Managing Breast Cancer: Collaboration Throughout the Treatment Journey

Mark D. Pegram, MD: Breast cancer is a very complex disease. As you know, there are multiple subtypes, and most of those subtypes have subtypes within them. Indeed, it’s been said that breast cancer is like snowflakes: there are probably no 2 cases that are identical in terms of actual mutational profiles of an individual’s tumors. So it’s a very complex situation. Consequently, it’s necessary to engage multiple disciplines in medical sciences to diagnose and treat breast cancer definitively. To do that, in my opinion, it’s required to have experts from a range of medical disciplines to make the correct diagnosis, establish prognosis, and direct the appropriate therapies. For example, a patient who’s having routine annual mammographic screening relies on the mammography unit and also the radiologist, who’s interpreting the mammographic images to make the right calls and doing callbacks in case additional views need to be taken. Sometimes, ultrasonography needs to be done to adequately stage breast cancers, and MRI can be necessary for this disease as well. That’s a whole discipline unto itself of breast imaging that has experts that focus only on that issue.

Next, you might need to do a biopsy, so that’s going to involve the pathologist. And the pathology is critical to establishing the correct diagnosis to do all the special stains, to get a look at all the biomarkers in breast cancer, the steroid receptor status, as well as the HER2 [human epidermal growth factor receptor 2] status. Consider the fact, for example, when you’re looking at a HER2 copy number using fluorescence in situ hybridization [FISH] techniques, the current ASCO [American Society of Clinical Oncology]–CAP [College of American Pathologists] guidelines recognize 6 patterns of FISH staining in breast cancer. It’s become so nuanced that you need a dedicated breast pathologist to make interpretations about the histopathologic subtype, and to make all the interpretations necessary for all the biomarkers that inform your therapeutic decisions. All of that is extremely critical.

The surgeons do the lion’s share of the work in terms of treating cancers. They surgically can remove the tumor on block with clear margins, and that’s probably the most impactful treatment used. But it’s a very complex situation because breast cancer presents in different stages. Some are even unresectable at the time of diagnosis if they present in a locally advanced or stage III disease. It’s a whole discipline of breast surgical oncology unto itself, and it requires extra training and special expertise to become a breast surgeon.

After the surgery, all that material goes back to the pathologist to get the correct staging. Additional images may be required if the lymph nodes are positive or if they have other high-risk features, and you need to do, let’s say, CT scan imaging, PET [positron emission tomography]/CT, or CT and bone scan imaging to look for distant metastatic sites. Then the medical oncologists weigh in on integrating all this information from surgery regarding stage and all the pathologic information, the biomarker information. The medical oncologist integrates all that data and comes up with a systemic therapy recommendation on the basis of the best-available science, and all the historical literature from randomized controlled trials that direct our modern approach to therapy of early stage breast cancer. The radiation therapist also weighs in, especially for patients who have lumpectomy as opposed to mastectomy.

Although they received postlumpectomy radiation, there are multiple techniques in breast radiation. It’s not a 1-size-fits-all discipline anymore at all. There can be localized ways of giving radiation therapy—intraoperative radiation, for example—and there could be different durations of radiation therapy. That’s a very nuanced and specialized area, also with a lot of ongoing research. In addition to all these individuals, it’s not infrequent that we find genetic predisposition to breast cancer. For example, a BRCA1 or BRCA2 mutation in the germline, or PALB2, or RAD51, or any number of other cancers predisposing genetic alterations that can be inherited. We’re often in consultation with geneticists to discuss those alterations, some of which may inform treatment for breast cancer—for BRCA mutations, for example. Some of these mutations require screening for other types of cancer. You may be interested in screening for pancreatic cancer, for example, in a patient with a BRCA mutation.

Then you’ve triaged the rest of their family, who might be carrying an alteration and might require a high-risk screening program or even prophylactic surgery. That’s another discipline that’s integrated into the mix. Finally, this is such a complex and difficult series of medical interventions that patients go through. It can be very stressful and emotional, so we often call on our colleagues who have expertise in psychosocial support as well to support our patients. At a typical tumor board, we’ll have representatives from all these disciplines in a group in the same session, and we review all the data firsthand and get the entire relevant patient history. Then I come up with a treatment plan that’s informed by all these disciplines in an interdisciplinary fashion. It’s a consensus treatment algorithm that the group decides would be highly tailored to that patient’s case.

You can have 2 patients in the waiting room with the same-size tumors and the same number of lymph nodes, and they may get completely different treatment recommendations. That’s how different breast cancers become compared with the old days where staging was the main criteria for deciding on treatment algorithms. Now it’s much more about biology of cancer and genetics of cancer, not just the anatomical stage that makes these difficult decisions. It’s really a group effort, and everyone has equal weight in these decisions. Ultimately, we’ll present that entire group’s recommendation to the patient for their consideration and help educate the patient about the contributions that each team member has made to their overall treatment plan.

Charles A. Powell, MD, MBA: Pulmonology and critical care will have roles at different times for patients with different diagnoses. The cancer that we see very frequently is lung cancer, and we have a role in all different stages of the patient’s journey if they have lung cancer. We have a role in prevention of lung cancer, and that usually focuses on identifying risk factors for lung cancer. Most commonly that’s smoking and helping our patients stop smoking. Then our role also is important in terms of early detection. There are screening modalities that are effective for early identification of lung cancer—mainly, chest CT screening for high-risk individuals.

We play a significant role in helping our patients navigate the pathway to have a lung cancer screening and to then determine if there are abnormal findings and whether those abnormal findings relate to a cancer. If so, we’ll have a role in staging that cancer and in guiding the patients to the most appropriate treatment based on the specific diagnosis of lung cancer they may have and their staging. During the course of their disease and their disease treatment, there may be symptoms that develop related to their treatment or related to the tumor progression over time if that occurs. Then we’ll have a role, typically through interventional pulmonology subspecialists, for the diagnosis that may be related to those symptoms and treatments that may help patients have symptom relief.

That’s the story for lung cancer. For other cancers, such as breast cancer, our place in the journey will likely be different. For patients who have breast cancer and a prior history of lung disease, prior to beginning systemic therapy that may be associated with a risk of lung disease, the pulmonologist will often have an important role in characterizing the underlying lung disease, determining its severity, and working with the oncologist and with the patient to determine what might be the most appropriate systemic treatments for the patient given the potential risk of treatments for furthering lung disease or causing new lung disease.

For patients who receive treatments for breast cancer, there can be complications associated with the treatments, including interstitial lung disease. When patients have new symptoms or new abnormal findings on their chest imaging, a pulmonologist often will have a role in working with the oncologist and the patient to determine what might be the cause of the new symptoms or findings, determine if they may be related to the study drug, and work with the oncologist and the patient to determine the best approach toward treating those new symptoms and new findings. That will depend on the drug. It will depend on the setting and the abnormal findings.

Finally, also in the breast cancer sphere, patients have systemic disease, so there may be involvement of the lung, with metastases to the lung that can cause symptoms. We’ll have a role in helping to determine whether the findings on the chest imaging from the breast cancer can be treated with a variety of tools we have available—for example, tools to drain fluid that may accumulate in the lungs and tools to address metastases that may occur in the lungs. We have multiple roles at multiple times in patients’ journeys that occur in multiple different cancers. In all these scenarios, the key is the continuity of communication between the patient, the providers on the pulmonary specialty and the oncologist specialty, and any other specialties involved.

Transcript Edited for Clarity