The new Duke Cancer Institute inflammatory breast cancer (IBC) clinic—the only program of its kind in the Southeast—aims to help standardize and optimize the clinical treatment regimen for patients with this relatively rare and highly aggressive form of breast cancer.
Often misdiagnosed as an infection or mastitis, this disease is characterized by a rapid onset of breast swelling and skin changes including erythema, peau d’orange, nipple retraction, and persistent itching; however, it does not always present with a solid tumor mass, making imaging and diagnosis difficult. Contrary to its inflammatory namesake, the classic skin symptoms are secondary to tumor cell invasion into the dermal lymphatic channels.
Jeremy Force, DO, medical director for the Duke clinic and a medical oncologist with expertise in IBC, says there is a need to educate patients and providers about how to treat the disease, which disproportionately accounts for 10% of all breast cancer deaths. IBC tends to be diagnosed at a younger age, and African Americans are disproportionately at a higher risk of developing aggressive inflammatory breast cancer with poor outcomes.
“When a patient with IBC is misdiagnosed, it leads to catastrophic consequences if they aren’t treated appropriately in a sequential fashion,” Force explains. “Patients in the community are commonly prescribed antibiotics or antifungals for the inflammation, which won’t help, and by the time a patient is scheduled for a mammogram and workup, it’s often too late—they’ve already developed metastatic disease.”
Currently there are no therapeutic regimens developed specifically for inflammatory breast cancer, and it is critical to recognize that all aspects of treating inflammatory breast cancer—including staging, diagnosis, and therapy—are vastly different than other breast cancers. Force encourages providers to have a low threshold for performing a mammogram and a skin punch or breast biopsy if certain clinical symptoms are identified, and to refer patients to an academic medical center for rigorous monitoring and the best chance for a positive outcome.
Our team and treatment approach
The Duke IBC clinic includes breast cancer surgeons, medical oncologists, radiation oncologists, and breast pathologists who have specific expertise in diagnosing and treating the nuances related to IBC. In addition to the IBC clinic, Duke Cancer Institute also runs the multidisciplinary Duke Consortium for Inflammatory Breast Cancer, co-led by Gayathri Devi, PhD, program director, and Susan Dent, MD, clinical director.
“Because of the volume of IBC patients we’ve seen, our team is vigorously aware of how the disease progresses, when to do skin punch biopsies, when to perform neoadjuvant radiation therapy, and how to clinically monitor the disease over time, especially if there’s not enough of a clinical response,” Force explains.
As an example of the team’s expertise, Force describes the aggressive measures that he and his team have taken from a surgical, radiation, and medical therapy perspective that have saved many patients’ lives, he says. One patient—an African American woman in her 40s—came to Duke several years ago with an early IBC diagnosis, and Force recommended neoadjuvant chemotherapy, mastectomy, lymph node dissection and radiation, and adjuvant endocrine therapy, all of which helped change the course of her disease.
“Since her diagnosis in 2017, she has had a great response and is tolerating everything very well,” says Force, noting that the patient continues to be monitored every three months for potential disease recurrence.
Another patient came to Duke with a suspected diagnosis of IBC, but she had not been able to confirm a diagnosis in the community setting. When Force biopsied her upper chest, he found stage 4 disease and was able to resect the locally advanced dermal lymphatic invasion, despite the patient being advised otherwise. The patient is undergoing systemic therapy every three weeks at a local therapeutic infusion center, which the Duke team helped her to identify, and has not had local recurrence at this time.
“Because of the clinical events and sequencing prior to her presentation at Duke, we took radically innovative measures to individualize this patient’s care and try and alter this patient’s disease course, reducing her risk for distant recurrence,” Force says. “I believe our out-of-the-box approach to her care changed her outcomes.”