Blog Highlights:

• Martina Navratilova describes her initial reaction when informed she had ductal carcinoma in situ (DCIS) breast cancer
• “This was my personal  9/11″ says Navratilova
• For those of you just confronting the diagnosis of cancer, read below for a list of what I would recommend

This interview of Martina Navratilova with Robin Roberts (herself a breast cancer survivor) describes the initial emotional reaction that women go through when informed: “you have breast cancer”.  In her case, there was a “good news/bad news” circumstance, for her diagnosis was “ductal carcinoma in situ” (DCIS). This is actually a precursor of invasive breast cancer and associated with a very low risk of relapse or dying of breast cancer. Nevertheless, the diagnosis can strike fear and uncertainty because breast cancer can be a “silent killer” and it can occur – and recur – without warning or symptoms.

I can imagine how Martina felt when informed that she had breast cancer.  She is one of the most athletically fit women in the world and is the Health and Fitness Ambassador to the American Association of Retired Persons (AARP). She exercises regularly, has a healthy diet, drinks very little alcohol – and yet that doesn’t protect her against cancer.

Listen to the emotional reaction as she described her initial encounter with the diagnosis of breast cancer in this interview:  “This was my personal  9/11”…. “I couldn’t think, couldn’t move”…..“The emotions took so much strength out of me.” She is no doubt an emotionally strong person in other domains of her life, but facing the diagnosis of cancer is very unsettling. These are typical reactions of women and men when confronted with the diagnosis of cancer.

• First: “I made a plan.”
• She engaged a support system around her. As Martina stated, it is difficult sometimes to ask for help, especially among women who are inherently caregivers themselves. Her friends accompanied her to the surgical treatment and supported her through the experiences.
• She talked about it in a public forum. It was not only therapeutic for her, but her message is vitally important for other women.

The treatment options for DCIS vary enormously. They range from a lumpectomy (or segmental mastectomy) alone, to lumpectomy plus radiation, to mastectomy. What is right for you depends upon the size of the tumor and other features of the tumor such as the “nuclear grade”.  Martina revealed that she had a Grade 3 DCIS tumor, which is associated with a higher rate of relapse within the breast after lumpectomy alone.  So she and her doctors elected to add radiation therapy to the breast in order to reduce the risk of relapse.

In another article titled “Why Are Biomarkers Important for DCIS Breast Cancer Patients?“, I have discussed a new advance in using biomarkers in patients with DCIS that can help partition patients with this condition into very low risk for breast relapses (and therefore more safely allow for conservative treatments) compared to other presentations of DCIS associated with a higher risk of breast relapses for which breast radiation therapy or even mastectomy might be appropriate.

In retrospect, should she have done anything differently? Well, yes. She skipped a few years and did not have an annual mammogram, as we have recommended for someone of her age of fifty-two years old. “I let it slide. Everyone gets busy, but don’t make excuses,” she said. A central theme of her message (which I totally support) is: “Everyone (in my age group) should have a mammogram every year.”  Good advice!!!

For those of you just confronting the diagnosis of cancer, here is what I would also recommend ( in addition to the valuable advice above):

• Be a student of your cancer. Learn the basic facts from reliable sources, including our own websites www.patientresource.net
• Know the stage of disease and the details of the pathology report
• Know  the options for treatment that would apply to your circumstance. For example, if you have breast cancer look at the charts of treatment options from our companion website patientresource.net
• Be prepared to engage your cancer doctors with good questions and an attitude that you are a partner in the decision-making. You and your doctor will make a “joint decision” that blends together the doctors medical opinion plus your input in selecting treatment options (when they are equal in outcome) that takes into account your own philosophy about potential benefits and risks of various options when they are available.

I’m convinced after 35 years of counseling and treating cancer patients that an informed, educated patient will always get better care and enjoy a better quality of life. Make sure you are focusing on information that is pertinent to your own diagnosis and stage of disease. Don’t get misled by information that is too general or by reading about aspects of diagnosis and treatment that don’t apply to you. It can lead to unnecessary anxiety or, conversely, to unjustified complacency.

Cancer is a complex and diverse collection of diseases, so getting the right information from trusted and reliable sources that is directly pertinent to your situation is key. Look at comprehensive websites for cancer patients, such as www.patientresource.net,  www.cancer.net, and www.cancer.org as starting places for information. Be sure to talk with your doctor and the staff in order to be sure that the information you are gathering correctly applies to your situation.

Blog Highlights:

• Study identifies biomarker expression that were helpful in predicting risk of recurrence for patients with ductal carcinoma in situ (DCIS) treated by lumpectomy alone
• Information may be helpful in the future in counseling women about their options with regard to radiation therapy of the breast or having mastectomy with the option of reconstruction if their risk for recurrence is high
• Those patients for whom the risk is low might be spared these more aggressive treatments
• Talk to your doctor and find more information about biomarkers at patientresource.net

Biomarkers are the telltale signature of a cancer that can describe its characteristics, including the capability to grow back or spread to another organ. It is one of the most important areas of cancer research, and is becoming an important component of “personalized cancer medicine”.

The news report on this video describes a major study performed at the University of California at San Francisco Medical Center. Published in the Journal of the National Cancer Institute on May 5, 2010, these investigators performed a study of 1162 women who were diagnosed with Ductal carcinoma in situ (DCIS) and treated by lumpectomy alone between the years 1983-1994. They had long term follow up and standardized pathology review as well as biomarker studies on the pathology specimen.  They identified combinations of biomarker expression, size of the tumor, and the surgical margins that were helpful in predicting the risk that a patient with DCIS treated by lumpectomy alone would face: lower risk for recurrence vs. higher risk for recurrence. This information, as it would apply to an individual patient circumstance, may be helpful in the future in counseling women about their options with regard to radiation therapy of the breast or having mastectomy with the option of reconstruction if their risk for recurrence is high. On the other hand, those patients for whom the risk is low might be spared these more aggressive treatments.

Below is the abstract of this study that was published in the Journal of the National Cancer Institute  titled, “Biomarker Expression and Risk of Subsequent Tumors After Initial Ductal Carcinoma in situ Diagnosis”

BACKGROUND: Studies have failed to identify characteristics of women who have been diagnosed with ductal carcinoma in situ (DCIS) and have a high or low risk of subsequent invasive cancer. METHODS: We conducted a nested case-control study in a population-based cohort of 1162 women who were diagnosed with DCIS and treated by lumpectomy alone from 1983 to 1994. We collected clinical characteristics and information on subsequent tumors, defined as invasive breast cancer or DCIS diagnosed in the ipsilateral breast containing the initial DCIS lesion or at a regional or distant site greater than 6 months after initial treatment of DCIS (N = 324). We also conducted standardized pathology reviews and immunohistochemical staining for the estrogen receptor (ER), progesterone receptor, Ki67 antigen, p53, p16, epidermal growth factor receptor-2 (ERBB2, HER2/neu oncoprotein), and cyclooxygenase-2 (COX-2) on the initial paraffin-embedded DCIS tissue. Competing risk models were used to determine factors associated with risk of subsequent invasive cancer vs DCIS, and cumulative incidence survival functions were used to estimate 8-year risk. RESULTS: Factors associated with subsequent invasive cancer differed from those associated with subsequent DCIS. Eight-year risk of subsequent invasive cancer was statistically significantly (P = .018) higher for women with initial DCIS lesions that were detected by palpation or that were p16, COX-2, and Ki67 triple positive (p16(+)COX-2(+)Ki67(+)) (19.6%, 95% confidence interval [CI] = 18.0% to 21.3%) than for women with initial lesions that were detected by mammography and were p16, COX-2, and Ki67 triple negative (p16(-)COX-2(-)Ki67(-)) (4.1%, 95% CI = 3.4% to 5.0%). In a multivariable model, DCIS lesions that were p16(+)COX-2(+)Ki67(+) or those detected by palpation were statistically significantly associated with subsequent invasive cancer, but nuclear grade was not. Eight-year risk of subsequent DCIS was highest for women with DCIS lesions that had disease-free margins of 1 mm or greater combined with either ER(-)ERBB2(+)Ki67(+) or p16(+)COX-2(-)Ki67(+) status (23.6%, 95% CI = 18.1% to 34.0%). CONCLUSION: Biomarkers can identify which women who were initially diagnosed with DCIS are at high or low risk of subsequent invasive cancer, whereas histopathology information cannot.

REFERENCE:
Journal of the National Cancer Institute. 2010 May 5;102(9):627-37. Epub 2010 Apr 28. (Comment in: 2010 May 5;102(9):585-7.)
Biomarker expression and risk of subsequent tumors after initial ductal carcinoma in situ diagnosis.
Kerlikowske K, Molinaro AM, Gauthier ML, Berman HK, Waldman F, Bennington J, Sanchez H, Jimenez C, Stewart K, Chew K, Ljung BM, Tlsty TD.
University of California, San Francisco, CA 94121, USA.

Blog Highlights:

• Genetic test (oncotype DX) aids decision as to whether or not to undergo chemotherapy after surgery
• Profile of the breast cancer genes can be used to predict whether or not there is a survival benefit of adding chemotherapy to hormone therapy
• Test is covered by most private insurance and by Medicare
• A good starting place to learn more  is the section on predicting recurrence and genetic testing on our companion website

Genetic testing may help decisions to avoid breast cancer chemotherapy. For some women with early stage breast cancer, a genetic test (oncotype DX) may be helpful to you and your oncologist when deciding whether or not to undergo chemotherapy after surgery. This test is made on the breast cancer itself for which a multi-gene assay is performed to determine the “genetic signature” of your tumor. The profile of the breast cancer genes can then be used to predict with accuracy whether or not there is a survival benefit of adding chemotherapy to hormone therapy for those women who have hormone-responsive (ER+) breast cancer, especially those who are post-menopausal. This assay has been recommended both by the Guidelines of the American Society of Clinical Oncology and the National Comprehensive Cancer Center. When indicated, the test is covered by most private insurance and by Medicare.

Those women for whom the genetic testing may yield valuable information are two groups:

1. Women who have no evidence of spread to their lymph nodes and whose breast cancer expresses hormone receptors (estrogen-receptor-positive) and
2. Women after menopause whose cancer has spread to their regional lymph nodes and whose breast cancer is hormone-receptor-positive.

In both of these circumstances hormone therapy with either Tamoxifen or one of the aromatase inhibitors (Arimidex, Latrozole, etc.) would be indicated as standard therapy for at least five years. The side effects in most women are very tolerable, if not minimal. On the other hand, chemotherapy has more side effects and should be considered only when the potential survival benefit outweighs the risk or toxicity of receiving drug therapy in addition to hormone therapy.

Ask your doctor about this genetic test if you have the stages of breast cancer described above. Though advances in cancer chemotherapy have been dramatic, especially in breast cancer, it is equally valuable to know which women have such a good outcome after surgery and hormone therapy that they do not otherwise get from additional chemotherapy.

In the March 8,2010 issue of the journal Cancer, researchers at the University of North Carolina surveyed 77 women with breast cancer who underwent genetic testing. One-third reported that they did not understand the doctor’s explanation of the genomic test and one-quarter felt distress as a result of the discussion. On the other hand, most women agreed that genetic testing helped them understand whether their treatment would be successful. I learned from this article that:

1. Doctors need to do a better job of educating patients and explaining the test results, and
2. Patients need to get enough basic information and knowledge of the jargon (terminology) of these tests so they can understand the results and the meaning behind them.

A good starting place to learn more  is the section on predicting recurrence and genetic testing on our companion website, patientresource.net.

Also for more information, go to www.oncotype.com or review the Guidelines from ASCO at www.Cancer.net or NCCN at www.nccn.org.

This is a nice patient education video for women who are undergoing their first mammogram. I have posted other blogs detailing the indications and benefits of screening mammography. See my blog, Raging Debate On Mammography Screening.

This is an Oncology Podcast that covers three news highlights in breast cancer. The first one, and the most significant, concerns a report from Europe in women with inflammatory breast cancer (expressing the HER2 receptor) that is associated with a very high risk of dying. In a randomized study, researchers found that the complete response rate (that’s right: COMPLETE RESPONSE) in patients who received Herceptin (trastuzumab, Genentech Oncology) plus chemotherapy had a 55% complete response in these HER2+ breast cancers compared to only 19% for those women who had chemotherapy alone. Similar impressive results with Herceptin plus chemotherapy have been reported from UT MD Anderson cancer center in Houston.

The second report here describes FDA approval for a new drug Ixabepilone (Ixempra, Bristol Meyers Squibb) for advanced breast cancer refractory to other forms of chemotherapy.

The third news highlight describes a large study in Germany of 7000 women undergoing breast screening with mammography and breast MRI. The MRI scans were more accurate in detecting breast cancer, but it is a more expensive study and requires skill in interpretation. Breast MRI is used selectively in the United States, especially for women who have an inheritable form of breast cancer (BRAC! and BRAC2)

In November last year, a series of “bombshell” recommendations about screening mammography was made by the U.S. Preventative Services Task Force , an independent panel that makes health care recommendations. Their recommendations were published in the Annals of Internal Medicine..(2009;151:716-726). (www.annals.org) and are summarized below:

Recommendations: The U.S. Preventative Services Task Force (USPSTF) recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient’s values regarding specific benefits and harms. (Grade C recommendation)
The USPSTF recommends biennial screening mammography for women between the ages of 50 and 74 years. (Grade B recommendation)
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (I statement)
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women 40 years or older. (I statement)
The USPSTF recommends against clinicians teaching women how to perform breast self-examination. (Grade D recommendation)
The USPSTF concludes that the current evidence is insufficient to assess additional benefits and harms of either digital mammography or magnetic resonance imaging instead of film mammography as screening modalities for breast cancer.

While their recommendations are indeed provocative, I strongly believe they are not valid and they should NOT be adopted. For example, when mammography screening was introduced in Sweden, the death rate from breast cancer was reduced by about 40%. In the U.S., the breast cancer death rate has decreased by 30% since 1990, when screening mammography began to be widely used. Before that, the breast cancer death rate had been unchanged for the preceding 50 years. Of course, my worry is the insurance carriers will use these USPTF recommendations as a “cover” for denying coverage for the costs of breast screening and further, that the public will be unnecessarily confused by the conflicting opinions and not seek regular screening. That would be a major setback, for breast cancer will get a longer headstart prior to detection (if these guidelines would be followed) and more women with breast cancer will require more radical (and expensive) treatments, more debilitating symptoms, and a lower probability of living a normal life span.

The USPSTF recommendations have been endorsed by the following organizations: American Academy of Family Physicians, American College of Medicine, American College of Preventative Medicine, National Association of County and City Health Officials, and the American Public Health Association.

On the other hand, virtually all the national organizations whose physician members are directly responsible for the screening and management of breast cancer are strongly opposed to these recommendations, including the American Cancer Society, the American College of Radiology, the American College of Surgeons, American Society of Breast Surgeons, the Society of Breast imaging, and the National Comprehensive Cancer Network. Indeed, many of their leaders have made very strong statements lamblasting the conclusions of the USPSTF.

“The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women, beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider. When recommendations are based on judgements about the balance of risks and benefits, reasonable experts can look at the same data and reach different conclusions” Otis W. Brawley, MD Chief medical Officer, American Cancer Society.

The American College of Obstetricians and Gynecologists (ACOG) also maintains its current advice that women in their 40s continue mammographic screening every 1 to 2 years and women age 50 or older continue annual screening, stating: “ All women, along with their physicians, should individually assess the benefits as well as the risks of mammographic screening”.

The American College of Surgeons (ACS) also affirmed the the American Cancer Society Guidelines have resulted in an effective approach toward dealinig with brest cancer and that women should continue to follow them in consultation with their physicians. Dr Lemar S. McGinnis, MD, President of the ACS, stated: “ While recognizing that mammography is not perfect and supporting continuing research for improved methods, the surgical community believes that the American Cancer Society’s screening guidelines offer an optimal approach to detecting breast cancer early, when it can be most successfully treated.”

The American Society of Breast Surgeons is strongly opposed to the recommendations released November 16, 2009 by the USPSTF. “We believe there is sufficient data to support annual mammography screening for women age 40 and older… these recommendations effectively turn back the clock to pre-mammography days by making the diagnosis of breast cancer occur only when the tumor is large enough to be felt on a physical exam. Mammography screening reduces breast cancer mortality and saves lives.”

Read the withering criticism that leaders in the field have made, and their recommendations that current guidelines be maintained:

“For women age 40 and over, the benfits of annual breast screening continue to outweigh the risks…age should not be an absolute when determining who should receive mammorgraphy screening. It is imperative to consider the patient’s individual risk factors when considering an appropriate screening routine. Therese B. Beavers, MD, Chair, Guidelines Panel for Breast Cancer Screening and Diagnosis, National Comprehensive Cancer Network.

“The UTPSTF recommendations are a step backward and represent a significant harm to women’s health. To tell women they should not get regular mammograms starting at age 40 is shocking. At least 40% of the lives saved by mammographic screening are of women aged 40-40. These recommendations are inconsistent with curtrent science and apparently have been developed in an attempt to reduce costs. Unfortuneately, many women may pay for this unsound approach with their lives!” W. Phil Evans, MD, President, Society of Breast Imaging. Oncology, 23:1214, November, 2009

The U.S. Preventative Services Task Force recommendations “have taken a tremendous toll, and I believe they set us back”. “After all we’ve done to urge people to get screened, now they hear maybe they shouldn’t bother. That’s dangerous”. Nancy Brinker, the Founder of Koman Foundation and a breast Cancer Survivor was quoted in the Washington Post (November 24th,2009) stated at the National Press Club

“These unfounded USPSTF recommendations ignore the valid scientific data and place a great many women at risk of dying unnecessarily from a disease that we have made significant headway against over the past 20 years. …The new recommendations seem to reflect a conscious decision to ration care……it could have deadly effects on women.” Carol H. Lee, MD Chair of the American College of Radiology Breast Imaging Commission. Oncology, 23:1214, November, 2009

“I can’t help but think that we are moving toward a new health care rationing policy that will turn back the clock on medicine for decades and needlessly reverse advances in cancer detection that have saved countless lives”. James H. Thrall, MD Chair of the American College of Radiology Board of Chancellors. Oncology, 23:1214, November, 2009.

There is no new data to support these guidelines –they are completely insane..as a women, I find the rhetoric about anxiety and unnecessary testing offensive and patronizing.”. Dr Elsie Levin, Medical Director, The Boston Breast Diagnostic Center (General Surgery News, December, 2009)

“The net effect of the recommendations is that screening would begin too late and would be too little. We would save money but we would lose lives,” Stephen A. Feig,MD, President-elect of the American Society of Breast Disease, (Elsevier Global Medical News. 2009 Dec 3,2009)

The fastest-growing cancers, and thus the ones likely to be missed with screening every two years occur in younger women. Thus, the implied suggestion that screening mammography be delayed until the age of 50 and then undertaken every two years, makes no sense… I wonder if the recommendations would have been the same had there been greater representation on the Task Force of physicians involved in the detection and treatment of breast cancer.” Dr Carol Fabian, Director, Breast cancer Prevention Center, University of Kansas Medical Center. (General Surgery News, December, 2009)

“What does this tell women in their 40s? It tells them basically that they can go back to the 1950s, when they waited until a cancer was too large to ignore any more and then bring it to their doctor’s attention,… They’re basically saying ignore your breasts until there’s an obvious cancer.” Daniel B. Kopans,MD, Breast Imaging Division, Massachusetts General Hospital and Professor of Radiology at Harvard Medical School. (Elsevier Global Medical News. 2009 Dec 3,2009)

“Recommendations as important as these should not be decided on narrow evidence that is not widely supported by the breast cancer and provider community,” Robert Rifkin, M.D., Chair, Patient Advocacy Foundation Scientific Advisory Board. Until there is much more conclusive evidence, we continue to join our non-profit colleagues, including the American Cancer Society, Susan G. Komen Foundation, National Comprehensive Cancer Network, and the American Medical Association, in recommending that women over the age of 40 continue regular, annual mammography screening.

A video-animation presentation about breast biopsies. Both fine needle aspiration and core biopsies are covered. 3D graphics are used to explain the process. Here’s more information from our companion website, patientresource.net:

Although mammography can show the presence of a lump or abnormality in the breast tissue, the test cannot distinguish between a benign or malignant lump. Magnetic resonance imaging (MRI) may be done to provide more details about a suspicious area on a mammogram, and an ultrasound can help distinguish between a fluid-filled cyst (benign) and a solid mass (possibly a cancerous tumor).

A biopsy is the only way to confirm that a lump is a breast cancer. With this procedure, the oncologist or a consulting surgeon removes a sample of cells or tissue from the lump or the entire lump itself. A pathologist will examine the biopsy sample under a microscope to see if signs of cancer are present. There are three types of biopsy:

* Fine-needle aspiration: removal of fluid or some cells from the lump using a thin needle
* Cone needle: removal of tissue from the lump using a wider needle or newer instruments
* Surgical: removal of the entire lump (excisional) or only part of it (incisional)

Fine-needle aspiration is the least invasive method for obtaining cells from a suspicious lump in the breast; it is most often done for a lump that was felt during a clinical breast examination. This type of biopsy is best for distinguishing between a fluid-filled cyst and a solid mass. Tissue samples can be obtained with a core needle biopsy, and this method is the one commonly used for biopsy of a lump that was detected on mammography or another imaging study. If the findings on examination of a sample obtained with a needle biopsy are inconclusive, then a surgical biopsy offers the opportunity to obtain the greatest amount of tissue from the lump. If the entire lump and a rim of normal breast cancer tissue around it are removed during surgical biopsy, the procedure is actually a form of breast cancer treatment (lumpectomy).

The type of biopsy actually done depends on several factors, such as the size or location of the lump, and physicians prefer to use the least invasive method possible).