Significant progress has been made in numerous facets of breast cancer care in recent years, including developments in treatment, imaging, pathology, radiation, and surgery. In this interview, Dr. Richard Zelkowitz, a Regional Medical Director of the Breast Program at Hartford HealthCare, highlights the advances that have been made and explains the importance of subspecialties in ensuring that patients with breast cancer receive the most individualized care possible.
Oncology Data Advisor: Welcome to Oncology Data Advisor. I'm here today with Dr. Richard Zelkowitz. Dr. Zelkowitz, could you tell us a little bit about what you do at Hartford HealthCare?
Richard Zelkowitz, MD: I've been in town for about 32 years. I came in 1989, and my practice has been limited to breast cancer for probably 20 to 25 years. I'm a clinician, so most of what I do is clinical work. I'm very interested in clinical research and putting people on trials. I have seen a lot in 30 years of doing this.
Oncology Data Advisor: As a medical oncologist, what are some of the most important pathological factors of breast cancer that influence your treatment decisions?
Dr. Zelkowitz: We've made enormous strides in all the different options that we have and all the different technologies, but so much of it still comes down to what the pathologist tells us: what the size of the tumor is, what the tumor looks like, the status of the lymph nodes, and whether the tumor is hormone receptor–positive or human epidermal growth factor receptor (HER2)–positive. Status of HER2 is something that was not available even when I first went into practice. It's just another example of how things have changed.
Oncology Data Advisor: What have some of the most significant advances in breast cancer treatment been over the last few years?
Dr. Zelkowitz: If I look back to when I went into practice, we did not have the same technology for diagnosis. There was no magnetic resonance imaging (MRI), let alone computed tomography (CT) scan. Mammography technology has exploded as far as increasing sensitivity. From a diagnostic point of view, it has escalated. Two of the mainstays of what I do are hormone therapy and chemotherapy, and the number of hormone therapies has escalated from basically tamoxifen, megestrol acetate (megace), and a drug that's no longer given called aminoglutethimide (Cytadren®), to innumerable new hormone agents, as well as agents that sort of modify how hormones work. There are multiple new chemotherapies.
More importantly, there are now more directed, targeted therapies. As I said, HER2 status was not available when I first went into practice. We have kind of revolutionized HER2-positive breast cancer with the advent of biologic therapies like trastuzumab and pertuzumab. We probably made the worst prognosis type of breast cancer into one of the better prognosis types. We have targeted therapy and we have immunotherapy: huge changes in the last 20 to 30 years.
Radiation techniques have been deescalated, and surgical techniques have been deescalated. If you could do more with less, that's really what we want to do. We want to have the same outcomes and sort of intervene less than we need to. As far as surgical techniques, we do far more breast conservation. We have multiple new breast-conserving procedures and multiple new plastic modifications. We don't do full axillary dissections in the majority of patients, a procedure which was very standard years ago. It's really remarkable in the breast cancer world.
Oncology Data Advisor: Of the other agents that are currently under investigation, which do you think are the most promising?
Dr. Zelkowitz: The agents that are always going to be the most promising are the targeted agents. Instead of globally trying to kill cancer cells, if we can target the bad cells, that is the future. That will enhance efficacy and reduce toxicity because you get less scatter. The biologic agents for HER2 positivity, agents that modify how the hormones work, and immunotherapy, which interacts with your own immune system: those are the future of this disease.
Oncology Data Advisor: Do you have any advice for members of the cancer care team in how to select treatment for the patients with breast cancer?
Dr. Zelkowitz: It's kind of a global question, but the one thing I tell people is that I do believe in subspecialization. I think if you have a breast cancer issue, you should go to people who are equipped to treat breast cancer and who focus on breast cancer. I think that it's hard to know everything about everything. It's easier to know a lot about a little, and I really believe in subspecialization.
I believe that surgery should be done by a breast surgeon, and I believe breast reconstruction should be done by a reconstructive surgeon who specializes in that. It's the same for medical oncology and radiation oncology. The subspecialization makes a difference. The other thing that I really think makes a difference is research. Again, looking back at how things have changed in the past 30 years, it blows you away, and that's a byproduct of research.
Oncology Data Advisor: Well, thank you so much for sharing all this great information with us.
About Dr. Zelkowitz
Richard Zelkowitz, MD, is Regional Medical Director of the Hartford HealthCare Cancer Institute Breast Program in Fairfield County, Connecticut. He specializes in the treatment of patients with breast cancer, with particular interest in risk assessment, survivorship, patient advocacy, and clinical trials. Dr. Zelkowitz is a member of the American Society of Clinical Oncology, the New York Metropolitan Breast Cancer Group, and the American Society of Breast Disease, as well as a Medical Advisory Board member of the Breast Cancer Alliance.
Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor.