Breast Cancer: New Detection and Treatments
Contributed by Anne Akers. This article original appeared in Glow Beauty & Health Magazine and is reprinted with permission.
After the venerable pink ribbons, where are we now? r. Sheldon Feldman,Chief of Breast Surgery at Columbia University Medical Center, reports on the evolution of new detection and treatments.
Imagine being a young doctor in his residency program. Full of desire, skill and knowledge to protect, heal and comfort those under his care. Now imagine that same doctor hearing that his sister is dying of advanced breast cancer and he can do nothing to save her. Meet Dr. Sheldon Feldman, Chief of the Breast Surgery Division at Columbia University Medical Center. That tragic experience, in fact, initially repelled Dr. Feldman from having anything to do with breast cancer. Thankfully, destiny intervened. We could have lost one of the most brilliant and dedicated surgeons and researchers fighting on our mutual behalf today. Dr. Feldman explains it this way: “I always say I didn’t choose this specialty — it chose me. After approximately ten years in practice it seemed more and more of my patients were women with breast cancer. Something was pulling me in that direction. My sister is never far from my mind and that inspires me to optimize the level of care with every newly diagnosed woman I meet. For me, it’s personal.”
Since 1990, Dr. Feldman’s name has been synonymous with some of the greatest advances in the evolution of detection and treatment for breast cancer. “The explosion of research and information continues to progress, but just not at the pace we would like.” According to Dr. Feldman, mammography is still the gold standard. Digital mammography has made a huge difference in the clarity of images, as have MRIs and ultrasound. His ultimate goal is moving beyond the mammogram toward a simple blood test like those used in detecting HIV. But it would have to be a very exact blood test, a so called liquid biopsy.This would not only cause fewer false alarms and discomfort for initial detection, but dramatically change the way survivors are monitored. “After doing surgery, radiation, hormone blocking and chemotherapy for breast cancer can we guarantee no cancer is left? Whole body scans can pick up large amounts of cancer in the system, but not the microscopic variety and so we have no way to identify if there is any residual activity.” Another part of Dr. Feldman’s research involves identifying abnormal genetic material (microRNAs) which can be detected in very small amounts of extracted nipple fluid. This would allow for the development of a simple PAP smear of the breast to allow for early diagnosis of breast cancer.
No Longer One Size “Fits All”
Once a woman becomes a breast cancer patient she is usually surprised by the sheer variety of breast cancers and the host of recommended treatments depending upon her distinct diagnosis. Years ago, breast cancer routinely meant a mastectomy and removal of lymph nodes followed by primitive forms of chemotherapy. All breast cancers were seen as one. Over the last few decades, the money, time and energy poured into research have not disappointed. Today, breast cancer is very specifically targeted and no longer has a one size fits all approach. Treatment is influenced by the cancer’s profile…whether it is aggressive, hormone sensitive or genetically inspired. The stage, size, location and lymph node involvement also play a role. Surgery and medical therapy (chemo or other drugs) have become less radical and more exact. “This is very personalized medicine. You can have 100 patients and every one of them would have a different treatment plan,” says Dr. Feldman.
The trend in breast cancer surgery is toward less invasive surgery, but does this compromise survival rates? Dr. Feldman believes more radical surgery is not necessarily better.
I would be happy to be made obsolete innovations in women’s health
“What defines survival is not the local breast disease but cancer cells that are elsewhere in the body which are treated with systemic therapy. Once we understand the biology of the cancer, we give targeted local treatment through a combination of surgery, radiation and comprehensive medicine.” One example of this is using Herceptin which is a monoclonal antibody for the 30% of cancers where the mortality in the past was very high. By giving this medication along with chemotherapy prior to surgery, we can demonstrate that the medicine is working since the tumor begins to melt away. This allows the extent of surgery to be minimized. However, some women remain unconvinced and opt for as radical a surgical intervention as possible. While he tries to counsel women on the right surgical plan, Dr. Feldman is very sensitive to the fact that long after his work is done, the patient must be able to sleep at night. “It’s a very personal decision, almost primal. Ignoring my recommendation to use a ‘less is more’ approach is not wrong if it feels right to the patient.” For me the guiding principle is to be certain patients are making good decisions based on medically correct information.
The option of immediate reconstruction after a mastectomy or a larger lumpectomy has helped women as much physically as psychologically. This is where aesthetic plastic surgery can be the “silver lining” in an otherwise dark cloud. Nipple sparing mastectomies are a newer option performed in conjunction with a colleague such as Dr. Grant. This allows for maintaining a normal breast appearance. Reconstruction can include a breast lift, implants or tissue flap as part of the repair. Abdominal flaps (DIEP or TRAM) have the additional benefit of a “tummy tuck” as a result of the fatty tissue being moved to create a new breast. Are there any cases where immediate reconstruction is not an option?
“We recommend that patients having a more advanced form of disease receive radiation after their mastectomy which can affect the appearance of the reconstructed breast.
They can have a temporary type of reconstruction but it is best if the final reconstruction is delayed until healing from the radiation is complete.” Immediate reconstruction is not recommended for patients with inflammatory breast cancer because of possibly lessening the effectiveness of the radiation, risking a reoccurrence. Sometimes patients are simply not healthy enough due to the effects of smoking, heart disease, or diabetes, though Dr. Feldman says this group is “relatively small.”
The Bottomline is “Prevention”
Advances in detection and treatment are gaining speed, but the bottom line is prevention. Where are we on stopping this disease before it starts? Dr. Feldman explains. “The prevention piece is challenging because the basic cellular biology is so unclear. What is clear is that we are doing it to ourselves.” He cites a study done on twins featured in the New England Journal of Medicine. Twins have the same DNA and yet one got breast cancer, one didn’t. Dr. Feldman leans toward the cause very likely being something common in the environment. Case in point: Asians have 1/6 th of our statistics and yet within two generations of moving to the United States, their risk becomes identical to ours. The western lifestyle, diet, water, stress, pesticides, food chain, flame retardants — even computers could all be to blame.
His advice includes verbiage not usually seen on any prescription.
“Maximize the good stuff in your life. Pay attention to your diet and exercise and build some fun into your days.” For some cancer survivors a recurrence can be prevented with drugs like Tamoxifen, Raloxifene and aromatase inhibitors. Vitamin D in larger doses has gotten recent attention around the world as preventing breast and colon cancers because of its affect on the immune system. Studies evaluating this are ongoing.
One of the most exciting pieces of research being done by Dr. Feldman is an intraductal approach to both the prevention and treatment of breast cancer. It has worked 100% on mice. “Using local anesthesia, we insert mini endoscopes as big as a human hair through the nipple. This would confirm if women leaking fluid might have cells that look like cancer. The idea is if we could infuse medicine directly into the breast through the nipple and interrupt those cells we could prevent it.” Aside from prevention, this vehicle and avenue might also help treat cancers without surgery.
“We could see exactly where the cancer is through a scope and destroy it with a laser or radiofrequency or map the exact extent of the disease to allow surgeons performing lumpectomies to always remove the right amount of breast tissue to obtain clean margins.”
For those unfortunately diagnosed with breast cancer, Dr. Feldman feels the approach at Columbia University Medical Center offers a powerful tool to patients — namely the multidisciplinary team with whom he works. The team inspires confidence and provides incredible perspectives from a wide variety of backgrounds—medically, holistically and spiritually. “After the devastation of the diagnosis, patients are looking for a way to get ready. We can provide those teachable moments focusing on creating a better experience during treatment and a healthy approach for life after cancer. Nutrition, visualization, coaching, and reike is part of the patient centered approach contributing to getting the mind and body in sync to smooth the journey.”
A framed picture of Dr. Sheldon Feldman’s sister, Fern, sits atop his desk as a constant reminder of what is important. “She pulls me back to what takes priority and that is recognizing what an honor, privilege and opportunity I have been given to help heal each of my patients as if they were my sister.”
Dr. Sheldon Feldman, Chief, Breast Surgery at New York-Presbyterian Hospital/Columbia University Medical Center, is a distinguished clinician, researcher, and educator, who works in close collaboration with a multidisciplinary team of radiologists, medical oncologists, radiation oncologists, plastic surgeons and other support staff. Recipient of the American Cancer Society award for outstanding service, America’s “Top Doctors”, and Castle Connolly Medical “Best Doctors”, his research interests are focused on preventing breast cancer through a better understanding of environmental toxins. http://www.breastmd.org.