‘Right-sizing’ breast cancer care for women in South Carolina

“I don’t care what you do. Just get this cancer out.”

That’s a sentiment that Andrea Abbott, M.D., has heard before. She understands how women facing a breast cancer diagnosis would be willing to undergo anything to be cancer-free.

But as a surgical oncologist and medical director of the Comprehensive Breast Program at MUSC Hollings Cancer Center, she also knows that, sometimes, less is more.

The key is knowing which patients need more aggressive treatment – and which patients would actually do well with less treatment. Doctors at Hollings, the only National Cancer Institute-designated cancer center in South Carolina, are on a continual quest to tailor treatment more precisely to each individual patient so that women receive the most effective care with the fewest side effects, something that Abbott refers to as “right-sizing.”

“Our doctors are developing and conducting clinical trials, participating in ground-breaking research at a national level and working with colleagues across the country to stay ahead of the curve and implement the latest data into clinical practice,” Abbott said.

“You don’t have to wait five years for cutting-edge treatments. We’re incorporating recently released clinical trial data to right-size treatment for patients right here, right now.”

Andrea Abbott, M.D.

While it usually takes about five years for new treatment guidelines to trickle down to most oncology practices, that’s not the case at Hollings.

“You don’t have to wait five years for cutting-edge treatments. We’re incorporating recently released clinical trial data to right-size treatment for patients right here, right now,” she said.

For example, in Radiation Medicine, Jennifer Harper, M.D., and colleagues are incorporating newer data that allows for less radiation – or even no radiation.

They’re doing this by getting very specific information about the type of breast cancer that a woman has and understanding how that fits into clinical guidelines.

“Breast cancer is not all one thing. There is a spectrum,” Harper said. “We're omitting radiation therapy for patients with Stage 1 estrogen-driven breast cancer who are 65 or older because the benefit is relatively small, and it doesn’t change overall survival.”

For other women, radiation is still necessary, but they can receive less than they would have in the past.

“We’re utilizing partial breast irradiation to shorten the duration of radiation therapy – so instead of several weeks of radiation, it's a five-day course of treatment. And instead of treating the whole breast, we’re treating the area around the lumpectomy cavity. That dramatically lowers side effects and shortens treatment time,” Harper said.

As academic physicians, the doctors on the Radiation Medicine team develop their own clinical trials to refine care further. They also participate in national trials and attend conferences where they share knowledge with colleagues from across the country. This allows them to immediately apply the newest findings.

“We're taking evidence from 2023 and 2024, and we're modifying our practice so that we can optimize the treatment approach,” Harper said.

In surgery, Abbott and colleagues use new technology to offer more precise operations. One example is the Molli 2 system.

Molli 2 helps surgeons to pinpoint the location of a lesion within millimeters, meaning they can remove less tissue and still be more accurate in targeting cancerous tissue. And that precision means less chance that a re-excision, or second surgery, will be needed. The national re-excision rate is over 20%; it’s less than 10% at MUSC.

Breast surgeon Amy Murrell, M.D., director of the MUSC Health Comprehensive Breast Program, Pee Dee Division, noted that breast cancer treatment has made huge advancements during her 20 years of practice.

“When I began my career, lumpectomies were done frequently but not done well. Many surgeons resected far more normal breast tissue than necessary and then gave very little thought to repairing the breast,” she said. “Today, there is a huge focus on oncoplastic breast surgery, performing a complete cancer operation but with an emphasis on the cosmetic outcome as well. There are 4 million breast cancer survivors in the United States, and we want them to be happy with their appearance.”

The breast team has also incorporated new research guiding lymph node removal.

Lymph nodes were traditionally removed during surgery to determine if cancer cells traveled beyond the breast. Unfortunately, removing lymph nodes can cause side effects like chronic pain, decreased range of motion and lymphedema. Because the lymph nodes that are removed after breast cancer are in the armpit area, the lymphedema that can result can lead to painful swelling in the arm.

But new clinical trials have produced better information about which patients should have lymph nodes removed and how many to remove.

“Today, there is a huge focus on oncoplastic breast surgery, performing a complete cancer operation but with an emphasis on the cosmetic outcome as well. There are 4 million breast cancer survivors in the United States, and we want them to be happy with their appearance.”

Amy Murrell, M.D.

Women over 70, for example, have their lymph nodes checked by ultrasound first. If they look normal, then the patient can avoid surgery. Murrell noted that the team is following research that could show that some women as young as 50 could have their lymph nodes checked by ultrasound.

“Each woman requires an individualized approach to her recommended surgery,” Murrell said.

And for those women who do need to have lymph nodes removed, MUSC Health is the only health system in the state offering lymphaticovenular anastomosis (LVA) surgery, also called lymphovenous bypass (LVB).

In this “supermicrosurgery,” surgeons connect lymphatic vessels in the affected area directly to veins.

“What we're able to do with this operation is redirect the flow from the lymphatic system into the vasculature in the vein at an earlier point to prevent the fluid from building up and causing symptoms,” explained plastic surgeon Gabriel Klein, M.D.

MUSC Health has been offering this surgery for about three years. Initially, it was offered to patients who were already suffering from lymphedema, but now, the surgery is also offered as a prophylactic option to women who will have most or all of the lymph nodes in the armpit, called the axillary nodes, removed.

“Anyone who has invasive axillary disease or breast cancer that requires removal of all their lymph nodes and radiation is usually a candidate for the surgery as a preventive to reduce the risk of developing lymphedema,” he said.

Even better, the surgery is minimally invasive.

“Patients are always pretty amazed at how small the incisions that we make are,” Klein added.

The doctors at MUSC relish being part of – and helping to lead – improvements in care.

“It’s about downsizing or ‘right-sizing’ treatments so people aren't over-treated,” Abbott said. “If I can treat patients accurately but also get them back to playing golf or pickleball and picking up their children or grandchildren, I consider that a win-win.”

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