Dr. Michael Berry, president of the American Society of Breast Surgeons, explains how personalized care and genomic testing are reshaping breast cancer treatment for each patient.
Michael Berry, M.D.
President, American Society of Breast Surgeons
How would you define personalized care in breast surgery, and how has it shaped the way you approach treatment planning with your patients?
Historically, breast cancer has been treated as one entity, and based on whether it looked aggressive or not, or was large enough, that determined how much therapy you would get. As time has gone on, we’ve realized that you can target certain therapies or even omit certain therapies based on the actual tumor that the patient has. So, instead of generally treating a breast cancer, we’re now focused on treating the subtype of breast cancer, and there are ways of determining subtype that are modern, that use genomic tests, that use molecular tests, and that can help us identify how these tumors are going to respond in the patient generally and how they’re going to respond to therapy, or even omission of therapy.
Which emerging technologies are making the biggest difference in that personalized approach?
Currently, the ones that are the most impactful are genomic and molecular studies that look beyond what our traditional estrogen receptors or HER2 receptors will show us. They indicate how these cancers are predicted to respond to therapy and how aggressive they are. Those studies are utilized in a large number of our patients every single day.
With 3D mammography, that’s just a better look at the patient. However, the advent of AI allows the ability to see things and patterns that we aren’t trained as physicians to see, or maybe that are at such a small level that we can’t see them. That can help even with earlier intervention, which may be of benefit to the patient. There’s also emerging technology with breast MRI and melding that, with AI, may be even better at identifying patterns and responses that we may not see with traditional mammography. That is still in an experimental phase, but much more is to come.
How do you use those molecular and genomic tests in practice?
Not all cancers are the same; not all of them respond to the same therapies. Some respond to different therapies. Some don’t require certain therapies. It allows us that next level of pathologic evaluation beyond what we’ve had for decades. It allows us to tailor therapy to your specific tumor, not a general tumor.
The entire care team can know that if I treat this patient this way, I can predict or discuss with my care team what is to follow. A lot of patients haven’t had that. They’ll walk in with breast cancer and say, “I just want to get this out.” That’s their first inclination. I totally get that. But there are certain orders that we can give therapy that may affect overall survival, and just taking it out immediately may actually hurt them in the long run, unless we’ve looked across the whole treatment spectrum.
What I usually encourage patients to do is to ask their physician, “Is this the appropriate treatment for me? Is this the appropriate order for me?” What I ask physicians to do is be aware that different orders of treatment may ultimately affect the patient’s overall survival.
How do you work with oncologists, radiologists, genetic counselors, and others on the care team to ensure patients are truly receiving personalized care?
Some centers are very formalized, and they have pathways where everyone sits down and discusses together. Many patients across the country are not treated in those systems. That doesn’t mean physicians aren’t working together. It requires communication between the people taking care of that patient. Surgeons cannot work in a silo anymore. They may see the patient first, but that doesn’t mean surgery has to come first.
There needs to be communication with the other people treating that patient to formalize the best care. It doesn’t have to be in a big center, but communication is essential, whether through phone calls or established treatment plans. That includes medical oncology, genetic counselors, or social workers. You don’t have to be in a big center to receive personalized care.
What strategies have you found most effective in empowering patients to actively participate in decisions about their breast health and treatment options?
This has really changed. Patients now come in with a Google search on their cancer and rattle off questions. There are many websites that give you a list of questions to ask your physician. The information is out there. If you ask probing questions, it alerts your physician that you’ve done your research and may challenge them to ask themselves those same questions.
The patient really needs to familiarize themselves with the basics of their cancer type and the generalities of how it is treated, and then ask questions. If they’re not getting responses that show their physician is aware of different treatment choices for their specific tumor type, they often need to find another physician or get a second opinion.
Looking ahead, what developments or innovations are you most excited about that could further advance personalized, patient-centered care in breast cancer treatment?
For our less aggressive cancers, there are office-based procedures that allow treatment with cryoablation that will make an operation unnecessary. What may be the most exciting are current studies of our most aggressive cancers. The patient is given chemotherapy first, and if there is no evidence of cancer by imaging and biopsy following chemotherapy, they may never have to step foot in the operating room. We’re not there yet, but these studies are showing great promise.
There may be a day that my job as a breast surgeon is to react to what did not respond to initial therapies. Not every cancer is going to respond to targeted therapies, but one day our job may be to operate only on those particular cancers. That is what I see potentially coming, because we’re seeing interesting results from those studies.
Some patients believe more surgery is better. How do you address that?
Some patients come in and think that more surgery is better treatment. That’s really not the case most of the time. We’ll see patients who want both breasts removed. That is historical thinking. There are reasons sometimes to do a whole breast removal or prophylactic contralateral mastectomy. However, more surgery does not equal more cure, and we’ve known that for years.
You’ll hear an actress say, “I took control of my situation. I had both of my breasts removed.” That sounds heroic, but not knowing their situation, I don’t know that it was necessary. Christina Applegate, for example, had a genetic mutation, and it was reasonable for her. That’s personalized care.
The treatment you hear about from famous people may be very appropriate for them, but may not be the most appropriate therapy for you. The message is: Be informed as a patient. There could be very different ways of treating one cancer from the next. You and your doctor will come up with the right plan for you, and it’s not going to look exactly like the right plan for someone else.
People will come in and say, “My mother had this,” and we’ll say, “You’re not your mother.” Your situation is different. You can’t always say, “My friend on Facebook said I should have this.” Maybe that was appropriate for them, but that doesn’t mean it’s appropriate for you. That gets to the heart of personalized care. We want to treat your cancer in you, at this time in your life, with the current therapies we have available. That’s where we want to go with personalized care.
