Applying Recent Advances to Personalized Breast Cancer Care, A Breast Surgical Oncologist’s View: Brigid Killelea, MD, FACS
Over recent years, numerous developments have occurred in the fields of breast cancer prevention, genetic testing, screening, and surgical procedures. In this interview, Dr. Brigid Killelea, Medical Director of Breast Surgery at Hartford HealthCare, explains strategies for incorporating these advances into the care of patients with breast cancer.
Oncology Data Advisor: Welcome to Oncology Data Advisor. Today I'm here with Dr. Brigid Killelea.
Brigid Killelea, MD, FACS: Hi, my name is Brigid Killelea. I am a breast surgical oncologist. I focus my practice on patients with benign and malignant breast disease. This includes women who have breast cancer; women who are at high risk for breast cancer, either because of their own history or family history; and those that have benign diseases of the breast. I practice in Bridgeport, Connecticut, and I'm with Hartford HealthCare.
Oncology Data Advisor: Thank you so much for joining us.
Dr. Killelea: My pleasure, thank you for having me.
Oncology Data Advisor: As a surgical oncologist, how do you counsel patients about breast cancer prevention?
Dr. Killelea: There's a lot that we can talk about when we think about risk factors and preventing breast cancer. Some of the risk factors are under our control, and others really are not. The two biggest risk factors for breast cancer are being a woman and age. Obviously, there's nothing we can do about either one of those, but the modifiable risk factors—which is what we call them when they're under our control—include things like maintaining a healthy body weight. Obesity is certainly a risk factor for breast cancer.
Another risk factor is alcohol. Alcohol consumption is associated with an elevated risk of breast cancer, and it becomes a little bit difficult to decide exactly how much is too much. Certainly we all need to live our lives and enjoy our lives, but no more than one drink per day for women is recommended. I do think that if we can try to keep it under even two to three drinks per week, that is a healthy amount in terms of preventing or trying to prevent breast cancer. Exercise certainly also plays a role. Exercise is good for a variety of things, including maintaining your bone density, mental health, and feeling your best and looking your best, and obviously it's good for maintaining a healthy body weight, as well.
Family history also plays a role in a person's risk for breast cancer. There are two genes that we screen for and that we talk about with patients that really increase a woman's risk of breast cancer. Those are called BRCA1 and BRCA2. People that are at risk for these genes tend to be people that have an extensive family history of breast cancer in multiple generations, especially if any of those women are under the age of 50 or if any of those family members have a certain type of breast cancer that's more aggressive called triple-negative breast cancer.
A family history of male breast cancer is also another red flag for having an identifiable or a BRCA mutation. People that have a family history of ovarian or fallopian tube cancer at any age—not necessarily cervical or uterine cancer, but ovarian or fallopian tube—and women who are of Ashkenazi Jewish descent are also at higher risk for BRCA mutations. The field of genetics moves quickly, so there are some other mutations that can place people at higher risk. Oftentimes, we'll work with experts in the field, genetic counselors, to help us determine what genes convey a particular risk for our patients.
Oncology Data Advisor: That was a really great overview, which definitely leads into my next question. What factors should be considered when determining the age at which individuals should begin to undergo screening?
Dr. Killelea: Oh, this is another very good question. If you look at different societies, not all of the guidelines will give us the same age to begin screening. In general in the United States, we recommend for women who are at what we call average risk to start breast cancer screening with annual mammography around age 40. For many women who are at this age, they may have what's called dense breast tissue; and for many of those women, we supplement mammography with another test called a screening breast ultrasound. This doesn't take the place of mammography; sometimes patients will ask if they can not have their mammogram and do an ultrasound instead. It doesn't really work that way because mammography is really the best screening test that we have, and the only test that's been demonstrated in several randomized controlled clinical trials to decrease the mortality from breast cancer.
Another screening test that we have is called breast magnetic resonance imaging (MRI). This is a very sensitive test, which means that it may pick up things that could or couldn't be cancer. Oftentimes in my practice, I reserve MRI for women who are at highest risk or for women who have breast cancer and were using it to define the extent of disease, or to help us work up patients before surgery who may have gotten chemotherapy already.
In the United States, we screen annually, which means once a year. In some other European countries, they'll screen every two years or even every three years, and this is all for women who are at, again, average risk. For women who are at higher risk, like the BRCA mutation carriers that we were talking about a few minutes ago, these women really are at higher than average risk. For this population of patients, we often will recommend an annual mammogram with or without ultrasound if the breast tissue is dense and an annual MRI every year. We like to space these two screening modalities apart by six months. In addition, we recommend monthly self-breast examination and then annual clinical breast examination with either a breast surgeon or the patient's obstetrician-gynecologist (OB-GYN) doctor or physician assistant (PA) or nurse practitioner. Many patients, if they're no longer going to an OB-GYN, will have a breast examination with their primary care doctor.
Oncology Data Advisor: To move a little bit into the topic of surgery, what have some of the most recent developments in breast cancer surgery included?
Dr. Killelea: One of the things that I've been very excited about in the past several years is what we call oncoplastics. This is a type of breast surgery that we use very commonly. It involves taking elements from plastic surgery and using them to help us when we're doing what's called a lumpectomy or a partial mastectomy. It can really be something very simple and straightforward, like moving tissue around a little bit after a tumor has been removed to fill in the spaces and the gaps that are left in the breast; or it can be something more extensive where we're doing almost a breast lift or a breast reduction after a lumpectomy. I think this has really changed our practice and has allowed many more women to feel comfortable getting a lumpectomy instead of a mastectomy, which is a longer, more invasive, more extensive procedure. It really allows women to feel like they're getting a great cosmetic outcome and still getting a complete cancer operation.
Another thing that I've been excited about recently is that we are doing far fewer axillary dissections, which is a procedure where we remove all of the lymph nodes from underneath the armpit if cancer has spread to the lymph nodes. This procedure does put women at higher risk for what we call lymphedema (arm swelling), which is not dangerous, per se, but can be very uncomfortable and can last for the remainder of a woman's lifetime. These days, based on some data from several years ago, when we're doing a lumpectomy for breast cancer, if we find one or two lymph nodes that have cancer cells in them, we no longer do an axillary dissection. We will just do the sentinel lymph node biopsy and then follow up with radiation for those patients.
Oncology Data Advisor: Sounds like a lot of very exciting advances.
Dr. Killelea: It is very exciting, and like I said, the field does move quickly. As surgeons, we're always looking to improve our skills and improve the outcomes for our patients while still making sure that we are being oncologically safe and taking care of the cancer.
Oncology Data Advisor: Of the agents that are in development and the other surgical advances on the horizon, which do you think will impact treatment the most in the future?
Dr. Killelea: One of the therapeutic modalities is using either chemotherapy or something called endocrine therapy before surgery. What this allows us to do is tell patients who we know are going to need one of these systemic therapies either before or after surgery, "You have a tumor that if we were to operate on right now, might require a mastectomy, but let's see if we can shrink this tumor a little bit with some targeted therapy." We use this often for women that have a certain kind of breast cancer called human epidermal growth factor receptor (HER2)–positive breast cancer. We work closely with our colleagues in medical oncology, and oftentimes we'll have very good clinical or pathologic responses to giving this type of therapy before surgery.
In addition to allowing us to do perhaps less extensive surgery, it also gives us good information about how that patient's tumor has responded to the therapy. If the tumor is completely gone, that gives us good prognostic information about how that patient is going to do in the future. If it isn't, that also gives us good information; it means that perhaps that patient may benefit from some more therapy, which we wouldn't have known if we had removed the cancer previously.
With all of this, I just want to make sure that I add that it really does depend on the type of breast cancer that somebody has, and there really is no one-size-fits-all approach. These are all very personalized recommendations for breast cancer. I want to make sure that everybody understands that it really is best to talk to your doctor and work with your doctor depending upon the type of breast cancer that somebody has.
Oncology Data Advisor: Thank you so much for explaining all of this and for sharing all this great information today.
Dr. Killelea: It's my pleasure.
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About Dr. Killelea
Brigid Killelea, MD, FACS, is the Medical Director of Breast Surgery and the Director of Clinical Integration, Fairfield Region, at St. Vincent's Medical Center of Hartford HealthCare in Connecticut. As a breast surgical oncologist, she specializes in benign and malignant breast disease, breast conservation and reconstruction, mastectomy, axillary node dissection, sentinel node procedures, and oncoplastic breast surgery. She has authored and coauthored numerous publications in peer-reviewed journals.
Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor.