Breast Cancer Update
New advances in screening, treatments and clinical trials are offering new hope for patients.
Breast cancer is the second most diagnosed cancer in American women, after skin cancer, and until a few years ago a diagnosis of metastatic disease was often regarded as a death sentence.
However, increased awareness of the disease has resulted in earlier screening, and research funding has helped to develop more life-saving treatments.
“We have a better understanding of breast cancer now than ever before,” says Susan Kesmodel, M.D., director of Breast Surgical Oncology at Sylvester Comprehensive Cancer Center, part of the University of Miami Health System. “We know that it’s not just one disease, and our growing understanding has led to many treatment options that were not around just 10 years ago.”
A Treatable and Survivable Disease
One in eight U.S. women will be diagnosed with breast cancer at some point in their lives. According to the American Cancer Society’s estimates, about 297,790 new cases of invasive breast cancer and 55,720 of non-invasive (in situ) breast cancer will be diagnosed this year. Some 43,700 women will die of this disease every year.
Yet, breast cancer is considered one of the most treatable — and survivable — cancers today. Currently there are more than 4 million breast cancer survivors in the U.S. Thanks to early detection and treatment breakthroughs, it is estimated that breast cancer deaths have dropped by 43% since 2020.
At the Braman Family Breast Cancer Institute at Sylvester Comprehensive Cancer Center, physician-scientists explore ways to offer the latest in diagnostic testing, treatment and follow-up care. A multidisciplinary team includes not only oncologists and radiologists but also social workers, therapists and genetic counselors.
The search for better and more targeted therapies continues. Currently, Sylvester is home to 18 breast cancer clinical trials, some of which will likely improve longevity and the quality of care for future patients by expanding our knowledge of the disease.
Here are some areas being studied and advances being implemented in clinical practice by Sylvester physicians:
Advanced Breast Cancer Screening
Mammography is considered the standard for breast cancer screening in women with average risk. For those with increased risk, magnetic resonance imaging (MRI), contrast-enhanced mammography and ultrasound serve to supplement information.
Sylvester, the only National Cancer Institute (NCI)-designated center in South Florida, offers an advanced screening technique called tomosynthesis for all patients. This 3D mammography takes images from different angles and then puts them together to create a three-dimensional picture of the breast.
“It has increased our ability to detect breast cancer at a less-advanced stage,” Dr. Kesmodel says.
Early detection of breast cancer improves the chances of survival and allows for more treatment options.
The imaging center at Sylvester, which has garnered a Breast Imaging Center of Excellence designation by the American College of Radiology, also offers contrast-enhanced mammography (CEM), a new type of mammogram that uses a contrast agent to help with more precise diagnosis. In addition, breast biopsies help experts study the genetic makeup of a tumor, an essential step in determining more effective treatment.
New, Targeted Breast Cancer Therapies
Oncologists believe that ongoing advances in genomic analyses, which provide information on the molecular structure and diversity of a tumor, may eventually identify many cancer subtypes and thus lead to therapies specific to those genomic mutations. For now, however, clinicians work with three main types of breast cancer, and the subtype determines treatment protocol.
The most common types are the hormone receptor-positive cancers. These tumors express sensitivity to estrogen and/or progesterone. A third type has excess HER-2, a protein found on the surface of cancer cells. A tumor that has none of these three markers is referred to as triple-negative breast cancer, and is more difficult to treat because there are fewer treatment options.
Standard care for most diagnosed cases of breast cancer usually involves surgery, sometimes radiation, and, depending on the type of breast cancer, chemotherapy. If you have a tumor with estrogen and progesterone receptors, you can be treated with therapies that block estrogen that fuels these cancers.
Targeted therapies, a newer line of cancer treatment, aims to attack abnormalities within cancer cells. Targeted therapy blocks cancer cells’ growth and spread, and it has been effective with the previously difficult-to-treat HER2-positive tumors, improving the survival rate for HER2-positive cancer in the past two decades.
Immunotherapy, which uses a patient’s own immune system to fight off cancer, is promising but still limited to patients with triple-negative cancer. (Since these tumors don’t have estrogen and progesterone receptors, triple-negative cancer doesn’t respond to hormone therapy.)
Sylvester Clinical Trials Hope to Expand Treatment Toolbox
Elisa Krill-Jackson, M.D., a breast medical oncologist at Sylvester, has designed a clinical trial that seeks to determine whether patients with HER-2 positive metastatic breast cancer can stop their maintenance anti-HER2 therapy and remain cancerfree.
The study, aptly titled Free HER, uses a blood test to detect changes in ctDNA (circulating tumor deoxyribonucleic acid), which is a marker of disease recurrence. Enrolled participants will be monitored with these periodic blood tests.
Currently, long-term survivors of metastatic HER2-positive cancer receive indefinite targeted therapy every three weeks.
“We want to see if we can de-escalate treatment, essentially relieve these women of having to come in every three weeks,” Dr. Krill-Jackson says. “By discontinuing treatment, we are trying to determine if they are really cured or if it’s feasible to take a break while monitoring for relapse.”
Another Sylvester breast medical oncologist, Frances Valdes-Albini, M.D., is the principal investigator of a trial that hopes to determine if an early switch of frontline treatment based on molecular progression prior to clinical progression is a more effective therapeutic approach. The expectation is that, by changing therapy early on, when a cancer is just becoming resistant, and before the cancer continues to advance, second-line therapies will be more effective.
Like Dr. Krill-Jackson, Dr. Valdes-Albiini will use liquid biopsies — the blood tests that detects changes in ctDNA — to guide an early switch in therapy, because they can detect disease progression earlier than imaging. Later detection through diagnostic imaging results in later subsequent effective treatment options for metastatic patients. ctDNA can also give oncologists information on the molecular composition of the tumor, thus informing them if there are any “actionable mutations” to be targeted.
“We’re hoping that, by using ctDNA as a surveillance marker, we can better understand if a therapy is working,” she explains. “If we have this information earlier on in the disease course, the sooner we can implement a switch in treatment that is not working. This could increase the amount of time a patient has her metastatic disease under control and, in turn, increase longevity and quality of life.”