The overwhelming majority of breast cancer is diagnosed at an early stage, is relatively easily treated, and patients have an excellent survival rate. For complex situations, Emerson physicians regularly break away from their busy clinical schedules and bring their collective knowledge and experience to bear on treating difficult cases, such as the ones described here.
At these breast cancer conferences, as well as at the weekly thoracic conference and biweekly tumor panel, specialists discuss specific cases, examining test results and sharing opinions. The goal is to develop the most effective treatment plan for each patient who seeks care at Mass General Cancer Center at Emerson Hospital-Bethke.
On this particular afternoon, the group is reviewing several challenging patients — cases that are not straightforward and require their varying perspectives, along with their considerable experience in diagnosing and treating breast cancer.
Robin Schoenthaler, MD, radiation oncologist, describes a new patient, an elderly woman who has cancer in both breasts. David I. Rose, MD, chair of radiology, points out the lesion on the left — a small area of ductal carcinoma in situ (DCIS) — and the more worrisome tumor on the right. "It is an invasive, 12-millimeter lesion, hormone-receptor-positive, and there are two negative nodes," says Richard Geller, MD, a pathologist.
After the group agrees that the best initial treatment will be lumpectomies on each side and biopsy of the right sentinel node, Sadhna Vora, MD, a medical oncologist from Massachusetts General Hospital, notes that the risks and toxicities of chemotherapy may outweigh potential benefits in this case. "However, the patient should be advised to take an aromatase inhibitor," suggests Dr. Vora, in reference to an estrogen-lowering cancer medication.
"With such a small tumor, clinical trials have shown that her risk of recurrence is quite low, and the benefits of radiation therapy are minimal," adds Dr. Schoenthaler, who notes that the patient has a fairly serious medical condition and may not opt for radiation.
"In cases like this, patients often help us with the medical decisions," says Susan Sajer, MD, a medical oncologist who specializes in breast cancer. "Once she understands her excellent prognosis, she may choose not to have radiation and instead receive an aromatase inhibitor."
A young woman who had been successfully treated for colorectal cancer with surgery, radiation and chemotherapy was found to have a small, grade 1 breast cancer. Dr. Schoenthaler mentions there is a history of cancer in the patient's immediate family.
"Well then, the first thing we'll need is genetic testing," says Dr. Sajer. "Once we have those results, then we can move on to appropriate surgical and radiation recommendations, as well as potential hormone therapy. The moral of the story is, as patients are cured of one cancer, they are at risk for other cancers and should receive standard cancer screenings, including mammography."
The group then discusses a patient who had come to Emerson with stage IV breast cancer that had metastasized to her lung. "She has been on hormone therapy — an aromatase inhibitor — for more than two years," notes Dr. Sajer. "I see her on a regular basis, but last month my exam showed a new 8-millimeter breast tumor. It appears her hormone therapy is losing its effectiveness."
"Is it time to operate?" Dr. Schoenthaler asks.
"No, there is no evidence this patient will benefit from mastectomy," says Elizaveta Ragulin Coyne, MD, a general surgeon, noting that the standard of care for stage IV breast cancer is systemic therapy with hormonal therapy or chemotherapy and possibly radiation.
"Yes," says Dr. Sajer. "I think the patient is a good candidate for alternate hormone therapy to help put the brakes on cancer cell growth and division." Dr. Vora suggests that the patient may wish to consider participation in a clinical trial evaluating new endocrine therapies alone or with alternate hormone therapy.
Dr. Rose then shows different imaging views of a woman on whom he recently performed a core biopsy. "You'll see a small, 4-millimeter lesion," he says. Dr. Geller draws the group's attention to a second tumor in the other breast — an invasive, 7-millimeter breast cancer.
Dr. Sajer notes that the patient previously was treated for a slow-growing gastrointestinal tumor. "Then she had an abnormal mammogram," says Dr. Sajer. The group discussed whether or not her previous tumor is known to be associated with breast cancer.
Dr. Schoenthaler says that the patient will have genetic testing, and surgery on her right breast is scheduled, along with an ultrasound exam to look more closely at her left breast.
The benefits of collective discussion
Before the group breaks up, Dr. Schoenthaler notes that she recently attended a national conference where it was reported that the number of mastectomies performed in the U.S. is increasing. "Bilateral mastectomies appear to be occurring more often in women who have had MRIs, regardless of the findings," she says. Dr. Ragulin-Coyne asks about the criteria for performing an MRI, both at Emerson and Mass General. The group discusses how each hospital uses a relatively conservative criteria.
"Still, I think we need to monitor our own numbers," says Dr. Schoenthaler. All agree, and the session ends, with a few of the physicians staying to continue discussing specific patients while others head back to Emerson inpatient units or their offices.
Through their work today, they have helped assure that women who come to Mass General Cancer Center at Emerson Hospital-Bethke — including those with complex, advanced cases of breast cancer — have the best possible chance of survival, which today is true for the overwhelming majority of women who are diagnosed.
Conference reviews a range of images, considers a range of treatments
There is much information to consider at Emerson's breast cancer conference — not just an individual patient's situation and medical history, but all the diagnostic information in a variety of formats and numerous options for treatment.
Imaging tests are presented to the group, including mammograms, ultrasounds, chest CT scans, breast MRIs and bone scans, as well as PET/CT images. The pathology reports that are presented may be based on tissue taken during biopsies or surgery, with or without lymph node sampling. Treatment may include each or all of the following: surgery — lumpectomy, mastectomy or re-excision — radiation therapy, chemotherapy, hormone therapy and targeted therapy, including in the context of a clinical trial.
Today, treatment is based on a number of factors, starting with the stage of the disease — its size, whether lymph nodes are involved and whether the primary cancer has metastasized to another part of the body. The treatment plan also considers whether or not the tumor has hormone receptors — that is, sensitive to either estrogen or progesterone — as well as the HER2 status (indicating the presence of a protein associated with a specific type of breast cancer) and the patient's genetic status. For example, does the woman carry the BRCA1 or BRCA2 mutation that puts her at high risk for developing breast cancer?
Finally, a woman's age, medical history, overall health and personal preferences are each considered by the breast cancer conference members as they work together to develop the right treatment plan for each patient.
Visit emersonhospital.org/cancer or call 978-287-3436 for more information.