The good news is that cases of breast cancer in the United States, which had been increasing for more than two decades, began dropping around the turn of the century and have continued to do so. It’s thought that the main reason for this decrease is the decline in the use of hormone therapy after menopause.
Every day we hear about a new drug, screening tool or technology that promises to improve our knowledge of health and disease. Generally, the news is good, or at least hopeful, reassuring the public that important research is progressing. Often, the new breakthroughs have been demonstrated in the lab or in animal models and has not yet been studied in humans, a process that could take years.
Sometimes the lab findings do not translate well to the human and the researcher may have to start all over with a new strategy. This is particularly frustrating for individuals who have a disease or condition that is debilitating and could be deadly. The new movie, Extraordinary Measures, is the story about a father who self-funds a researcher to accelerate the process for a promising drug for Pompe disease because his children have the condition. It is a great example of how driven and focused we can become when our own loved ones are ill.
When a patient is faced with the shock and worry associated with breast cancer, there are many issues to face and decisions to be made. The last thing she needs is to be confused by the results of diagnostic tests. Sometimes a “positive” or “negative” test result can be confusing because it’s not always clear if it is good or bad news.
Your doctor might, for example, tell you that a test result is positive, which gives you the false impression that it’s a good outcome. Similarly, when a result is negative, it sounds bad when it could in fact be good news. It’s important that you fully understand the implications of any test results, but particularly ones in which the results can be ambiguous.
Few things frighten a woman more than discovering a lump in one of her breasts. With good reason: breast cancer may transform a woman’s breast into the vehicle of her death. It is twice as likely to be diagnosed in an American woman today as it was sixty years ago. And the treatment surgery, usually followed by radiation and chemotherapy is disfiguring, painful, and all too often unsuccessful.
I have been researching and treating this disease for more than thirty-five years, a period in which the public’s awareness of breast cancer has risen enormously. The disease has brought into being an entire industry of research organizations, charitable agencies, commercial ventures, and advocacy groups. Every new statistic is trumpeted in the media, and every encouraging research finding, no matter how tenuous, is held up as a potential breakthrough.
One result of this visibility has been a rise in public sympathy for victims of breast cancer and a concomitant rise in funding for breast-cancer research. But the growth in awareness has had another, less desirable result: a flood of often contradictory information that has led to public confusion. Paradoxically, women are both too anxious about their chances of developing breast cancer and too hopeful about our current approaches to diagnosing and treating the disease. They believe that breast cancer is an epidemic and that it is being cured. Unfortunately, both these beliefs arise from flawed reasoning not by women but by the medical profession.
Two groups in the health-care profession are involved in the fight against cancer indeed, against any kind of disease. The first works principally on the front lines, helping patients understand the therapies available and offering insight, treatment, and reassurance whenever possible. The second works mostly at scientific institutions, performing the methodical, frustratingly slow tasks associated with epidemiology, clinical trials, and laboratory analysis. As researchers, the members of the second group are necessarily less concerned with the fate of specific patients than with understanding specific diseases and whether medicine is successfully combating them.
To move forward, they must coldly distinguish between genuine advances and wishful thinking. I have spent my career as a member of the first group, although I have also spent years helping to conduct and analyze clinical trials. In what follows I have adopted the researcher’s view of the big picture, while also summarizing the risks and benefits of the treatments now available to women with breast cancer treatments the clinician in me still recommends and performs, though the researcher wonders how often they will be of meaningful help. Only by stepping back from the perspective of caring for individual patients can one hope to make clear what doctors mean (or should mean)when they use such broad words as “epidemic”and “cure.”
But here’s some potentially bad news
Breast cancer cases in the United States could rise by as much as 50 percent by 2030, according to some new government predictions. The researchers predict that by around 2030, 441,000 women will be diagnosed with the disease (this is alarmingly greater than the 283,000 diagnosed in 2011).
There are basically two types of medical test results
These provide information about how the levels of certain substances compare to those that are considered within a healthy range by the medical community. A blood test would fall in this category.
“Positive” or “Negative” results
These types of tests are used for diagnostic purposes and provide information in a “yes” or “no” format. In medical terms, this translates into a “positive” or “negative” result. A “positive” result in a medical test means that the lab found whatever the test was searching for, which may equate to a good or a bad finding. On the other hand, a “negative” result means that the lab did not find what the test was searching for. Similarly, this could be good or bad news.
Let’s decode some results of tests associated with breast cancer
Positive Biopsy: Not good.
This means that the biopsy of the suspicious area on a mammogram or ultrasound (and confirmed by a physical exam) is a pre-cancer or cancer.
Double Negative: Not good.
This means that the breast cancer tumor cells do not express the gene for the Estrogen or Progesterone Receptors (the two hormones which represent the “double” in the double negative result). Normal breast tissue cells have estrogen and progesterone receptors which stimulate cell growth and function. When cells go awry and become abnormal (i.e. cancerous), they fail to function correctly or to “express” these receptors. A double negative result for hormone receptors mean that the tumor will not respond to hormonal therapy (usually estrogen antagonists of different types).
Triple Negative: Not good.
The “triple” in this test result means that the breast cancer cells do not express the gene for Estrogen, Progesterone or Her2/Neu receptors. These are considered the most aggressive form of breast cancer and must be treated with chemotherapy (and are usually quite responsive to it).
BRCA 1 or BRCA 2 Negative: Good.
The BRCA gene, when functioning properly, corrects mistakes in cell function that could lead to mutations. In some cells, genes are mutated because of hereditary mistakes in the gene coding—for example, mistakes that could be passed down from your mother or father and his/her family. When someone is BRCA 1 or BRCA 2 negative, this means that they do not carry these specific breast cancer gene mutations. Most people would consider this a favorable outcome, because their cancer is not linked to a genetic transmission due to mistakes in these specific genes. Also, the patient’s children would not be at obvious risk of developing breast or ovarian cancer.
Sentinel Node biopsy Negative: Good.
Sentinel lymph nodes are the “first stop” lymph nodes where cancerous cells might “drain” from the breast. When a sentinel node biopsy is negative it means that no cancer cells have been found in the lymph node and, therefore, have not traveled beyond the breast.
When it comes to medical test results, don’t be afraid to ask questions. Be sure you understand exactly what your test results are telling you so that you can make informed decisions.
Elizabeth Chabner Thompson, MD, MPH,
Is a radiation oncologist and founder of BFFL Co (Best Friends for Life), which provides a wide range of products for patients undergoing various surgical procedures or cancer treatments. One such product is the Axillapilla® post-surgery pillow featured on the Katie Couric Show. This heart-shaped pillow provides support and stability for a patient recovering from surgery, especially cardiac surgery.
Is Breast Cancer An Epidemic?
Many of my patients have conflicting images of their breasts. On the one hand, breasts are symbols of beauty, sexuality, and nurturing; on the other, they are troublesome organs that are increasingly likely to threaten women’s lives. In the United States the likelihood that a woman will be found to have breast cancer has slowly and inexorably mounted since the 1930s, when some systematic data collection began.
The increase in diagnoses, already a cause for concern, accelerated in the 1980s, growing by a rate of four percent a year. This year, according to the American Cancer Society, some 184,300 women will discover that they have the disease; another 44,300 will die of it. Of the women in whom cancer is diagnosed, 9,200 will not yet be forty nearly twice the number of women under forty who were found to have breast cancer in 1970. The disease is now the leading cause of death for American women aged forty to fifty-five, and causes women to lose more years of productive life than any other disease. Numbers like these are why breast cancer is often called an epidemic.
To our grandparents, this picture would have seemed amazing. At the turn of the century cancer of the breast was a relatively unusual disease. What happened? Why does the incidence of breast cancer seem so much higher today?
Some of the increase is more apparent than real. Because women today are less likely to die young in childbirth or of infectious disease, they live long enough to develop diseases of middle and old age, breast cancer among them. And the recent jump in the number of breast-cancer victims under fifty is almost wholly due to the concurrent jump in the number of women in that age group, caused by the Baby Boom.
A third reason for the increase in diagnoses of breast cancer is the growing use of mammography, a technique that uses x-rays to examine the breast. With mammography doctors catch many cancer cases earlier than they otherwise would have and some cases that would never have been caught at all. The technique surged in popularity in the 1980s, and accounts for much of the recent spurt in diagnoses. (Now that mammography is routine, the rate of increase in diagnoses has slowed.)
At the same time, most experts in medical statistics believe that these factors do not explain all of the rise. Even when greater longevity, the population bulge, and the introduction of mammography are taken into account, a real, underlying increase remains. Minus those three factors, the chance that a woman will be found to have breast cancer has been growing steadily for decades, at roughly one percent a year.
What lies behind this rise? Although there is not enough evidence to say with certainty, an increasing number of observers have come to believe that the emergence of breast cancer as a widespread health problem is tied to the extraordinary transformations in women’s lives. Coupled with better nutrition, the expansion of opportunities for women, especially in the industrialized West, altered not only women’s lives but also their bodies, and especially their cycles of reproductive hormones apparently making them more susceptible to certain cancers.
For most of human history menarche, the age of first menstruation, usually occurred in the late teens. (This is one reason that previous generations saw less early-teenage pregnancy fewer adolescents were physiologically capable of having babies.) Once fecund, women of past millennia quickly became pregnant with the first of perhaps half a dozen children, each of whom they breast-fed for an extended period a practice that regularly stops the menstrual cycle.
If they survived to their mid-thirties, they were aged in appearance and probably post-menopausal; their brutal living conditions usually did not permit them to live much longer. Late menarche, multiple pregnancies, long nursing times, early menopause all these combined to make women of the past menstruate much less often than their modern counterparts. Many women in the past may have ovulated only twenty times in their entire lives.
This grim picture changed only recently. Not until modern times has a large percentage of humankind been able to obtain a continuous supply of nutritious food and potable water or been able to control infectious disease. The average age of menarche has fallen to twelve in Western industrialized nations. Meanwhile, the age of first marriage has risen. According to the U.S. Census Bureau, it now averages twenty-four for women in this country; many educated and affluent women do not marry until their thirties, partly because of the increased opportunities to have careers outside the home.
Pregnancy, too, has become much less common, as lost working time drives up the cost of having babies. Marriages produce an average of two children, which women nurse briefly if at all. And menopause does not occur until age fifty or later. Women today are thus exposed to reproductive hormones over a much longer span than in the past. They may have 300 to 400 periods fifteen to twenty times as many as their ancestors had, exposing their breasts to historically unprecedented numbers of estrogen-progesterone cycles.
Estrogen and progesterone, like aspirin, have such familiar-sounding names that people often don’t realize how powerful their effects are. Among these effects is the multiplication of cells within the breast. With repeated menstrual cycles that are rarely interrupted by full-term pregnancy, the number of cells in some parts of the breast can increase by a factor of a hundred or even more. If only because of the simple increase in number, this constantly repeated cellular multiplication is believed to increase the likelihood of genetic accidents. Most cancers are believed to arise from such accidents, and so the strong suspicion is that repeated menstruation is a precursor to cancer of the breast.
Breast Cancer Basics
Female breasts are one of the most variable parts of the human anatomy. Evolved from sweat glands, they are designed to provide milk for infants through a system of ducts and lobules. The ducts are small tubes that run several inches back from the nipple to the milk-producing lobules, which stick out from the ducts like clusters of tiny grapes.
Both are enveloped by fat and connective tissue, which are contained within a sac of skin shaped roughly like a teardrop. The whole assembly changes dramatically in size, shape, and constitution during the menstrual cycle, pregnancy, breast-feeding, and menopause. Not only do breasts vary from woman to woman but each woman’s breasts continue to change throughout her life.
At any given time a third to a half of all Western women have some kind of breast problem, although most are not particularly concerned about the symptoms nor need they be. The symptoms frequently include swelling and aching before menstrual flow; women may feel their breasts engorge and grow tender. If their breasts become lumpier, however, this may be owing to cysts fluid-filled balloon-like sacs within the breast.
Or the lumps may be solid, nodular clumps of overgrown breast-duct cells, known generically to doctors as mammary dysplasia or , the most widely used term, fibrocystic disease. These conditions are benign a term doctors use to mean “not cancerous.” (“Benign” does not mean “not painful” or “not harmful.” Many benign conditions should be treated.)
If much of the breast is palpably lumpy, as is often the case, the diagnosis is usually “benign.” Matters are less clear when the problem is in a small area: “dominant mass” is the term used by most doctors for a swelling that stands out sharply. In such a case a biopsy is almost routinely recommended. Sometimes the biopsy involves nothing more than extracting a sample from the breast with a needle, but the surgeon may also remove the entire lump. Afterward, the tissue is examined in a laboratory.
Most of the time the news is reassuring; two thirds to four fifths of all biopsies reveal that the abnormality is not malignant. (Women in their forties are more likely than older women to have negative biopsies, because mammograms of their naturally lumpier breasts are harder to interpret.)Yet the specter of breast cancer remains many of these “benign” conditions are statistically linked with the disease.
Does Mammography Help?
Finding breast cancer as early as possible seems to be a great idea, like trying to diagnose high blood pressure before it damages the heart or the kidneys. And mammograms can occasionally detect tumors as small as an eighth of an inch across, whereas the lower limit for tumors diagnosable by palpation (examining the breast manually) is about half an inch across. Yet one would like to be sure that this difference actually translates into a higher likelihood that treatment will be successful.
An official nationwide mammography program would be a huge commitment: 51.5 million American women are aged forty or above. And one must bear in mind the cost of needless medical procedures generated by the huge number of false-positive mammograms—two to four false positives for every true positive, according to some measures. (A false positive shows a mass or lump that proves after further testing not to be cancerous.)We continue to consider creating a national screening program, but I believe it has never been proved that such a program would, on balance, be beneficial even if it served the secondary purpose of bringing into the health-care system women who otherwise could not afford it or would not see a doctor frequently.
To prove the value of mammography scientifically is more difficult than it might seem. In some studies investigators ask women to volunteer for screening, and then report the number of breast-cancer cases and the percentage of women who survive five years after diagnosis. This figure is compared with the percentage in the population at large. In these studies researchers often go to considerable trouble to eliminate potential sources of confusion. For example, they may try to match by age the women undergoing regular mammography with other women. Or they may match by race or socioeconomic class. No matter how hard researchers try, though, such studies remain susceptible to three of the most common sources of bias in medical research.
Mammography may find a tumor as early as two years before it could have been detected by palpation. Let us, however, consider a hypothetical case in which the cancer has already spread to other parts of the body by the time it is discovered, and the woman goes to her grave on exactly the same day she would have if the tumor had been discovered later. In that case the sole effect of early detection has been to stretch out the time in which the woman bears the knowledge of her condition.
But that is not how the woman would appear statistically if she had happened to become part of a research study. Pushing back the date of first diagnosis would increase the interval between diagnosis and death, apparently lengthening her survival. Statisticians call this effect “lead-time bias.” Although nothing has actually changed, a woman who would have died, say, three years after treatment now dies five to six years after treatment manufacturing an apparent victory for medicine.
That’s confusing. How, after a steady decrease, is that possible?
It’s due to the growth of an aging population, researchers say. They also say the specific type of breast cancer that will increase is a type of tumor known as ER- positive, meaning that the tumors rely on estrogen to fuel their growth. About 70 percent of women with breast cancer have this type.
But the potential silver lining in this is that the rate of ER-negative breast cancer, usually the type that’s tougher to treat, is expected to drop in the coming years.
There’s also breaking news that’s good for women who have already been diagnosed with breast cancer: Removing your ovaries can reduce your risk of cancer death by 56 percent. And the protective effect of ovary removal the most recent surgery performed on actress and director Angelina Jolie to reduce her cancer risk is particularly strong in women with ER-negative breast cancer after age 50.
It’s important to remember that breast cancer is not one single disease, but rather consists of different subtypes. Within those subtypes, responses to treatment, survival rates and incidence vary with age, race, ethnicity and a host of other factors.
And although researchers scramble for a cure, spending billions each year and constantly finding new and improved treatments, cancer is still very much a part of our world. So it’s not surprising that the information is always changing and evolving.
What’s clear is that with this new set of statistics comes the opportunity, once again, to be reminded that we must do everything in our power to be proactive about our health and with breast cancer prevention, especially those of us in the baby boomer demographic those women whom this study was looking at.
Even if you are at high risk for breast cancer, everyday lifestyle changes have been shown to reduce your risk. Of course, some risk factors can’t be changed like your age, race or if you were treated as a child or young adult with radiation therapy to the chest. But others definitely can.
Limit all alcohol consumption.
Drink no more than one drink per day.
Control your weight.
Especially troublesome is weight gain after menopause.
Be physically active.
As little as 1 1/4 to 2 1/2 hours per week of brisk walking can reduce your risk by 18 percent.
Limit the dose and duration of hormone therapy.
Also try managing your symptoms with non-hormonal therapy.
Eat a healthy diet.
Get plenty of fruits, vegetables, poultry, fish or other proteins low in saturated fats.
Be vigilant about screening and detection.
Don’t ignore any changes you notice in your breasts, like a new lump or changes in the skin.
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