Huge inconsistencies have been reported regarding the value of screening mammography, from some studies showing no survival benefit to others reporting a 15-35% reduction in breast cancer mortality. The trouble with these reports is that they’re often lacking context. A Canadian study published in February of this year, for example, was a randomized trial initiated in 1980. Both groups of women received a yearly clinical breast exam, and the mortality rate reported was the same in the mammography and no-mammography groups. While this might lead some women to abandon mammograms, it’s important to note that the mammography equipment used during the study is now obsolete. That’s important context.
In addition, experts have revealed that the design of the study was flawed. Women with signs and symptoms of breast cancer were allowed to enter this screening study. (Screening is meant for picking up cancers too small to be felt.) 68% of the cancers “diagnosed” by mammogram could already be felt on physical exam. In fact, the mammogram group included more women with physical signs and symptoms of breast cancer than the control group. No surprise that no benefit was seen for mammography.
The medical community acknowledges that mammography does have limitations.
- It may cause false positives, unnecessarily alarming women. At a good breast center, the rate of false positive should be less than 10%.
- It may miss some important cancers. 17% of breast cancers will be missed by mammogram. This rate is higher in women with dense breasts.
- Finally, it may find some cancers that do not need treatment and lead to unnecessary surgery, radiation and chemotherapy.
Despite these concerns, guidelines from the American Cancer Society, American Society of Breast Surgeons, American College of Radiology and the National Comprehensive Cancer Network all recommend a yearly high-quality mammogram and clinical breast exam for the average risk woman age 40 and over.
No single study should cause a change in screening practice. Medical consensus favors some life-saving benefit from screening women ages 40 – 75. Mammography works best for women greater than 50 with a diagnostic accuracy of around 83%. This means that if 100 women with breast cancer are screened, 83 of the cancers will be detected by mammogram. Not perfect … but pretty good. Hopefully research will discover an even better screening test that’s more accurate and more comfortable. Until then, get your mammograms.
Radiation–or radiotherapy–is a highly effective but often misunderstood treatment for breast cancer. Radiotherapy delivers high-energy beams that damage the DNA in cancer cells. Cancer cells grow and multiply, two activities which can be stopped by radiation. Healthy cells can be affected too but because they are better organized, they can repair themselves. Healthy cells survive the treatment and cancer cells are destroyed.
Radiotherapy is recommended for women who have had a “lumpectomy” for treatment of Stage 0-3 breast cancer. Radiation kills any stray cancer cells that may be left after surgery. Radiation decreases the risk of recurrence by 70%.
Myth #1 – If I have a mastectomy I won’t need radiation.
If your tumor is large or if the cancer has spread to one or more lymph nodes radiation is usually recommended. 20 – 30% of women who undergo mastectomy will also need radiation.
Radiation is a local, targeted therapy and only affects the area being radiated. Receiving radiation is painless. It may cause the skin to be pink or tan and sensitive. Similar to a mild sunburn. Treatment is given five days a week for 6 – 7 weeks. Each treatment lasts only a few minutes. Women can continue their normal routine during therapy.
Myth # 2 – Radiation will make me lose my hair.
No – (unless your head is the area being radiated) Nipple hair and hair in the armpit may temporarily be lost. Radiotherapy is usually started right after chemotherapy and women lose their hair during chemotherapy. Thus the misperception that radiation makes your hair fall out.
Some women feel tired during radiotherapy. This feeling can last for a few weeks or months but is temporary. Radiation of the breast does not cause nausea or vomiting.
Myth # 3 – I will be radioactive or “glowing” after radiation.
No, you can hug your children and grandchildren. External beam radiation stops the second the machine is turned off and no radiation lingers in your body.
In summary, radiation is a safe, effective and easily tolerated way of destroying any leftover cancer cells. Remember, radiotherapy plus lumpectomy (breast preservation) is equal to mastectomy in survival and recurrence rates. (link to blog post from 9/14)
Inflammatory breast cancer accounts for 1-5% of breast cancer. It is characterized by rapid development of redness, warmth and swelling often without a lump. This can occur over a few weeks or months and is often mistaken for an infection.
99% of the time, if you have a swollen, red, painful breast a few days of antibiotics will treat your infection. However, if your breast does not quickly return to normal see a breast specialist to check for this rare but serious type of breast cancer.
In the case of inflammatory breast cancer, skin changes are due to cancer cells clogging the lymphatic vessels of the skin, which causes the skin to become thickened like an orange peel (peau d’orange).
This type of cancer is considered locally advanced. It is stage 3 or 4 at presentation. The first treatment is systemic chemotherapy, usually followed by mastectomy and radiation.
Although this type of breast cancer is rare, I saw two women with inflammatory breast cancer this week. Inflammatory breast cancer is more common in African-American women, and the average age at presentation is five years earlier than for other types of breast cancer (mid 50′s compared to early 60′s).
This aggressive form of breast cancer has seen a marked improvement in overall survival since the advent of trimodality treatment (chemotherapy, radiation and surgery). So make sure to see your breast specialist right away if you are concerned you may be experiencing any of these symptoms.
In June 1990, the National Cancer Institute Consensus Conference concluded that breast preservation (partial mastectomy or lumpectomy plus radiation) is the preferred treatment for the majority of women with Stage I and II breast cancer. This method of treatment is equal to mastectomy in survival and recurrence risk, while preserving the breast.
Women I counsel often think that more “drastic” surgery is better and that removing the entire breast will decrease the risk of the cancer coming back. The risk of recurrence after mastectomy is 6% equal to the risk after lumpectomy plus radiation (also 6%).
It amazes me that 20+ years later, mastectomy and even bilateral mastectomies are still commonly being performed on women who could be treated equally as well with breast preservation.
It is the surgeon’s obligation to carefully explain the options for treatment and dissuade a woman if she thinks more radical surgery is better.
A recent study has linked birth control pills to an increased risk of breast cancer. (Cancer Research August 1, 2014) This concern is not new. Previous studies have reported this, while other studies have not supported the link.
The study includes 23,052 women between ages 20 and 49, 1102 of whom were diagnosed with breast cancer. Women on high-dose estrogen pills (sold as Continuin or Femulen) and moderate-dose pills (sold as Ortho 75) were 2.7 and 1.6 times more likely to develop breast cancer. Those on low-estrogen pills had no increased risk.
Before you toss your pills please consider:
- The high-dose pills are rarely prescribed. There is no increased risk with low-dose pills.
- The elevated risk was only seen in women who had taken high and moderate-dose pills within one year. Their risk returned to normal one year after stopping birth control pills.
- Breast cancer is really rare. A women’s risk of developing breast cancer at 40 is 1.5% and only 2.38% at age 50. Increasing those numbers by a factor of 1.6-2.7 causes only a slight increase in overall risk.
- Elisabeth Bieber, the study’s author, and a scientist at the Fred Hutchinson Cancer Research Center, said the findings are not significant enough to recommend that you should change your prescription if you are on a high-dose pill.
- The pill has cancer-fighting effects. It’s been shown to slightly decrease a women’s risk of ovarian and endometrial cancer.
- Finally, all medicines carry a risk, even Aspirin! For the vast majority of women the benefit of the pill far outweighs any risk.
The most common and well-known hormonal therapy is Tamoxifen. Tamoxifen is an anti-estrogen treatment that is used in postmenopausal women with estrogen positive breast cancer. Tamoxifen treats the cancer you have and reduces your risk of getting cancer in the opposite breast by 50% (from 15 – 20% down to 7.5 – 10%). The side effects are milder than those of chemotherapy. The most common are hot flashes and muscle aches. Premature menopause is the most common long-term side effect. Other rare side effects are blood clots and uterine cancer.
Another anti-estrogen hormonal therapy now being used in women over the age of 50 (or postmenopausal) are Aromatase Inhibitors (AI’s). There are three AI’s that are used to block estrogen production from postmenopausal ovaries and adrenals. Some of the side effects associated with AI’s are similar to those of Tamoxifen. AI’s have a decreased risk of endometrial cancer related to Tamoxifen but are may lead to some joint pain. Switching from one AI to another will often lessen these symptoms if they do occur.
Hormonal therapy treatment is recommended following surgery, chemotherapy and radiation. Administration of hormonal therapy is taken in pill form, once a day, usually for the span of five years.
Here’s how chemotherapy works: Chemotherapy drugs interfere with the process of cancer cell division or reproduction. Often more than one drug is used to attack the cells at different points in the process. Unfortunately the drugs act on all cells that are rapidly dividing–not just cancer cells. This is why hair cells are affected during chemotherapy, leading to hair loss. (Just think of it as the chemotherapy doing what it is supposed to do.)
Bone marrow cells which produce red blood cells, white blood cells, and platelets, are also affected. For this reason chemotherapy is given with a time lapse in between doses, so the bone marrow can recover.
Seven drugs are commonly given as adjuvant treatment for breast cancer:
- Cyclophosphamide (Cytoxan) (C)
- Methotrexate (M)
- 5-fluorouracil (F)
- Doxorubicin (Adriamycin) (A); and
- Paclotaxel (Taxol) or docetaxel (Taxotere) (T)
These are usually given in combinations CMF or AC, followed by T.
Nausea and vomiting is a side effect in about 20% of women who get CMF and more of women who get AC. There are many drugs to prevent and treat the symptoms. Nobody should have to suffer.
Premature menopause is more common with CMF than AC. 15 – 35% of women younger than 40 and 60 – 90% of women over 40 will become menopausal.
Women who receive Adriamycin as part of their treatment will lose their hair, usually within 2 – 4 weeks. Women who receive CMF usually have gradual hair loss that is often mild and they may never need a wig.
Doxorubicin (Adriamycin) (A) can be toxic to the heart. However, this is rare. Taxol and Taxotere can cause a reversible neuropathy (pins and needles sensation) of the hands and feet.
It is important to be aware of possible side effects. It is equally important not to assume you will have all or any adverse reactions. Remember that if chemotherapy is needed the benefit in terms of survival outweighs any risks or side effects.
As always, let us know if you have questions or concerns we can help you with.
Invariably, in my early discussions with a woman newly diagnosed with breast cancer she’ll declare “I do not want chemotherapy!” or “Will I need to lose my hair?”
Chemotherapy gets a bad rap, but it happens to be one of the most powerful weapons against cancer. “Chemotherapy” literally means a chemical used to treat disease.
Systemic therapy used to treat breast cancer includes chemotherapy, hormone therapy and targeted therapy. Systemic therapies have the ability to affect the whole body, not just the breast.
Chemotherapy is the most important element of treatment, because it deals with the life-threatening aspect of cancer. Women do not get sick or die of breast cancer in the breast but of cells that spread elsewhere, commonly to the lung, liver, brain or bones.
Adjuvant systemic therapy is given at the time of initial diagnosis, when there is no evidence of metastatic disease. It is given after surgery and goes in every nook and cranny of the body to kill or disable any cancer cells that might escape the body’s immune system. These unchecked cancer cells could multiply and become life-threatening.
Neoadjuvant chemotherapy, is the term used when chemotherapy is the first treatment a woman receives after her diagnosis of breast cancer. If a woman’s tumor is larger than 3 cm, chemotherapy may be given before surgery. There is no survival advantage or disadvantage to getting chemotherapy first. However, this upfront systemic therapy has been shown to cause an 80% decrease in tumor size and in one third of women their tumors disappeared completely. Preoperative chemotherapy often allows women who would have needed a mastectomy to have a lumpectomy.
3-D mammography or tomosynthesis, is a test that takes many x-rays at different angles and creates a three-dimensional image of the breast. The procedure is nearly the same as a routine mammogram except that in mammography the machine is stationary, while in tomosynthesis it moves around the compressed breast.
A study was just reported in the New England Journal of Medicine (June 2014) and headlined in the New York Times (June 24,2014). It is retrospective (previous records were looked at rather than randomizing women to compare screening). The study compares tomosynthesis + mammogram to mammogram alone. 454,850 exams were evaluated from 13 centers (281,187 digital mammograms and 173,663 digital mammograms + tomosynthesis.)
For every 1000 women:
•Tomosynthesis improved cancer detection. 5.4 cancers were detected compared to 4.2 for mammogram alone.
•Adding tomosynthesis lowered “callback” rates. 107 women were called back per 1000 with mammography alone and 91 when tomosynthesis was added.
•Tomosynthesis + mammography resulted in more biopsies, 19.3 per 1000 scans compared to 18.1 if mammogram alone was used.
•More of the biopsies in the combined exam group did show cancer 29.2%, compared to 24.2% in the mammogram alone group.
Facts to consider before running out for your 3-D exam:
1) There are only 1100 mammography units in the country that can perform tomosynthesis.
2) The units are very expensive, so not all communities can afford one.
3) Insurance may not cover the extra cost and many clinics charge a fee.
4)Tomosynthesis uses more radiation than mammography, however, the amount is still low and considered safe.
5) Very important, there is no evidence regarding whether or not this technology will save lives. Mammography is the only test (not MRI, ultrasound or thermogram) proven to increase survival from breast cancer. The experts call tomosynthesis “extremely promising” however more research is needed.
6) Finally 3-D mammography is only as good as the radiologist reading the exam. If you decide to have tomosynthesis, you want to go to an experienced clinic. Two of the 13 centers in the study showed a lower detection rate and increased “callback”rate. This was felt to be due to inexperience.
As I discussed last week, the stage at the time of diagnosis is very important in deciding whether a woman will benefit from chemotherapy. Women with early-stage, estrogen-receptor-positive cancer now have the Oncotype DX test to further assist in guiding their treatment decisions.
Performed on a small sample of tumor tissue, the Oncotype DX test (developed by Genomic Health) measures the activity of 21 different genes to determine how a tumor is behaving. The report generated from the test provides a Recurrence Score between 0 and 100. Women with a lower Recurrence Score have a lower risk that their cancer will recur and are less likely to benefit from chemotherapy. Women with a higher Recurrence Score have a greater chance that their cancer will return, and they may gain a larger benefit from chemotherapy.
There have been exciting advances in breast cancer treatment during my tenure. Breast preservation and sentinel node biopsy are the most prominent; Oncotype DX is the latest. It allows women with larger tumors and a low score to avoid unnecessary chemotherapy that previously would have been recommended. Conversely, women with higher scores can take comfort that they are getting a benefit from chemotherapy.
Prior to the widespread acceptance of the Oncotype DX test, women with small tumors may not have received potentially life saving chemotherapy. Now a high Recurrence Score would indicate not only an increased risk of recurrence but also a benefit of chemotherapy despite a small tumor size.