And Now, The Good News

Thanks to blockbuster awareness campaigns and stepped-up science, women with breast cancer are living longer, fuller lives - and the outlook is getting better.

by Mary Anne Dunkin

October 1, 2005

A s breast health coordinator at Northside Hospital's Breast Care Program, oncology nurse Susan Lucier sees 800 to 900 breast cancer patients each year. She spends much of her time trying to reassure patients and their families that their fate is much better than what the diagnosis of breast cancer denotes. She spends the rest trying to ensure that what once happened to mothers, grandmothers and other women in their lives truly won't happen to them.

While we don't know yet how to prevent breast cancer - indeed, an estimated one in seven American women will be diagnosed with the disease at some point in their lives - the majority of women diagnosed will survive their cancers, says Lucier. Most will never have to undergo the traumatic and disfiguring surgeries that were common just a decade ago or two ago.

Lucier and other experts cite two key reasons for the improved outlook: earlier detection and advances in treatment. Many of the developments are the direct result of fundraising and hugely successful awareness-building efforts, including National Breast Cancer Awareness Month, the now two-decade-old campaign sponsored by more than a dozen national public service organizations, professional medical associations and government agencies working in partnership to raise awareness and provide access to breast cancer screening services.

This campaign and others - including the Avon Breast Cancer 3-Day Walk and the Susan G. Komen Breast Cancer Foundation's Race for the Cure - as well as an increase in celebrities sharing their struggles with the disease, have helped bring breast cancer to the forefront of our minds and pocketbooks. At the National Cancer Institute, the nation's largest funding organization for cancer research, funding for breast-cancer-related research has risen more than $200 million - from $348.6 million to $548.7 million over five years.

More women are getting mammograms, too. A recent national study of more than 93,000 women age 40 and older published in the American Journal of Health Behavior showed that 76 percent of women had received a mammogram in the past two years - a figure that exceeds the goal of 70 percent set by the government for 2010.
 
Early Detection Is Key
Breast cancer screening - primarily through mammography - has been shown to reduce deaths from breast cancer by increasing the number of breast cancers detected at their earliest, most treatable stages, says Elissa McCrary, communications director at the American Cancer Society. Currently, 63 percent of breast cancers are diagnosed at a localized stage (meaning they have not spread beyond the breast tissue) for which the five-year survival rate is 97.5 percent.

In fact, some cancers today are diagnosed at a stage referred to as in situ carcinoma. "This means the cancer is just sitting there kind of like an egg waiting to hatch," says Lucier. "It is encapsulated, so it has not even spread to the breast tissue yet. Before mammography, cancers were virtually never diagnosed at that stage."

But mammography alone is not the whole answer to early detection. "An awful lot can happen between yearly mammograms," says Lucier.

Betty Gowins, a senior auditor at BellSouth, knows that all too well. Two years ago - just three months after having a perfectly normal mammogram - Gowins discovered what felt like a small pencil eraser beneath the skin on her left breast. She called her doctor immediately and insisted on an ultrasound of the breast. And good thing. Within days she was having a lumpectomy to remove what turned out to be an aggressive tumor.

Six months of radiation and chemotherapy later, Gowins is doing well and is humbled by the thought of how her story might have gone had she not taken time to do her monthly exam.

Lucier, who teaches women to do breast self-exams, also stresses the importance of this early diagnostic tool. If anything, she credits the self-exam with the improved prognosis for women with breast cancer. "Of course, treatment has improved. But treatment can only happen after breast cancer is diagnosed, and we are diagnosing women earlier," Lucier says. "A big part of that is that women are becoming more educated about the importance of self-exam."

Researchers around the world - and in Atlanta - have been looking for more effective and less extreme ways of treating breast cancer. The findings of their research, combined with the ability to diagnose breast cancer earlier and a greater recognition of the emotional pain the disease causes, have led to numerous improvements in the way breast cancer is treated, especially in the areas of surgery, radiation, medications and even emotional counseling.


Less Radical Surgery
A diagnosis of breast cancer virtually always means surgery of some type. Not so many years ago a cancerous lump in the breast meant an automatic mastectomy. When Gowins' mother was diagnosed with breast cancer in1976, she went to the hospital for a biopsy and left with a mastectomy, she says. Gowins, on the other hand, was given the option of a mastectomy or lumpectomy (removal of the lump, not the entire breast) with radiation and chemotherapy. She opted for the latter.

Increasingly women are choosing this option, based on research that shows lumpectomy with radiation and chemotherapy is as effective at treating breast cancer as a mastectomy, says Lucier. And regardless of the type of surgery a woman has, she says, new surgical techniques - often using a woman's own abdominal fat to create newbreasts or fill in spaces left by lumpectomy - have improved the cosmetic appearance of the surgical site.


New Detection Tools
Because cancer cells can travel through the lymphatic system to remote areas of the body, checking for the spread of cancer traditionally has meant surgically removing as many as 20 to 30 clusters of lymph nodes to check for signs of cancerous cells. The result was extensive surgery and often a problem called lymphedema, in which excess fluid accumulates in tissues, causing swelling.

Today, many larger centers are using a procedure that involves injecting a radioactive substance around the tumor in the breast and following its movement to the lymph node (called the sentinel lymph node) where the tumor would drain. The surgeon can then remove the sentinel node (or cluster of nodes) and check for signs of spreading cancer. Only if the sentinel node is affected do other nodes need to be tested.

As doctors better understand how to target radiation and the precise amounts needed to shrink a tumor without causing undue damage to the surrounding tissue, radiation burns are less common. "It's like tuning a fine instrument," Lucier says. "We learn constantly in the field of medicine how to make things better."

The same applies to medicines themselves. Although many of the same chemotherapy agents have been used for years, doctors have better learned how to adjust dosages and combine treatments for better effects. They have also discovered drugs that help minimize the side effects of chemotherapy, including nausea and vomiting, loss of energy and low cell counts that put the patient at risk of serious or even fatal infections.

Some of the most exciting new drugs for breast cancer are ones that help prevent its occurrence or recurrence, says Janice Galleshaw, M.D., a medical oncologist in Atlanta who focuses exclusively on breast cancer. Three drugs - Anastrazole (Arimidex(r)), Letrozole (Femara(r)) and Exemestane (Aromasin(r)) - in a class called aromatase inhibitors have been approved by the FDA for preventing the recurrence of breast cancer in postmenopausal women with estrogen-sensitive cancers. The drugs work by inhibiting the aromatase enzyme, which helps the body make estrogen once the ovaries shutdown at menopause, says Galleshaw. For women who are past menopause these drugs have all but replaced Tamoxifen, a longtime breast cancer drug that was approved as a preventive therapy in 1998.

For premenopausal women, doctors are looking at another drug called Raloxifene (marketed as an osteoporosis treatment under the trade name Evista(r)). A recent study, which has not yet been published, compared the safety and effectiveness of Raloxifene with tamoxifen in 19,000 women at 200 centers in the U.S., Canada and Puerto Rico. "The thing we are trying to find is a drug that works at least as well as Tamoxifen but with fewer side effects," says Galleshaw, who led the study in Atlanta. "Hopefully with raloxifene, even if it's not more active, it may be less toxic."

Perhaps the most promising treatment to date, at least for one specific group of women, is a drug called Herceptin that targets a gene called HER-2-neu. About 20 percent of women overexpress the gene - meaning their tumors have more than two copies of it - which places them at increased risk of cancer recurrence. "Up until last year, we waited until a woman's cancer recurred, and if it did and we found that she had multiple copies of that gene, we would offer her Herceptin usually in combination with other chemotherapy drugs," says Galleshaw. But three large studies reported at last spring's American Society of Clinical Oncology meeting changed prescribing habits for Herceptin virtually overnight.

The studies, which compared the use of standard chemotherapy to chemotherapy plus Herceptin in women with lymph node-positive cancers, found that for women taking Herceptin there was an additional 52 percent reduction in recurrence rate.

"Obviously, we don't know how this is going to play out in five years or 10, but in the first two years [the length of the studies], the recurrence of breast cancer was cut by more than half if they were on Herceptin therapy," says Galleshaw. "That's huge. If you look at incremental steps we have been making with chemotherapy and other things like hormonal therapy, we are happy if we can reduce things by another 10 percent. So when you get something that's 50 percent, it's a giant step forward."

Yet another study showed that women who had completed their chemotherapy as much as six months earlier had a 50 percent reduction in the recurrence of their cancer when they were given Herceptin. Betty Gowins was a part of that study. "Now I am taking herceptin as a preventive," she says.

Galleshaw is looking for patients in her practice who have completed chemotherapy and may be good candidates for Herceptin therapy. She encourages women, particularly if they know they overexpress HER-2-neu, to speak with their doctors about whether Herceptin is an option.

Emotional Support
Despite these many advances, one of the biggest improvements, in Lucier's opinion, is an increased concern for women's emotional as well as physical health.

"Nowadays we treat not just the disease but the whole woman and her family," says Lucier, who has a degree in psychology as well as in nursing. "Physiologically, most women bounce back very well, but emotionally the disease can be devastating to both the woman and her family. We address each component of the family."

In addition to receiving professional counseling, many women find help from groups, such as the American Cancer Society's Reach for Recovery or Lucier's own group, the Network of Hope, that match breast cancer patients with volunteers who have been there. "I can take care of you and answer your questions, but I have not walked in your shoes," says Lucier. "Sometimes nothing helps like talking to someone who has gone what you are going through."

What's Ahead
Current research is looking at the effectiveness of MRI and ultrasound in detecting early cancers, and at new treatments that will more specifically target the mechanisms that trigger or perpetuate the disease.

Herceptin, which is a type of biologically derived drug called a monoclonal antibody, is a good example of such targeted treatment, says Galleshaw. It specifically targets the HER-2-neu gene while leaving the rest of the body alone. "In cancer, across the board, we are trying to find more targets for novel therapy so that we might be able to get away from chemotherapy, which kills not just cancer cells, but many other rapidly growing cells. That's why people feel so awful on it and lose their hair," Galleshaw says. "On the other hand, if you have a target and you have a drug that will just hit those cells with the target, you get away from all of those side effects."

Other types of drugs being developed are small molecules that work on the communication inside the cancer cells that tells them to keep dividing and never die.

"I think in oncology we will see dramatic evolution of treatment over the next five to 10 years," Galleshaw says. "The way we treat cancers will make an enormous shift. It's exciting to know that we have that much on the horizon."

In the meantime, Lucier says, "It's a beautiful thing to see how far we have already come. I have been a nurse for over 20 years and have worked in this position [with breast cancer patients] for six of them. I don't think I could have stayed with the job this long if the majority of my patients weren't doing well."

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Reducing Your Cancer Risk
While the greatest risk factor is having a close female relative with breast or uterine cancer, the majority of women diagnosed with breast cancer have no family history of the disease, says medical oncologist Janice Galleshaw. Here, Galleshaw's advice on reducing your risk.

 ¥ Drink only in moderation. "Some data suggest that women who drink alcohol regularly carry a higher risk of breast cancer," says Dr. Galleshaw.
 ¥ Watch your weight. New research shows that women who have had breast cancer and are obese are more likely to have a recurrence of the disease because they make more estrogen and many breast cancers feed on estrogen.
 ¥ Exercise regularly. Likewise, new research has shown that the breast cancer recurrence rate for women who exercise at least 30 minutes a day, five times a week is lower than for more sedentary women.
 ¥ Consider tamoxifen (Nolvadex). In a five-year study 13,000 women at high risk of breast cancer, those taking tamoxifen halved their risk of getting the disease. The drug's protective effects were seen in both pre- and postmenopausal women, says Galleshaw.

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Do Implants Hurt?
Not according to Janice Galleshaw, a medical oncologist in Atlanta. "No data shows that cosmetic implants increase the risk of breast cancer and, if anything, having implants may make cancer easier to find." The reason, she explains, is that implants are surgically placed beneath the breast tissue, pushing the tissue forward and making it easier to feel lumps and irregularities when performing a self-exam