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    Academic medicine’s role in breast cancer treatment innovation

    patient in a ct scanner

    Women who may once have found breast cancer a devastating diagnosis now have life-saving options and improved interventions due to innovative therapies pioneered by researchers in medical schools and teaching hospitals. Emerging protocols for treating breast cancer are providing thousands of women with enhanced quality of life and increased longevity.

    Breast cancer remains the leading cancer diagnosis in women. Every year, 252,000 cases of female breast cancer are diagnosed, with almost 41,000 deaths. In addition, another 63,400 women are diagnosed with noninvasive breast cancer. One out of every eight women living in the United States today will be diagnosed with breast cancer at some point in her life.  

    The disease accounts for billions every year in medical expenditures and additional costs in short-term and long-term disability, as well as the loss of productivity for both patients and caregivers. 

    The good news, however, is that mortality rates are declining and the rate of survival for women with breast cancer is on the rise. Academic medicine's contributions to the diagnosis and treatment of breast cancer have stemmed from research that has allowed health care providers to tailor care strategies to individual patients using genetic testing of patients’ tumors and enhanced imaging that minimizes risk, discomfort, and sometimes cost. 

    The advancements come as physicians working or trained at teaching hospitals in a range of specialties — including genetics, radiology, surgery, epidemiology, medical oncology, and pharmacology — ask the critical question, “How can we better serve patients?” Academic medicine seeks answers through many long-running clinical trials and as a result, researchers have:

    • Improved the capacity to identify women who are at higher risk for breast cancer, allowing them to be monitored more closely, diagnosed earlier, and/or choose preventative interventions;
    • Increased the ability to detect cancers in earlier and more treatable stages;
    • Used rigorously evaluated surgical and treatment strategies to improve outcomes while reducing invasiveness, disfigurement, and disability.

    Innovative therapies emerge from academic medicine research

    The fight against breast cancer has converted what was once a terminal illness into a survivable health event, if treated early. Progress in the field — due in part to the contributions of physicians and scientists in academic medicine — has led to a nearly 40% reduction in breast cancer death rates since 1975

    Advances in treatment have progressed from early detection and rethinking how mastectomies are performed to cutting-edge options personalized to each patient. 

    Developments in research have led to emerging therapies that attack breast cancer tumors in innovative ways. New treatments for breast cancer include genetic profiling, proton radiation, and immunotherapy.

    Genetic profiling advances breast cancer treatment options

    One of the most promising breakthroughs in breast cancer treatment has been the genetic profiling of tumor cells. These profiles help patients and clinicians determine whether chemotherapy will be beneficial following surgery or radiation therapy. 

    Researchers at the University of Kansas and New York University developed the only genetic profile used in staging for HR+ tumors. Oncotype DX, a genomic test, was reviewed in independent trials that demonstrated that it accurately predicts patient outcomes, including the risk of recurrence and breast cancer survival. According to the manufacturer of the test, studies showed that 99% of those with low Oncotype DX scores who were treated using hormone therapy alone and without chemotherapy were cancer-free after five years

    One of those trials was TAILORx, which validated the usefulness of the genetic profile in identifying breast cancer patients who would or would not benefit from chemotherapy. The TAILORx trial was led by a consortium of U.S. academic medical institutions and involved hundreds of medical schools and teaching hospitals. 

    “Before TAILORx there was uncertainty about the best treatment for women with a mid-range [reoccurance risk] score of 11-25 on the Oncotype DX Breast Recurrence Score test. The trial was designed to address this question and provides a very definitive answer,” said Joseph A. Sparano MD, associate director for clinical research at the Albert Einstein Cancer Center and the Montefiore Health System in New York City, New York. "Any woman with early-stage breast cancer age 75 or younger should have the 21-gene expression test and discuss the results with her doctor to guide her decision to the right therapy." 

    Academic medicine research leads to shorter, gentler radiation therapy

    One of the therapies available to those with breast cancer is radiation therapy — using radioactive beams or particles in breast and adjacent tissue to kill cancer cells. Radiation therapy is used mostly for women who have had breast-conserving surgery and some who have had mastectomies.

    Reducing the time radiation treatments take as well as the cost of the treatment has been a priority for physicians and researchers. Traditionally, treatment has been five times per week for five to seven weeks — a plan that is expensive and disruptive to patients’ quality of life. When health care providers asked whether a shorter, more intensive course of treatment would be as effective as well as less expensive and less costly, academic medical centers began to study accelerated radiation therapy that lasts two to three weeks. 

    In 2018, a special task force of the American Society of Radiation Oncology, comprised of representatives from academic medicine including Duke University, University of Pennsylvania, and Johns Hopkins University, issued new treatment recommendations favoring the accelerated approach. 

    In addition to accelerated radiation therapy, researchers at medical schools and teaching hospitals identified proton therapy as a possible treatment. Unlike traditional radiation therapy, proton therapy does not cause so-called collateral damage to the heart and surrounding tissues. An ongoing study led by the University of Pennsylvania with Mayo Clinic; University of California, San Diego; University of Florida; Massachusetts General Hospital; Memorial Sloan Kettering in New York; and the University of Washington is evaluating the benefits of proton versus photon therapy in reducing cardiac and other side effects and in controlling the reoccurrence of breast cancer

    Immunotherapy signals new approach to attacking cancer cells

    Along with proton therapy, immunotherapy — Adoptive Cell Transfer (ACT) — is a relatively new form of cancer treatment. It identifies the attributes of a patient’s cancer cells and determines which of the patient’s own immune cells are most effective against the tumor cells. These aggressive “cancer fighters” are then grown in a lab and transferred back to the patient. An experimental therapy, it is time intensive, costly, and can generate serious and potentially life-threatening side effects. 

    However, in 2018, researchers at the National Institutes of Health (NIH) reported that a new approach to ACT has led to ongoing total remission (22 months, as of June 2018) in a patient with metastatic breast cancer. Steve Rosenberg, MD, PhD, noted that his team developed a high-throughput method to identify mutations present in a cancer that are recognized by the immune system. 

    “This research is experimental right now. But because this new approach to immunotherapy is dependent on mutations, not on cancer type, it is in a sense a blueprint we can use for the treatment of many types of cancer,” said Rosenberg.  Outside of the NIH, academic medical centers such as the University of Washington are studying potentially new immunotherapy-based approaches to fighting breast cancer. 

    Investing in breast cancer research by academic medicine

    The strides made in the fight against breast cancer are the result of a highly successful model of interspecialty and interinstitutional collaborations. It is estimated that the federal government spends more than $700 million on breast cancer research, with foundations, private philanthropists, and commercial companies spending millions more.  Most of this sponsored research takes place in America's medical schools and teaching hospitals. What is less known, however, is the financial investment that academic medicinal centers make to these efforts on their own because external funds often do not fully cover the costs of this critically important research.

    A 2015 assessment published by the AAMC found that the average medical school investment applied to externally supported research projects was an additional $0.53 for each dollar of sponsored research received — necessary because federal grants often exclude some types of research-related expenses, cap salary allocations, and do not cover start-up costs for new areas of investigations or new researchers.

    For all sponsored research in 2015, the analysis estimates that accredited medical schools spent more than $26 billion on research-related activities. Academic medicine is not only supplying intellectual capital, but also a significant amount of financial resources in the fight against breast cancer and other diseases.

    Breast cancer affects the lives of tens of thousands of women every year. However, researchers working in the nation’s medical schools and teaching hospitals are constantly developing trailblazing approaches to identifying tumors early, treating the disease with advanced patient care strategies, and increasing quality of life for patients and their overall survival rate.