It’s a subject about which so much has been written and reported, yet it still strikes fear in the hearts of all who hear it: breast cancer. The good news is, advances in treatment and management of the disease have changed the landscape for patients. The bad news is, women, and men, are still afflicted with breast cancer at alarming rates.
[mammogram message]
For a handful of women, the routine annual mammogram brings a heart-fluttering moment: a letter asking the woman to return for a diagnostic mammogram. What does it mean?
screening vs. diagnostic
“The screening mammogram is a quick study to determine if there is a mass present or any new findings compared to an old mammogram,” says Dr. John W. Finnie, a hematologist-oncologist at Mercy Clinic and David C. Pratt Cancer Center. “Frequently that could mean we want to take a closer look and make sure it is not something we need to biopsy.”
“Of 1,000 women who undergo a screening mammogram, we might recall 8 to 10 percent to come back,” says Dr. Geoffrey S. Hamill, medical director of Missouri Baptist Breast HealthCare Center. “Of those patients, we may do a biopsy on 1 or 2 percent.”
the early bird catches the cancer
Early detection is an important tool against cancer, which by definition consists of abnormally fast-growing cells. Nearly 232,000 new cases of invasive breast cancer will be diagnosed in American women this year, according to American Cancer Society estimates. About 40,000 will die from the disease, even though the incidence of breast cancer has been falling since 2000, which the Society attributes to declining use of hormone therapy after menopause.
Mammograms screen for abnormalities, although oftentimes women are uncertain about what those entail. “One thing we look for is calcifications—little flecks of calcium,” Finnie says. “The patterns of the calcium deposits can sometimes point toward a diagnosis of malignant or benign.” Calcifications typically result from hormone stimulation of breast tissue over many years, Hamill explains. “The red flags we look for in a mammogram are distortions or asymmetries in the breast tissue,” he says. “If we see a density that has an irregular margin, that is a worrisome finding.”
Findings like these in the screening mammogram may prompt that letter seeking the more detailed diagnostic mammogram, Finnie says. “We will do more imaging, and we might do an ultrasound.” If a benign diagnosis can’t be given after more imaging, “we will recommend a biopsy just for clarification,” Hamill adds. “At the extreme, a lump may reflect a developing cancer.”
second opinion?
Rita Wilson, wife of actor Tom Hanks, underwent a double mastectomy earlier this year after her cancer was diagnosed during a second exam that followed an initial negative diagnosis. “A second opinion is critical to your health,” she advised women in a magazine interview. “You have nothing to lose if both opinions match up for the good, and everything to gain if something that was missed is found, which does happen.”
So should women routinely seek second opinions? “We know outcomes are better in higher-volume centers, where people who read more mammograms are going to be better able to discern a confident assignment of risk,” Finnie says. In other words, where you get your mammogram can have an impact on the accuracy of the findings.
[targeted therapy]
Today, women don’t have to worry that the treatment for breast cancer might be worse for them than the breast cancer itself. Advancements like targeted therapies and hormone-blocking pills are helping patients avoid the discomfort of whole-body treatments like chemotherapy.
fear factor
“Targeted therapies are much better tolerated and a lot less scary than standard chemotherapy,” says Dr. Theresa Schwartz of SLUCare Physician Group. “The nice part about it for both patient and clinician is knowing that it is working directly against the cancer, unlike a full-body medication, which targets a lot of other cells.”
Dr. Cynthia X. Ma of Washington University School of Medicine agrees. “Non-targeted therapy such as chemotherapy can affect normal cells as well as cancer cells and be more toxic,” she says.
in a nutshell
Chemotherapy has been used to treat cancer since the ‘50s, and about 100 chemotherapy drugs now are in use, according to the American Cancer Society. Cancer starts when something changes in a normal cell, the Society’s patient handbook explains. This cancer cell then grows out of control and makes more cancer cells. Because chemo drugs are very strong, they kill any cell that’s growing fast, even if it’s not a cancer cell. That is one downside to chemotherapy: sometimes healthy cells that grow quickly can be damaged.
In recent years, scientists have found medications that disrupt factors found only in specific cancer cells. “The estrogen receptor and HER2 are known targets for breast cancer, so we always classify our breast cancers as estrogen-receptor-positive or –negative and HER2-positive or –negative,” Ma explains.
block busters
“The most common targeted therapies are hormone-blocking or estrogen-receptor-blocking pills,” Schwartz says. “They work in one of two ways. One blocks the receptors where estrogen acts, and the other keeps your body from making estrogen.”
These therapies have revolutionized treatment for breast cancers responsive to estrogen or hormones, which, Schwartz says, account for about 80 percent of patients. “Taking these pills for five years will reduce the risk of breast cancer recurrence by 40 to 50 percent,” she explains.
And the blockers are a better treatment for women with slow-growing breast cancers for another reason. “If you have a slow-growing tumor, chemotherapy doesn’t do anything for it,” Schwartz says. “Yet 20 years ago, these women would have been recommended for standard chemotherapy, which may not have helped them at all.”
Hormone-blocking medications can be taken for extended lengths of time. “Women are on them for at least five years, and the research is saying 10 years is probably better,” Schwartz adds. “It is well-tolerated and continues to give women cancer-recurrence blocking. It has fewer side effects and more manageable side effects than chemotherapy.”
what is her2?
Cells in about one of five breast cancers hold too much of a growth-promoting protein called HER2. “HER2 refers to cancers that have the HER2 gene amplified, which is not happening in normal tissue or normal cells,” Ma says. “It is a growth factor receptor that can trigger cell growth and drive cell proliferation.”
Still newer drugs block cell proteins called CDK4 and CDK6, for ‘cyclin-dependent kinase.’ By blocking these proteins, the drugs interrupt the cell division process that produces new cancer cells.
A HER2 medication sometimes is prescribed for women who will undergo surgical tumor removal, Schwartz says. “It is tremendously effective. We are seeing that nearly 50 percent of those women have their disease completely gone at the time of operation.”
[outlooks & outcomes]
Optimism may not improve the odds of a successful breast cancer treatment, but it doesn’t hurt, either. For one thing, a positive attitude can make the challenges more tolerable; it also makes life easier on family members, who may themselves be emotionally challenged by a patient’s cancer diagnosis.
power of positive
“People have tried to study this and found no real clear evidence that having a positive or negative attitude will make a difference,” says Dr. Stephanie Schnepp, a surgeon for SSM Breast Care at SSM Health St. Mary’s Hospital. “But how do you measure attitude? Some people can go through very stressful life events and take them in stride. For others, minor stresses can be catastrophic.”
Most women who receive a breast cancer diagnosis have reason to remain hopeful, says Teresa Deshields, a psychologist and manager of Siteman Counseling Service at Siteman Cancer Center. “The news keeps getting better and better in the world of oncology.” Breast cancer is a very emotional diagnosis for many, notes Schnepp. “Some women are very calm because they know people who are many years out from treatment and have done well. Others are more upset because they know friends who have had a rougher experience.”
find distractions
Distraction is among the best means of dealing with the waiting periods between diagnostic exams and cancer treatments, Deshields says. “Keep yourself busy with whatever helps time pass. You can’t make it come faster.” She also advises thinking about previous challenges that were well-handled. “You don’t get too far in life without having been challenged. What worked for you before— gathering information, praying, exercising?” Schnepp adds, “A lot of people find exercise, yoga and meditation helpful.”
lean on me
Encourage friends and family to get onboard during the trying times, Schnepp says. “It is helpful to have support systems. Sometimes that means coming with you to appointments, helping with things around the house, cooking dinner, giving the kids rides. That is the best support a friend or family member can offer.”
Support groups and books can guide patients through the stressful times, Deshields adds. Counselors can assist in addressing specific issues, such as the fears of an MRI exam or loss of sleep, but some kind of support group can be invaluable, especially when you don’t want to put additional stress on family members. “It’s important to have a place to talk, a place to process what is going on, to talk about scary things,” she says.
half empty vs. half full
For patients who fear chemotherapy, it’s helpful to look at that glass as more than half full, Schnepp says. “That is the way I present it when people are upset about certain treatments,” she says. “ ‘It’s good that you are eligible for this treatment because that means we have another tool to fight the cancer,’” she tells them. “The option has helped many others with this type of cancer, I point out. We frame it in a way that gives them hope.”
The side effects of chemo are better controlled than they were in the past, she adds. “There are nausea medicines that they didn’t have years ago,” she says. Chemotherapy also might be utilized differently these days. “It may be given before surgery to shrink a large tumor so we can do a smaller lumpectomy. There are so many options that weren’t available 15 years ago. The outcome is hopeful for most people.”