For Maryam Lustberg, MD, MPH, her commitment to a specific medical specialty was clear to her early in her career.

“I really enjoyed the close bonds that physicians and patients were developing as they tackled this scary diagnosis” of breast cancer, Dr. Lustberg says. “And, at the same time, I was also very much drawn to the active scientific inquiry and clinical trials that were being devoted to breast cancer. Both as a scientist and physician I wanted to make an impact in this very common disease.”

Dr. Lustberg, who is director of the Center for Breast Cancer and chief of Breast Medical Oncology, recently discussed the latest breakthroughs in treatments and the multi-disciplinary approach to patient care at Smilow Cancer Hospital on the Connecticut Public Radio show Yale Cancer Answers. Her conversation was with Tracy Battaglia, MD, MPH, an associate director at the Yale Cancer Center.

What are the most common kinds of breast cancers and treatments?

Breast cancer can be categorized into hormonally driven and non-hormonally driven types. Hormonally driven breast cancers comprise approximately two-thirds of all breast cancer types, characterized by rich expression of estrogen and progesterone receptors. They are most common. The second categorization is HER2-positive, HER2-negative and HER2-low and some subcategories. Treatments for breast cancer surgery, radiation, chemotherapy, hormonal therapy, chemotherapy, HER monoclonal antibodies, immunotherapy, and others, depending on the type and stage of the cancer.

How do you know what kind of tumor a patient has?

Initially, after a biopsy or breast surgery, the tumor tissue is very carefully inspected for size, lymph node status, and driver of the cancer mutations. Breast cancer care is a multidisciplinary practice, with many specialists. Pathologists use specific testing protocols to identify the type of cancer. All the pieces of information are brought together to determine next steps. This accurate tissue diagnosis helps devise the most personalized and accurate treatment plan.

Can you describe the different types of tumors and how that affects treatment?

There are multiple factors that influence our advice to patients. We talked about subtypes and additional factors include the stage of the cancer. Generally, we start with surgery, which helps us understand how much tumor and disease involvement there is, and then there is deciding on whether radiation is needed and additional systemic therapies that treat the whole body. They include hormonal therapy, chemotherapy, HER2 monoclonal antibodies and immunotherapy in certain situations. There are situations in metastatic/ stage 4 breast cancer that systemic therapy is the best.

How does the multidisciplinary team approach affect cancer treatment decisions?

The patient has a central role in decision making. The team members are the guides sharing what we have learned know and the pros and cons of each approach after interrogating the biology of the cancer to make sure we’re on track. Scientific evidence helps inform the decisions. And then there needs to be time. We have really strong data that shows that taking a few weeks to make a decision is OK and it can actually help you find that right treatment plan. Many of these cancers have been in the body for quite some time so taking those next few weeks has not been shown to be detrimental.

Why is there a rising incidence of breast cancer in young women?

That’s an important question and we’re still actively learning. The rising incidence is likely due to multiple factors, including lifestyle changes, we’re more sedentary; dietary patterns; reproductive patterns; and environmental exposures. However, in many cases, the exact cause is unknown, and younger women can develop breast cancer regardless of lifestyle choices.

There are things about ourselves we can change and things that we can’t. What are modifiable and non-modifiable risk factors for breast cancer?

Non-modifiable risk factors include family history and genetic predisposition. Modifiable risk factors include lifestyle habits such as exercise, maintaining healthy weight, limiting alcohol use, and healthy eating.

What is your advice about screening and early detection?

Every woman should understand her risk based on family history. A woman with average risk, we suggest screening starting at age 40. Also, it’s important to know what your breast tissue looks like on mammogram, knowing your breast density – 50% of US women have dense breasts. That’s harder read in screening and may need consideration of supplemental imaging such as ultrasound and in select cases MRIs. It’s also an independent risk factor for breast cancer and may impact when you begin screening in conjunction with presence of other risk elevating factors.

What should patients consider regarding fertility and breast cancer treatments?

t is a central question when we see patients under 45. Fertility is a personal decision. It’s very important for your team to be checking in with you and taking the time to meet with a fertility preservation. The most toxic of our therapies are chemotherapy and patients have tough decisions there. Treatment can affect fertility. It’s important to ask the question early on of your team.

Why is it important for patients to have access to clinical trials?

It's important to remember that every standard of care we have now originally came through a clinical trial. Clinical trials are essential for advancing the science of breast cancer care. Patients are encouraged to ask about clinical trial options, as these trials offer potential opportunities for novel therapies and contribute to future standards of care.

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