Advanced Breast Cancer Care at GW Hospital
October 17, 2024
Over the years, breast cancer has become more treatable with better outcomes. Anita McSwain, MD, MPH, FACS, a board-certified breast surgeon and the Associate Director of the GW Hospital Comprehensive Breast Care Center, explains the many options for treatment.
Q. What is the most common form of breast cancer?
A. When we talk about breast cancer, the most common type we see is what's called ductal carcinoma. That means the cancer started in the lining of one of the ducts of the breast. You start with normal ducts, and then some of the cells lining the duct can become abnormal or atypical. There are two types of ductal breast cancers.
Q. What are the different types?
A. One is called ductal carcinoma in situ. That means is the cancer cells are still confined inside the lining of the duct. This is considered a stage zero, or a pre-invasive type of breast cancer. By definition, if that is all that is found, then it has not spread anywhere else in the body.
That is a little different from the second type, invasive ductal breast cancers. In that case, some of the cancer cells have broken through the lining of the duct out into the surrounding tissue. The invasive term does not necessarily mean that it has spread anywhere, but it does mean it has the potential to have done that.
For invasive breast cancers, as part of our treatment, not only do we focus on removing cancer from the breast, but we also remove a couple of lymph nodes from under the arm on that side to see if there’s been any spread. The reason we focus on those lymph nodes is because if breast cancer does spread, that would be the first place it would go. If we look at the lymph nodes and do not see any cancer, we feel very comfortable that it hasn't gone anywhere else in the body.
Q. What screening methods does the Comprehensive Breast Cancer Center offer patients?
A. Starting between the ages of 40 and 50, women should be screened annually for breast cancer. We offer 2D and 3D digital mammography, automated breast ultrasound, or ABUS, MRI, and molecular breast imaging.
In terms of imaging and screening, GW Hospital is the first in the area to use artificial intelligence, or AI, to evaluate every mammogram, in addition to the mammograms being read by a radiologist. It’s been found that AI can find cancers up to four years earlier on imaging than when they’re read by radiologists alone.
Q. How do you approach the treatment of breast cancer with your patients?
A. There are three big categories of treatment. There are surgery, radiation and chemotherapy. Some people need all three. Others don’t. I typically try to go through all three with the patient just so they have a good understanding of the options.
Traditionally, the first step has been surgery. The goals of the surgery for invasive cancers are to remove the cancer from the breast and then to remove a couple of those lymph nodes to be analyzed under a microscope.
Concerning removing the cancer from the breast, we have two options. One is to do what’s called a lumpectomy or a partial mastectomy. Those are the same thing. The other surgical option is a total mastectomy.
Q. What happens during a lumpectomy or a partial mastectomy?
A. That’s where we just remove the portion of the breast with the cancer and a little bit of normal tissue around it to make sure that we got it all.
If we do a lumpectomy, we do recommend following that with radiation to the remaining breast tissue on that side. The reason we recommend the radiation is it's been shown to decrease your likelihood of getting another cancer in that breast by about 50% compared to if you don't have radiation.
Q. How does a mastectomy work?
A. A mastectomy involves the removal of all the breast tissue. In most cases, after a mastectomy, you would not need radiation. There are a couple of exceptions to that, including when the tumor is particularly large or if you do have lymph node involvement, then we might recommend radiation.
In general, if we do a mastectomy, we can also talk about doing your reconstruction at the same time. On the day of the surgery, I would do the mastectomy portion with the goal of removing all the breast tissue, but in a way that we keeps as much of the skin as possible. Potentially in a lot of patients, we can even keep the nipple and areola if the cancer is not too close to that area.
After I’ve done the mastectomy portion, one of our plastic surgeons would come in to do the reconstruction. They have a number of different ways they can do reconstructions. There are implant types of reconstructions, and then there are tissue reconstructions, where they take tissue from elsewhere on the body. The classic place is to take tissue from the abdomen and use that to reform a breast.
Q. What happens next?
A. Regardless of whether the patient does the lumpectomy or the mastectomy, we would do what’s called a sentinel lymph node biopsy for invasive cancers. On the day of surgery, we inject some dye into the breast and that dye goes from the breast through the lymphatics to the first one or two lymph nodes.
Everybody has somewhere between 10 and 40 lymph nodes under the arm, and they drain fluid from the breast in a certain order. The dye would go to the first one or two while the patient is in surgery and asleep. That dye would help me find the first one or two lymph nodes. I remove those nodes and clinicians actually look at them under the microscope while the patient is asleep. If they don't see any cancer in those first one or two lymph nodes, I leave the rest of the lymph nodes in place and don’t have to remove any more.
If they do see cancer in the lymph nodes that were removed, then we have to decide based on how much cancer they saw and what procedure the patient’s having as to whether I need to remove more lymph nodes while already in surgery. The reason it’s great to not have to remove all the lymph nodes is there are long-term effects of removing all the lymph nodes from under the arm. The big one is called lymphedema, which is swelling of the arm, and it can be particularly hard to deal with if a patient develops lymphedema in the future.
Q. How do radiation and chemotherapy factor into treatment?
A. Any time we do a lumpectomy, we recommend radiation. Radiation decreases a likelihood of recurrence in that breast about 50% compared to if the patient does not have radiation. The last aspect of treatment is the question of whether chemotherapy or hormonal therapy, or both, are needed. Chemotherapy refers to a regimen of medications given through an IV. Hormonal therapy involves taking one pill a day.
We look at a number of things to determine which is needed. The things we look at are the size of the tumor, whether it is in the lymph nodes, and if so, how many and whether it spread anywhere. One of the most important things we consider these days are what are called the hormone receptors of the tumor itself.
Any time a biopsy shows breast cancer, it is tested for estrogen, progesterone and HER2 neu hormone receptors. If the tumor is estrogen and progesterone negative and HER2 neu negative, the patient will need IV chemotherapy. If it is estrogen and progesterone negative, and HER2 positive, they'll need IV chemotherapy. Anytime it is HER2 positive they will need IV chemotherapy.
The one subset that doesn't need that IV chemotherapy is the estrogen and progesterone positive and HER2 negative cancers. Those are the folks that often will be treated with hormonal therapy. That involves taking one pill a day, so things like tamoxifen or Arimidex®. Those pills actually block the hormone receptors so that, hopefully, patients don’t have breast cancer show up anywhere else in the body in the future.
These days, if a patient is going to need IV chemotherapy, we often now give it prior to surgery. When indicated, there has been shown to be a survival benefit in patients who get their chemotherapy upfront. In addition, if your tumor is particularly large, we may be able to shrink it down with the chemotherapy, and sometimes we can go from needing a mastectomy to instead being able to do a lumpectomy. We also are able to get a good sense of how well the tumor is responding to the chemotherapy. For all those reasons, we often start with chemotherapy in that subset of patients, rather than going straight to surgery.