With the backdrop of Breast Cancer Awareness month Neos Kosmos spoke to Dr Georgios Iatropoulos, an oncologist and cancer specialist to discuss in depth the latest developments, statistics, research breakthroughs, available treatments, and the importance of early detection.

Dr Iatropoulos was born and raised in South Africa and has lived on three continents. He completed his medical degree in Greece then trained and worked in the UK before settling in Australia in 2015, where he practices at Austin, Waverley & Mulgrave Private.

The risk of developing breast cancer in females by the age of 85, is one in eight. and one in 15 in males, according to the latest statistics.

“Of all the new cancers, 13% is breast cancer. That’s the estimate in Australia for 2022. And of all cancer-related deaths, 6.5% are from breast cancer,” Dr Iatropoulos says after studying the latest statistics published by the Australian Institute of Health and Welfare.

“In 2018, there were under 19,000 breast cancer diagnoses in the whole country. Now, 4 years later, in 2022, the estimate is that there will be about 20,500 breast cancer diagnoses, so around 1500 more. Obviously, the population of the country has grown as well, so you have to take that element into account as well,” Dr Iatropoulos states.

Breast cancer is the second most common cancer in Australia, in 2022, after prostate cancer, and it is also the second most fatal after lung cancer.

Worldwide, by the end of 2020, there were around 2.3 million new breast cancer patients. The figures from 2020, he tells us, place Belgium as the country with the highest rate of breast cancer among its population in the world. Belgium is followed by the Netherlands. France is in 4th and Australia in seventh place, followed by New Zealand. The U.S.A is in 10th place. Interestingly these high figures reflect the population in developed countries.

Risks factors associated with Breast Cancer

Dr Iatropoulos explains that there are some risk factors that arise from elements you cannot change, which is of course are your gender, age, family history of breast cancer, personal history of previous cancers, dense breasts, defective genes.

“Everyone’s probably aware of the BRCA gene mutation, but now we’re learning more about new genes or a combination of genes.”

Other risk factors that are associated with this type of cancer are, obesity in postmenopausal woman, early menarche (starting your period before the age of 12), late natural menopause (after the age of 55), not bearing children, not breastfeeding, first pregnancy over the age of 35, ionising radiation exposure from medical treatment such as X-rays, particularly during puberty, and hormone replacement therapy (though not the pill for contraception).

These are all just associations he stressed, emphasising that if you don’t have children, for example, it doesn’t mean you will necessarily develop breast cancer.

Smoking, alcohol, a lack of regular exercise, an unhealthy diet, are elements that will increase your risks in developing breast cancer but also cancers in general, he added. A low fat diet (fruits, vegetables, grains), especially for post-menopausal women, and regular moderate physical activity have shown to offer protection.

What has been ruled out from the list of associated risk factors are caffeine, IVF, abortions, breast implants and hair dyes.

“There’s no doubt that breast screening saves lives”

“Breast cancer is a highly curable cancer, especially when diagnosed early, and that is why early detection is so important, because if treated early, you can be cured.”

To prove how breast screening has saved lives, Dr Iatropoulos says that since breast screenings were implemented nationally in 1991, we saw a significant drop in deaths from breast cancer from 74 per 100,000 in 1991 to 40 per 100,000 patients in 2018.

“The basic tool of detection is a mammogram. It has small amounts of radiation, similar to 2-3 months of radiation we would be exposed to anyway, in our environment. In Australia, people get notified, they get invited between the ages of 50 and 74, every two years to do a mammogram, in one of the hundreds of breast screening clinics across Australia (to find out more call 13 20 50). I would still recommend to fit and healthy women over the age of 75, to continue doing the mammograms.”

“I cannot emphasise enough that if you feel a lump or a change in your breasts, go and get it checked. Even though the incidents are high, a lump is less likely to be breast cancer. But if it is breast cancer and you keep postponing it, you might have to face the hard reality of it being advanced.”

Self-examination, he added, is helpful but should not be used as your sole tool to find breast cancer because you may miss it. If the lump is deep inside your breasts, you may not be able to feel it while it’s still small.

In the event that a lump is detected and is confirmed as cancer through a biopsy, then the breast surgeon comes into the picture to gather all the data.

This, Dr Iatropoulos says, is then discussed in what they call a multidisciplinary meeting between the surgeon, the oncologist, the radiation oncologist and allied health nurses, in order to decide whether surgery should be done upfront or not.

These days, chemotherapy is sometimes given before surgery, in order to shrink the tumour, allowing the surgeon to do a lumpectomy, instead of a mastectomy. But even if a mastectomy is decided, chemotherapy before surgery, means that the surgeon can operate on clear margins.

After upfront surgery, depending on the size and features of the tumour, an individualised treatment plan that may or may not include chemotherapy and/or radiotherapy and/or hormonal therapy will be mapped out for the patient to follow.

Types of breast cancer

“Every breast cancer is different. There’s no breast cancer the same as another, but generally there are two main types of breast cancer, depending on where they originate from. The ductal cancer is in the milk ducts, and it the most common (70-80%) and the lobular cancer which is in the small sacks, the lobules, where the milk is made.”

Something that is always investigated is whether the cancer is HER2-positive (tumors that have high levels of a protein called ‘human epidermal growth factor receptor 2’), or HER2-negative. “It is something we always look at,” Dr Iatropouolos says.

HER2-positive cancers, used to have worse prognosis compared to the HER2-negative, but with breakthroughs in research and new drugs available, such as Herceptin, it’s the other way around now, according to Dr Iatropoulos.

He added, however, that there is good news for the advanced breast cancer patients with HER2 in the spectrum between clear positive and absolute negative that represents a significant number of patients.

“This is fresh off the press. The breakthrough that we had this year, from a new study is that even patients with advanced cancer and HER2 in the spectrum may benefit from new targeted treatments, and this is going to change things!”

He explained that it is a revolutionary drug for advanced cancers. “It’s not Herceptin, It’s called Trastuzumab Deruxtecan (T-DXd). It is pretty much the old Herceptin which targeted the cancer, binding itself with the HER2 pocket, to dampen the effect that ‘crazy’ gene has on the tumour. We have now developed this antibody, which slows down the cancer more effectively, so the idea was to link that antibody to a chemotherapy molecule which, to put it simply, is targeted to kill the cancer cell. So we haven’t really found a new drug, we have found a better way of delivering the treatment.”

With the improved version of Herceptin, there might be a few new side effects, he adds, like lung toxicity, but we know about it and we can monitor patients and address early before it gets worse. It’s a huge new chapter that gives hope to patients with advanced cancers because they will have more available treatments.

Referring to advanced triple negative cancer, which is one of the hardest cancers to treat, Dr Iatropoulos says that even for this there is a new drug approved in Australia which offers some response. “It may not be as great as the Herceptin, but it’s definitely a development, a breakthrough also.”

The convenience of oral drugs

There are other important relatively new advances, such as three different targeted CDK inhibitors which are given orally for advanced hormone receptor positive breast cancer along with oral hormone therapies.

“They are beautiful drugs, and they’ve been approved. We’ve got them all in Australia. And they are definitely prolonging survival significantly. They are oral therapies, which means the patient can travel and live independently without having to go into hospital for a session of chemotherapy.

“It’s convenient. That’s the beauty of it. We want to see advanced breast cancer becoming a chronic disease. It’s not yet like diabetes, but that’s where I can probably see it going by the end of my career in 20-25 years. Because I’ve experienced the change myself in the survival rates. Maybe by the time I retire, advanced breast cancer patients will be living 10 or 15 years longer.”

A huge part of a patient’s journey is a psychological one, and it is important that they seek some form of counselling if they are not coping.

“I’ve noticed that in Greek culture, and many others of course there is usually strong family support and involvement, probably every step of the way along the disease and treatment journey. It’s cultural obviously, I believe it helps but I’m also biased because of my Greek background.

It can also sometimes be overwhelming and patients may want to have some autonomy and decide for themselves. The most important though is that Australia has one of the best health systems that I have worked for with many support mechanisms available to all cancer patients, and for me as a doctor that is what matters the most!”