[6 min read]
In this article:
- Patients with breast cancer have numerous treatment options, depending on their type of cancer and their treatment goals.
- Genetic testing plays a significant role in determining risk and the treatment path a patient might choose.
- A Providence Swedish breast surgeon shares information about two classes of drugs currently used to treat breast cancer, including how they work and their benefits and side effects.
Navigating the complex landscape of breast cancer treatments can be an overwhelming journey. Advancements in medical research and technology and the treatment landscape for breast cancer have expanded significantly, offering a range of therapies tailored to the specific needs and circumstances of each patient.
Understanding these options is crucial in supporting patients and informed health care decision-making. From surgery and radiation therapy to chemotherapy, hormone therapy, and targeted treatments, each approach has its unique benefits and considerations. Personalized medicine has also gained prominence, emphasizing treatments that are specifically designed based on the genetic makeup of both the patient and the tumor.
Experts at Providence Swedish Cancer Institute are committed to a personalized, compassionate approach for each patient and understanding of how treatments may affect their quality of life. To demystify some of the complexities of breast cancer treatments and care options, we spoke with Colleen M. O’Kelly Priddy, medical director for the North Sound Breast Program at Providence Swedish Cancer Institute, who shared insights into some treatments to help patients confidently engage in discussions with their care team and choose the path that feels right.
What are some hereditary factors related to breast cancer, what are we learning about those, and what should patients know?
We know that 10% of all breast cancers are considered inherited, meaning there is an identifiable genetic component to them. We know that women who have a family history of breast cancer are at increased risk of developing it themselves, so genetic counseling and genetic testing are a big part of identifying whether or not there is an increased risk, but sometimes you can go through all the testing and it's all negative and still be a high-risk patient. That is something I want patients to understand: just because your genetic testing is negative doesn't mean you always go back into the normal risk category.
What does that looks like in practice with a patient? How do you guide patients based on their risk pool?
Referrals usually come from gynecology or primary care. They've identified that the patient has a family history of breast cancer or ovarian cancer, or they got a note back on a mammogram saying the patient may be at elevated risk. They will send them to us for risk assessment and there are a few different parts to that process.
The first is obviously getting a good family history and making sure that we really understand a patient’s genetic pedigree (a chart that visually diagrams the inheritance of traits or conditions through generations of a family). Then we will do formal risk calculations based on breast density, body makeup, any prior biopsies, and family history. This allows us to calculate a patient’s lifetime risk of developing breast cancer.
It’s a really important thing for patients of all risk groups and backgrounds to know that there are things we can do to reduce the risk of breast cancer, and knowing your risk allows you to have the information you need to make smart decisions about your future.
There are multiple models that we can use to get those numbers. For the general population, the number is somewhere in the range of one in eight women in this country will develop breast cancer over their lifetime — that’s around 13% or so. If we calculate a patient’s lifetime risk at greater than 20%, there are things that we can do to help with enhanced surveillance to make sure that if something develops, we're not waiting a whole year between imaging, and we do more frequent clinical breast exams. We want to make sure we're not missing something, and that if something does arise, we catch it as quickly as possible.
We can do genetic testing if it looks like a patient has a significant familial component to their risk profile. In severe cases we can talk about risk reducing medications that can significantly cut back on the risk of breast cancer, which have their own side effect profile, but for some women it's absolutely worth it. And in very severe cases we can talk about risk-reducing mastectomies, which is a reasonable choice for some patients.
What are the medications used to reduce the risk of breast cancer? How do they work, what are the side effects, and what's the cost-benefit analysis?
Our bodies are always making estrogen and progesterone. And we know by just looking at population data that there are patients who have increased overall lifetime exposure to estrogen, so they are at increased risk of developing breast cancer because most breast cancers feed on estrogen; they sort of eat it for breakfast.
We have medications that can block the body's estrogen, either by blocking the receptors for estrogen within the breast tissue or, in patients who are postmenopausal, by blocking the enzyme that creates estrogen from pre-estrogen hormones that live in the fat cells.
For premenopausal patients, we will usually talk about using selective estrogen receptor modulators, or SERMs. Tamoxifen is the most commonly known; it essentially makes it so that the breast tissue can't see the body's estrogen, so you still have all your estrogen, but the breast tissue can't see it. Tamoxifen has some side effects that can include big bad scary ones like an increased risk of blood clots, particularly in smokers, and a small (but not zero) risk of uterine cancer.
This class of drugs is called SERMs because they selectively alter the receptors for estrogen based on where the receptor is; they sort of “up-regulate” the estrogen sensing in the uterus and “down-regulate” it in the breast. That is why there is that slight increased risk of uterine cancer with tamoxifen. There can also be menopausal type side effects like hot flashes, night sweats, that sort of thing. But most women will find that things get better after several months as the body figures out its new normal.
The other class of medications is the aromatase inhibitor group. They block the enzyme that lives in fat cells that convert pre-estrogen into estrogen. These medications tend to be better tolerated but they're not very effective in premenopausal women because the amount of estrogen produced by the fat cells compared to that produced by the ovaries is a drop in the bucket, but for patients whose ovaries are no longer active, these medications can be very effective. The most common side effects for these are some joint stiffness, though most of my patients will tell me they had it before and they still have it now. It certainly won’t make joint stiffness better, but for a lot of patients it might not cause much of a noticeable difference. Aromatase inhibitors can cause some fatigue as well as the same menopausal-type side effects, but in general, they are well tolerated. There can be some risk to bone density with the aromatase inhibitors, so when we start the drugs, we're always very careful to keep a really close eye on bone density scans.
Can you talk more about breast cancer risk in younger premenopausal patients, including the reproductive risk factors that are considered with prevention, diagnosis and treatment?
With younger patients we talk about the things that are (at least theoretically) within one's control, like the amount of alcohol you drink, when you have babies, how many babies you have, whether you breastfeed those babies or not, and your overall body habitus. Maintaining a normal body weight by having a lower overall fat mass, means less contribution to your overall estrogen exposure and risk.
Having babies earlier in life also reduces your overall chances of developing breast cancer. Breastfeeding, because it’s a relatively low estrogen state, can also reduce your risk of developing breast cancer. We also note that alcohol use is linearly correlated with breast cancer risk. The more you drink, the higher your risk.
With all that said, though, the important thing to recognize is that not all these things are completely within our control, and there is no “Get out of jail free” card that guarantees someone will never get breast cancer. If I take 100 women who do everything “right” and 100 women who do everything “wrong” — for example, no babies, no breastfeeding and high alcohol intake in one group, and no alcohol, multiple pregnancies, and breastfeeding in the other — there will still be cases of breast cancer in both groups. There will just be more, relatively, in the group with higher-risk behaviors.
So, it’s a really important thing for patients of all risk groups and backgrounds to know that there are things we can do to reduce the risk of breast cancer, and knowing your risk allows you to have the information you need to make smart decisions about your future.
Learn more and find a physician or advanced practice clinician (APC)
At the Providence Swedish Cancer Institute, we know that no two cancers are alike. That’s why we focus on you — not your disease. If you need cancer care or are looking for testing to determine your cancer risk, we can help.
You can also learn more about available clinical trials. Our physician investigators and researchers are involved in hundreds of ongoing trials involving most types of cancer.
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Related resources
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Day in the life: Our Breast Cancer Express brings care to our communities
Separating breast cancer myths from reality can help you understand you risk
This information is not intended as a substitute for professional medical care. Always follow your health care professional's instructions.
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