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October is National Breast Cancer Awareness Month. To mark it, UHN News sat down with Dr. Tulin Cil, one of UHN's – and Canada's – leading breast cancer surgeons.
Q: Why did you decide to become a breast surgeon?
(Dr. Cil) I really love breast surgery because of the huge and immediate impact we can have on our patients' lives right away. Breast cancer is such a highly curable disease when it's caught early that so many of our patients go on to live healthy lives after their treatment. It's very rewarding to be a part of that!
Q: Tell us about the app you're developing for breast cancer patients/survivors?
We've developed an app we hope patients will find helpful to navigate their own breast cancer journey. During the COVID-19 pandemic, virtual care has become a huge part of medical practice. While the information patients get regarding diagnosis and treatment is certainly available during their clinical visits, we also know that patients go online to access different sources of information. Some of that is really, really helpful, while some of it may not be. We wanted to find a way to harness all the information that we give to patients as part of their education around their diagnosis and treatment, and then deliver it to them in a way that makes sense and is appropriate for the time in their treatment.
Q: How does the app work?
The app follows patients on their cancer journey from diagnosis to treatment and through to survivorship. When you get a diagnosis of breast cancer, it starts from the very first thing that's noticed, whether that's a finding on a mammogram or a lump that a patient feels. That's followed by imaging tests, a biopsy, a meeting with a breast surgeon, and then treatment discussions. Following surgery, there are other treatments including medical therapy, radiation, or a combination. There are a host of side effects from these treatments. The app helps us deliver the appropriate information at the relevant time in the patient's cancer journey.
The app also allows patients to text and video chat with members of the health care team. We have leveraged this feature by integrating a peer support service in the app in partnership with the Healing Beyond the Body program. This allows cancer patients to connect with volunteer e-coaches for support.
Q: What role does survivorship play in a breast cancer diagnosis?
Survivorship is a key part of the breast cancer journey. It's about adjusting to a new normal. When patients have surgery, chemotherapy and radiation, the timeline is usually around four to six months. But a lot happens after that. Some patients undergo physiotherapy or rehab, some deal with the symptoms they might have after surgery and radiation, or side effects from medications, such as being on estrogen blockers. A lot can happen psychologically and physically after treatment. It's important to address all aspects, because thankfully, patients are living a lot longer following a breast cancer diagnosis. This is in part because we're catching it earlier, but also because treatments have become so effective. Some of these symptoms persist for a long time and require different interventions to help patients manage. It's also important to get used to regular surveillance, monitoring and ongoing breast imaging. Some of our patients have never had anything wrong with them and are used to always being healthy. Patients need to figure out how to integrate all of those things in their life.
Q: Are mammograms the preferred method of screening?
Yes. All studies have shown that mammograms are the most effective means of screening for breast cancer. There are limitations to what a mammogram can see, though. A lot of women may have dense breasts. The younger you are, the denser your breasts are, and the higher the density, the less sensitive the mammogram is. So it's not going to pick up things as clearly as in a breast where there's less density and more fat. Breast density is also a risk for breast cancer. If you have very high breast density, the concern becomes, is a mammogram enough for screening you? And the answer to that is, probably not. For patients with denser breasts, we consider supplemental screening, like an ultrasound or MRI, as well as for patients in the high-risk category for developing breast cancer.
And that's where the discussion points come in around the need for supplemental screening, and screening at a younger age. So women with a lifetime risk of over 20 per cent to 25 per cent are eligible for the Ontario high-risk breast screening program, which is a yearly mammogram and MRI. The main takeaway for every patient is to understand your own lifetime risk.
Q: Who is considered high-risk?
If women have a family history of breast cancer, their lifetime breast cancer risk may be higher than average depending on the history. We know some patients are high-risk due to previous treatment such mantle radiation for Hodgkin's lymphoma, or if their biopsy shows abnormal cells. Some women may have a gene mutation like BRCA 1 or 2, which is the most significant risk factor, and can bring their lifetime risk to 60 or 80 per cent. Women of Ashkenazi Jewish descent, West or South African descent, Northern European and French-Canadian descent, have also shown higher incidences of the BRCA genetic mutations. For some high-risk patients, we can help lower the risk with estrogen blocking drugs or surgical risk reduction. But if they don't choose to have these interventions, we want to screen them frequently to hopefully catch breast cancer at a very early stage. That's where the yearly breast exams, mammograms and MRIs come in.
Q: How can someone calculate their lifetime risk?
One of the most common calculators to determine lifetime breast cancer risk is called
Ibis or Tyrer-Cuzick. It works by putting in a patient's characteristics like their age, height, weight, their menstrual history, their reproductive history, their family history, previous biopsy history, and now their mammographic breast density is included. All of those components get factored in, and we can then get a lifetime risk calculation.
Q: Are there other genes associated with breast cancer?
Absolutely. Right now, Princess Margaret Cancer Centre is working on an initiative called Unify, which is a new program where we're able to offer genetic testing to all patients who have a new diagnosis of breast cancer. Previously, under the Ministry of Health, you could qualify for genetic testing if you satisfied certain criteria. Now with Unify, we can open up testing to everybody with a breast cancer diagnosis, and I would say, generally, the majority of people want to know if there's a gene mutation that has caused their breast cancer, because it's important for them to know in terms of informing their own treatment decisions – not only for breast cancer – but also ovarian and other associated malignancies.
Q: Is there anything else you want to highlight?
We have made amazing strides in the research around breast cancer, diagnosis and treatment, which has allowed us to personalize care for each of our patients. We know more about the disease than ever before and that's really exciting. Our patients benefit because we can provide the best recommendations based on their disease, instead of a blanket treatment approach.
Some of the things in the surgical world are de-escalating surgical therapy and minimizing the side effects of those treatments, in particular, lymphedema. We know more about the behavior of different breast cancers, because there are different profiles of the disease, and now have more targeted treatments for some of those tumours.
Being able to control the disease with medical therapy has really advanced. Awareness around breast cancer means that more patients know what to look out for. Having conversations about your personal risk, and understanding the different types of screening, helps in terms of prevention.
Ideally, we would like to have patients not get breast cancer at all so it's helpful to understand what they can do in terms of lifestyles that may help such as regular exercise and decreasing alcohol intake. There are so many exciting developments in breast cancer research and the pace of this development is fast- which is great news for our patients.