Dr. Stephen Thatcher is a radiation oncologist at Cancer Care Northwest in Spokane.
In a recent interview, Dr. Thatcher talked with The Spokesman-Review about some of the latest updates for breast cancer screening, genetic testing and treatment approaches. Answers have been edited for length and clarity.
Q: Do you think there is still confusion in the general population about how often women should have mammograms?
A: Yes, there is still confusion probably because if you ask different doctors, you’ll get different answers. The new guidelines are mainly every other year or every two years. A lot of oncologists feel it should still be every one year. I happen to be one of them. There are definitely pluses and minuses of doing it every other year. Personally, what I’ve noticed is when patients try to go every other year, there are a lot who go three or four years and they think it’s only been a year. It’s easier for people to forget about it, rather than when you say, ”Every January, I’m doing mammograms like clockwork.”
We’re seeing more women who are coming in who haven’t had a mammogram in four years. They’ll say, “I thought that was a year ago.” We’re a little biased because they see everything after the fact. Certainly, if they have family history, I definitely do recommend once a year. There are some people who are higher risk that you want to watch closer, but this is for the 40 and up and all the other criteria. The age criteria hasn’t changed that much. It’s just the frequency that’s been the dilemma.
Q: Many women have conventional mammograms, but what about other screening choices?
A: The best answer right now is something called tomosynthesis, which is a more advanced mammogram basically. It has fewer false positives. It catches more, so less false negatives. It is a little bit more expensive, but in my opinion that is the best screening tool that we have right now. It’s similar to a mammogram except it takes it from more angles. You get more information than from just a single-slice mammogram. They’re usually covered by insurance, and another name for it is 3-D mammography. It’s the best of both worlds. You’re catching more cancers, and you’re not calling as many things cancer that are not cancer.
Now, if you get a mammogram and the breasts are really dense, then a lot of radiologists who are reading them might say a MRI could be considered. So there are certain circumstances where we consider a MRI. Ultrasound has not proven to be a real great screening tool. We’ll use it more as a tool in conjunction with a mammogram if we want more information. The MRI story is also a complicated one because it has a lot of false positives, meaning it calls attention to more things that aren’t necessarily cancer. There is certainly a role for it. Mammogram is still the mainstay, and tomosynthesis is quickly replacing the standard old mammogram.
Q: With past news surrounding the mutation in the BRCA1 gene or the BRCA2 gene, are women with a family history of breast cancer asking for and receiving genetic testing to understand risk?
A: We recommend it for patients in specific risk groups. If you’ve already had a breast cancer, you’re younger than 50 or you have two or more first-degree relatives who have had breast cancer, then yes, we’ll often recommend it. The most common mutation people know about is BRCA 1 or 2 (Angelina Jolie had BRCA 1). Even if you have a family history for breast cancer, still only about 5 percent of patients are going to have that mutation. There are other mutations we didn’t previously have a name for, and that we can now test for. The problem is these are all new developments. Patients will often get a “genetic mutation of unknown significance,” which is a difficult thing for a doctor to explain because we don’t know what to do with that information. Over the next 10 years, we’re going to see a big change in that area, I think. We’ll be much more able to classify the genome than we have been able to in the past, not just the BRCA 1 and 2 mutations, but others.
It’s a good discussion to have with your doctor because there are a lot of different classifications for when genetic testing should be ordered and when it shouldn’t be. Certainly not every women should get genetic testing done, but women with a strong family history and who had breast cancer already, there are all kinds of classifications set up. The women who need it should be getting it. Even still, for most of the women with family history for breast cancer and then they have breast cancer, we can’t identify a genetic mutation.
Q: Are you seeing that more women preemptively are having mastectomies, based on genetic testing, family history or desire to avoid future treatment?
A: It’s pretty rare to do a mastectomy just based on family history if you don’t have a genetic mutation, but yes, women who are BRCA 1 or 2 positive are often counseled about it. We give them the statistics and depending on whether they’re BRCA 1 or 2, we let them choose whether they want a mastectomy. It doesn’t mean they have to have a mastectomy. Where we have seen a big increase in mastectomies is for early-stage breast cancer that don’t necessarily need a mastectomy; there are other less-invasive options like lumpectomy, or lumpectomy and radiation. Say cancer is in the left breast, and a woman says, “I don’t trust that I won’t in my other breast.” They’re getting bilateral mastectomies. There has been a trend in that. We have good evidence that we don’t really save more lives by doing the procedure for the other breast.
Oftentimes, it is more of a cosmetic request because then they can get reconstruction done on both sides and have it look more symmetric. That’s a whole other discussion, but that is probably where I’m seeing more mastectomies that probably don’t need to be done, when you have breast cancer on one side and then you do the contralateral-side mastectomy. We’re trying really to help patients understand, you don’t have to have the other breast removed. But for some women, just through the whole anxiety of getting diagnosed with one side and the idea of going back for mammograms every year, they want that mental peace that there is a very low chance they’ll ever have to deal with breast cancer again, so they elect to do mastectomies for both sides. The problem is there is a downside to that. Anytime you do a big procedure, things can go wrong and there are higher complication rates.
Q: Can you explain some of the newer radiation technologies?
A: For one, we now know that a lot of lower-risk breast cancer patients who have had a lumpectomy, in particular, we can do the radiation a lot quicker than we used to be able to do. It used to be there would be a five- to six-week course, Monday through Friday, daily treatment basically. We can now do that in 16 treatments or three weeks basically. There’s good evidence that’s equivalent in certain cases to that longer, more protracted six-week course. It saves the patient time and money; it’s a way of giving it faster and more efficiently.
We use a lot of what we call a breath-hold technique. On left-sided breast cancer patients, one of the issues is trying to avoid hitting the heart, which is of course right behind the breast. We’re able to use four-dimensional CT scans with the patient holding a breath and without the breath held. We can see how that changes the position of the heart. When you take a deep breath, the lungs fill up and it pushes the heart away from the chest wall and kind of down more. That allows us to treat the whole breast without having to worry about skimping on part of the breast to try to protect the heart. The technology has like a snorkel that the patient breathes into, and we can tell exactly how much air they’re taking in, and how big a breath. Patients have this little screen they can watch to tell how deep of a breath to hold, and they take it in and we have them hold it there for 30 seconds, and we then treat while the patients have their breath held. Before you do that, you do all this planning (with CT scans) and put it on the computer; then you can map everything.
Q: What’s are other advancements you’re excited about?
A: What’s called partial breast radiation has been around for a while now, but we are now well-versed for those options. For really low-risk breast cancer patients, you can just treat part of the breast. We have decent evidence to say that is safe and well-tolerated as a way to minimize toxicity, and often done in those condensed schedules.
What we have noticed in lots of different types of cancers is that different types of targeted chemotherapy have really improved. We’re much better at testing each specific breast cancer now, looking for what specific mutation that breast cancer has and giving them chemotherapy targeted to that mutation. Thirty years ago, we would give for lack of better term just the standard chemotherapy that was uniformly toxic but relatively effective for the cancer. Now, the main example would be Herceptin, which targets the HER2 gene that’s often over-expressed in breast cancer. That’s revolutionized breast cancer treatment. We also now have immunotherapy, mainly for patients who are metastatic, meaning it’s Stage 4. We’re able to help the immune system recognize the tumor cell is bad, which has been difficult in the past because it’s a tumor that started with you. I’d say those are exciting frontiers, the chemotherapy or immunotherapy type of treatments.
Q: Any additional thoughts?
When I have family members calling me about breast cancer, I tell them one of the most important things is that you get a multidisciplinary approach. It’s very important to have the surgeon, the radiation oncologist and the medical oncologist all on the same page and knowing what each other is doing, because it’s very much a team approach. We have weekly conferences about difficult cases and we’re all in the same room. We even have plastic surgeons there with us so we can think about all the factors that affect a breast cancer patient. When it gets complicated, it is very important to have all the specialists there talking to each other so you don’t have fragmented care. The good news is we have a lot of breast cancer treatments, but sometimes that gets overwhelming for patients because they have choices, so having a multidisciplinary approach I think is very helpful in making decisions upfront.
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