From the Duke Cancer Institute archives. Content may be out of date.
The Right Team at the Right Time
Rebecca Cook poses with her family on the last day of her latest round of chemotherapy treatments — July 21, 2021. Her cancer is currently in remission.
A DCI breast cancer care team joins forces with a genetics counselor to treat mother with high-risk genetic syndrome; prompting testing, then preventative screening for her kids.
Living a good life at age 35, Rebecca Cook thought she had more time before she needed to start thinking about screening for breast cancer. After all, she was a young mom of four kids who successfully managed to breastfeed for the past seven years, including a set of twins. (Breastfeeding, she had heard, is believed to lower breast cancer risk.)
And she thought time was on her side. (Cook hadn’t yet reached age 40, the recommended age to start screening women of average risk.)
But in February of 2020, as news reports began to swirl about the emergence in the U.S. of a potentially deadly virus, COVID-19, Cook found herself facing her own health crisis — a diagnosis of stage 3 inflammatory breast cancer.
She described the next few months on chemotherapy — 16 rounds of infusions at a clinic close to home in Norfolk, Virginia — as a whirlwind. Due to pandemic-safety rules, she was forced to attend her treatments in isolation — without the comfort of family or friends by her side.
Genetic Testing
Her doctors then suggested genetic testing, which revealed a rare, inherited, genetic disorder — Li Fraumeni Syndrome. The condition, identified by mutations in the TP53 gene, had predisposed her to cancer — not only the breast cancer she already had, but perhaps additional cancers down the road.
Cook said she felt "the deep and dark void of depression looming."
With the new diagnosis of Li Fraumeni Syndrome and with her cancer showing little sign of improvement, she requested a referral for more specialized care at Duke Cancer Institute.
"When I first arrived at Duke, I had that feeling that something was different," shared Cook. "It was a feeling that started to illuminate my dark path."
From her first appointment, she felt like she'd gained a fresh start with a care team that included breast surgical oncologist Lisa Tolnitch, MD, breast medical oncologist Michael Spiritos, MD, and radiation oncologist Diandra Ayala-Peacock, MD, as well as genetic counselor Elizabeth Wignall, MS, CGC, with the Duke Supportive Care & Survivorship Center’s Clinical Cancer Genetics program.
First, she'd undergo a double mastectomy. Unfortunately, the pathology results from her surgery showed that cancer was still present.
“The news is not what I wanted to hear, but I knew that I could put all my faith in their care,” said Cook, who then began a regimen of 14 more cycles of chemotherapy and intensive radiation at Duke Women's Cancer Care Raleigh.
When she walked into the initial appointment with genetic counselor Wignall, she was preoccupied. She wondered, "What could I have done differently?"
Wignall helped her to stop dwelling on the past and shift her focus to the future.
Because LFS is associated with a high lifetime risk for cancer — including, most commonly, soft tissue sarcomas, bone cancers (osteosarcomas), premenopausal breast cancers, colon cancer, gastric cancer, adrenal cortical tumors, and brain tumors — she advised Cook about the various types and timing of preventative scans she should undergo in order to detect any new cancers at the earliest stage possible. (More than one type of cancer may occur in the same person.)
In addition, knowing that there was a 50% chance her children shared her LFS diagnosis (and on Wignall's recommendation), Cook had her children tested for LFS. The tests came back positive for two of her four children. Next, Wignall worked with a team at Duke Children’s to get those children scheduled for preventative cancer scans — testing that will continue on a regular basis for the foreseeable future.
Taking action for herself and for her children gave Cook hope.
"Working with Elizabeth helped me to embrace that LFS is now part of my life story, NOT the defining moment of it," she shared. “While my heart may break that I passed on this gene to my kids, Duke provides a great genetics team to give us hope, as we walk this journey. Elizabeth's guidance has empowered me to educate my children that LFS is not something to be feared.They can carry on a 'normal' life. Their life just means more frequent scans, and being very aware of their bodies and any changes."
Support & Care: Rebecca Cook has all the love and support of her family and an all encompassing care team that has her back.
Cook completed the latest round of chemo treatments in July and was soon after declared "in remission." Over Labor Day weekend, she was able to participate and cross the finish line of her first half marathon.
“As much as I strive to keep the cancer away, keeping my mental health strong in this journey has been just as important. Running, counseling, medication, a healthy diet and medical providers that value mental health all help me do that,” she said.
Julie Poucher Harbin, Senior Writer, DCI, contributed to this report.
For decades, a diagnosis of metastatic breast cancer has carried a clear message: while treatments can help control the disease and extend life, the disease is generally considered incurable. As a result, treatment strategies have traditionally focused on managing cancer and maintaining quality of life rather than pursuing a cure.New advances in breast cancer therapies are changing that conversation. Research led by Duke Cancer Institute breast surgical oncologist Jennifer Plichta, MD, suggests that some patients with limited metastatic breast cancer may benefit from a more aggressive treatment approach than has traditionally been offered. The findings, published in JAMA Surgery, add to growing evidence that metastatic breast cancer is not the same for every patient and that treatment decisions may need to become more personalized.Plichta's research builds on years of work focused on improving how physicians classify and predict outcomes for patients with breast cancer. Historically, a diagnosis of metastatic, or stage IV, breast cancer, was associated with poor survival. However, the development of targeted therapies and other advances in systemic treatment have dramatically improved outcomes for many patients."Many women with metastatic breast cancer are now living for years and sometimes even a decade after diagnosis," Plichta said. "We've come a long way in terms of treatment options and survival."At the same time, researchers have discovered significant variation among patients with metastatic disease. Some experience aggressive cancer that progresses quickly, while others have relatively limited disease that remains controlled for long periods.This variability led Plichta and her colleagues to ask an important question: Are there certain patients with metastatic breast cancer who could benefit from treatment strategies typically reserved for patients with earlier-stage disease?The study focused on patients with what is known as oligometastatic breast cancer, a form of metastatic disease in which cancer has spread to only a limited number of sites. Researchers believe this group may represent a distinct subset of patients whose disease behaves differently than widespread metastatic cancer.Using data from the National Cancer Database, which captures information on many newly diagnosed breast cancers in the U.S., the team analyzed outcomes among patients with limited metastatic disease. They examined whether patients received treatment directed at the primary breast tumor, treatment directed at metastatic sites, both treatments, or neither.The goal was to determine whether a treatment approach that more closely resembles care for stage III breast cancer—combining systemic therapy with aggressive local treatment—might improve outcomes for selected patients."What stood out was that removing the primary breast tumor seemed to be the factor most strongly associated with improved survival," Plichta said. "Treating the distant sites did not appear to offer the same survival advantage on its own."While previous studies have explored surgery for patients with metastatic breast cancer, results have been mixed. Plichta believes one reason may be that metastatic breast cancer is often treated as a single category, even though patients can have vastly different disease characteristics and prognoses.One of the most significant implications of this research is how clinicians think about treatment goals. Patients with stage III breast cancer are typically treated with curative intent, meaning doctors use every appropriate therapy available, including chemotherapy, surgery, and radiation, in an effort to eliminate the disease. Patients with metastatic breast cancer, by contrast, are usually treated with palliative intent, focusing on disease control rather than cure.But as outcomes improve, the line between those groups may not be as clear as it once was."We're seeing some patients with metastatic disease living longer than patients with locally advanced breast cancer," Plichta said. "That raises important questions about whether some patients with limited metastatic disease should be approached differently."Because the study was retrospective, the results point to an important association that warrants further study. Several clinical trials are now being developed to investigate curative-intent treatment strategies in specific subgroups of metastatic breast cancer patients, including those with HER2-positive disease. Duke hopes to participate in these multi-institutional studies as the field continues to evolve.As breast cancer treatments continue to improve, researchers are gaining a more nuanced understanding of metastatic disease. For Plichta, the study represents an important step toward that goal."I hope this work encourages further research into which patients may benefit from a curative-intent approach," she said. "The ultimate goal is to find the right treatment strategy for the right patient."
For decades, a diagnosis of metastatic breast cancer has carried a clear message: while treatments can help control the disease and extend life, the disease is generally considered incurable. As a result, treatment strategies have traditionally focused on managing cancer and maintaining quality of life rather than pursuing a cure.New advances in breast cancer therapies are changing that conversation. Research led by Duke Cancer Institute breast surgical oncologist Jennifer Plichta, MD, suggests that some patients with limited metastatic breast cancer may benefit from a more aggressive treatment approach than has traditionally been offered. The findings, published in JAMA Surgery, add to growing evidence that metastatic breast cancer is not the same for every patient and that treatment decisions may need to become more personalized.Plichta's research builds on years of work focused on improving how physicians classify and predict outcomes for patients with breast cancer. Historically, a diagnosis of metastatic, or stage IV, breast cancer, was associated with poor survival. However, the development of targeted therapies and other advances in systemic treatment have dramatically improved outcomes for many patients."Many women with metastatic breast cancer are now living for years and sometimes even a decade after diagnosis," Plichta said. "We've come a long way in terms of treatment options and survival."At the same time, researchers have discovered significant variation among patients with metastatic disease. Some experience aggressive cancer that progresses quickly, while others have relatively limited disease that remains controlled for long periods.This variability led Plichta and her colleagues to ask an important question: Are there certain patients with metastatic breast cancer who could benefit from treatment strategies typically reserved for patients with earlier-stage disease?The study focused on patients with what is known as oligometastatic breast cancer, a form of metastatic disease in which cancer has spread to only a limited number of sites. Researchers believe this group may represent a distinct subset of patients whose disease behaves differently than widespread metastatic cancer.Using data from the National Cancer Database, which captures information on many newly diagnosed breast cancers in the U.S., the team analyzed outcomes among patients with limited metastatic disease. They examined whether patients received treatment directed at the primary breast tumor, treatment directed at metastatic sites, both treatments, or neither.The goal was to determine whether a treatment approach that more closely resembles care for stage III breast cancer—combining systemic therapy with aggressive local treatment—might improve outcomes for selected patients."What stood out was that removing the primary breast tumor seemed to be the factor most strongly associated with improved survival," Plichta said. "Treating the distant sites did not appear to offer the same survival advantage on its own."While previous studies have explored surgery for patients with metastatic breast cancer, results have been mixed. Plichta believes one reason may be that metastatic breast cancer is often treated as a single category, even though patients can have vastly different disease characteristics and prognoses.One of the most significant implications of this research is how clinicians think about treatment goals. Patients with stage III breast cancer are typically treated with curative intent, meaning doctors use every appropriate therapy available, including chemotherapy, surgery, and radiation, in an effort to eliminate the disease. Patients with metastatic breast cancer, by contrast, are usually treated with palliative intent, focusing on disease control rather than cure.But as outcomes improve, the line between those groups may not be as clear as it once was."We're seeing some patients with metastatic disease living longer than patients with locally advanced breast cancer," Plichta said. "That raises important questions about whether some patients with limited metastatic disease should be approached differently."Because the study was retrospective, the results point to an important association that warrants further study. Several clinical trials are now being developed to investigate curative-intent treatment strategies in specific subgroups of metastatic breast cancer patients, including those with HER2-positive disease. Duke hopes to participate in these multi-institutional studies as the field continues to evolve.As breast cancer treatments continue to improve, researchers are gaining a more nuanced understanding of metastatic disease. For Plichta, the study represents an important step toward that goal."I hope this work encourages further research into which patients may benefit from a curative-intent approach," she said. "The ultimate goal is to find the right treatment strategy for the right patient."
