P&S Journal: Spring 1997, Vol.17, No.2
The Human Portrait of Breast Cancer
A New Era of Breast Cancer Treatment

Mammographer Jeanette Weston views a group of new films, while Angelica Dominguez, also a mammographer, completes some paperwork.

 Like the estimated 183,000 American women diagnosed with breast cancer each year, women who come to the Herbert Irving Comprehensive Cancer Center often begin their treatment with dread and fear. Those feelings, it seems, are fueled in part by a breast cancer awareness blitz that has convinced women of the seriousness of the disease and the importance of early detection in saving lives.

 The more encouraging fact, however, is that at least 80 percent of biopsies are benign and most women treated in the early stages of breast cancer face excellent odds for survival. That reality, though, is of little comfort until a woman knows whether her lump is malignant, whether the malignancy has spread, and what she can expect from treatment.

Dr. Marc Brown, a postdoctoral clinical fellow in radiology, examines mammography films in the radiology quarters of the breast cancer center.

 "The hype around breast cancer is so big," says Dr. Alison Estabrook, professor of clinical surgery and chief of CPMC's breast surgery service. "Every single woman who comes here for the first time is almost crazy with anxiety." That's understandable, she says, but it also makes her work and that of the other CPMC breast surgeons so critical. "The most important thing I do is talk," she says. "I really emphasize that this is not an emergency, it's something we can take care of, and that they can take their time and ask as many questions as they wish."

Medical oncologist Dr. Linda Vahdat explains a treatment plan to a patient.

 That first visit to Dr. Estabrook, or one of the other surgeons, usually follows a routine mammogram. Perhaps a patient has a mammogram as part of her yearly physical exam and comes to CPMC for further examination and advice. With films in hand, and a slide with a tissue biopsy for further study, patients seek the expertise of doctors who focus strictly on breast surgery. "We are not general surgeons," says Dr. Estabrook.

The breast center has acquired the new Advanced Breast Biopsy Instrumentation (ABBI) unit, which enables surgeons to pinpoint mammographic lesions and then biopsy them with only one piece of equipment. Previously, a radiologist would insert a needle into the breast as a guide for the surgeon, who would then remove the lesion in the operating room. Before it is ready for patients, physician assistant Marybeth Hans conducts a trial run. Filling in for a real patient is an eggplant, in which Ms. Hans has inserted a raisin to simulate a breast lesion.

 Various treatment approaches to breast cancer are coordinated with surgeons, medical oncologists, and radiation oncologists on an individual basis. Factors such as type and location of the cancer, whether the disease has spread, and the patient's general health and age are all considered. Typical steps in the process:

1 Surgery Consultation. Establishing trust through communication goes a long way toward ensuring a patient's comfort because what follows a surgery consultation brings the most uncertainty for a woman. "Will my body be altered, will they find the cancer is more advanced, will there be complications?" a patient may ask herself. That's why the surgeon must listen and clearly respond to questions.

 When breast reconstruction is desired, a plastic surgeon is involved from the start. "We try to figure out whether breast conservation is possible, but if not, a lot of women who have mastectomies have reconstruction at the same time," says Dr. Estabrook. She estimates that 80 percent to 85 percent opt for breast reconstruction at the time of mastectomy. The benefits are many, from an improved final appearance to the need for fewer surgeries. If reconstruction is chosen, the patient may be able to consult immediately with the plastic surgeon at the surgery consultation.

 Even so, it's a lot to face in one visit. "To tell someone they may have cancer and they need surgery is something they can't always absorb at once," says Dr. Estabrook.

2 Education and Support. The surgeon may direct the patient to the Women At Risk (WAR) Resource Center, a library down the hall from the surgeons' offices in the cancer center. Breast cancer survivors staff the library, which offers books, video and audio tapes, an on-line computer system, support groups, and up-to-date information about treatment for breast cancer as well as reconstructive surgery and prostheses. "To even look at a woman who had cancer five years ago and is now healthy is very calming," says Dr. Estabrook.

3 Surgery. Depending on the lesion's size, surgeons remove the lump (a lumpectomy) or the entire breast (a mastectomy) and surrounding tissues that are also affected, such as underarm lymph nodes. Following the lumpectomy or mastectomy, the surgeon can determine the stage of the cancer and whether the disease has spread to lymph nodes. "We don't lie," says Dr. Estabrook, believing that honesty is part of the established trust between patient and doctor. "We tell them what we see during surgery."

4 Treatment Plan. Within a few days after surgery, a patient is informed of findings in the pathology report. At that point, a treatment plan is coordinated with a medical oncologist whose office is nearby.

5 Chemotherapy. The chemotherapy prescribed by one of the medical oncologists in the breast cancer center is usually administered in the chemotherapy center located three floors below the breast service or at Columbia-Presbyterian/Eastside. Dr. Linda Vahdat, assistant professor of clinical medicine, explains that although many people believe the side effects of chemotherapy are almost worse than the disease, refinements in drug combinations have reduced unpleasant associations. "The side effects aren't as bad these days."

 Adjuvant chemotherapy, given to kill cancer cells that may have spread, consists of a combination of anticancer drugs given by mouth or injection into a blood vessel. Chemotherapy is generally given in cycles for four to eight months after the removal of the cancer.

6 Radiation. For some cases of breast cancer, oncologists choose to follow chemotherapy with radiation. Unlike chemotherapy, which works throughout the bloodstream, radiation therapy focuses on the area around the tumor. Radiation helps destroy breast cancer cells that have spread to areas near the breast.

7 Stem Cell Transplant. One of the newest forms of treating breast cancer--of which CPMC is a pioneer in research and clinical trials--involves autologous stem cell transplant. In the blood bank, stem cells are collected from a vein and then frozen and stored until the patient has completed high-dose chemotherapy. After chemotherapy ends, the stem cells are infused in the patient.

 High doses of chemotherapy kill more tumor cells but also injure the immune system. A stem cell transplant replenishes blood cells that do not survive the toxicity of high dose chemotherapy but are important in fighting infection.

 Dr. Vahdat specializes in autologous transplants and the study of hematopoietic stem cells. "I always wanted to do transplant work," says Dr. Vahdat of her days as a medical student. "I did research projects that set me on my way to specialize in breast oncology." Since last year, Dr. Vahdat has been director of the breast cancer autologous transplant program at CPMC.

8 Tamoxifen. For certain women, the oral drug tamoxifen can help prevent the recurrence of breast cancer when taken for five years following conventional treatment. Although studies to further increase its effectiveness are still under way, tamoxifen is an adjuvant hormone therapy that seems to deprive cancer cells of the estrogen some breast cancer cells need to grow.

9 Follow Up. Typical treatment for breast cancer lasts six months with regular follow-up visits continuing five to 20 years after treatment. At CPMC, medical oncologists like to see patients at three-month intervals following treatment.

Photos by Jonathan Smith