Prof Carol-Ann Benn talks us through the innovations in oncology that now offer breast cancer patients a more personalised treatment pathway.
Ever been to Epcot Theme Park or Universal Studios or seen that sci-fi movie that is like wow? Iron Man crossed with The Hulk and Thor and add Dr Strange versus Suicide Squad. Oh geez, I’m mixing my superhero metaphors. But actually, these superheroes exist in oncology.
When you’re faced with a cancer diagnosis, particularly when you feel that your world is on the line, and possibly you’ve been through the queues and turnstiles and the ride isn’t what you feel is right for you. Maybe the wild water ride or the slow boat of It’s a Small World and now you feel that you need the Fast pass, or actually you can tolerate the roller coaster as long as it doesn’t take forever. You want to explore the innovations that are new and hot-on-the-scene with the time to work out. You want to know what the superheroes for your cancer might be.
When to look outside the box
You have a cancer diagnosis. You’ve been discussed in an MDM and you feel you don’t fit criteria for standard of care or choose not to fit criteria, or have gone through all the correct processes and the umbrella is looking a bit tattered with a few missing spokes and you’re still sitting with cancer.
There are some serious T&Cs here when you move into the world of superheroes and other dimensions (understand that there are oncology innovations happening all the time and many will move on to become mainstays of treatment, yet some will not).
Choosing to walk on the wild side without understanding the regular rules and outcomes of the game is a little bit like moving into the superhero dimension. This may be the amazing world of superpowers and outcomes but may be a little like a matrix you can’t extricate yourself from.
What is hip and happening on the cancer street?
Before we look at the nitty gritty of trials and understanding why they are so important, let’s look at the new and hip innovations that have been around for many years and are currently leading the forefront on changing how we see and manage breast cancers.
In terms of diagnosis, it’s all Dr Strange – artificial intelligence is the future of breast cancer screening. The ability of the computer eye to assess ultrasound; mammogram and MRI accuracy in determining if that spot or splat is a cancer. By creating multiple image correlations between what is and what may be, the computer gurus can determine if there is a cancer. This is a bit like multiple Google images working out where the treasure is (X marks the spot). We are playing at PET scans literally (dogs sniffing out breast cancer). But, actually, at this stage the diagnosis of breast cancer is still reliant on a core needle biopsy.
Have you heard of a liquid biopsy? Was is das? This is based on the concept of identifying circulating DNA tumour fragments in the blood. These are also known as circulating cell-free DNA (cfDNA) and provide the opportunity to diagnose breast cancer in the bloodstream.
This can be of value for diagnosis as well as for treating cancers, particularly for assessing response to treatment or treatment failure as advanced cancer patients have higher circulating tumour cells. This may be a diagnostic alternative in the future.
Currently this technique provides possibilities for treatment choices, particularly in cancers that haven’t responded to standard treatment. Studies from a while ago show that in patients with higher circulating cancers cells around diagnosis were more likely to have a poor response to treatment.
This data can be used to aid breast cancer patients to have a more personalised treatment. This is a super cool addition to the weapons our superhero oncologists have to ensuring more personalised treatment and less super-blast-everything-treatment.
Other cool innovations
Innovations in placing markers to find the cancer involve fancy magnetic markers and other cool gadgets so multiple needles don’t need to be inserted to ensure the surgeon finds the cancer.
Innovations in surgical treatment definitely embrace a less is more approach. In other words, less big surgeries; more breast-saving surgeries with sleight of hand ways of moving tissue around; more nipple-sparing mastectomies with clever reconstructive options, if this is the choice of treatment (very few indications for mastectomies still exist); and less axillary surgery.
Axillary dissections have gone from taking all the glands (21 plus) under the armpit (a sure way to ensure lymphoedema) to 16 glands then 12. Now seven or more is considered a full dissection. We focus on the sentinel (first gland) the cancer will spread to both before and after primary oncology treatment and are even looking at when we shouldn’t take any. We mark these glands prior to treatment with magnetic markers and dyes and target them exactly when removing them.
Innovations in radiation have seen the less is more trend as well. Shorter courses, and finally after at least 15 years that I’ve been going to units and checking the how and when to, we have over the last couple of years succeeded in sexy devices to give radiation in theatre with a single elegant safe dose, from a natty mobile machine that is team- and patient-safe and incorporated into many international guidelines. This is always an important breakthrough for innovations, the step from super sci-fi hero to hey I recognise that skill is part of our day to day.
From good to better
I’ve trained in the era of big open surgery to keyhole surgery; to surgery being replaced by interventional radiology concepts for the heart and vascular problems; from carrying pagers to smartphones with more computing powers than wow who knows.
To changes in consultations going from face to face to virtual; to virtual MDM being a thing and wait for it…
We can now avoid surgery altogether in some breast cancer patients. Yes, cryo-surgery, the ability to freeze certain breast cancers has been shown through some very robust trials (The FROST trial to name but one) to be a useful addition to managing breast cancer patients.
So, how does it work? Guided by ultrasound, a small probe is inserted into the tumour and liquid nitrogen is poured into a balloon that is around the probe. This generates temperatures well below zero which turns the tumour into an ice ball. How cool (literally) is this? The freeze-thaw, freeze-cycle destroys the targeted tissue immediately while leaving the tissue in the vicinity, mostly not effected. Side effects can include a cold burn (rarely) and more often a ball of dead tissue is left inside the breast (only in area of tumour). This is absorbed over time and monitored by ultrasound.
And, yes despite what everyone hears about chemotherapy, this too has experienced innovations from nuke everything to specialised treatments personalised for your specific cancer to more targeted therapies and immune-modulating therapies. Some treatments are now being offered in oral forms. New classes of drugs developed for advanced cancers, targeting different parts of the cancer cell, specifically allowing us to say to many patients with advanced cancer that survival rates can be measured in 10 years plus and not in months.
And with the advent of better understanding the genetics of cancer cells, we can work out who shouldn’t get chemotherapy even when the cancer had spread to the lymph nodes and who should get what drug treatment. High-tech superhero medicine at its best.
How do all these innovations happen?
Stark Industries and other fancy biotech firms performing lots of research allows for all these developments. Before they can be accepted, we perform medical trials.
A medical trial doesn’t mean that patient A gets the drug, if it’s a drug and patient B get sugar water. Trials in medicine, by the time they are trialled on people, have undergone rigorous phases of testing and always pitted against the gold standard. This means that you’ll either get the best of the best or something that possibly can be better than the best of the best. This is particularly useful for patients that may not have access to certain expensive drugs that may not be fully funded by medical aids.
You should and must always review the specs and criteria for a trial; look at what is new and happening on the street.
Understanding that this may sound cool and hip but also comes with understanding that the tried and tested is tried and tested for a reason. But for those who feel as if they have tried all options and aren’t winning the war, looking at trials is important.
MEET THE EXPERT – Prof Carol-Ann Benn
Prof Carol-Ann Benn heads up breast cancer centres at Helen Joseph Hospital and Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established Breast Health Foundation.