Amy Adam, 46, has two children — Charlie, 11, and Ben, 8, who are also referred to as the “clinical-minded kid” and “our big feelings kind of kid,” respectively.
When she told them she had breast cancer, they reacted differently. Charlie asked detailed questions about the treatment, and Ben, disappointed to learn that his mother wouldn’t gain any superpowers from radiation, shouted: “You’re gonna stab it in the eye. And kill it with fire.”
In his mind, surgery was stabbing in the eye. And radiation was killing it with fire,” Adam said. “And I was like, ‘Buddy, that’s just the best way of describing that.’”
Roughly one in eight women in the U.S. will develop breast cancer in their lifetime. Survival rates have been steadily increasing, and now around 91 of 100 women will live at least five years after being diagnosed. One of the major reasons is that more women are getting screened.
In recent years, the diagnosis and treatment of breast cancer have changed. Almost all women with early-stage breast cancer like Adam’s can be treated with a shorter course of radiation, according to new guidelines from The American Society for Radiation Oncology, which were updated in March this year. Earlier, this option was only recommended for women over age 50 with early-stage.
Meanwhile, the use of chemotherapy is declining because of better testing. Chemotherapy prescribing has declined overall from around 34.5 percent to 21.3 percent of women diagnosed with breast cancer between 2013 to 2015, according to a study published in May.
Women in Columbia are already feeling the effects of these changes, and cancer treatment centers here are offering patients some of the least invasive procedures and looking at adding other options. This year, some local physicians began reducing the duration of the radiation treatment and extending the hormone therapy.
Adam was one of these women. She received the maximum benefit with minimum damage from her cancer treatment, the result of decades of research.
Better screening, better outcomes
After she turned 40, Adam started having yearly mammograms. “Doing mammography was like getting your teeth cleaned,” she said. “You know, one of my preventative things to do every year.”
Adam did two-dimensional X-rays. About six years ago another option became available in Columbia — 3D mammography, a procedure approved by the U.S. Food and Drug Administration in 2011.
“It’s important to know it’s available,” said Gregory Biedermann, a radiation oncologist at MU Health Care. “I think it’s important for patients to have that discussion with their primary doctor as well as the center where they have it.”
It works like this: A machine takes many low-dose X-rays as it moves over the breast. A computer then puts the images together in a 3D picture. “We’ve seen a lot of smaller tumors in some patients and some of them detected earlier because of the 3D mammograms,” Biedermann said.
In the first five she had mammograms, Adam received the same email with a negative test result. That ended last March.
“So I have my mammogram and they said, ‘Uh, we see a little spot, but let’s come on in and do another mammogram and an ultrasound,’” Adam said.
Then Adam did a biopsy. Two weeks later she was at work when she received a call with a diagnosis, not an unusual way to receive that kind of news. It was invasive ductal carcinoma — estrogen and progesterone receptor positive — lurking under the right breast.
Adam got home from work and cried.
“It’s just like being hit by a truck,” she said.
The estrogen- or progesterone-receptor positive piece of the diagnosis was important because there are proteins outside cancer cells that the hormones can attach to, fueling cancer growth. A physician may prescribe hormone therapy to either lower estrogen levels or stop estrogen from acting on breast cancer cells. Women used to take these for five years after the treatment. But a study published in September in JAMA Oncology showed that extending anti-estrogen hormone therapy to 10 years reduces the risk of a recurrence of breast cancer and decreases the chance of a new cancer emerging in the other, healthy breast. So clinicians began extending the therapy for some patients.
“So they got me in to a surgeon for consult and by beginning of May I had a lumpectomy,” Adam said.
She began hormone therapy afterward.
Lumpectomy is a surgery where only the part of the breast containing the cancer is removed. Surgeons began performing the procedure back in 1980s. From 1994 to 2003, the proportion of women having lumpectomy steadily increased. However, from 2004 on the trend has reversed.
Lumpectomy vs. mastectomy
Not only did women begin having their breasts removed rather than conserving them, they also began doing more risk-reducing mastectomy — having their breasts taken because of the risk of developing breast cancer later in life. A couple of studies attributed that trend to the so-called “Angelina Jolie effect.” Jolie, whose mother and aunt died of breast cancer, was one of several prominent people who talked about having a prophylactic mastectomy, encouraging other women to do the same.
Indeed, mastectomy has been shown to reduce the risk of breast cancer by at least 95 percent in women like Jolie who have a disease-causing mutation in the BRCA1 gene or the BRCA2 gene and by up to 90 percent in women who have a strong family history of breast cancer.
But for women who already have breast cancer, choosing mastectomy may not be better than conservation therapy. Even after having the breasts removed, cancer is still possible. It can grow in connective tissue along the scar from the mastectomy or reappear in the lymph nodes, Biedermann said. “I think seeing stars doing (prophylactic mastectomy) kind of puts in someone’s mind ‘Aha, that’s clearly the better way to proceed.’ I don’t think that’s necessarily the case.”
Even so, breast cancer surgeons are able to get away with less drastic surgery with similar outcomes, said Nicole Nelson, a breast cancer surgeon at MU Health Care.
And it’s not only about removing part of the breast instead of all of it altogether; it also means avoiding axillary dissection, a surgery to remove lymph nodes from the armpit in patients who undergo breast conserving surgery or neoadjuvant chemotherapy.
“Every time we take out all of those lymph nodes, it significantly increases the risk of lymphedema, swelling in the arm and increases the risk of nerve injury and things like that too,” Nelson said.
Shorter radiation, less chemo
After surgery Adam received radiation — the second part of the breast conservation therapy — but instead of six weeks, she received just four. So that’s 20 treatments instead of 30 treatments.
“When I met with Dr. Biedermann, he said, ‘There’s 20 years of research that show that four weeks is just as effective as six weeks for this particular situation,’” Adam said. “He was like, ‘You will be the first one I would offer it to’. And I was like, ‘Sign me up!’”
Twenty treatments could be reduced to 10 with a new technique that will be available at Ellis Fisher Cancer Center starting in December. It’s called balloon brachytherapy.
The technique is used if a tumor hasn’t spread to the lymph nodes. A single soft catheter with a balloon at the tip is placed in the cavity after the lumpectomy. The balloon is then inflated with saline solution.
So the radiation goes from the machine through the catheter to the ballon and stays there for a period of time, Biedermann said. This way the radiation doesn’t directly contact the skin. He compares the technique to a candle: radiation is delivered to the area that is at highest risk of developing recurrent cancer. In this way, balloon brachytherapy spares radiation to a lot of the healthy breast, lungs and heart.
Adam also avoided doing chemotherapy.
“They do an oncotype test, which is basically a genetic test for your tumor, and it kind of shows how the aggressiveness is with the tumor,” Adam said.
“If the risk of recurrence of that tumor based on its genetics is very, very low, then we can we feel a lot safer saying, ‘OK, you know, this chemotherapy really isn’t going to do that much benefit because your tumor is so biologically non-aggressive that it’s probably not going to come back regardless of what we do,’” Nelson said. “So that’s actually helped to drive us away from doing chemotherapy more.”
Adam was relieved to learn she didn’t have to do chemo.
“I was like, ‘Thank goodness!’” she said.
Almost three months have passed since she had radiation treatment, and she’s had no post-treatment side effects, other than a little tightness under her arm from the incision for the lymph node biopsy, she said. She had some fatigue from the radiation therapy, but that also has mostly subsided.
While having radiation treatment, Adam went to work, had her treatment and then returned to work. That schedule might have been helpful, in the end.
“Actually, women who are more active tend to have less fatigue,” Biedermann said.
Another unavoidable side effect from radiation is skin changes in the treated area similar to a sunburn.
“We’re trying to take the stigma away from that,” Biedermann said. “Yes, it is bad, it looks awful, but the skin actually can recover.”
Researchers are trying to decrease side effects and make the duration of treatment even shorter. However, Nelson and Biedermann say it’s hard to predict the next breakthrough. Genomic profiling of tumors (studying how the activity and interaction of certain genes in tumor tissue influence its behavior) and immunotherapy (use of immune cells to attack cancer) may be on the horizon.
When looking back on her experience, Adam remembers a phrase she saw in a coloring book for cancer survivors: “I had cancer. Cancer never had me.”
For the next five to 10 years, Adam will start her day with hormone pills. In January, she will get another screening. If the cancer returns, she’ll regard it as she does now: not a deadly disease, but something to live through.
Supervising editor is Katherine Reed.