Breast Cancer: Expecting A Shift Towards A More Minimal Approach & Focus On Quality Of Life

Dr Nita Nair is an Associate Professor in Surgical Oncology in the Breast Disease Management Group at Tata Memorial Center (TMC).  She is also the Principal Investigator for clinical trials at TMC validating the Navya Expert System for decision making in oncology.

Dr Nair in an email interaction with Ekta Srivastava, Health Technology.inBreast-Disease-Management-Group

You treat breast cancer at all stages. Is there any chance of curing patients in the fourth stage of the disease?

A very small group of patients with limited metastatic disease (i.e. when cancer from the breast has not extensively spread to other organs in the body) and good prognosis disease (like diagnosis at early stage), may be considered for curative intent of treatment, (i.e. treatments given for the purpose of curing the disease versus managing symptoms or limiting spread of disease). This means patients are treated with all relevant modalities of treatment such as chemotherapy, surgery, radiation therapy, hormone therapy or targeted therapy. But at late stage, such as stage IV breast cancer, cannot be cured.

You are in charge of the treatment of breast cancer diagnosed in young women. What is the level of morbidity in the world?

Young women are traditionally defined as women under 40 years of age. They constitute less than 15-20% of the patients who present with breast cancer.   More often than not they present in more advanced stages due to the lack of awareness – in recognizing early signs and symptoms of breast cancer.  Though age is a prognostic factor (i.e. can determine how well a patient will respond to treatment) one cannot give you a number on how many succumb from that group.

What options are available in reconstructive surgery for breast cancer patients.

If the breast is conserved, (i.e. not completely removed as surgical treatment for breast cancer and instead only the cancerous lump in the breast is removed, which is called lumpectomy), local tissue may be used to reconstruct the breast mound using oncoplasty based techniques. Additionally, pedicle myocutaneous flaps may be used for partial breast reconstruction. If the whole breast is removed, (which is called mastectomy),  the breast can be reconstructed using the patient’s own tissue using pedicle or free flaps, implants or expanders.

For each patient the reconstruction is personalized, keeping the patient’s treatment and body build in mind.

What kind of therapy do you administer during pregnancy?

During the first trimester, most treatments are dangerous with side effects that carry a risk of abortion or harm to the fetus.

In the second or third trimester,  surgery or chemotherapy may be considered, but risk of still birth or IUGR must be considered. Treatment is sequenced depending on the stage the patient presents in, for example if the patient presents with early stage cancer with low risk, she may be treated with surgery first and delay or avoid chemotherapy until later trimesters.

Radiation therapy and hormone therapy are contraindicated during pregnancy, i.e. must not be administered during pregnancy.

Additionally, radiology imaging needs to be done with caution, e.g. mammography, CT scan, Bone scan are not done given the risk to the fetus. Ultrasound or MRI may be considered where indicated/when needed.

In your opinion, which of the preoperative treatment of breast cancer showed the best results?

Neoadjuvant chemotherapy (i.e. chemotherapy treatment given prior to the primary treatment of surgery),  and targeted therapy (in Her2 positive patients, who have a certain hormone that has relevance in prognosticating the breast cancer), have shown good results of down staging of tumor size (i.e. shrinking the tumor size prior to attempting surgery), and thus improving the success rates of breast conservation/lumpectomy in women with large tumour size at presentation.

What is the most accurate diagnostic protocol for the early detection of breast cancer?

The triple test, which includes a good clinical examination, Mammogram +/-ultrasound, and histopathological confirmation with core biopsy or FNAC.

You are managing various clinical studies. Do you expect a revolution in the treatment of breast cancer?

I hope we are first able to tackle the late presentation by creating awareness so that patients present in early stages to oncologists.  For breast cancer treatment, I expect a shift towards a more minimal approach in early breast cancer and more focus on quality of life as survival improves.

What has changed in the mechanism of action of drugs?

They are now targeting specific pathways/ receptors (such as the Her2/neu hormone receptor) in specific subtypes, rather than non directed approaches.

Are there instances when women with breast cancer cannot be helped?

Patients who continue to progress (example, cancer continues to spread to other organs) despite multiple lines of treatment or those who cannot tolerate any further treatment (because of side effects or deteriorating general health condition) are deemed best for supportive care and palliation, and no further active treatment .

How an online opinion in surgery from experts at tertiary care centers can help patients undergoing surgery in local areas.  Specifically, how does Navya help standardize expert grade surgical decisions in breast cancer

TMC NCG Online – Navya Expert Opinion Service allows patients in different parts of the world get access to a second opinion from cancer experts. Often it allows them to gain confidence in the options offered by the treating physician, and other times it allows them to realize what other options can be explored.

Most patients do not have the resources to travel to tertiary centers for an opinion and online opinions allow for that at their convenience and empowers the patient with some information regarding their cancer. However, many decisions are based on the clinical findings and may require the treating physician to evaluate the feasibility of the same. Certain surgical decisions, for example, require in person evaluation by the local experts/treating oncologists.

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