One in eight women in the United States annually will be diagnosed with invasive breast cancer, according to recent American Cancer Society estimates. Although one in 43 will die from the disease, the death rate has fallen sharply – by 44 percent – since 1989, largely due to earlier detection and improved treatment.

At the same time, the five-year U.S. survival rate for all types and stages of breast cancer is 91 percent – and that survival rate rises to 99 percent for breast cancers caught early.

We spoke with Fox Chase Cancer Center surgeons to discuss how the detection and management of breast cancer has evolved to bring about these improvements, and how these innovations are finding their way to Temple Health - Chestnut Hill Hospital.

The evolution of treatment

Dr. Richard J. Bleicher, chief of the Division of Breast Surgery at Fox Chase Cancer Center, has seen many remarkable advances in his 21-year surgical career. Many of the same procedures that were being performed when he started out are still being done, but with vast improvements.

"The general trend is that we do things in a less invasive fashion," he explains. "We know how to minimize recurrence better. We do things in a better cosmetic fashion."

Of course, mastectomies – removing all tissue from the breast – and lumpectomies – removing the cancerous tissue and some surrounding healthy tissue but largely preserving the breast – are still performed. But when you look at the complete picture, Dr. Bleicher adds, every aspect of detection and treatment has evolved dramatically to improve not only patient survival, but quality of life.

"We have better technology now," Dr. Bleicher says. "We tend to do things in a less invasive fashion. For example, two decades ago, sometimes you did incisional biopsies (surgically removing potentially cancerous breast tissue for diagnosis) and sometimes you did core biopsy (using a thin needle to extract suspect tissue for analysis). Now, we primarily do needle biopsy. In conjunction with better imaging, we have a better handle on what patients need for treatment."

There has also been an evolution in medications like chemotherapy. For instance, it used to be that you would only get chemotherapy after surgery, Dr. Bleicher says, and there were certain criteria for that. Now, he adds, "we use genomic testing of the tumor (analyzing gene changes within a person's cancer cells) to better define who will and won't benefit from it. And it's not always just after surgery. We do chemotherapy before surgery, and we do chemotherapy before and after surgery, and there are studies that have shown when it's beneficial to do any of those variations."

There have been many changes in how radiation therapy is administered as well.

As just one example, Dr. Bleicher says, "We didn't used to think that we could give radiation to the breast twice. If a woman had a lumpectomy and radiation, and the cancer recurred, then she had to have a mastectomy because she couldn't have radiation again. Well, now we have clinical trials that show that if you have a woman who has had radiation after a lumpectomy, and she develops a singular recurrence in the breast, she can have radiation again. And she can have a repeat lumpectomy with repeat radiation."

Management of breast cancer starts with detection, and on this score, the situation is also evolving. One example, Dr. Bleicher says, is contrast enhanced mammography, in which a contrast dye is injected into the vein and it "lights up" the tumor on the mammogram. Fox Chase is looking at acquiring that technology.

Looking at all the aspects of breast cancer care, he says, "the field has been moving forward and there is great reason for optimism on the part of patients."

Innovations in reconstructive surgery

Dr. Michael G. Tecce, assistant professor of Surgical Oncology in the Division of Plastic and Reconstructive Surgery at Fox Chase, offers yet another perspective.

Often during breast cancer surgery, the nearby axillary (armpit) lymph nodes are removed. This can lead to painful swelling – lymphedema – in the affected arm. Dr. Tecce performs a type of surgery called immediate lymphedema reconstruction that keeps lymphedema from happening.

"Think of the lymphatic channels that run throughout the affected extremity as a system of pipes, and those pipes transport water and proteins throughout the body," he explains. "These pipes run on a system of pumps – think of the lymph nodes as those pipes. If those lymph nodes are removed because they have cancer in them, then there's no pump to pump the water anymore, and the water just fills up in the pipes and the pipes over time experience increased pressure. And then the pipes can crack and leak. That's how a patient gets lymphedema. And so, the fluid just builds up in the arm."

Lymphedema reconstruction is a type of microsurgery that reroutes the fluid from the lymphatic channels into the venous system – the veins. "The vessels that we're sewing together to make this work are about the size of a strand of hair," he says. "They're a millimeter in diameter."

Dr. Tecce is now performing this surgery at Temple Chestnut Hill. "If you look around the area, there aren't any other programs that are doing it other than Fox Chase," he says. "If you leave Fox Chase, you have to go to New York City to find somebody who's doing it."

Another advanced surgery currently performed by Dr. Tecce at Chestnut Hill: free-flap breast reconstruction.

"When a patient has breast cancer and they have their breasts removed, there are two main methods of reconstruction," Dr. Tecce explains. "One is implant, and the other is using the patient's own tissue. If the patient wants to use their own tissue and they're a candidate for it, then we transplant tissue from one part of the body, generally the abdomen, and we transplant that tissue from the abdomen up into the chest, but I have to dissect the blood vessels that come along with it that give it blood supply and have to find new blood vessels to sew those blood vessels into so the flap can survive."

Dr. Tecce performed the first such surgery – it takes about eight hours – at Chestnut Hill in March.

Looking to the future

The innovations don't end there.

Dr. Allison A. Aggon, assistant professor of Surgical Oncology at Fox Chase, also practices at Chestnut Hill. She employs relatively new technology that eases patient discomfort and improves surgical accuracy.

"We were the first hospital in the region to use Elucent technology for lumpectomies," she says. "It's a form of wireless localization and navigation to help us remove cancers from the breast that we might not otherwise be able to feel. Traditionally, women had a wire placed into their breast the morning of surgery to help the surgeon identify where the cancer was. It would essentially point to the cancer like an arrow. Now, we can place a 'smart clip' into the breast ahead of time and utilize Elucent's 3D navigation to provide a more comfortable experience and a more accurate surgery for the patient. We are now offering that here at Chestnut Hill."

Much of the recent progress in breast cancer treatment occurs at the level of clinical trials, she adds.

Dr. Aggon points to several clinical trials currently underway at Fox Chase that hold out still more hope for the future. One of those trials explores both escalating and de-escalating treatment. "We're at a point where we're looking to tailor recommendations for women in order to not undertreat them or overtreat them," she says. "We're also working with radiation oncology on a trial that looks at de-escalating radiation for certain patients with early breast cancers. And then we have multiple clinical trials in the medical oncology realm looking at ways to escalate care for aggressive triple negative cancers (a rare form of aggressive breast cancer). So, it's very encouraging and exciting to see that we are taking an active approach in trying to give patients better care."