Two physicians performing breast reconstruction surgery

The University of Maryland Cancer Network physicians and surgeons embrace a curative approach to breast cancer, incorporating the latest surgical techniques and oncologic treatments for patients with all types and stages of the disease. Here are a few of the network's recent advances.

Biomarkers to Tailor Treatment

The UM Cancer Network uses biomarkers, which patients' tumors express, to develop custom anticancer treatment plans.

The most common of these biomarkers for breast cancer are estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2). Each network breast cancer patient is tested for all three before treatment begins, says Katherine H. R. Tkaczuk, MD, professor of medicine at the University of Maryland School of Medicine and director of the Breast Evaluation and Treatment Program at the University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center.

"By testing the tumor tissue for these biomarkers, we can better tailor the systemic anticancer treatments for these patients," she says. "Breast cancer is not just one disease. It's many different sub-types of breast cancer that are treated in a different way."

For example, breast cancers that test positive for the HER2 biomarker respond better to treatments that include agents that block HER2 such as Herceptin, a monoclonal antibody to HER2, or Kadcyla, an antibody drug conjugate. Both are approved by the U.S. Food and Drug Administration (FDA) for HER2 positive breast cancer.

"In the last 10 years, we've had a lot of targeted treatments for the HER2 protein," says Phil Nivatpumin, MD, medical director of the Kaufman Cancer Center at University of Maryland Upper Chesapeake Health System. "That used to be a devastating type of condition, but now the treatments are so effective and there are so many targets for that it's actually become one of the more treatable and curable ones."

Cancers that test negative for the three common biomarkers are deemed triple negative - a notoriously aggressive cancer that accounts for 10 to 20 percent of all breast cancer cases.

Triple negative patients who have a biomarker called PD-L1 have responded well to a combination of chemotherapy and infused medicine known as PD-L1 inhibitors (also known as checkpoint inhibitors), says Dr. Nivatpumin.

Dr. Tkaczuk and fellow network physicians are also studying new biomarkers, including a circulating tumor biomarker known as glycoprotein 88 (GP88) found in the blood or tissue of some lung, prostate and breast cancer patients. A Columbia-based A&G Pharmaceutical developed a humanized monoclonal antibody for the GP88 marker and is working with Dr. Tkaczuk on the antibody's first-ever human clinical trial. While GP88 is not breast cancer specific, the trial will test whether the antibody stops the growth of triple negative breast cancer cells.

Preoperative Therapy

Traditionally, most breast cancer patients receive chemotherapy after surgery, says Suliat Nurudeen, MD, assistant professor of surgery at the University of Maryland School of Medicine and breast surgical oncologist.

Studies showed no difference in overall survival of patients who received chemotherapy before or after surgery. That's why clinicians now provide chemotherapy before surgery, also known as neoadjuvant chemotherapy, as an option.

"With neoadjuvant chemotherapy, oncologists can see how a tumor responds to the treatment," Dr. Nurudeen says. "In addition, we can decrease the amount of surgery we perform for some patients."

For example, many of the patients who need chemotherapy up front are the ones whose breast cancer has spread to the lymph nodes under the arm. In the past, patients had to have all of the lymph nodes removed through axillary lymph node dissection - a procedure that has a 30 to 40 percent risk of lymphedema. Now, if the cancer has only spread to a small number of lymph nodes, surgical oncologists can consider targeted axillary lymph node dissection, which preserves unaffected lymph nodes.

UM Cancer Network physicians have also studied how a combination of neoadjuvant chemotherapy and PARP inhibitors impact patients with BRCA-positive breast cancers, Dr. Nivatpumin says. PARP inhibitors may keep cancer cells from repairing their damaged DNA and eventually cause cancer cells to die.

Another network advance is the new breast cancer seed program, where oncologists place magnetic seeds inside a patient's breast up to a month before a partial mastectomy to accurately locate the cancer site.

"In the past, we had a wire system where patients had to come in early the day of surgery, have their seeds inserted and then have their surgical procedure," Dr. Nurudeen says. "Now, they can come in as early as 30 days ahead of surgery to have the magnetic seeds placed. As a result, we're able to shorten the length of the surgical days and decrease amount of delays on the day of their surgery."

Studies show patients with magnetic seeds have a lower risk of positive margins during breast conserving surgeries.

Breast Conservation/Reconstruction

Patients have multiple options when it comes to breast conservation and reconstruction, including DIEP flap and TRAM flap, which use a woman's own tissues to reconstruct the breast, implants and lumpectomies.

One of the newer options for patients who have had mastectomies is silicone or saline breast implants on top of their pectoralis major muscle, says Nelson H. Goldberg, MD, professor of surgery at the University of Maryland School of Medicine and a plastic surgeon who specializes in breast reconstruction.

"Several years ago, we determined through clinical trials that we didn't need to put the implant under pectoralis major muscle anymore," he says. "Most of the time they can now go on top, which means a lot less pain for the patient."

Network surgeons also offer oncoplastic breast surgery, where they combine a traditional lumpectomy with a standard breast reduction. This procedure allows women with moderately large breasts to have the same amount of breast tissue removed in their healthy breast as the tissue removed during a lumpectomy, Dr. Goldberg says.

Nipple- and areola-preserving techniques have also improved - so much so that when patients have a mastectomy, surgeons can hide the incision at the lower fold of the breast and remove tissue without impacting the nipple, Dr. Nurudeen says.

"The thing with breast cancer now is that we are finding cancers at a much earlier stage," she says. "They're more treatable, and we have a wide variety of treatment options for our patients... And with the vast majority of patients who are presenting with early stage breast cancer, we can preserve the breast tissue without having an impact on their overall survival and risk of breast cancer returning."

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About the UM Cancer Network

With the NCI-designated UM Marlene and Stewart Greenebaum Comprehensive Cancer Center as its hub, the UM Cancer Network offers patients access to nationally-renowned experts, cutting edge treatments and technologies, and the latest clinical trials. UMGCCC was ranked High Performing for cancer care in the 2021-2022 US News and World Report's Best Hospital rankings. Learn more about the UM Cancer Network.