Breast

A decade ago, it was fairly common to treat most breast cancer patients with chemotherapy. Since then, research that focuses on overtreatment and molecular profiling of tumors has shown that many patients do not need chemo. The reasons are as complex as each individual — ushering in an era of truly personalized care.

“The less-is-more trend is most successful in low-risk estrogenfueled cancers,” says O’Regan, who also serves as physician-inchief at Strong Memorial Hospital at the University of Rochester Medical Center.

“Overall, research has prevented thousands upon thousands of patients with breast cancer from having to undergo chemo, and that’s a huge step forward,” O’Regan says. “The question now is: Are there more patients who don’t need chemotherapy at all, or who just need less chemotherapy?”

Thanks to O’Regan, Wilmot is one of only two places in the nation to enroll patients in a clinical study of a two-drug combination that sets up a direct hit on triple-negative cancer cells. Wilmot is also part of a larger national network of clinical trials, evaluating the effectiveness of the newest drugs for triple negative breast cancer. Those studies, led by Carla Falkson, M.D., involve collecting tissue samples from patients so that investigators can conduct correlative laboratory studies to understand why the drugs work or don’t work on TNBC.

The vast majority of breast cancer cases in the U.S. are hormonally driven cancers. They are the most treatable forms, particularly if found in early stages before the cancer has spread to the lymph nodes.

Less common subtypes — which is the focus of a lot of research at Wilmot and elsewhere — are known as HER2-positive breast cancer, and triple negative breast cancer (TNBC). The latter, which O’Regan primarily investigates, accounts for less than 15 percent of all breast cancer cases but is aggressive and has a lower survival rate. TNBC also comes with fewer treatment options because these tumors lack hormone receptors and do not make much of the HER2 protein.

Wilmot offers the latest treatments, including immune therapies for breast cancers that may have started to metastasize; targeted drugs known as PARP inhibitors for patients with the inherited BRCA gene mutation, a gene that greatly increases the risk of developing aggressive disease; and studies to discover if some patients with the HER2 gene signature can safely use a lesstoxic precision drug.

“We’re very on top of things in terms of new therapies,” O’Regan says. “The idea is to move away from the standard chemotherapy and give patients only the treatment that they need — to find agents that are more effective but with less toxicity, especially for patients with metastatic disease because they will be on treatment indefinitely.”

The same treatment trends are occurring in radiation therapy. For women who opt for breast-sparing surgery (lumpectomy), the standard care had been to follow up with six weeks of radiation treatment, five days a week. Later, research began to show that physicians could safely give slightly more radiation each day, and reduce the duration to three or four weeks. Today, some cases qualify for just a single week of radiation.

“Patients are shocked when they learn this,” says Gergelis. “It’s a pretty neat thing, to see where we’re evolving.” The treatments are biologically equivalent in terms of killing the cancer cells, but more convenient. Daily radiation is a burden, even though the treatment itself only takes a few minutes. It hampers work schedules, delays travel, and creates concern about injury to skin and nearby organs.

The evolution toward condensed radiation therapy, including partial versus whole breast irradiation, is often based on tumor type, age, lifestyle, and treatment goals. Wilmot has new clinical studies in this area.

Research allows physicians to be nimble, to design precision therapy.

“The whole point is to ‘right-size’ treatment for each person based on their circumstances,” Gergelis says. “To give all the treatment that’s needed and escalate it in the most aggressive cases, while customizing cancer treatment for those who have less aggressive disease.”