By Ashley Mackin
Director of the Breast Care Unit and Professor of Clinical Surgery at UC San Diego, Dr. Wallace opened with the point “this field is changing really rapidly.”
“If I gave this presentation six month ago, I’d have to change the whole thing,” she told the gathering at La Jolla Country Club. “There’s a lot to breast cancer, it’s not just a matter of diagnosing or doing reconstructing, it’s looking at a patient from a lot of different aspects.”
Who’s at risk?Risk factors, as well as how those risks can be quantified, has changed dramatically over the years, Dr. Wallace reported. She said scientists know quite a bit about the role genetics play in the risk for developing breast cancer, but the scientific exploration of the “BRCA” gene has changed the game. She said someone with a BRCA gene — which actress Angelina Jolie famously announced she carries — has up to an 87 percent chance of developing breast cancer.
However, “This gene is associated with other cancers, too, like melanoma and prostate cancer or pancreatic cancer,” Dr. Wallace said. “Some women don’t have breast cancer in their family, but they might have these other cancers in their family, so we’re putting the word out ... to make sure you take a detailed family history.”
In addition to family history, other risks are also becoming clearer. “What we didn’t know until very recently is that there is a clear relationship between diet, obesity, exercise and alcohol (to the risk for developing breast cancer).”
When it comes to alcohol consumption, she said four drinks a week are considered cause for a slight risk increase, and seven drinks a week a significant risk increase. However, exercise can help decrease the risk of cancer.
Dr. Wallace said a woman’s body size factors in, too. An adult woman should not weigh more than five percent of what she did when she was 18 years old. “I always kid and say I would like to have a study that puts exercise against alcohol to see if you can exercise off your alcohol,” she joked.
Once risk is determined, there is a mathematical model some doctors use that takes in all risk factors and issues a number indicating one’s overall risk of developing breast cancer, she said.
Screenings and preventionIn an effort to further personalize the approach to breast cancer, once a person’s risk level is determined, doctors can implement different screening strategies, depending on the patient’s breast size and density.
She said in California, there is a law that mandates patients be told if their breasts appear dense on mammograms so they can be counseled on additional imaging techniques.
Dr. Wallace said she uses a MRI machine on many of her patients.
“MRIs are now used for women who have dense breasts, high-risk women or women who present with something in the lymph nodes,” she said, showing slides of how breast tissue with a small tumor looked after a mammogram, and then how it looked after an MRI. The MRI indicated there was cancer present in much of the breast tissue.
In addition to screenings, those with in an increased risk of developing breast cancer can also undergo chemoprevention and surgical prevention.
“Chemoprevention basically means getting drugs to somebody so we can lower their risk for breast cancer,” she said.
When it comes to surgical prevention, Wallace said there is an attitude of old-is-new-again. “We can remove the ovaries (of high-risk women) when they are done with childbearing,” she said, adding that surgeons in the 1950s removed women’s ovaries for breast cancer risk- reduction and everyone thought that was appalling.
“Then data started coming out to suggest that ovarian shutdown is very good for breast cancer (prevention) in extremely high-risk women,” she said.
Similarly, women can elect to have their breasts removed through a bilateral mastectomy. However, she explained there was a paper published in 2010 that showed when women have a mastectomy to reduce their risk for breast cancer, it doesn’t guarantee an extended lifespan.
“So when Angelina Jolie chose to have her breasts removed, her statement, ‘I did it because I want to live,’ was a little misleading,” Dr. Wallace said. “The statement, ‘I didn’t want to put my kids through me having cancer,’ is more correct.”
Removal and repairHowever, she said perhaps women are jumping to this solution a little too quickly.
“We are in a little bit of an epidemic of doing these very radical surgeries right now. I think some of it is we’ve gotten very good at reconstructing, but the rest of the world does not do as many bilateral mastectomies as we do,” she said.
Other options for cancer removal include radiation, which has been improved in recent years, especially for larger-breasted women. Thanks to better technology, instead of increasing the amount of radiation to accommodate the larger amount of breast tissue — which can expose the heart and lungs to radiation — radiation can be localized to specific areas of the tissue.
Whether patients have a lumpectomy or mastectomy, there are also several developments in reconstruction.
Dr. Wallace said there is a new breast implant (nicknamed “the gummy bear implant”) that the FDA approved in March. It has an anatomic shape, which it keeps when placed upright, and does not collapse. It is implanted higher up on the breast for a more natural look and does not have liquid inside, so if it breaks, there is no leakage.
Looking aheadDr. Wallace said the future of breast cancer is in understanding biology. “Ten years ago, if you had a three- centimeter tumor (of a certain type), you got chemo because it was three centimeters. Now we are sending that tumor for genetic testing and ... that tells us if chemo is going to be effective. That person can go on a drug (instead).”
She said there are new drugs in the works that focus on specific biological signatures of the tumor. “That’s where we are going in cancer; finding specific care for a specific tumor as opposed to the same thing for everybody.”