State of the Union: Breast Care in 2020

From Radiological Society of North America; Imaging shows a malignancy easily missed with 2D mammogram and clearly shown with 3D mammography


An interview with Roshni Rao, MD, Chief of the Division of Breast Surgery.

What's new in breast care? Have we seen breakthroughs in any area?

It’s the management of patients post-operatively where things are changing most. We're really trying to minimize our use of opioids, especially for breast patients, by using what we call multi-modality approaches. We're not only infiltrating things during the operation. We're giving them blocks by anesthesia beforehand; we're setting them up to get a few medications in the post-op setting, including standard ones like Tylenol, Advil, as well as nerve medications that we put them on for seven to 10 days. We also use ice a lot, even aromatherapy. And we're putting all these things together so that we can avoid narcotics. So, we have a nice pathway we've developed here that we try to put patients on routinely, and it’s been really helpful in reducing our use of them.

Can you explain that pathway a little bit more? What can patients expect?

I think the key thing is that we understand surgery can be painful for some patients. It's definitely not that we don't acknowledge that. It's just that for the majority of patients, especially with the types of operations that we do, narcotics are not really necessary. Or we can minimize using them as much as possible so we will give you other methods for relief and pain control. With this approach, we're trying to figure out any other way to get these patients through their post-op recovery very comfortably, but without a narcotic.

And that's really important because it's not just what happens when we give patients 20 or 30 narcotics. They may not use them, but we also worry about diversion of those narcotics. Many times, it’s completely unintentional. Like someone visits their home and they see the narcotics that may have been sitting there for six months and they take them. So those are the things, on a global level, that we're trying to avoid. 

I know that you've recently released a paper on post-op pain management as well. It’s pretty remarkable to see the success of these multi-modality approaches from the patient perspective. 

Right, right, it is! I think there is this thought process that if you have surgery, you have to have a narcotic. “Make sure they give you a pain medication.” And in most of our experiences, with a lot of our patients, they'll take it because they feel like they need to because we're giving them this prescription. Then they end up taking one or two. And what do you do with the rest of them? If you look online like I was, I saw this complicated approach to properly get rid of narcotic medications. You have to get coffee grounds and ground it...And it's a whole crazy thing.

Is there anything else we should know about the pain management studies you’re doing?

We are starting a trial, and it's done in conjunction with our medical oncology group, led by Dr. Dawn Hershman. This trial uses a prescription bottle that is connected to an app on your phone. When patients are scheduled for surgery and we prescribe some number of medications, they get the app and this bottle of medication is mailed to them. And let's say they're starting to have some discomfort, they click on their app. It asks them some questions, and they have to say what their pain level is. Based on that it tells you, “Oh, why don't you try a Tylenol?” Or it says, “Oh yes, you probably need a narcotic.” And then it gives you a code to open up your narcotic bottle. When you're done after 10 days or so, whatever you have or haven't used, you just mail the bottle back to them. It's a whole concept of avoiding these pills continuing to circulate randomly.

Wow, that’s really interesting. Let’s pivot to preventative care. What are the latest protocols, is there anything new?

There isn’t too much that’s new, but we’re still doing 3D mammograms and they’re very good. There’s no doubt about it.

Are 3D mammograms recommended for everyone? If you’re reading a 3D mammogram, is the difference that you're seeing more in the image? More of the dimension of tissue? 

Exactly, yes. It’s more information and better-quality information. And we do recommend it for everyone. I think it's helpful for everyone to get this from our perspective, but not all insurance companies cover it, which is unfortunate. For the patients who do get it and don't have insurance coverage, it’s an extra $200 or something like that. So, it’s consequential, but something that’s not entirely unmanageable for many patients.

What have been the biggest changes in surgical approaches in the last five years?

There are two things to talk about here. The first is the results of the intra-operative radiation therapy trial. Until now we didn’t have long term data on it, and that study just got published. So, it's called the Target Trial and that study just came up on its seven-year or so follow-up. 

There's always been a question when we do intraoperative radiation therapy: “is it really enough for long-term?” And we're finding it is enough for long-term based on this trial data. When I would present this option to patients before, I would explain we had this trial but we don’t yet have any long-term data on it, and now we’ve finally reached that phase, which is fantastic.

What’s recovery like for someone getting radiation intraoperatively?

It’s much easier, especially in the era of COVID. Standard radiation involves coming in five days a week for three to six weeks. You can imagine having to be somewhere five days a week for three weeks and that exposure to people, if you're taking the train to get here and those types of things. I think it's very helpful for a lot of our patients to know that they're going to have to come in once, they get their lumpectomy, they get the radiation and they're done. 

Absolutely. When is intraoperative radiation used? What types of cancer?

It's only for very selective patients. Generally, we say they have to be at least 50 years old and not have particularly aggressive cancers. It has to be less than three centimeters and can't be in the lymph nodes because intraoperative radiation is very, very focused, and targeted. So, it has very specific criteria. If you have cancer in your lymph nodes, that area also needs to receive some radiation and this is not sufficient. 

What other changes in breast cancer treatment should patients know about?

This actually brings us right to the other trial I want to mention. We're starting to do more and more what we call axillary reverse mapping when we do lymph node dissections. So that's a study that Dr. Bret Taback has opened as part of a national trial, and it's a whole effort to try and hook together these very tiny lymphatics at the time of surgery to potentially avoid lymphedema in the future. 

How common or prevalent is lymphedema after surgery?

For patients who undergo complete lymph node dissection, where all their lymph nodes are removed, it's about 30 percent. If they're just undergoing a sentinel node, it's about 1 percent. So, it's more relevant to the patients who undergo removal of all their lymph nodes, and that trial has just opened.

Anything new with immunotherapies or targeted therapies to know?

We're still doing our studies on immune therapy. But with Pembrolizumab, which is the big immune therapy for breast cancer that came out, I've had two patients who had horrible side effects on it. And it was done as part of the study, so it was done appropriately, but both of them went into adrenal failure. 

Wow. Where does that leave you when you’re doing a trial like this?

You know, this is why we do the trial. If this is a known consequence of receiving the immune therapy we need to know that. And right now we also have patients who are doing fine with it. But, we don’t know why and it’s a little, “ahhh” for us as the trial continues.

How do genetics factor into treatment these days? If you can give us a lay of the land.

Genetics is important for determining the best surgery for patients because there are some genes that predispose to a higher risk of cancer in the future. So, for specific patients who meet the criteria, we do routinely get genetic testing. And our genetic counselors are actually now doing telehealth visits. So you can virtually meet with your genetic counselor, and then they will mail you the test. It's like a swab. Patients do the swab, mail it in and get their testing. We didn't really do that before, and it’s nice being able to offer those video visits as a way to increase access to genetic counseling and testing.

As that accessibility opens up, do you recommend genetic testing for all or most patients?

We’re not doing genetic testing for every breast cancer patient because I think for a lot of them, it's not relevant. And that's an area of controversy right now, but as a general rule we are not offering or doing genetic testing on everyone.

Why is it an area of controversy? 

Because 85 percent of breast cancers are not genetic. We know that so why would you test every single person? It makes sense to test for people who have a family history, or they're very young at their age of diagnosis, or they have specific types of breast cancer. That makes sense. But it doesn't make sense for everyone right now. It may, at some point in the future, it may be that we do test everyone, but we're just not there yet. 

Tell us a little bit about the medical therapies that are available. When do you use them?

Our preference is always for the patients who are operable to do the surgery first. But for instance, during the peak of the pandemic when we had to halt all elective surgery—under that specific circumstance, for those who were hormone sensitive it was great to be able to use medical therapies because they bought us time. We could put those patients on Tamoxifen or aromatase inhibitors which should keep things under control. And that's been safe. We know that we can do that very safely for three to six months and the cancer won't grow or anything like that. And it made sense to do it for those patients whose tumors are more sensitive to hormones, or who were older and we wanted to be able to keep them out of the hospital. 

You know, for a fair number of patients, we give them chemotherapy first. Though, if we're giving them chemotherapy upfront and then doing the surgery, those patients have a very narrow window. You have to take them to the OR within six weeks or the tumor regrows. So those patients were the ones who got their surgery even during the pandemic because that's our window and we have to do it. 

What are you most optimistic about the future of care? 

Oh, good question. I think one thing that this pandemic has helped us figure out is that many times patients come in and they really want to have their surgery the minute they hear the word cancer. They want their surgery tomorrow, which I get it, you know it's cancer. But I think what this told us is that short-term delays—as long as we're thinking about cancer as a whole and things like that—are going to be safe. I think that's what it's going to show us. We have another paper out there talking about resource conservation, and we'll see what the future papers show as far as any potential detriment from this three-month period where nationally cancer care got put on hold a bit. 

And you know, what I'm really impressed by are my patients. We went on this pause, if you will, for cancer care. We canceled all our clinics, anything that was a follow-up, and things like that. And then we opened back up again—and I heard this from our pathologist, as well as our radiologists—it was our breast patients who came back first. They were the bravest ones.

I had a lot of my patients come in and say this is my first time in the city. They've been at their home in Connecticut or wherever and they've been hanging out there, but they made it to their mammogram and follow-up appointments. They didn’t ignore that aspect of their care, they showed up. And that makes me proud and hopeful.

In terms of breast care, say you put off a check for several months. How can a tumor change in that amount of time? 

There are several studies that show delays of more than 90 days can affect survival and recurrence, those types of things. So, if you have delayed your care, I would get in before it becomes threatening. Time does matter.

What are your goals for the next year? Five to 10 years?

Well, we have brought on two new faculty that I’m thrilled about. The first is Dr. Luona Sun, she was our fellow last year and she actually speaks Mandarin as well as Russian and it’s so great that she’s joined us because she can really take care of a diverse population of patients without barriers.  She has an office in Queens and she's from that area, so she’ll be able to see those patients and converse with many people without the language block that a lot of us have.

The other person is Dr. Stacy Ugras. And she is going to be extending our reach into Hudson Valley, at the Hudson Valley hospital. Now we're bringing the Columbia services and expertise to these locations that didn't really have immediate access to them, which is exciting.

What do you think breast care will look like in, say, 10 years?

I think the exciting thing is that it will be more and more individualized. That’s where everything is going, trying to really sort out exactly what this treatment needs versus that treatment versus this treatment. This tumor versus that tumor versus this tumor. I think that's really where it needs to go. And that’s where our collaboration is headed. 

Fortunately for us where we are at on HIP10 at Columbia, the entire care team is on the same floor. So, we have our medical oncologist, radiologist, and surgeons all on the same floor. We're not in different buildings, we're all right here. And we have a very close relationship, we're constantly texting each other through Epic [the medical records system] about our patients. We have meetings every single week, at least once a week. Many times, two or three times a week to discuss things. So it works really well and just strengthens that individualized approach now and certainly will continue to in the future.


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