The Baltimore Breast Cancer Revolution

Thinking pink for breast cancer awareness goes well beyond October for women diagnosed with and surviving breast cancer. (And men, too. Though rare, approximately 2,800 men are diagnosed with breast cancer annually in the United States.)

The same goes for the experts focused on better treatments and outcomes for whom “think pink” is a year-round mantra.

“With the increase in knowledge, research, drug development, and treatment, breast cancer outcomes are significantly improving,” says Dr. Paula Yellon Rosenblatt, most recently an oncologist at the University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center and an assistant professor at the University of Maryland School of Medicine who is now at Tampa General Hospital.

Today, the American Cancer Society cites the overall five-year survival rate on average for breast cancer at 90 percent, with new treatment options at each disease stage.

“It is a scary, scary time for patients, but we have options for a comprehensive plan that likely has a lot better outcomes than they may be imagining,” Rosenblatt explains.

Because today’s breast cancer interventions are highly personalized, most times, a full plan means more tests and imaging, but detailed information is essential.

Treatment Advances

Breast cancer treatment has moved beyond chemotherapy and hormone therapy. Oncologists like Dr. David Riseberg, chief of medical oncology and hematology at Mercy Medical Center, employ therapies like HER2 inhibitors, which target the human epidermal growth factor receptor 2 (HER2), a protein that promotes cell growth, and antibody-drug conjugates (ADCs), a combination of a chemotherapy and an antibody that directly targets cancer cells.

“Targeted therapy is different from chemo,” Riseberg says. “It’s like a smart bomb, delivering the drug directly to the cancer cell.”

Approximately 15 to 20 percent of breast cancers are HER2-positive, according to the Breast Cancer Research Foundation and the American Cancer Society. These breast cancers have an excess of HER2, which can also promote cancer cell growth. Though aggressive, these cancers are treatable, especially when caught early.

New IV and oral therapies for HER2-positive breast cancer specifically focus on the HER2 protein and are effective in both early-stage and metastatic breast cancer (cancer that has spread elsewhere in the body).

“HER2-directed therapies have been transformational,” Riseberg says. “What was once aggressive and deadly is now often manageable.”

Immunotherapy, another new treatment for breast cancer, boosts the body’s immune response to fight cancer “by releasing the brakes on the immune system [and] allowing the body to fight the cancer itself,” he adds.

Rosenblatt notes that in the past five years, 10-plus new medications or indications have been approved, including CDK 4/6 inhibitors, a medication previously used to treat advanced metastatic breast cancer now approved for use in early-stage breast cancer.

“This is the first major change in treatment for estrogenpositive [ER-positive] breast cancer in the last 20 years,” she says. “It’s exciting to use it to help prevent cancer from coming back, help prevent metastatic disease, and hopefully cure more breast cancer patients.”

The Greenebaum Cancer Center, in partnership with the Maryland Proton Treatment Center (MPTC)—the first and only proton therapy center in Maryland—uses proton therapy to treat a variety of cancers including breast cancer. Proton beam radiation, versus X-rays used with traditional radiation, is extremely accurate. The radiation is sculpted around the tumor, layering it in 3D-like brushstrokes. Surrounding healthy tissue is less affected or damaged through proton treatment, which is not the case with traditional radiation.

Other benefits are that it’s quick, non-invasive, done as outpatient treatment, and can reduce side effects. If the cancer recurs, protons can often safely re-radiate areas, something traditional radiation cannot do.

A radiation oncology physicist at the Greenebaum Cancer Center also invented GammaPod—the world’s first radiation therapy system dedicated specifically to treat early-stage breast cancer.

A form of stereotactic body radiation therapy (SBRT), GammaPod delivers a very precise, higher dose of radiation in the exact shape of the tumor and less radiation to nearby vital organs such as the heart and lungs. It’s gentler on the skin and healthy breast tissue, offers potentially fewer cosmetic side effects like tissue discoloration, requires fewer treatment sessions, and may prevent cancer recurrence.

While chemotherapy is often still necessary, doctors are giving it more selectively, thanks to testing innovations.

“There are definitely patients we can now omit chemotherapy from, like early-stage cancer patients, through molecular tests,” Riseberg says. The focus, he explains, is shifting toward the use of newer drugs that target cancers by delivering higher concentrations of drug selectively to the cancer leading to greater benefit and often fewer side effects. “If someone is suffering at home with additional nausea, diarrhea, or various side effects, we have a lot of ability to intervene,” Rosenblatt adds.

Next-Generation Genomics

Understanding the molecular subtypes of breast cancer has enabled more targeted and effective treatments, especially in metastatic cases.

“We lump breast cancer all as one thing, but in fact, there are so many different subtypes with three main subtypes: ER-positive, HER2-positive, and triple negative,” Rosenblatt says.

Tumor profiling and the cutting-edge technology called Next-Generation Genomic Sequencing (NGS) to subtype a tumor now play central roles in matching treatment to specific genetic mutations or biomarkers, especially in metastatic disease.

“The tumor you started with often looks nothing like the one you’re battling today,” explains cancer biologist Dr. Utthara Nayar, who founded the Nayar Lab at Johns Hopkins University. She and her team use NGS to sequence tumors and test the actual function of every identified cell mutation in breast and ovarian cancers. The goal is to understand how to treat each tumor with a mutation.

Nayar’s research focuses on ER-positive breast cancer, which needs the hormone estrogen to grow. Endocrine therapy, a hormone therapy that blocks estrogen from reaching cancer cells, is effective, but many tumors will become resistant to treatment.

Another challenge: Nayar discovered that up to 10 percent of resistant ER-positive tumors acquire mutations that allow the tumor to grow without estrogen, rendering standard therapies ineffective. These mutations don’t show up on traditional staining, so only NGS can detect them. The Nayar Lab compares tumors before and after they become resistant to therapy to identify genetic mutations driving resistance.

“Sequencing helps us understand that evolution—and treat it smarter,” Nayar says. “Resistance doesn’t come from the patient, it’s the tumor that evolves.”

Her team is creating the first-ever, comprehensive HER2 mutation library to determine which drugs each mutation responds to. Eventually this will become a public lookup tool to guide treatment decisions. They’re also working on forecasting future resistance by developing models to predict how tumors will evolve under new drugs.

“Our job as scientists is to stay one step ahead, to decode those changes and turn them into action,” she says.

Surgical Innovations

Breast cancer surgeries were first noted 3,000 years ago. In 1889, Dr. William Halstead of Johns Hopkins Hospital pioneered the procedure that became known as the “Halsted radical mastectomy,” the surgical standard for decades.

Like new treatments and medicines, breast cancer surgery is highly personalized. There’s no “one-size-fits-all” approach, explains Dr. Wen Liang, oncology surgeon at Mercy Medical Center. Treatment plans, from lumpectomy to mastectomy, are tailored to the individual patient’s anatomy, cancer characteristics, and personal preferences.

“Every patient is different,” she says. “If I do five lumpectomies in a day, I’ll do it five different ways.

“The priority of surgery is to remove and stage the cancer, but we must balance the patient’s future mental and emotional health as they live with a history of cancer,” Liang notes. “Their desire to optimize their appearance and minimize treatment and follow-up imaging often leads them to request surgery that can be done to give them the lowest risk of recurrence with beautiful results as soon as they are out of the operating room.”

Nipple-sparing mastectomies, hidden incisions, and immediate reconstruction, often performed at the time of mastectomy, have changed the cosmetic and psychological experience of surgery.

The Vinnie Myers Team in Finksburg offers 3D nipple and areola tattooing with lifelike results.

“Even a mastectomy can be the less burdensome option for some patients when considering future imaging or biopsies,” Liang notes. “Sometimes doing a mastectomy is actually the desired surgery for a patient, even though it sounds more aggressive.”

Fewer lymph nodes are removed now, she says, even if one tests positive. “I would love to see the day when I may not have to do surgery on some cancers,” Liang says.

“We’re still chasing the cure, but every new therapy—every delay in progression—buys patients time,” Nayar adds. “And that time matters. It’s hope, quality of life, and more moments with loved ones.”