Cancer Updates GI and Breast Nashville: Breast Cancer Insights for Primary Care Physicians with Dr Erika Hamilton
Presenter:
Dr. Erika Hamilton, Sarah Cannon Research Institute
Conference:
Cancer Updates: GI and Breast, Nashville, TN
At the 2025 Cancer Updates GI and Breast Conference in Nashville, Tennessee presented by Total Health, Dr Erika Hamilton provided an in-depth discussion on breast cancer screening, genetic risk assessment, treatment-related toxicities, and the evolving role of the primary care physician (PCP) in managing patients during and beyond a breast cancer diagnosis.
Screening and Early Detection: The PCP’s Role
Dr Hamilton underscored how breast cancer screening has become more sophisticated in recent years, improving detection rates while also minimizing false positives and unnecessary biopsies. Mammography remains the gold standard, with 3D tomosynthesis methodologies significantly enhancing accuracy compared to traditional 2D mammography. She highlighted a key study demonstrating that the adoption of tomosynthesis has resulted in a 35% increase in breast cancer detection rates while at the same time reducing the incidence of false-positive recalls by 15%.
She also noted that, beyond mammography, breast MRI plays a critical role for women at high risk, particularly those with BRCA mutations, a strong family history, or extremely dense breast tissue. While MRI is highly sensitive, it is not without drawbacks; the test itself is cumbersome for some patients, requiring them to lie face down in an MRI machine for nearly an hour. Furthermore, its increased sensitivity often leads to unnecessary biopsies—roughly one in eight MRI scans results in a benign biopsy. This, she emphasized, is why MRI should not be used indiscriminately, but rather only as an adjunctive screening tool for carefully selected patients.
Dr Hamilton noted that one of the most impactful changes in breast cancer screening policy has been the new recommendation from the U.S. Preventive Services Task Force (USPSTF) to begin mammograms at age 40 instead of 50. The update aligns with long-standing guidance from the American College of Radiology (ACR) and the National Comprehensive Cancer Network (NCCN). The shift was driven by a concerning rise in younger women presenting with more advanced disease, particularly among Black women, who are disproportionately affected by early-onset aggressive breast cancers. For PCPs, this means actively engaging patients in conversations about screening earlier than ever before, especially for those with additional risk factors such as family history or high breast density.
Genetic Risk and BRCA Carriers: Navigating Preventive Strategies
The second portion of Dr. Hamilton’s talk focused on the management of patients with BRCA1 and BRCA2mutations, which dramatically increase a person’s lifetime risk of breast and ovarian cancer. She explained that while the general population risk for breast cancer is approximately 12.5% (or 1 in 8 women), BRCA1carriers face a staggering 50-80% lifetime risk, and BRCA2 carriers, a 30-60% risk. The implications extend beyond breast cancer—BRCA mutations also elevate the risk of ovarian, pancreatic, and prostate cancers, with emerging data suggesting a possible association with melanoma and stomach cancers.
For patients who test positive for a BRCA mutation, risk-reducing surgeries remain the most effective preventive measure. Bilateral mastectomy reduces breast cancer risk by over 90%, while removal of the ovaries and fallopian tubes (bilateral salpingo-oophorectomy) significantly reduces ovarian cancer risk. The timing of these interventions, however, must be carefully tailored to the individual’s age, family planning goals, and personal risk tolerance. Given the aggressive nature of ovarian cancer, which is often diagnosed at an incurable stage, Dr Hamilton strongly encouraged early discussions about surgical prevention, particularly for BRCA1 carriers, who face a 15-54% lifetime risk of developing ovarian cancer.
For patients who choose surveillance instead of immediate surgery, close monitoring through alternating MRI and mammography every six months is recommended. Additionally, some risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, may be appropriate for postmenopausal women with BRCAmutations.
Dr. Hamilton also challenged the common misconception that breast cancer is a female-only disease, noting that men with BRCA2 mutations have a significantly elevated risk of male breast cancer (up to 12%), which approaches the baseline risk of women in the general population. Due to a lack of awareness, however, men with breast lumps or other concerning symptoms often delay seeking medical attention, leading to more advanced-stage diagnoses.
Toxicities and Long-Term Effects of Breast Cancer Treatments
As breast cancer treatment advances, Dr Hamilton noted that PCPs are encountering more patients on targeted therapies, including cyclin dependent kinase 4/6 inhibitors (CDK4/6i) including palbociclib, ribociclib, and abemaciclib, antibody-drug conjugates (ADCs), and human epidermal growth factor receptor 2 (HER2)-targeted therapies. While these therapies are often well-tolerated, they come with unique toxicities that PCPs should be aware of.
One of the most misunderstood toxicities, according to Dr. Hamilton, is neutropenia caused by CDK4/6i. Unlike chemotherapy-induced neutropenia, which can lead to life-threatening infections, CDK4/6i-related neutropenia is typically low-risk. Even when absolute neutrophil counts (ANC) drop to 800 or 900, there is usually no need for intervention, as the risk of infection remains less than 1%. PCPs should reassure patients that this is an expected side effect rather than a cause for alarm. Fatigue is another frequent complaint among patients on these drugs, and Dr Hamilton shared that low-dose Ritalin has proven beneficial for many older patients experiencing significant energy loss.
A more concerning treatment-related issue is interstitial lung disease (ILD) associated with trastuzumab deruxtecan (T-DXd), an ADC used in HER2-positive and HER2-low breast cancers. ILD can be fatal if not recognized early, and PCPs play a crucial role in ensuring that any patient on this drug who develops even mild respiratory symptoms undergoes immediate evaluation, including a CT scan. She noted that too often, patients with ILD are misdiagnosed with bronchitis or pneumonia at urgent care centers which can significantly delay proper management.
Breast Cancer as a Chronic Disease: The Future of PCP-Oncology Collaboration
One of the most compelling themes of Dr Hamilton’s talk was the shifting landscape of breast cancer survivorship. With the introduction of CDK4/6i, ADCs, and novel endocrine therapies, the survival of metastatic breast cancer patients has significantly improved. In hormone receptor positive (HR+)/HER2- metastatic breast cancer, median overall survival now exceeds five years, and for HER2+ disease, some patients are living more than a decade with active treatment.
This trend, she noted, necessitates a fundamental shift in how we think about metastatic breast cancer. Many patients with metastatic disease are not in immediate decline but rather living with cancer as a chronic condition. As a result, they require ongoing primary care just as much as any other patient with a chronic illness. She expressed frustration that many of her long-term metastatic patients are prematurely referred to hospice simply because of their diagnosis, when in reality, they are responding well to treatment and still have years of life ahead of them.
PCPs, she emphasized, must remain actively involved in the long-term care of breast cancer survivors, managing their cardiovascular health, bone density, and metabolic conditions while coordinating with oncology for cancer-specific needs. With continued innovation in breast cancer treatment, more patients than ever are living long lives after a metastatic diagnosis, and they need both their oncologists and PCPs to support them along the way.
Final Thoughts
Dr. Hamilton closed by thanking PCPs for their integral role in the fight against breast cancer. Whether through early detection, risk assessment, toxicity management, or survivorship care, primary care providers remain at the front lines of ensuring the best possible outcomes for patients with and beyond breast cancer. The future, she stressed, lies in stronger collaboration between primary care and oncology, ensuring that no patient falls through the cracks.
Speaker Disclosure Information: While not relevant to the presentation, Dr Hamilton reported her institutional participation in numerous clinical trials, and the following conflict of interest (COI) disclosures:
Consulting Advisory Role (to institution only):
Accutar Biotechnology, AstraZeneca, Daiichi Sankyo, Ellipses Pharma, Entos, Fosun Pharma, Gilead Sciences, Greenwich LifeSciences, Jazz Pharmaceuticals, Lilly, Medical Pharma Services, Mersana, Novartis, Olema Pharmaceuticals, Orum Therapeutics, Pfizer, Roche/Genentech, Stemline Therapeutics, Theratechnologies, Tubulis, Verascity Science, Zentalis Pharmaceuticals
Contracted Research/Grant (to institution only):
Abbvie, Acerta Pharma, Accutar Biotechnology , ADC Therapeutics, AKESOBIO Australia , Amgen, Aravive, ArQule, Artios, Arvinas, AstraZeneca, AtlasMedx, BeiGene, Black Diamond , Bliss BioPharmaceuticals , Boehringer Ingelheim, Bristol-Myers Squibb, Cascadian Therapeutics , Clovis, Compugen, Context Therapeutics , Cullinan, Curis, CytomX, Daiichi Sankyo, Dana Farber Cancer Inst, Dantari, Deciphera, Duality Biologics, eFFECTOR Therapeutics, Eisai, Ellipses Pharma, Elucida Oncology , EMD Serono, Fochon Pharmaceuticals, FujiFilm, G1 Therapeutics , Gilead Sciences, H3 Biomedicine, Harpoon, Hutchinson MediPharma, Immunogen, Immunomedics, Incyte, Infinity Pharmaceuticals , Inspirna, InventisBio, Jacobio, Karyopharm, K-Group Beta, Kind Pharmaceuticals , Leap Therapeutics, Lilly, Loxo Oncology, Lycera, Mabspace Biosciences, Macrogenics, MedImmune, Mersana, Merus, Millennium, Molecular Templates, Myriad Genetic Laboratories, Novartis, Nucana, Olema, OncoMed, Oncothyreon , ORIC Pharmaceuticals, Orinove, Orum Therapeutics , Pfizer, PharmaMar, Pieris Pharmaceuticals , Pionyr Immunotherapeutics , Plexxikon, Prelude Therapeutics , Profound Bio, Radius Health, Regeneron, Relay Therapeutics , Repertoire Immune Medicine, Rgenix, Roche/Genentech, SeaGen, Sermonix Pharmaceuticals, Shattuck Labs, Silverback Therapeutics, StemCentRx, Stemline Therapeutics, Sutro, Syndax, Syros, Taiho, TapImmune, Tesaro, Tolmar, Torque Therapeutics, Treadwell Therapeutics, Verastem, Zenith Epigenetics, Zymeworks