Baystate Health Breast Network's Dr. Grace Makari-Judson offers perspective on disease - MassLive.com

SPRINGFIELD - Dr. Grace Makari-Judson is a veteran oncologist and chair of the Baystate Health Breast Network. She was asked about guidelines Baystate Health provides on mammogram screenings, and how it approaches treatment options available today based on individual diagnoses.

Q. What factors do you discuss with a patient of average risk for breast cancer in terms of when to have a mammogram?

A. Baystate Health developed practice guidelines intended to provide background on the pros and cons of screening mammography to support primary care providers as they have one-on-one discussions with women.

The consensus recommendation is to initiate the mammogram discussion at age 40, and consider starting between ages 40 to 49 but no later than age 50. Screening should not stop at any arbitrary age, but should continue based on a woman's overall health. Mammograms should be done every one to two years as a minimum, but not longer than every 24 months. Women who are at high risk based on family or personal history are excluded from these recommendations and are considered separately.

Q. There has been much medical discussion in recent years of how to treat DCIS, the most common form of non-invasive breast cancer.

Because DCIS represents a spectrum of changes, it is not fair to generalize treatment as if it were one disease. Low grade (indolent DCIS) is often difficult to differentiate from certain types of benign breast conditions, and has an excellent prognosis.

Small areas of low-grade DCIS may be appropriately treated with surgery to remove the area as the sole treatment. High grade DCIS has a higher recurrence rate and half of recurrences may be invasive (in other words, have the potential to spread outside the breast). This type of DCIS should be considered for additional treatments after surgical removal including radiation and possible hormone medication.

Q. What about treatment of invasive breast cancer?

For invasive breast cancer, after removing the lump, radiation is generally recommended to treat the remaining breast tissue. There are new radiation options with doses adjusted to allow for a shorter course in certain situations. Radiation may be omitted completely in patients over 70 with hormone receptor positive cancers who will be taking hormonal treatment.

Q. What are you seeing in terms of women with DCIS or invasive breast cancer elected to have a mastectomy rather than breast conservation surgery?

A. Mastectomy rates are sometimes higher for DCIS than invasive cancer because DCIS spreads as though it were running along branches of a tree rather than forming a lump making it harder to conserve the breast.

For most women with breast cancer, be it the non-invasive DCIS or invasive cancer, breast conserving treatment is recommended. Sadly, although we have over 40 years of experience showing that survival rates are the same after mastectomy compared to breast conservation, mastectomy rates have gone up in recent years.

Mastectomy is often recommended for certain advanced breast cancers, and bilateral mastectomy is considered for those with genetic risk, but many women are selecting this not out of necessity, but out of preference.

The complication rate is higher with double mastectomy. This means that for women with invasive breast cancer who need chemotherapy after surgery, this may delay the start of chemotherapy, which may negatively impact survival. Some women also still need radiation after a mastectomy depending on the features of the cancer.

Q. What do genomic tests on a tumor allow you to determine and are you using them to help women with early stage breast cancer decide on their course of treatment?

A. We routinely perform genomic testing on hormone receptor positive invasive breast cancers to determine the need for chemotherapy in addition to hormone medication. Genomic profile identifies those tumors that are most likely to derive added benefit from chemotherapy above and beyond hormone treatment alone. We started performing these tests close to 10 years ago and Baystate patients participated in the landmark TailorX clinical trial. Thanks to this testing, we are recommending approximately 30 percent less chemotherapy than in years past.

Q. Are their better options today in terms of chemotherapy drugs and in terms of their toxicity?

A. Supportive care, i.e. the art of managing side effects from chemotherapy, has continued to improve each year. Before, the focus was preventing vomiting, and now we are honing down on nausea and have new drugs to attempt to eliminate even that.

Q. What type of breast cancer may be treated today with targeted therapies and what percentage of Baystate's breast cancer patients are? Are any biological therapies used for breast cancer treatment?

Targeted treatments are recommended for nearly all breast cancer patients that have tumors that overexpress "her 2 neu" a protein associated with cell growth found in 20 to 30 percent of breast cancers. These cancers had previously been considered some of the most aggressive cancers, but they have been "tamed" by the monoclonal antibody trastuzumab (Herceptin). Trastuzumab has been used along with chemotherapy in early stage breast cancer. For advanced breast cancer, additional biologics and targeted agents are also available.

Of course, the first "target" ever identified in cancer treatment was the estrogen receptor and the drugs used include tamoxifen and aromatase inhibitors. Additional targeted treatments include new drugs to overcome resistance to these hormone treatments in patients with ER positive cancer. Many of these small molecules are available as pills. These drugs are used to treat advanced breast cancer but we also have clinical trials investigating use in earlier stage disease.

Q. Are you seeing any improvement in treatment outcomes for diagnoses of triple negative breast cancer, and are researchers close to targeted therapies for TNBC?

Triple negative cancer is breast cancer that is ER, PR and Her2 negative and represents 20 percent of all breast cancers. These cancers are a challenge because in general, there is not a "target" like the estrogen receptor or Her2 neu. Chemotherapy is the standard treatment for triple negative cancers.

At Baystate Medical Center, we have clinical trials for subsets of triple negative patients. For example, in hereditary breast cancer patients with BRCA 1 or 2 mutations, drugs called PARP inhibitors are being tested. In other triple negative patients, representing a very small percent, the tumor may express androgen receptor and there is a clinical trial for this subset.

Q. What do you advise patients in terms of hormonal therapy?

Hormonal treatment is important to consider in every patient with a cancer that is estrogen receptor positive. For premenopausal women, tamoxifen is recommended. For postmenopausal women either tamoxifen or one of the three aromatase inhibitors is prescribed. The best hormone medication is the one that the patient can stick with for at least 5 years. Recent clinical trials support the notion that longer is better. We now have information that 10 years is better than five for both tamoxifen and the aromatase inhibitors.

When I have this important discussion with my patients we consider these questions: What is the risk of breast cancer coming back?; How is their overall health?; and How are they tolerating the medicine? The hard part is that breast cancer can come back even 20 to 30 years later. My patients at high risk of recurrence are pleased that we have the data to support longer duration treatment. For most patients, this requires a thorough discussion of risks versus benefits.

Q. When do you use hormonal therapy to lower the risk of someone getting breast cancer?

A. We have three different agents that have been shown in large clinical trials to lower the risk of developing breast cancer in individuals that do not have a diagnosis but are at higher risk. High risk includes those with a significant family history, or certain types of benign breast disease including atypical hyperplasia and a condition called LCIS. All three drugs lower risk of hormone positive breast cancer but do not lower risk of the less common hormone negative cancer.

Tamoxifen is the only medication for pre-menopausal women. For post-menopausal women, tamoxifen, raloxifene (Evista) or one of the aromatase inhibitors are all options. My preference in post menopausal women is raloxifene since it is generally well tolerated and also helps prevent bone loss.

Q. Studies have shown a link between obesity and mortality in terms of breast cancer. What do you think of studies looking at weight loss and breast cancer re-occurrence, as well as studies looking at how effective eating a Mediterranean style diet is in breast cancer prevention?

There is no proven breast cancer prevention diet. The Mediterranean diet is a healthy diet similar to what the American Cancer Society and American Heart Association recommend. For women that have had a diagnosis of breast cancer, the Women's Intervention Nutrition Study (WINS), that Baystate participated in, suggested that a very low fat diet was beneficial in reducing risk of recurrence in women with a diagnosis of breast cancer, but the women who benefited also lost weight. Currently, we are involved in studying exercise after a diagnosis. Women who exercise regularly appear to lower the risk of recurrence.

For women without a diagnosis of breast cancer, I recommend eating a healthy diet, similar to the Mediterranean diet, exercise 2 to 3 hours per week, limit alcohol and don't smoke. It's never too late to start exercising, so join us for the Rays of Hope Walk/Run, Oct. 30th!

Editor's note: The annual Rays of Hope Walk/Run Toward The Cure for Breast Cancer will be held Oct. 30. The 8K run steps off at 8:30 a.m., with registration at 7:30 a.m. at Temple Beth El, 979 Dickinson St., or in advance online. The walk begins at 10:30 a.m. from Beth El. The event has raised $13 million to date. In partnership with the Baystate Health Breast Network and Baystate Health Foundation, funding benefits research at the Rays of Hope Center for Breast Cancer Research, and helps fund state-of-the-art equipment, breast health programs and outreach and education throughout Baystate Health, as well as grants to community support programs.