb the area and limit discomfort. It requires no stitches, and most women return to normal activity after a day or two.

Biopsy results provide the information we need to tailor treatment to the type and stage of disease. At MedStar Washington Hospital Center, treatment planning is very much a team effort. Each case is reviewed by a panel of experts, including breast surgery, medical and radiology oncology, plastic surgery, genetic counseling and physical therapy. The team works collaboratively towards a cure, leveraging every possible resource.

Because every woman and every cancer is unique, each plan is custom-tailored for the best possible results.

Staging has also advanced significantly. Years ago, the stage of the cancer was determined by where the cancer was found—whether it was confined to the breast tissue or spread to the lymph nodes, most often under the arm.

Today, staging is much more nuanced. Tumor size and lymph node involvement are important, but hormone receptor and HER2 status and even genomic test results are used so that we can be more confident in determining if the cancer was responsive.

Three decades ago, almost all women with breast cancer required a mastectomy (removal of the breast). In the 1980s and 90s, we learned that removing only the mass—lumpectomy—followed by radiation can be just as effective, with less than 2% odds of the cancer returning. Without radiation, those odds jump to 20–30%.

At the Hospital Center, we want our patients to have the best possible outcomes. Information guides our decisions—and the information gets better and more accurate with each passing year. Today, many breast cancer patients have the potential to be cured the minute they leave the operating room.

Through clinical trials conducted at our Cancer Institute, breast cancer patients also have access to leading-edge research with opportunities to receive next-generation treatment.

The Importance of Mammograms

The most survivable breast cancer involves small tumors in their earliest stages. The mammogram remains our most powerful tool for detecting these tumors. Thirty years ago, before screening mammography became the standard of care, less than 2% of precancerous growths were found. Today that number is at 20%, a significant lifesaving advance.

Even the smallest lump or bump should be investigated. If a patient waits too long to act on this, it doesn’t take long for a cancerous growth to move past the most treatable phase. Given the chance, more aggressive varieties can migrate to other parts of the body—significantly reducing the odds of successful treatment.

For survivors as well, we encourage them to continue with their annual mammograms, to monitor the potential return of the previous cancer or spot any new growths.

Most women can be cured of early-stage cancer—and sometimes we can only discover those cancers with screening mammography.

Breast Cancer and COVID-19

There is no reason to delay your annual mammography screening during the coronavirus pandemic. The Hospital Center is taking all necessary precautions, including pre-test COVID-19 screening, personal protective equipment and temperature checks. We have also expanded our telehealth visits and imaging hours to accommodate patients’ needs.

Cancer doesn’t stop with the pandemic, and fortunately women have continued coming to us for diagnosis and treatment. That means that lives are being saved.