As I write this, it is about 5:30AM and I am sitting in the airport in Cincinnati waiting to continue my travels to Chicago. I am the victim of what the airlines call an “irregular operation,” which for me means the plane bound for Chicago was pulling away from the gate when I arrived from the first leg of my trip from Harrisburg.
I have been on a bit of a road trip, giving talks in several different cities over several different days. It has been hectic, but rewarding and enjoyable, even if the rigors of travel make it somewhat more complicated than I would prefer.
As a result of this tumult, I haven’t had time to do any formal research or reading in preparation for a blog this week, but I have seen the headlines about the continued reduction in deaths from breast cancer.
And that has made me think that, although breast cancer awareness month may be coming up in October, in fact this has been a breast cancer awareness year. Although much of the news has been good, there has been some that is not so good as well.
For example, thinking back over the past year we have had the continuing story of the declining deaths from breast cancer. That is in fact, fortunately, not new news—it is old news, and very welcome news.
There has been a continuing decline in deaths from breast cancer in the United States since the early 1990s. Research has shown that, until now at least, much of that decline has been the result of mammography leading to early diagnosis, and more effective treatment options including better approaches to surgery and radiation, as well as better chemotherapeutic options to prevent the cancer from returning.
There is no doubt that we have made considerable progress in the treatment of breast cancer. When I started practice in the mid-1970s, an early breast cancer was one you felt yourself as the patient or by someone like me, the doctor.
But those weren’t early breast cancers. There were a high percentage of women at more advanced stages since the cancer had already spread to the lymph nodes or elsewhere in the body.
Now, with mammography, we can find most breast cancers before they are felt, and even before they invade the breast tissue—which is a key step in the cascade of events we call cancer. The death rates have fallen, and the survival rates have increased.
But not all the news is good news.
When we look at survival rates from breast cancer, we see a clear divergence between white women and African-American women in this country beginning in the early 1980s.
Why this has happened is unclear, but I can’t help but point out the fact that the mid-1980s is when mammography began to get real traction in this country.
Access to mammography services for African-American women has continued to be problematic for many years. If you can’t get a mammogram because you can’t afford it, or you don’t have health insurance, or you don’t have someone in your neighborhood who can perform the service, you lose the advantage of finding a breast cancer early.
Recently, a study was reported from a breast cancer conference that found African American women have a higher incidence of what we call estrogen receptor negative breast cancers, which are not hormone sensitive. Those cancers are more aggressive, and have a poorer prognosis than the more typical estrogen sensitive form of breast cancer.
That, too, could explain why African American women—despite the fact that they have a lower incidence of breast cancer compared to white women—have a worse prognosis when they are diagnosed with the disease.
The arguments about how much biology vs. access contribute to this serious problem of poor prognosis for breast cancer in African American women continue, but I suspect the reality is that the poorer outlook is likely a combination of multiple factors—with a heavy dose of emphasis on the lack of access side of the equation.
This year also brought reports of declining use of screening mammography by women, first with an article from the CDC in January and more recently in another article that was published in the journal Cancer.
As I mentioned in my blogs over this past year, if women don’t get mammograms they don’t get diagnosed with breast cancer. But that won’t wish the breast cancer away. It is still there and growing, and eventually it will be diagnosed, albeit at a later stage. Later stage translates into more aggressive treatments with lesser chances of survival.
A basic principle in my book: our advances in the effective treatment of breast cancer start with a mammogram. Find it early, when a breast cancer can first be seen, and the chances of survival increase significantly.
That doesn’t mean mammograms are perfect. They aren’t. They don’t find every breast cancer early, unfortunately. And that is why it is so important that if you note any change in your breast—even if you had a mammogram last month—you must see your health care professional promptly.
But a mammogram still remains our best first line of defense for most women in terms of finding breast cancer early when it is most responsive to treatment.
So, if women for whatever reason are shunning mammograms, they are playing a bit of Russian roulette with their lives, in my opinion.
And that brings up another event of the past year, namely the guidelines for screening mammography released by the American College of Physicians, which suggested that screening mammography for women less than 50 was more of a choice than a recommendation. (This is in contrast to the American Cancer Society’s recommendation that women should have an annual mammogram and breast examination performed by a health professional every year beginning at age 40.)
Some of my colleagues have suggested I shouldn’t write about these alternative guidelines, since publicity may focus more attention on them.
The reality is that, despite a lot of press, they haven’t had much traction. Most physicians I speak with can’t understand what they should tell women to do, if they tried to follow these guidelines. These guidelines don’t give firm recommendations to doctors and their patients, which makes decision making more difficult.
As I mentioned in my previous blog on the subject, they essentially tie mammography to a woman’s risk of breast cancer. But I am not aware (and neither are my learned colleagues who are experts in this field) of any study which supports such a recommendation.
That brings us to the issue of breast cancer risk, which itself has been a fertile area of discussion over the past year.
The reason this topic is so important to me is that I believe most women—and most health care professionals—do not know their own risk or the risk of their female patients of developing breast cancer, and they don’t know how to approach this subject.
That doesn’t mean the docs are bad people or the patients are ignorant. What it does mean is that we haven’t done a good job of educating the public and the profession on the topic and what they can do to deal with that risk.
A recent announcement of an advertising campaign by the company that markets and performs a genetic test to check for the risk of breast cancer in women made another publicity splash a couple of weeks ago.
I was asked on more than one occasion what I thought of the campaign.
Although I have certain feelings about direct-to-consumer advertising—such as the fact that although the ads may raise awareness, they may also inspire fear and issue a “call to action” to more audiences than really would benefit from the test or the treatment—the real issue for me was what I said above: we simply have not incorporated risk measurement and risk mediation into our everyday thinking and the practice of medicine.
This past year brought another step forward in this area when the FDA approved raloxifene for the reduction of risk of breast cancer in women at high risk.
We have had tamoxifen available for this purpose for many years, but uptake by women and their physicians has been very low.
The hope is that now, with a drug that is more familiar to doctors and patients (raloxifene has been commonly used in the treatment of osteoporosis in post-menopausal women) that the use of these medications to reduce breast cancer risk in the target group of women will increase. Only time will tell.
This past year also brought guidelines from the American Cancer Society on the use of MRI as part of a screening program for women at high risk of breast cancer, such as women with BRCA gene abnormalities.
This was a welcome set of recommendations, but it hasn’t been without its critics.
I personally was publicly and gently chided by one of my very respected colleagues who complained that the release of our guidelines increased the demands of many women to have a breast MRI when it was not indicated.
Although breast MRI is effective as a screening tool in appropriate women at high risk, it is NOT indicated for women at average risk.
What a surprising number of doctors didn’t read in the document that accompanied the guidelines was a very clear and unambiguous statement that, when indicated, breast MRI must be performed in a center that has the equipment and the expert doctors who actually know how to do the test, interpret the test, and follow-up with the appropriate biopsy procedures geared to the MRI findings.
The truth of the matter is that many breast MRIs are done by physicians and offices that do not meet these standards. That makes the value of the test much less than it would be if done by someone who has the background necessary to assure the best results from breast MRI.
More recently, a research report suggested that MRI may in fact be a very effective screening tool in women at average risk of breast cancer.
In this report, the MRIs were done in a university center in Germany that had radiologists and equipment that were solely devoted to performing and reading breast MRIs. Basically, they had years of experience doing the test, and how they interpreted the results used different criteria (a blood vessel blush) than most doctors use (looking for a mass).
The result was a stunning decline in deaths from breast cancer.
Obviously, further research is needed to evaluate this radically different approach to breast cancer screening.
The final topic I am going to discuss in this “year in review” on breast cancer was the observation reported earlier this year that breast cancer incidence declined dramatically over the first part of this decade.
The decline closely followed the reduction in the use of hormone replacement therapy. The relationship was remarkable, uncanny, and in my opinion not easily explained.
Other factors to consider were the declines in the use of screening mammograms. My colleagues here at the American Cancer Society reported shortly after the original reports on the hormone relationship that the decline in incidence actually began in the late 1990s, possibly because we had finally found many cancers early through mammography before they became invasive. This is what we call the “screening effect.”
Other follow-up research has been reported more recently suggesting that declining mammography did not explain the reduction in the frequency of breast cancer diagnoses.
What is the real explanation? Most likely a combination of all the above.
Time will tell, but the reality is that we are now diagnosing fewer breast cancers than we would have expected based on historical observations
Whether or not this is good news is uncertain.
If it is because in fact screening has finally begun to reduce the numbers of cancers that are present, that is good. If it is because hormones did indeed have a much greater impact than we could have anticipated, that is good.
If it is because the cancers aren’t being found because women aren’t getting a mammogram for whatever reason, or because stopping hormone treatment caused a temporary lull in the growth of a cancer, or because women aren’t seeing their doctors to get their hormone prescriptions refilled and missing the opportunity to hear a recommendation to get a screening mammogram, that is not good.
What is undeniable is that we have made considerable progress in the treatment of breast cancer, and this year has been no exception.
We may have a breast cancer awareness month coming up in October, but in reality we have already had a breast cancer awareness year.
Fortunately, we continue to make progress in understanding breast cancer, and how to diagnose it earlier, and treat it better—and how to even prevent it in the first place.
We have come a long way, but we can’t rest on our successes.
Let’s not deny or forget that we still have a long way to go.
As I post this, I am going from the Chicago airport to my hotel. Consequently, I can't create the links to the various stories I reviewed in this blog.
You can get to that information by using the "breast cancer" search feature at the top of the blog to list all of the entries over the past year--starting in January--that are mentioned in today's entry.