A Thoughtful, Personalized Approach Is Best Course of Treatment for Breast Cancer

By Andrew Wilson

The good news, according to the American Cancer Society, is breast cancer mortality rates have decreased by 42 percent since 1989. The bad news? The incidence of breast cancer is rising among women younger than 50, and it remains the most common and second most deadly form of cancer in women.

“On average, one in eight women will develop breast cancer in their lifetime,” said Sarwat Ahmad, M.D., a surgeon with St. Clair Medical Group. “Many factors influence the incidence of breast cancer.”

For those with a strong family history of breast cancer, Dr. Ahmad said there are two categories: familial or genetic. Only about 10 percent of all breast cancers are genetic, or due to a mutation that can be inherited. There are a handful of known genetic mutations linked to breast cancer, and knowing whether an individual carries one may greatly impact their clinical management and decision-making. In familial breast cancer, a woman may have several first or second-degree relatives with breast cancer but negative genetic testing. These women may need a tailored approach to their care.

“Women should undergo a risk assessment with their doctor, ideally in their 20s and 30s, that includes a thorough family history,” said Dr. Ahmad. “Generally, it is recommended that women begin annual mammogram screenings at age 40, but if your family history suggests you are higher risk you may want to start earlier than age 40.”

In addition to family history, Dr. Ahmad says there are other causes of breast cancer.

“It is common to get breast cancer even without a family history,” she said. “For example, someone who was treated with radiation therapy to the chest for a certain type of lymphoma may have increased risk of breast cancer. Dense breast tissue has been linked to an increased risk of breast cancer. Certainly, environmental causes and lifestyle factors can also contribute to the development of breast cancer.”

For those who have been identified as “high-risk” but do not otherwise have a breast cancer diagnosis, Dr. Ahmad recommends meeting with a breast specialist to learn more about what “high-risk” means in their particular situation and if there are any steps that can be taken to reduce the risk or improve the chances of early detection.

“There are modifiable risk factors that can be changed,” Dr. Ahmad said. “For one thing, there is a clear link between obesity and breast cancer, so a healthy well-balanced diet and regular exercise are highly recommended. Minimizing alcohol intake to less than one drink per day has also been linked to lower breast cancer risk.”

“There are also risk-reducing medications – such as tamoxifen – and risk-reducing surgery that may be appropriate for certain patients,” said Dr. Ahmad.

Dr. Ahmad said the St. Clair Hospital Breast Care Center uses the Tyrer-Cuzick Risk Assessment to stratify all women who come for a screening mammogram as either “average-risk” or “high-risk.” This assessment takes into account family history, demographics, menstrual and child-bearing history, and breast density to determine a woman’s five-year and lifetime risk of breast cancer.

“If the Tyrer-Cuzick model suggests you have a greater than 20 percent lifetime risk of developing breast cancer, you may qualify for enhanced screening with breast MRI, which can be more sensitive in picking up small, early breast cancers,” Dr. Ahmad said.

As for the future, Dr. Ahmad is encouraged by the results being shown with contrast enhanced mammography – a newer technology that uses iodine contrast to detect breast cancer and is thus more sensitive than a traditional mammogram.

“Contrast-enhanced mammograms will be another useful tool to detect what’s benign-appearing versus not, so we should keep an eye on this technology,” she said. “As more research comes through, I would hope it might greatly reduce the number of breast MRIs which need to be performed, particularly for women with dense breast tissue.”

Dr. Ahmad emphasizes that breast cancer is not the same in everyone, so she cautions patients not to jump to conclusions if their treatment plan is different from someone else.

“Every patient is different,” she said. “Not only in their preferences and background, but also tumor type. Tumor biology is king. How the cancer is behaving on a microscopic level – what kinds of receptors and molecular markers it is expressing, for example– is the most important factor when figuring out treatment and prognosis.”

Dr. Ahmad also shares the general trend in breast cancer surgery is a “less is more” approach. When it comes time to plan a surgery, there are decisions to be made about whether a total mastectomy or lumpectomy is the best approach, as well as whether to perform lymph node surgery. She said that several recent studies have shown that breast conserving surgery (lumpectomy), when feasible, has better long-term, patient-reported outcomes than mastectomy, and that limiting or omitting lymph node surgery altogether may be just as effective as more extensive lymph node clearance in select cases.

“It’s important to continuously examine whether the long-term effects of any surgical intervention are balanced by the benefits of it,” she said. “We try to spare women the burden of extra treatment while still providing really good long-term outcomes.”

She adds, “A good bit of my practice also involves high-risk lesions. Those are lesions that may not be cancer but may require close monitoring because their presence may indicate cancer risk later in life. Patients at different stages, sometimes even before developing breast cancer, require a more thoughtful, personalized approach to breast health and management.”

Dr. Sarwat B. Ahmad practices with St. Clair Medical Group Breast and General Surgery, is board-certified by the American Board of Surgery. She sees patients at the following locations:

St. Clair Health Village Square Outpatient Center
2000 Oxford Drive, Suite 301
Bethel Park, PA 15102
(412) 942-7850

St. Clair Health Peters Township Outpatient Center
3928 Washington Road, Suite 270
McMurray, PA 15317
(412) 942-7850