Health

Breast cancer in 2018: With research, new discoveries and continued awareness, what's working now

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Jennifer Wolfthal was barely into her 50s when she discovered she had breast cancer.

“I walked in, and right off the bat, the doctor said ‘mastectomy,’ and I walked right out. I was shell-shocked,” said Wolfthal, now 52, a mother of three teenagers. “Having had three C-sections before, I was no stranger to pain, but this pulls the rug from under you.”

Fortunately, breast cancer — the most common form of cancer in women besides skin cancer, says the American Cancer Society — has garnered so much awareness and research, that you’ll see remarkable improvements in just the past year in screening, diagnosis, technology, treatment, reconstruction and recovery.

More than 98 percent of the people diagnosed with cancer located only in their breasts will live  five more years at the very least, according to the society’s “Cancer Facts & Figures 2018” report, along with the National Cancer Institute.

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Screening and Diagnosis

“I see patients every day who save their lives by getting their mammogram. Do it every year starting at 40. We have data to prove it saves,” says Dr. Alice Police, regional director of breast surgery of Northwell Health. She treats patients at Northern Westchester Hospital in Mount Kisco and Phelps Hospital in Sleepy Hollow.

Early detection has been key to wiping out what used to be an almost automatic death sentence. Genetic testing is becoming a more popular way to determine even earlier who is most at risk. But it’s quite complicated.

A massive study of nearly 4,000 variants in a gene associated with cancer could help to better pinpoint people at risk for breast tumors, according to a Sept. 12 report released by Nature, International Journal of Science. Variations in the sequence of DNA in BRCA1 and BRCA2 genes are linked to breast cancer, but some are harmless. The findings could help physicians to interpret the mutations’ significance.

“The more genetic testing we do, the more we will start understanding what’s going on with all these genes and be able to determine the risk factor for patients,” said Dr. Robbi Kempner, medical director of Breast and Women’s Health Prevention Services at Montefiore Nyack Hospital and a breast surgeon at the nearby Highland Medical, P.C.

Kempner and Dr. Bonnie Litvack, director of Women’s Imaging at Northern Westchester Hospital, a full-service breast imaging center located at the hospital and also at Yorktown Imaging, agree that three-dimensional mammography is becoming more widespread. Compared to two-dimensional mammograms, this technology is more accurate and better at detecting breast cancer by screening the tissue in thin slices, which also has meant fewer false-positives and fewer callbacks for further testing.

Litvack said she’s glad that the American College of Radiology released new screening guidelines in April. This is the same institution that advises women to get yearly mammograms starting at age 40, which has dropped the death rate from breast cancer by 45 percent since mammograms became widespread in the 1980s.

The college, as well as the Society of Breast Imaging, now calls for all women to have a risk assessment at age 30 to see if screening earlier than age 40 is needed. The societies recommend that women previously diagnosed with breast cancer also get MRI screenings.

And for the first time, the college acknowledged that African-American women are at high risk and should be treated as such, because they are 42 percent more likely to die from breast cancer than non-Hispanic white women, despite the same incidence rate. They have a two-fold higher risk of getting aggressive “triple negative” breast tumors.

“These recommendations are going to help women, because those women found to have genetic reasons or found to have high risk will be screened at an earlier age, which means their cancer will be discovered more often and earlier,” Police said. “It’s potentially life-saving. The updates are just going to save more lives.”

Treatment and reconstruction

Another improvement in breast health involves the way surgery and reconstruction are handled – in the most minimally invasive way possible, often in the same operation.

At Nyack Hospital, Kempner was the first surgeon in Rockland County to be trained in the Hidden Scar surgery technique. In a mastectomy with reconstruction, she makes the incision below the breast crease. In a lumpectomy, the cut can be in the armpit, around the nipple’s areola where color changes or in the crease just below the breast.

“The idea is to leave the woman without any visible reminder of what they went through. We’re doing better and better every year with breast cancer screening, treatment and survival rates. Hidden Scar surgery is something we like to offer to our patients because it improves their quality of life,” Kempner said.

“And with more women being diagnosed with cancer in earlier stages, they live longer. They want to look good, and they’re entitled to look good.”

Police brought at least three new treatment techniques from University of California, Irving Medical Center when she moved to Westchester about 10 months ago. First, she uses a Savi Scout breast localization and surgical guide system. “We call it GPS for the breast,” Police said.

Next is MarginProbe, which enables real-time evaluation of the margins of the tumor so that patients don’t have to come back for a second operation. Nationally, more than 25 percent of patients have to return for another operation to get more tumor tissue removed, but this probe reduces that to 4 percent, Police said.

Also, inter-operative radiation therapy is now possible. That means selected patients with early-stage cancer can receive 20 to 30 minutes of radiation during surgery so that when they wake up, they can cut out about six weeks of radiation therapy.

Lastly, chemotherapy with all its disheartening side effects isn’t used on as many people with the help of Oncotype DX testing, which analyzes the biologic activity of individual tumors to determine if chemotherapy is necessary.

Dr. Preya Ananthakrishnan, director of breast cancer surgery at White Plains Hospital, was the first surgeon in Westchester to perform pre-pectoral implant reconstruction in 2017.

Since the 1970s, post-pectoral, or sub-muscular, reconstruction has been a drawn-out, painful process for patients, in which after many weeks of stretching the muscle, the plastic surgeon inserts the implant underneath the muscle in a separate surgery after the masectomy.

“Tissue expansion is like a water balloon gradually stretching out,” Ananthakrishnan said.

In pre-pectoral reconstruction, the implant goes above the muscle under the skin, which can reduce pain, breast deformities and weakness. Doctors worried that the new technique would increase infection, especially when post-op radiation therapy is needed. But now there’s a biologic mesh that acts like a sling over the implant, providing a barrier against the skin.

The new technique’s safety was bolstered by reports of fewer infections at the American Society of Breast Surgeons national meeting in May, when White Plains Hospital breast and plastic surgery teams presented their video of their pre-pectoral surgical technique.

The mesh costs extra and is expensive, yes, but it’s often covered by insurance because it’s performed at the same time as the surgery to remove the cancer.

“It’s remarkable the difference in patient experience and recovery. It decreases their need for narcotic pain medication,” Ananthakrishnan said. “I actually had one patient who tried to make her hospital bed the day after surgery, she felt so good. I had to tell her stop. I was shocked. But the patients, they really do feel that good.”

Wolfthal has had a similar experience. In June of 2017, Ananthakrishnan removed the tumor in the milk ducts of her left breast and then did a pre-pectoral reconstruction in the same surgery.

“Going in, you don’t know if they’ll be able to save the nipple,” Wolfthal said. “The first thing I did just out of surgery, while I was still loopy, was look under my shirt, thinking ‘Do I still have it?’ I’m just over the moon because after you’re diagnosed, you see all these pictures, the deformities. I was lucky.”

“Now I’m back to doing everything I was doing before.”

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