Breast cancer treatment now tailored to patient, less invasive

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Undergoing a mastectomy can be both physical and emotional, but in recent years, less invasive ways of treating breast cancer mean fewer breast-removing surgeries. With me to talk about some of the newer techniques is Dr. Scott Albert. He leads the breast cancer care team at the Upstate Cancer Center.

Welcome to "The Informed Patient," Dr. Albert.

Scott Albert, MD: Hi. Nice to be here, and thanks for having me.

Host Amber Smith: Now, are you seeing more younger women with breast cancer diagnoses?

Scott Albert, MD: Yeah, I think the short answer is we have noticed there's been a rise in breast cancer in younger women, and that's been sort of ongoing for the last couple years.

Host Amber Smith: Do we know why that is?

Scott Albert, MD: That's a good question. I don't think we have all the answers. I think there's a whole host of reasons. I think, probably, we have better screening. We probably are also noticing the effects of some of the issues in our society, like obesity and alcohol use.

Those are all factors that impact breast cancer, and I think that's contributing to this rise in a younger population.

Host Amber Smith: Now, before we get into surgery, let me start by asking you to address what has changed or improved about biopsies, because if something's wrong on a mammogram or breast imaging, isn't the next step often to sample the tissue with a biopsy?

Scott Albert, MD: Correct. Yes. We've gotten very good at biopsying abnormalities in the breast, and we can detect abnormalities that are very small, on the order of millimeters. And so really, the gold standard is to perform a core needle biopsy of an abnormality. This is for a couple reasons. One, it allows us to get adequate tissue for sampling and testing, but also it allows us to mark the site with a special clip in order to know where to go back and find this abnormality in the future. And that's a very important aspect of doing a core biopsy.

Host Amber Smith: I understand breast cancer treatment is extremely individualized these days, but that surgery may be part of that treatment. So let's talk about the different types. Are there fewer mastectomies where the entire breast is removed these days?

Scott Albert, MD: Yes. I would say breast cancer treatment has become very, like you said, individualized and tailored, and we really have a whole toolbox of options, and some of those options are actually flipping the order of treatments.

So we are shrinking tumors with effective chemotherapies. This allows us to then give patients the choice of breast preservation, so they can, rather than get a mastectomy, have the option of getting a lumpectomy. And we know based on huge clinical trials throughout the world over many years, that there's really no survival benefit to a mastectomy. And so obviously there's certain circumstances where a mastectomy makes a lot of sense, but we are at the point where we can offer more than one surgery to patients. And so I think the lumpectomy or lumpectomy and partial mastectomy, we use those words interchangeably, are more common than maybe 20 years ago.

Host Amber Smith: Has the recovery changed along with that?

Scott Albert, MD: Yes. The recovery for breast cancer surgery has, I think, changed dramatically.

From my experience, and actually during COVID, I think, we started sending more and more patients home after mastectomies and mastectomies with reconstruction. And we realized patients do just as well going home the same day in many cases, than staying in the hospital. And so the recovery has really been changed quite a bit, actually, I think in the last five years or so.

And from a lumpectomy, and patients do very well. It's an outpatient surgery. They take minimal pain medication afterwards, and so we've really started to minimize the effects of surgery on patients as we get better treatments overall.

Host Amber Smith: What improvements have been made in reducing scars?

Scott Albert, MD: We can position scars on the breast in areas that are more cosmetically appealing. So whether it's underneath the breast or at the edge of the areolar skin (around the nipple), or more in the axilla (armpit area), these are all areas that are pretty nice in terms of cosmesis (preserving appearance). But we also realize we can identify lesions using newer technologies, so this allows us to find these small areas through these smaller incisions.

So I think a combination of being able to put these incisions inlocations that are cosmetically appealing but also having these localization techniques where we can identify these small masses -- those techniques have improved.

Traditionally we've used wires, so we put these small wires in and identified these small clips that have placed at the time of biopsy, but now there's other techniques like radio frequency tags and stuff. So this allows us to minimize the incisions.

Host Amber Smith: Well, let me ask you about targeted, or immunotherapy. Is that changing the timing or the way that surgery is done?

Scott Albert, MD: Yes, I think we are realizing that many times, we can shrink tumors, and we can get pathologic complete response rates, meaning we take out the site that was biopsied, and there's no residual tumor, by using these targeted therapies. So these are in combination with chemotherapies, but as we continue to find the right recipes, the right chemotherapy regimens for certain tumors, we are increasing our chances of pathologic complete responses.

That's the goal: finding the right recipes to remove the tumor with systemic treatment and minimize the chance of this spreading to other parts of the body.

Different tumors require different treatments, and so we are really starting to tailor and hone in on which treatments are best for which tumors. In fact, we are opening a trial where we're using targeted therapies in hormone receptor positive breast cancers in the neoadjuvant setting, so before surgery, whereas we've been doing that for a little while for other types of breast cancer, like a triple negative breast cancer, but we just opened a trial for using that targeted therapy in hormone receptor positive breast cancer.

So this is actually very important. Surgery could be obsolete in five to 10 years, maybe longer, maybe 20 years. We'll see how effective these treatments are, but it's amazing how well our therapies are working.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Scott Albert, who leads Upstate's breast cancer care team. I've heard of something called axillary staging. Can you explain what that is and how it's used?

Scott Albert, MD: Yeah. So when I talk to patients about breast cancer, we talk about two aspects of the breast operation.

We talk about removing the tumor for therapy. Obviously we want to get rid of the tumor, make sure the margins are clean.

But the second part of the operation that I explain to patients is axillary staging, where we want to get information about the biology of the tumor by removing a lymph node or lymph nodes. And that can be done in a minimally invasive way, where we inject a dye in the breast that goes into the lymphatics, stops in a node, and we remove that node, called the sentinel node, or sometimes more than one, and that gives us staging information.

Now that, again, is pretty minimally invasive, but we don't always need that information at this point because we have other tools now, in terms of biology testing of the tumor, that we may not always need the axillary information. And that's important because the sentinel node procedure is better than what used to happen, where you would have a formal axillary dissection, where you'd remove a whole bunch of lymph nodes.

Now we're down to removing one, maybe two, three lymph nodes. And in the future we may be going to the point where we don't always need to stage the axilla because we have all this powerful molecular information from the tumor. So axillary staging is still an important component and sometimes can be actually therapeutic because we are removing abnormal nodes in certain cases, but usually it has diagnostic purposes only, meaning giving us staging information for that patient.

Host Amber Smith: Now, axillary is important. That's the lymph nodes that are closest to the breast, in the armpit?

Scott Albert, MD: That's correct. Yes. So the lymph nodes in the axilla, those are typically the first lymph nodes that drain the breast. And those are the lymph nodes that give us information about the potential for that tumor to spread elsewhere.

Host Amber Smith: Now, let me ask you about radiation. Is that typically part of a woman's treatment regimen?

Scott Albert, MD: Yes. The team that treats breast cancer patients is a surgeon, a medical oncologist and a radiation oncologist, amongst a larger group of team members. But radiation oncology is a subspecialty that really, I tell people a lot of times, it makes surgery better, meaning it reduces the risk of a recurrence in the breast or in the axilla by the addition of radiation.

And radiation can be given a whole variety of ways, various techniques to minimize the side effects, but really does provide added benefit to the breast cancer patient in terms of minimizing the chance of this becoming an issue in the future.

Host Amber Smith: Minimally invasive robotic surgeries are used in a lot of different surgical specialties.

Do they have a role in breast cancer surgery?

Scott Albert, MD: The short answer is, probably not yet. There are some clinical trials looking at using the robot for a mastectomy. My issue is that we don't want to compromise an oncologic operation for the benefit of a technology. So I think there's probably going to be a point where the technology will be beneficial, whereas I think at this point it might be too early to use on a routine basis. But I suspect there'll be a point in the future where as the technology improves, we can tailor our use of it to the oncologic operation.

Host Amber Smith: Well, let's talk a little about reconstruction. If it's needed, if there's a mastectomy, is that commonly done during the initial surgery?

Scott Albert, MD: The most common way to do breast reconstruction is in coordination with a plastic surgeon at the time of the initial operation, where the breast surgeon leaves a skin envelope for the plastic surgeon to do the reconstruction. And that reconstruction typically is done in stages.

And the first stage is a temporary expander or temporary implant.

And then the second stage, when the breast cancer treatment has been completed, is a smaller operation where the expander comes out and the more permanent implant is placed, so that's the most common way to do breast reconstruction. So it does take a bit of coordination.

There's obviously lots of other strategies, and using a patient's own tissue is another option, but in the last, maybe, 10 years, it's become more commonplace to use implants for a variety of reasons.

But there are other ways to reconstruct the breast. And also, interestingly, probably in the last couple years, it's been a little bit in favor, patients frequently ask about no reconstruction, and that's also an option for many patients. I think it's interesting how, I think, the mainstream media does have an influence on, and social media has an influence on, patients' decisions many times, and I think sort of a trend of going flat has been pretty common. Patients will ask for that pretty frequently these days, so kind of a pendulum that swings back and forth, in terms of the breast cancer operation itself.

Host Amber Smith: If a woman has the lumpectomy, where a smaller amount of tissue is taken out, is reconstruction ever needed? Or would it leave one breast smaller than the other, necessarily?

Scott Albert, MD: Not typically. I would say we try to minimize the amount of breast tissue that's removed, radiation techniques have improved, so there's less deformity to the breast. So not usually do we need to do anything, but maybe there is a point down the road where either the patient wants some symmetry to the untreated breast, so sometimes a plastic surgeon might get involved for a breast reduction or a breast lift, or in some cases you could put a small implant in on the treated side if needed.

But that, I would say, is not very common.

Host Amber Smith: Let me ask you about the implants that are used today. Are they liquid or solid or gel? What are they made of these days?

Scott Albert, MD: They're more or less a gel, a silicone gel. They work well. They don't have the issues in the '90s, where there was concern about silicone rupture. They don't rupture per se like they did maybe back then, and so they are safe and relatively easy to work with for a plastic surgeon.

Host Amber Smith: Now, I realize your specialty is surgery, but can you speak about the therapies that may be prescribed after a woman has surgery?

Scott Albert, MD: Yeah, I always tell people that breast cancer in many ways is a chronic disease. So, it's a disease that we treat, and then we follow. And, just like high blood pressure or diabetes, you give a therapy, and then you see how that therapy performed. And in breast cancer, many times after surgery and radiation, in certain breast cancers, we need some maintenance therapy.

So estrogen receptor positive breast cancer is the most common type of breast cancer, 60% to 70% of breast cancers. And many time those patients will be offered estrogen receptor blockade therapy or endocrine therapy. And so that's given for a long period of time, five years, sometimes 10 years, and that's a pill.

Other breast cancers may require some maintenance chemotherapy, and the use of neoadjuvant chemotherapy has then allowed us to offer different therapies after surgery, depending on how effective those neoadjuvant therapies were, those therapies before surgery.

So it's pretty common for patients that need some therapy after surgery and radiation.

Host Amber Smith: What about mammograms after surgery and after all of this? You said it's a chronic disease. Is that how you keep monitoring it?

Scott Albert, MD: Yeah, so exams, typically patients are seeing a few different physicians: the breast surgeon, the medical oncologist and the radiation oncologist if needed, and you're seeing a doctor a couple times a year. Mammography is still performed yearly, unless there'ssomething that we need to follow closer, so then it might be at most every six months. And clinical exams and having breast awareness is what we usually counsel patients about.

So this is a team approach, and we follow these patients for a long period of time afterwards.

Host Amber Smith: Well, Dr. Albert, I appreciate you making time for this interview. Thank you.

Scott Albert, MD: Thank you.

Host Amber Smith: My guest has been Dr. Scott Albert. He's the director of the breast cancer care team at the Upstate Cancer Center.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron.

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