Connections

The Blog That Builds Hope.

Breast Cancer Awareness

October is breast cancer awareness month, so I thought I would take a moment to discuss a few issues related to the diagnosis of breast cancer.   As you probably know, breast cancer is the most common type of cancer diagnosed in women, but it is not the most common cause of cancer related death in women.  This is attributable, in large part, to the earlier diagnosis and improvements in patient specific therapy.  As a medical community, we have also contributed somewhat to the rise in breast cancer through our errant recommendations for hormone replacement therapy (HRT) in postmenopausal women.  We initially thought that estrogen provided a protective effect in women based on observational studies that showed a significant rise in cardiovascular deaths after menopause.  As it turns out, a large study has confirmed an increase in the risk of breast cancer in those who took HRT, and absolutely no cardiovascular benefits.  There was some improvement in bone density in women on HRT, but we now have other ways to protect against this with the use of bisphosphonates (fosamax etc).  So, if possible, you should avoid HRT after the age of 50.

I know that there has been some question regarding the effectiveness of mammography in the diagnosis of breast cancer.  Mammograms are actually quite good at identifying abnormal calcifications in the breast tissue, which are caused by abnormal accumulation of cells within the ducts responsible for transporting milk to the nipple.  These calcifications are frequently an indicator of ductal carcinoma in situ – or noninvasive breast cancer, which can be surgically treated with a near 100% survival rate.  If left untreated, nearly all of these cancers will become invasive.  Mammograms may also detect an area of abnormally dense tissue in the surrounding fatty breast tissue, which may represent a cancer as well.  This is best demonstrated in post menopausal women whose breast tissues are less dense than their premenopausal counterparts.  This was the basis for the initial recommendations for screening mammograms to begin at age 50.  However, it is now recommended to obtain a baseline mammogram by age 40 and annually afterwards, as indicated by your physician. Family history plays an important role in this decision making process.  Families with a history of BRCA mutations can have as high as a 90% lifetime risk of developing breast cancer, and close surveillance or prophylactic mastectomy become extremely important in these individuals.  Annual visits with your OBGYN or primary care physician are a nice way to stay current in your breast health.  The one piece of advice that I cannot stress enough is to NEVER ignore a breast mass or lump.  EVEN if the mammogram is completely normal, any new breast mass should be further evaluated with ultrasound and/or biopsy, as occasionally the mammogram may not detect a malignancy in dense breast tissue.

With respect to the treatment of a breast cancer after a diagnosis is made, things have come a long way in the past 15 years.  Surgery remains the cornerstone of therapy.  Patients may preserve their breast and undergo a “lumpectomy” followed by radiation, or a mastectomy (complete removal of the breast tissue).  In some cases in women over the age of 75 with small nonaggressive tumors, radiation may even be omitted now after lumpectomy.  A procedure called “sentinel” lymph node biopsy is used to evaluate possible spread to the lymph nodes under the arm – rather than simply removing all the nodes upfront.  This decreases the chance of lymphedema (swelling of the arm after surgery).  These advances in surgery and radiation have significantly improved the cosmetic outcomes in breast cancer patients while maintaining the excellent survival in early stage disease.

The personalization of cancer treatment first began in breast cancer patients with the addition of Tamoxifen for estrogen receptor positive cancers.  After surgery, all patients with tumor cells that express the estrogen receptor should be treated with at least 5 years of anti-estrogen therapy.   In pre-menopausal women, we use Tamoxifen.  In post menopausal women there is clear evidence that some exposure to an Aromatase Inhibitor (Arimidex, Femara or Aromasin) –either in place of Tamoxifen or in sequence after Tamoxifen improves outcomes.  For more aggressive cancers, chemotherapy may be indicated to reduce the risk of recurrence and improve the chances for cure.  The Oncotype Dx test can help us better determine on an individual basis which patients benefit the most from the addition of chemotherapy to their treatment regimen.   Some breast cancer cells express a protein called Her-2, which can drive the growth of breast cancer cells.  We now administer a medicine called Herceptin to these patients which can turn off this signal.  In women with BRCA mutations and/or those with “triple negative” (Estrogen neg., Progesterone neg., Her-2 neg) cancers, a new class of drugs called PARP inhibitors may play a role in improving response to treatment and survival.

In summary, we have come a long way in the past 15 years, as evidenced by the decline in breast cancer deaths — but we must not rest on our laurels.  We must continue to better personalize diagnosis and treatment to maximize survival and minimize side effects.  You can do your part through self examination and compliance with annual physical exam and mammogram.

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