An Interview With a Leading Oncologist in the field of Breast Cancer
An interview with the leading oncologist Dr. Shani Paluch-Shimon specializing in the treatment of malignant diseases of the breast at “ Herzliya Medical Center."
In Russia, about 57,000 women are annually diagnosed with "breast cancer." Recovery percentage is only 57%. What's going on in Israel?
In Israel, the percentage of recovery is very high - more than 90% of the women who have breast cancer will recover because the disease is diagnosed in its earliest stages - first or second. Recovery rate in Israel is among the highest in the world.
You treat breast cancer at all stages. Is there any chance of curing patients in the fourth stage of the disease?
The fourth stage is characterized by the fact that the tumor is beyond the breast and has penetrated into the lymph nodes and other organs. Under these circumstances, the disease becomes chronic when recovery does not occur. In "Herzliya Medical Center" there is a vast arsenal of therapeutic agents through which we help patients to prolong life and maintain its quality.
You are in charge of the treatment of breast cancer diagnosed in young women. What is the level of morbidity in the world?
I want to note that the level of morbidity among young women is low. Breast cancer is mainly common in the older generation of women between 50 - 60 years of age. Breast cancer under the age of 40 is mostly genetic, which is about in 7% of all the patients.
Is there any difference in the treatment of women under 40 and that of the older generations?
Certainly. We involve a multidisciplinary team specializing in oncology for young women. This means that we create all the conditions in order to preserve the woman's ability to bear children: before chemotherapy, we carry out the procedure of egg collection and store them by cryopreservation. In case of women diagnosed with breast cancer during pregnancy, we involve a multidisciplinary team to keep the pregnancy while continuing therapy.
What kind of therapy do you administer during pregnancy?
After the third trimester, the implementation of the program of treatment is not difficult, as the team has gained extensive experience and has developed effective protocols. Patients receiving chemotherapy that is safe for the fetus undergo surgery during pregnancy. At the same time a women carries out a new life in her and resists the disease, it is a very difficult time for a woman to be in this situation.
Some treatment protocols require the introduction of an artificial organism that induces a state of menopause, which affects the overall health, her relationships with the spouse and the family. Therefore, psychological assistance to such patients is a must, and we provide it. We protect the woman and give her not only an effective treatment, but also a professional mental support.
In your opinion, which of the preoperative treatment of breast cancer showed the best results?
Not all women need a preoperative treatment. Chemotherapy is one of the proven methods which is assigned "before" or "after" surgery. Recent studies show that the result does not depend on the treatment phase of the introduction of chemotherapy drugs. The choice of chemotherapy as preoperative treatment occurs when an oncologist in conjunction with the surgeon come to a decision to reduce the size of the tumor for the purpose of conducting a surgery onwards. Some tumors have a very aggressive performance. In such cases, preoperative chemotherapy is also assigned.
What is the most accurate diagnostic protocol for the early detection of breast cancer?
The combination of a digital mammography with ultrasound is the most accurate and informative survey instrument. The quality of mammography in Israel meets very high standards. More than 85% of breast cancer is diagnosed through this kind of research. For women with suspected genetic nature of the disease (BRCA), the standard examination is magnetic resonance imaging.
How can a women prevent the development of breast cancer?
Women should be checked regularly. Every woman over 25 years should be screened annually by a specialist in the field of breast surgery. From the age of 50 and up it is necessary to undergo mammography every two years. This applies to those women as well who do not have a history of breast cancer. Women with a family history or the presence of BRCA mutations are recommended to undergo more frequent examinations. For example, if you know that your mother has breast cancer that was discovered at age 32, then you should begin preventive examinations from the age of 22; ten years before the cancer was diagnosed in your mother. Women who have a family history of BRCA mutation carriers undergo a regular MRI examination.
All doctors and nurses in Israel who are employed in the oncological department receive training in order to acquire knowledge about the psychological state of the patient who has to cope with a serious illness. Isn’t it enough that doctors are instructed only in the therapeutic process?
I am convinced, and studies prove this fact, that the better the understanding and the communication between doctor and patient is, the more effective the treatment will be. The more knowledge the woman receives regarding her treatment, the more confident she feels.
Due to the continuous exchange of views with the doctor, the patient acquires a stable positive attitude towards the recovery and the doctor acquires more tools for understanding the needs and problems of the ailing woman. Doctors who establish productive relationships with patients experience professional satisfaction from the high level of positive response of women in the treatment program.
How is the process of learning conducted?
A team of doctors are invited to educational and practical workshops. The first task is to pass to the doctors conventional knowledge about the psychological state of the patients that have to encounter with a heavy load in their lives: an awareness of the cancer, mobilization of physical and mental strength and overcoming the fear of the future. At the workshops professional actors are invited playing the role of women with breast cancer. Under the guidance of psychologists, actors act out real-life situations that reflect the mental state of patients: the huge despair, depression, physical pain and aggression. The actors convey the body language, intonation, complaints and questions of real patients. The task of the attending staff is to learn to recognize the root of the problem and, therefore, to respond intelligently. The workshop is to arouse empathy.
You are managing various clinical studies. Do you expect a revolution in the treatment of breast cancer?
Research that can make a breakthrough is related to the new generation of drugs. Herceptin, for example, has completely changed the terrible disease to a less frightening plight. Hundreds of thousands of women have been returned to life. The same thing will happen with the newest generation of Herceptin, which will improve the results of treatment of HER 2 positive breast cancer. And the future of the two drugs - Perjeta (Pertuzimab) and T-DM1 (Kadcyla).
What has changed in the mechanism of action of drugs?
T-DM1 (Kadcyla) refers to a group of highly targeted drugs, including the two active agents with different mechanisms of action. It is the first drug to treat breast cancer with a combination of antibody and chemotherapy. Herceptin antibody, whose task is to find the cancer cells and prevent its further growth and chemotherapeutic constituting fed to a cancer cell with a view to its destruction. The mechanism of the drug T-DM1 reminds of a projectile, hitting a target with a warhead chemotherapeutic action.
Tell us about the side effects of the drug T-DM1
On the part of the patients, they have no complaints, they feel good: no nausea, no hair loss. Of course, some potential side effects exist, but to date they are only in the professional literature.
Are there instances when women with breast cancer cannot be helped?
In my professional vocabulary there is no such thing. My colleagues and I believe that there is always effective aid. I have patients who come to me, quite exhausted, barely standing on their feet, but after the first course of chemotherapy they bloom and go back to work. For me, it is a strong professional and human experience that gives me the strength to continue to heal, explore and find new therapies, leading to victory over breast cancer.
How do you achieve victory?
Through the development of personalized medicine based on the consideration of the genetic information of the patient and the tumor itself. When we are able to determine the genome of each tumor and to select an individual biological treatment, then we can talk about unprecedented success. Today, we are taking the first steps on the level of scientific research: to study possible methods of genetic testing and the impact of the genetic profile of a woman on the susceptibility to the drug, as well as to assume the individual processes of the treatment.