Thinking Pink: Research changes breast-cancer treatment

Calling October the month of pink, local breast surgeon Dr. Melissa Hulvat launched into an update on groundbreaking studies and her work at the Bass Breast Center at Kalispell Regional Medical Center.

"It's amazing to me how frequently groundbreaking things happen that change the way I work day to day," Hulvat said.

Speaking to physicians, nurses and other professionals at Kalispell Regional Medical Center, she said the most important was research published in the Journal of the American Medical Association. Participants were patients whose breast cancer had spread to their sentinel or gatekeeper underarm lymph nodes.

The study compared survival rates of patients who had an average of 17 underarm lymph nodes removed (axillary dissection) versus those who had an average of just two sentinel lymph nodes removed. It was limited to women who had lumpectomies followed by whole breast radiation.

In a stunning result, the study showed no significant difference in survival rates after a little more than six years.

"This caused a huge flap in the breast cancer world," Hulvat said. "It just sat wrong with all of us that we leave lymph nodes in the patient that might have cancer. But you have to believe the data."

For women having lumpectomies with whole breast radiation, Hulvat said she no longer does axillary dissection if three or fewer nodes test positive. This spares the patients the potential of lymphedema, an uncomfortable swelling that impacts up to 30 percent of patients who have axillary dissection.

Hulvat said this has spared many women this unpleasant procedure and its possible side effects. She called this research a game changer in how breast surgeons treat women.

She also discussed a study in the New England Journal of Medicine that involved "chemo prevention drugs." She defined these as drugs given to disease-free people to prevent a disease in the future.

"There are not many chemo prevention drugs - so far we have two," she said.

The two drugs, tamoxifen and raloxifene, bind to estrogen receptors in the breast to reduce breast cancer risk. In the study, researchers compared the effectiveness of tamoxifen and raloxifene to exemestane, an aromatase inhibitor that works by blocking all estrogen.

According to Hulvat, the study showed exemestane had fewer side effects and was more effective in reducing rates of invasive and noninvasive breast cancer in postmenopausal women. More women might use the drug since it has fewer side effects, but the drug is much more expensive than tamoxifen.

"Tamoxifen is still the only drug for chemo prevention in premenopausal women," she said.

The third paper was published in The Lancet Oncology. It validated that a 21-gene assay test called Oncotype DX predicted for certain patients the likely benefit from chemotherapy.

"It's essentially looking at tumor genes, not genetics in a patient," she said.

She said the idea is to figure out which tumor is the bad player likely to return and threaten the patient's life. Test results separate tumors into low, medium and high potential for recurrence.

Because the test is expensive, Hulvat says she only orders it for patients who have not decided whether or not to have chemotherapy.

"I call it the tiebreaker test," she said. "We are entering the age of molecular medicine, personalized medicine. This is great. This is what the genes in your tumor are telling you to do. This is how we tailor a treatment to you."

Hulvat updated the group on the "single stage reconstruction" now offered at the Bass Breast Center.

She said that she performs the mastectomy, preserving the patient's skin and sometimes the nipple, then local plastic surgeons reconstruct the breast with an implant in one operation.

"The patient goes to sleep with a breast that has breast cancer or is at high risk and wakes up with the implant already in place," she said. "One surgery is becoming more common around the country, but we are still ahead of the curve with how many people we do."

According to Hulvat, the free walk-in center for women without health insurance or a primary physician has screened more than 50 people since May. Funded with a Susan G. Komen grant, the center operates every other Friday at the imaging center.

"Myself or another provider are doing breast exams and [sending them for] mammograms all in one visit," Hulvat said.

One woman was found with early stage breast cancer far back in her breast, so she has excellent prospects of a full recovery.

"If she had waited until we could feel it, it would have been a very different story," Hulvat said.

She told the health care professionals that she supports the American Cancer Society's recommendations for clinical breast exams after age 20 and annual clinical exams and mammograms after 40 in spite of the controversial recommendation by the U. S. Preventive Services Task Force to move that age to 50 and over.

"Mammograms are not perfect. They're 40 percent sensitive," she said. "They are not perfect but there is nothing better. MRIs are not better. Ultrasounds are not better. Thermograms - don't get me started - are not better. So the recommendation is still for mammograms after age 40."

Reporter Candace Chase may be reached at 758-4436 or by e-mail at cchase@dailyinterlake.com.