Health Report: Breast Cancer Awareness Month — A look at individualized care
This summer, an article in the Journal of the American Medical Association (JAMA) challenged standard treatment for “Stage 0” breast cancer, or ductal carcinoma in situ (DCIS). Most often, this is a nonaggressive precursor to breast cancer, though it can become invasive. For many years, DCIS has been treated with surgery. However, the JAMA study found that survival rates for women with DCIS were the same whether they had surgery or not.
While the temptation may be to look at these results and conclude women with DCIS should never get surgery, that may be overreaching. The study also showed that African American women, and women diagnosed before age 35, had a much higher risk of death stemming from DCIS – more than double. Further research may show that some patient subgroups benefit from surgery.
“These findings are good news because they highlight an emerging understanding of cancer,” said Paul Goldfarb, M.D., who specializes in surgical oncology and is chairman of the Scripps Health Breast Cancer Task Force.
“Breast cancer, or any cancer, is not a single, monolithic condition. Tumors differ from patient to patient. Some tumors are more aggressive, some respond to different therapies. Research like the JAMA study reveals that one-size-fits-all approaches need to be revised. Treatments should be individualized based patients’ own unique set of risk factors.”
Figuring out Mammograms
The recent JAMA article is not the first time a conventional approach to breast cancer has been challenged. In 2009, the United States Preventive Services Task Force concluded that women younger than 50 don’t need regular screening mammograms. This conflicted with “gold standard” mammography guidelines supported by the American Cancer Society, the American College of Surgeons, and others, which suggest women should have a baseline mammogram at age 40, followed by annual screening mammograms.
The choice of when to get screening mammograms should be made with a view toward individual risk, which can hinge on factors such as personal and family history, genetics, ethnicity, breast density, general health and other factors.
While mammograms are a good diagnostic tool, they are also flawed. They can miss small tumors, generate false positives or identify a low-risk condition, such as DCIS.
Fortunately, the science of detecting cancer is improving. New screening tools, such as tomosynthesis, provide higher resolution without increasing radiation. Tomosynthesis software is used with digital mammography equipment to convert images into a stack of very thin layers, creating a 3-D reconstruction of the breast. This technology can be particularly helpful for women with dense breasts. Biopsies are also improving, giving patients and clinicians a clearer picture of risk.
Better Risk Assessment and Treatment
As researchers find new associations between genetic mutations and breast cancer, care should improve. Discovering mutations in the BRCA1 and BRCA2 genes (which are genes that suppress tumors in humans) was revolutionary, helping to identify women who are at much greater risk, and can therefore benefit from increased monitoring or intervention.
Newer genomic tests may be less illuminating. BRCA mutations have a strong association with breast and ovarian cancer, while other mutations often have a weaker link. Sometimes, breast cancer mutations are only discovered after the patient is diagnosed. Still, these can be helpful for family members, for example, better identifying a daughter’s risk.
There are quite a few new therapies being developed, such as immunotherapies, which prime the immune system to attack cancer. There are also emerging treatments designed to convert breast cancer from an acute illness to a chronic condition. The cancer would not be eliminated, but the growth could be arrested and women could go on to live a normal life.
Some companies are working on liquid biopsies that use either blood or urine to detect cancer and monitor treatment. Once again, this would help to understand each patient’s individual risk and guide treatment accordingly.
The Big Picture
Much can be done to help women through this difficult process. The O’Toole Breast Care Center at Scripps Mercy Hospital is working on a rapid response approach, in which women who have a positive screening mammogram can quickly get a biopsy appointment. Reducing wait times can reduce associated stress.
It’s also important to take a hard look at life after cancer. So many women survive breast cancer and it’s important that they live well. There are many approaches that can address hormonal problems, bone density and sexual issues.
Breast cancer survivors should know there are many services available to help them as they navigate life after cancer. For example, Scripps offers several different types of breast cancer support groups in locations all across San Diego County, including one designed for young women and another for Spanish speakers. Survivors can also stay connected with resources at annual Scripps Cancer Survivors Day events every June. And cancer navigators and social workers at Scripps can provide additional support.
For more information, visit scripps.org/KUSI or call 858-240-5075.