Monthly Archives: September 2009

Going Beyond Pink Purchasing in Breast Cancer Awareness

Kudos to Rethink Breast Cancer, a group in Canada focused on young people affected by breast cancer.  They hold an annual film festival dedicated to not only breast cancer awareness but to the underlying issues connected with the disease. The festival uses films, panels, workshops and speakers to “connect people to the breast cancer cause, inspire dialogue, facilitate learning and foster community.”

This year’s Breast Fest will be held November 20-22 at the Royal Ontario Museum, in Toronto.

If you can’t make it up to Toronto in November, no worries, you can still watch and vote online for the short film competition.   Go here to check out more of the videos and vote for your favorite!

For more information about Rethink, visit www.rethinkbreastcancer.com.

breastfest

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When does breast cancer begin?

This debate reminds me of the emotional debate over when life begins.  If abnormal cells have the potential to become cancer, do we call it cancer, and more importantly, do we treat it like cancer?

When considering breast cancer, one step along the pathway can be abnormal cells confined to the breast ducts, or Ductal Carcinoma In Situ (DCIS).  But controversy has existed for years over whether this is indeed “breast cancer” and whether it should be treated as such.

After two and a half days, an NIH-convened panel tasked with summarizing the State-of-the-Science for DCIS concluded….drum roll please……we still don’t know much.

We do know DCIS is a risk for invasive cancer, but we still don’t know how much of a risk.   We don’t know the natural course of DCIS,  how often it would become invasive, who should be treated, and who can safely avoid the surgery/and or radiation.  Whew.  So much for the state-of-the-science.

There were two distinct camps at the panel proceedings in Bethesda, MD. – one strongly and passionately in favor of treating all DCIS, and the other camp just as strongly expressing concern about overdiagnosis and overtreatment of the disease.   And of course, they didn’t come up with any new recommendations in terms of diagnosis or treatment of DCIS.

But surprisingly, in the end, the panel did agree that the medical community should strongly consider eliminating the word “carcinoma” from the diagnosis.

“Because of the noninvasive nature of DCIS, coupled with its favorable prognosis, strong consideration should be given to elimination of the use of the anxiety-producing term “carcinoma” from the description of DCIS,” the panel concludes in their final statement, released yesterday.

This is a good first step.  Changing the language of DCIS  will help facilitate a change in attitudes and approaches to treatment for this disease.  But what we still need is good evidence for making treatment decisions.   Treatment decisions that tens of thousands of women will face in the next year.

The incidence of DCIS has increased seven-fold as a result of widespread mammography with about one-half million women currently living with the disease.  This would be great news if it meant we were catching the serious breast cancers early – but the data just doesn’t show that.  Catching all of this DCIS, may just be catching a lot of abnormal cells that would never go on to cause any problem.  Unfortunately, the conference didn’t help to clarify the issues.  Time to call for more research.  <sigh>

The panel correctly concluded that the primary focus of research should be on developing methods for determining who can safely avoid treatment.  And they called for better collection of data on DCIS nationwide, suggesting that pathologists adopt standardized reporting of DCIS.

Some of their specific research recommendations:

Develop models for identifying which patients are candidates for (1) active surveillance only, (2) local excision only, (3) local excision with radiotherapy, and (4) mastectomy.

Who is at high risk for recurrence of DCIS or the development of invasive carcinoma?

What do comparative effectiveness analyses tell us about the role of current therapies in DCIS patients?

Read the full panel statement here.

A shot (or three) to prevent breast cancer?

Once again, the dramatic claims reported recently in the news regarding breast cancer gave only a snippet of the real story.  This time, news reports announced the discovery of Human Papilloma Virus  in human breast cancer tissue. This report garnered quite a bit of attention.  Not only because finding a virus with a role in breast cancer opens up the possibility of a vaccine for breast cancer, but because we’ve already got the vaccine. The HPV vaccine is now given to pre-teen to teenage girls, in a series of three shots, to prevent some forms of cervical cancer.

It does make sense that HPV could have a role in breast cancer.  High risk strains of the virus are able to “oncogenically transform” normal cells, or in other words, cause cancer.   But is the theoretical risk real?  Do breast tumors contain HPV, and if so, what role do they play?

The recent news reports referred to research from Australian researchers that was published in the British Journal of Cancer.  The researchers found HPV in two out of eight breast cancer cell lines.  They then looked at breast tissue specimens and found HPV in 5 out of 13 DCIS breast cancer specimens; 3 out of 13 IDC breast cancer specimens; and in 3 out of 17 normal breast tissue specimens.  The authors conclude that the proportion of HPV in cancerous tissue is higher, and that the presence of HPV in some normal tissue is consistent with the requirement for HPV infection in the breast tissue before HPV-induced cancer transformation can occur.

But was this really a new discovery?  Turns out, no, not really.  Scores of research studies have been looking for many years at not only HPV and breast cancer, but other viruses as well, including the Epstein Barr Virus.  Studies around the globe have found HPV, Epstein Barr, and other viruses, in varying amounts in breast cancer tissue.  Other studies have failed to verify the same results, making the ideas controversial.  But the research may be picking up steam.  What IS news is that the laboratory methods used to identify viruses in breast tumors have recently advanced and are considered more reliable.

So where do things stand now?

There is “substantial, though not conclusive” evidence that viruses, including HPV and Epstein Barr may be involved in causing some breast cancers,  according to a review on the topic published this year in the Journal of Cancer Research and Clinical Oncology.  The exact role of the viruses is not clear, but it appears that the viruses are responsible for causing one of the steps in a series of steps required for cancer development, according to the authors.

I’m encouraged by this research, and hope to see more.  So much of the research into finding a cause of breast cancer and potential preventive strategies seems like searching for a needle in a haystack.  But the possibility of a virus having some role, and the possibility of vaccines for the disease,  seems well worth continued research efforts.

Surgery May Increase Survival in Stage IV Breast Cancer

Study results presented today at a European Cancer Organization conference in Berlin  may give physicians a reason to rethink the standard of care for Stage IV or metastatic breast cancer.

Treatment for women who are diagnosed from the beginning with a Stage IV breast cancer, or one that has spread to other parts of the body, is  typically focused on systemic, or whole-body treatments, such as chemotherapy.  Surgery to remove the primary tumor is usually not a priority in the treatment of metastatic disease.

However, researchers in The Netherlands found significant differences in survival between those who had had surgery to remove the primary tumor versus those who had not. In a retrospective study of 728 patients, the researchers discovered that those patients who had received surgery survived an average of 31 months, compared to 14 months for those who did not receive surgery. The five-year survival rates were also significantly different – 24.5% for the surgery group, compared to 13.1% for the non-surgery group.  Having had surgery was an independent prognostic factor even after adjusting for age, period of diagnosis, the number of metastatic sites and different types of treatment.

The researchers suggest that removal of the primary tumor reduces the number of circulating tumor cells in the rest of the body, or perhaps reactivates the immune system.  They are doing further analysis to determine if those who received surgery presented with less severe symptoms and perhaps had less severe disease.  They also plan to expand the study to look at the records of 10,000 patients over the last ten years.  In addition, the researchers would like to work with the Dutch Breast Cancer Research Group to set up a national randomised controlled trial to prospectively study the effect of surgery in Stage IV breast cancer patients.

Lots more work needs to be done to address the needs of women with Stage IV metastatic disease.  But this is one, small, encouraging step forward.

Research results presented today in Berlin, by Dr. Jetske Ruiterkamp, a surgeon from the Jeroen Bosch Hospital, Den Bosch, The Netherlands, at a European cancer congress, ECCO-15 and ESMO-34.

Direct to consumer advertising….of clinical trials?

We’ve all gotten used to seeing television ads for drugs.  But  a television ad for an investigational new drug and a clinical trial?  That’s new.

The commercial has been showing up during Good Morning America this week in several markets.   Watch the ad here.

Celsion Corporation is running the ad to promote their  DIGNITY Breast Cancer Trial, a clinical trial for treatment of breast cancer that has recurred in the chest wall.   According to their press release they intend to also run the ad in NYC during National Breast Cancer Awareness Month.

Something tells me this isn’t about recruiting patients for the study.   The study is an early phase clinical trial, and is only looking to recruit 100 women.  I suspect this is a new pharma tactic – trying to build market interest in a new drug or product- before it even has FDA approval.

The study is looking at the safety and efficacy of a new targeted method for delivering doxorubicin, the chemotherapy nicknamed “the red devil”  because of it’s harsh side effects.  Celsion has developed “Thermodox,” as a way to deliver more doxorubicin to the tumor, but less to the rest of the body to avoid some of the harshest side effects.  The drug is packaged in a liposome, which will burst open and deliver the drug when exposed to heat.  During treatment the chest wall area will be heated – thus giving more targeted drug delivery.

This may turn out to be a great development in the treatment of breast cancer recurrent to the chest wall – but it’s important to separate the science from the marketing.  Are television advertisements on unapproved drugs or products a good idea?  Should the science  be evaluated and proven before it’s “marketed?”  Or, on the other hand, is it good to get information out to the public about research, and new possible treatments?

What do others think about this?

Can we prevent breast cancer in our daughters?

The reason I’m so passionate about finding reliable, scientifically-based ways to prevent breast cancer, is the bright-eyed, ten-year-old girl that lives down the hallway.   If there is anything my daughter can do now to prevent the hell of breast cancer from visiting – and no, breast cancer is not pink, pretty, OR inspirational!- I want to know what it is.   Eat well?  Exercise? Throw out the Halloween candy?  What?

But looking at the evidence – none of those things seem to matter much.  When it comes to pre-menopausal breast cancer, the kind I had, and the kind that I worry about most for her, most of what we know about breast cancer just doesn’t apply.  In fact, one of the largest studies looking at prevention of breast cancer, the Nurses’ Health Study, found that many of the lifestyle associations with breast cancer -the ones you read about in the news – have OPPOSITE effects on pre- and post-menopausal breast cancer.

The Nurses’ Health Study is probably the largest and longest running study to look at factors associated with breast cancer development.   The study originally began in 1976, as a  study of the long-term effects of birth control pills.  Over 100,000 nurses have been followed since the beginning.  The nurses answer questions about health, smoking, hormone use, and menopausal status, every few years.  Questions about diet were added in 1980.  Over 115,000 additional nurses were added to the study in 1986.  It takes a long time, but this kind of study, a prospective study that follows people into the future, is the best kind of study to look at associations with development of disease.   It was a prospective study like this one, the Framingham Study, that gave us most of the information we have today about what contributes to heart disease.

The good news is that recruitment is underway for another group of nurses to join the study, younger and more diverse.  Plans are to invite a million women to join and to focus on adolescent diet and breast cancer risk, among other things.  The bad news is that it will be decades before we have the results.

So what can we say from the studies so far?  Women are at a slightly greater risk of premenopausal breast cancer while they are on birth contol pills, and for up to ten years after giving birth.  Even though giving birth, and giving birth at a younger age, is protective against post-menopausal breast cancer, is does appear to increase the  immediate risk of breast cancer for a period of time.

But one of the most surprising findings of the Nurses’ Health Study? Being overweight had the opposite effect on pre- and post-menopausal breast cancer.  For nurses in the study, being overweight increased the risk of post-menopausal breast cancer but decreased the risk of pre-menopausal breast cancer.  And more relevant to preteens, women who were overweight before their first periods had a lower risk of breast cancer.  That’s right, being overweight as a pre-teen was protective against breast cancer.

Physical activity?  According to the Nurses’ Study, activity was somewhat protective against breast cancer after menopause but had no impact on breast cancer before menopause.

Now, before I hear from Ann Fonfa, I want to be clear that I am not advocating for poor diets and increased weight for preteen girls, and either are the folks involved with the Nurses’ Study.   They were encouraged to find that if diagnosed with premenopausal breast cancer, those who were lean did tend to have smaller, and less aggressive cancers than those who were overweight.

From their newsletter, “Even though being active doesn’t offer much protection against pre-menopausal breast cancer – and being lean actually seems to increase risk – we still encourage women to be both lean and active throughout their lives.  The health effects of regular exercise and a low body mass far outweigh the risks of developing premenopausal breast cancer.  Furthermore, when premenopausal breast cancers do develop, they tend to be smaller and less-aggressive in leaner women than in overweight women.”

Any findings we can act on?  They have found a slightly higher risk of premenopausal breast cancer with higher intakes of animal fat, mostly high fat dairy, and mostly associated with estrogen receptor positive cancers.  And they found some suggestive results that higher consumption of Vitamin D and vegetables lowered the risk for premenopausal breast cancer, but not for postmenopausal.

Unfortunately, the biggest risk found for premenopausal breast cancer?  Having a mother diagnosed with breast cancer before age 45.  Damn.

So, bottom line for me and that ten-year-old?  I’m going to lighten up a little bit about the Halloween candy,  but continue using organic, non-fat milk and encourage the vegetables.  But in my heart I know, this  isn’t good enough.  We need to know more and do more to prevent this disease in these high risk, bright-eyed, ten-year-old girls that we love so much.  Please, don’t settle for the hyped news releases and the quasi- science.  Demand the right science so we can get the right answers!

Next, on to good basic science.  Could there be a shot (or three) to vaccinate our daughters against breast cancer? Check back ….

For more information on the Nurses’ Health Study, go to http://www.nurseshealthstudy.org.

Early Detection is Not a Cure

This is a surprise to many people.  Screening and early detection of breast cancer has been emphasized and elevated to such a level in our country that most women feel that screening and early detection IS the cure for breast cancer.

Unfortunately, it’s just not true.  Biology is just as important as the size and stage of the breast cancer.  Some breast cancers behave more aggressively, right from the start, even when found quite early.  Others, even when found early, linger in the body somehow to rear their head again many years later.

Detecting cancer as early as possible, and beginning appropriate treatments is the best we can do for now, but we need more.  We urgently need to understand how and why some cancers spread to other parts of the body (either early on or later), and we need more treatments to target those more aggressive cancers.

A study published this month on early, Stage I breast cancers in over 1000 women, showed that those with triple-negative disease (estrogen/progesterone receptor negative and her-2/neu negative) had over six times the risk of recurrence in the first five years than women with hormone receptor positive disease.  The differences in recurrence were found for tumor sizes between 0.5 cm and 2 cm.  Five-year relapse free survival was 89% for those with triple-negative disease, compared to 98% for the hormone receptor positive group.

This was in spite of the much more aggressive treatment received by the women with triple negative disease.  The authors of the study, published in the September/October issue of The Breast Journal, conclude that even aggressive chemotherapy treatment does not level the field for patients with early stage triple negative disease, and that new, more effective treatments are urgently needed.

Early detection of breast cancer is important, but it is not the cure.  Let’s not get distracted from the work that needs to be done.

“T1N0 Triple Negative Breast Cancer: Risk of Recurrence and Adjuvant Chemotherapy”
Henry G. Kaplan, MD, Judith A. Malmgren, PhD  , and Mary Atwood

Breast J 2009;15:451-460

A Second Breast Cancer – Alcohol, Obesity, Smoking…..and Not Taking Your Medication

How do you prove that lifestyle factors can prevent breast cancer or breast cancer recurrence? The best evidence would come from interventional studies, studies comparing groups that make lifestyle changes with those that don’t.  Unfortunately, we just don’t have many of those studies.  What we do have, are a lot of studies looking at associations.  But you learn in stats 101 to be careful with these studies.  Association is not causation.

One of these association studies was published yesterday, in the online Journal of Clinical Oncology.  Investigators from the Fred Hutchinson Cancer Research Center found that developing a second breast cancer was  associated with obesity, regular intake of alcohol, and smoking.

The researchers compared weight and lifestyle habits between a group of 365 women who were diagnosed with breast cancer twice and a group of 726 matched controls with just one breast cancer diagnosis.  All patients had been originally diagnosed with an estrogen receptor positive breast cancer.

Being overweight at the original diagnosis, smoking, and drinking more than seven drinks a week were all associated with an increased risk for a second breast cancer.  Those who both smoked and drank regularly had a seven times greater risk of a second cancer, compared to those who did not smoke or drink.

The headline in the news today?   “Obesity, Alcohol Consumption, and Smoking, Increase Risk of Second Breast Cancer”  Ok, but what else?  What wasn’t reported?

The most  important factor.

Those who didn’t develop a second breast cancer?  They were  also much more likely to have been treated with hormonal therapy (p< .0001, for you statistics geeks).   Almost 40% who developed a second breast cancer were never given a hormonal treatment, and futhermore, less than 20% of ALL those in the study actually completed the recommended five years of treatment.  The real news to me seems to be the extremely low numbers of people who complete their treatment!

Bottom line?  Should those who have had estrogen receptor positive breast cancer aim for a healthy weight and healthy habits?  You bet.  But will avoiding that glass of wine or refusing dessert protect us from another breast cancer?  Probably not, and certainly not nearly as much as taking our hormonal medication.

News report http://www.scienceblog.com/cms/obesity-alcohol-consumption-and-smoking-increase-risk-second-breast-cancer-24932.html

Journal article  http://jco.ascopubs.org/cgi/content/abstract/JCO.2009.23.1597v1

Will More US Women Die of Breast Cancer with Healthcare Reform?

Three hundred thousand more women will die of breast cancer each year in the US if proposed health care reform takes place, according to a multi-million dollar television ad campaign running in several states this week.   The ads, sponsored by the Independent Women’s Forum, cite as evidence a report from Lancet Oncology that shows “England’s breast cancer survival rate is much lower than in the US.”

What’s the truth?  The truth is LESS women will die of breast cancer in the US if every woman has access to screening and treatment for breast cancer.  The American Cancer Society  looked at insurance status and cancer outcomes in 2005 and 2006.  Not surprisingly, only 38% of women between 40-64 years with no insurance had had a mammogram in the previous two years, compared to 75% of those with private insurance.  More importantly, patients with no insurance were more likely to be diagnosed with Stage III or Stage IV breast cancer, and less likely to be diagnosed with a Stage I cancer.

And survival from breast cancer?  The 5-year survival rate was 76% for all uninsured patients, and 65% for uninsured African American women, compared to 89% for White women with private insurance.  We may have some of the best breast cancer care available in the world, but unfortunately, it’s just not universally available to all US women.

Now back to the ad – what about this Lancet Oncology report they cite?  According to their website, they are referring to an article published in 2008, “Cancer Survival in five continents: a worldwide population-based study (CONCORD).”  The article gives 5-year survival rates for breast cancer – the US came in at 84%, compared to 70% for the UK.  What they left out in the ad were the 5-year survival rates in the article from several other countries that have universal health coverage: Sweden 82%, Canada 83%, Australia 81%, Japan 82% and Cuba 84%.

There has been a lot written about the differences between the datasets in England and the US, and differences in how the rates were obtained.  But the most important thing to know is that the UK rates are determined from a cancer registry that includes everyone.  The US rates are estimates, based on SEER data, which include about 10% of the population, and only those who access the healthcare system.

The other striking thing I noticed in digging around – England has made terrific strides in breast cancer care.  According to the latest registry figures, the 5-year survival rate for breast cancer is now just over 80% (the 70% figure was from early ’90s data).  Since 1989, breast cancer mortality has fallen by 36% in the UK.   They recognized a problem and took steps to correct it.  What strikes me, is how much more effective it must be to implement new public health initiatives in a country when you have consistent care and universal coverage.  To improve public health in our country, so much time and energy must be spent trying to reach those outside the heathcare system.   But that’s another day’s topic….

Every major breast cancer advocacy group in the US is calling for healthcare reform to improve breast cancer care in our country.  Shame on the IWF for using breast cancer to scare people away from healthcare reform.

*Thanks to my advocate friends, Liz here in the US, and Sara in the UK, for helping me find information for today’s blog.

How much will you pay to hear what you want to hear?

Everybody wants to believe they can control whether they get breast cancer or not.   Of course we want control over this disease.  It’s pretty scary  to think it can happen to anyone.

It follows doesn’t it, that we will support the organizations that tell us what we want to hear.  The ones who give us control.

Yesterday, I reported on a large, well-designed study that followed over 300,000 women for eleven years and found no concrete link between a meat or dairy free diet and breast cancer risk.  But alas, the NY Times, and several other news outlets report this week that almost half of all breast cancers can be prevented – simply by a healthy lifestyle including a vegetarian diet.  Huh?  If it can make that much difference, how could that large, prospective study I reported on yesterday have missed it?

I did a little digging.  The news articles are basically reprinted press releases from the American Institute of Cancer Research.  Who are they?  Well, it turns out they are a “charity” that funds and “interprets” science on cancer prevention.  Here’s the rub – over half of the organization’s public education efforts  are tied to fundraising appeals.   And those donations?  CharityNavigator gave them a poor rating for putting those funds back into research.  According to the Better Business Bureau the CEO earns over $400,000.

Ok, what about the science?  Where did they come up with the claim that 70,000 cases of breast cancer can be prevented each year?  I read through several pages of the report and could find no valid scientific explanation for how they arrived at that number.  It appears to be a huge leap or “interpretation” made by their panel of experts.  As far as diet and breast cancer prevention, within their own report they list the evidence as “limited” and not convincing or probable. And even more interesting, they report convincing evidence that body fat is associated with an increased risk of breast cancer in postmenopausal women but a DECREASED risk in premenopausal women.  They couldn’t very well include that in their press release could they?  Get fat!  It will help you prevent breast cancer!

So the AICR got a lot of coverage for their bold, unsubstantiated claims and scientific “interpretations” which I’m sure they are using in their telemarketing campaigns as we speak.  I guess they are counting on very few people actually looking for the evidence in their report.

Read it for yourself.  NYTimes article:      http://www.nytimes.com/2009/09/08/health/08regi.html?_r=1&em

AICR Report:   http://www.dietandcancerreport.org/ Oh, and they will make you register to read the report.