16 Mar 2010
2010 Promise of Spring Luncheon February 26, 2010
Annual Update on Breast Cancer
Pamela R. Benitez, M.D.
Wrapped in a down winter coat, I stand before a 7 foot wall of shoveled snow overlooking my garden covered by ten inches of newly fallen fluffy white snow. A few brown sprigs poking up out of the whiteness are barely seen. Where in that picture is the Promise of Spring?
Past experiences and faith, often blind faith, tell us that spring will come and from the hard frozen soil tilled with the sweat of our efforts will come an abundance of blooms.
It is just such faith and hard work that draws us together believing that we can make a difference in our community. This past year has been a very difficult one for our community and our state. Today there is even a greater need for Shades of Pink Foundation to help women who have financial difficulties during a breast cancer diagnosis.
For those of you who have supported us from the beginning, you will be pleased to know that we provide support to three women a month and have not had to turn down any eligible request for assistance.
For those of you who are new friends of our Foundation, we welcome you with open arms in joining us in our mission.
Let’s begin our celebration of the Promise of Spring by thanking you for your continued belief in us and in our mission. It is truly your involvement and commitment that has allowed Shades of Pink and therefore you, to make a difference in a woman’s life, taking an edge off of her difficult journey. We applaud you.
Just as our snow-covered garden will take effort to bloom, so does creating the luscious landscapes that we see here today. Let me take a moment to acknowledge those whose passion has created the Foundation and fostered its growth – our president, Suzanne Krueger, Treasurer – Colleen Batdorff; Bev Napier, our fund-raising chair; Kitty Waldron, chair of governance (i.e. she keeps us in line); and Board members LuAnn Linker and Mary Quarton.
It is an honor for me to present the annual update on breast cancer for our Shades of Pink Foundation Promise of Spring Luncheon. It is exciting to be a part of the research and clinical trials, realizing the tremendous progress that we are making in understanding breast cancer in all aspects. I am Dr. Pamela Benitez, a breast cancer surgeon in solo private practice at William Beaumont Hospital, Medical Director and co-founder of Shades of Pink Foundation.
I thought this year that I would look at the topic a little differently and address some of the hot issues of the day.
“What were they thinking?” That is the question I am asked every office day in regards to the report of the US Preventive Services Federal Task Force on mammography and breast self exam.
Despite evidence from the combined analysis of the major mammography screening trials, the Task Force made the following recommendations:
- Routine screening should start at age 50, not 40.
- For women age 40 to 49 they stated that a determination should be made based on “patient’s context and values, taking into consideration the benefits and harms.”
- Screening should be every two years for women age 50 – 74; and
- For patients over age 75 there is “insufficient data” to make a recommendation so they do not recommend continuing mammography for women over age 75.
And what were they thinking when they made the recommendation that women should not be taught breast self exam?
Despite the fact that the combined analysis of mammography screening notes a decrease death rate of 15% for routine mammography in women ages 39 - 69, they concluded that false-positive results are common in all age groups and lead to additional imaging and biopsies. They argue that work-ups for false-positive findings subject women to additional imaging and procedures, countering the potential benefits of this approach. They point to the added anxiety women experience from call backs and biopsies.
They went on to state that mammography screening at any age is a “tradeoff of a continuum of benefits and harms.” And finally, they state: “The ages at which this tradeoff becomes acceptable to individuals and to society are not clearly resolved by available evidence.”
As for breast self exam, the Task Force states that trials of breast self exam show no reductions in mortality and increased numbers of benign biopsy results done as a result of BSE instruction.
Where does that leave us?
Per the Vice Chair of the Task Force: "So, what does this mean if you are a woman in your 40s? You should talk to your doctor and make an informed decision about whether mammography is right for you based on your family history, general health, and personal values."
The American Cancer Society, American Society of Breast Surgeons, Breast Diseases, and Radiology to name a few, all disagree with the findings and support annual screening over age 40.
That report created quite a stir.
Another hot topic is the media attention paid to the genetic risk of breast cancer. First and foremost, we must remember that our risk for getting breast cancer is:
- #1 that we are women. 80% of us get breast cancer out of the blue with no family history; 20% have a family history and of that 20%, only 5 to 7% have the gene for breast cancer.
However, with this being said, programs have been developed that specialize in genetic counseling and testing of women who may carry the gene for breast cancer. The implications of testing positive relate to how one undergoes increased surveillance, chooses chemoprevention, or bilateral simple mastectomies. In addition, she will be counseled on her risk of ovarian cancer and how she might choose to manage this. A woman with a BRCA 1 or 2 mutation has an ~60%+ chance of getting breast cancer compared to the normal population of ~12% to the age of 85. Her risk for ovarian cancer is 15 - 40 % rather than 1.4% for the general population.
The importance of the paternal family history has been emphasized to clinicians, who once were taught that the maternal side was the most important lineage in looking at risk.
One of the new research areas in the surgical management of women at increased risk is a study of nipple and areolar sparing mastectomies in these women who choose prophylactic surgery.
Our knowledge of these genetic mutations is evolving rapidly.
A third hot topic, as we move forward in the research on breast cancer, is targeted therapy. We see this with surgery, radiation, and adjuvant therapy, especially chemotherapy. The whole idea is to find a specific target and focus therapy to that target.
In surgery, we are now performing sentinel node procedures which are directed towards finding the first draining nodes in the axilla, i.e. the target for identifying cells that leave the breast, removing only those few nodes and evaluating them during the operative procedure.
Radiation therapy has perfected therapy, looking at not only the whole breast (that has been the target for over twenty years but now), but also focusing radiation to the tumor bed alone, the site where breast cancer is most likely to recur in the breast.
With breast preservation, radiation therapy is necessary. The delivery of radiation therapy is being perfected with improved techniques to minimize side effects. Not only are the techniques improved, but length of treatment is shortened. The standard therapy has been whole breast radiation therapy delivered every day, five days a week, for 6 – 7 weeks. New research publications, with over ten years of follow-up, focus on a program of whole breast radiation therapy delivered every day, five days a week for three weeks that yields excellent results with great cosmetic outcomes.
The research that I have been heavily involved in is directing radiation to the site where cancer is most likely to return, the site of the resected tumor. This is a system that delivers radiation to the target site with seed radiation, twice a day for five days rather than 6 – 7 weeks.
Our latest paper from William Beaumont Hospital, just published in February, is on the results of the same targeted seed radiation therapy delivered to the lumpectomy bed, twice a day for two days, and then you are done!
Pretty amazing progress! This makes the option of breast preservation more acceptable to more women who would not choose breast preservation due to time and/or travel constraints.
And finally, defining targets for systemic therapy has been a very hot topic. Targeted therapies are for the most part less likely than chemotherapy to harm normal, healthy cells.
One of the main reasons that we have seen a dramatic improvement in the overall 5 year survival from 65% in all patients to now 88% is the results of long term studies of systemic therapy.
One targeted therapy that has made a significant impact on women who have more aggressive cancers is the development of a drug, Herceptin, which targets the Her-2-neu protein expressed by more aggressive cancers. Herceptin reduced the risk of cancer returning by 40 - 60% in these women.
The question of whether a patient even needs chemotherapy has been addressed with an amazing test. This test is done on the patient’s very own tumor. A Recurrence Score is reported based on an analysis of 21 genes related to the tumor. The Recurrence Score equates to the chance of that cancer returning. From the studies done on this test, Oncotype Dx, we now can distinguish who needs chemotherapy and who does not. This has dramatically changed treatment patterns, where in the past we might treat anyone with a tumor over 1 cm in size with chemotherapy and now we may not treat a woman with a 3 cm cancer with chemotherapy. This test was originally performed on estrogen sensitive and node negative tumors. Future research will be on estrogen negative and node positive tumors.
Two other important areas that are receiving significant attention are the development of drugs and finding combinations of drugs that can help women who have a subtype of breast cancer, called triple negative tumors – tumors that are not sensitive to estrogen, progesterone, and do not express Her-2-neu protein. Conferences are being convened world-wide to look at research that is specifically looking at this subtype, with the sole purpose of finding effective, tailored, targeted therapies.
The second important area is for women who develop recurrences. For these women who have triple negative tumors, the development of new drug regimens is vitally important. A class of drugs called PARP inhibitors and others like it will make a big difference for women who have a return of their cancer.
So as you can see we are making great advances in the treatment of breast cancer but we still have a long way to go.
What might we have in our control that could prevent breast cancer? Understanding the importance of prevention is not only valuable to preventing breast cancer but also other health problems.
Much publicity has been printed on four significant factors for increased risk for breast cancer.
- The first is our weight - Substantial evidence indicates that weight gain is associated with an increased risk of breast cancer, especially postmenopausal weight gain.
- The second is physical activity - Numerous studies have examined the relationship between physical activity and breast cancer risk, and most of these studies have shown that physical activity, especially strenuous physical activity, is associated with reduced risk.
- Third is alcohol consumption - There is substantial evidence that alcohol consumption, two or more drinks a day, is associated with increased breast cancer risk.
- And last is Hormone Replacement Therapy—the results of the Women’s Health Initiative (WHI) study showed that HRT with estrogen and progestin is associated with an increased risk of breast cancer and increased risks of heart attack, blood clots, and stroke. The study also showed that HRT with estrogen alone was associated with increased risks of blood clots and stroke, but the effect on breast cancer risk was uncertain.
o This increased risk of HRT declined markedly and fairly rapidly once women stopped using hormones.
o Patients’ risks were at baseline at approximately two years following discontinuation of hormone therapy.
Research has shown a relationship of vitamins D3 levels and risk of breast cancer. This hormone has increasingly been found to play an important role in cell differentiation and could be a regulator of cancer progression. What they have noted is that women with lower levels of vitamin D3 have an increased incidence of breast cancer. Bottom line: Everyone needs to get their vitamin D level checked.
Summary
Given the continued yearly fall in the death rate from this disease, the evidence is strong that the enormous efforts of clinical trials, patient participation in trials, and the hard work of investigators has resulted in real progress for current and future breast cancer patients.
As approaches continue to be refined, we will see further improvement in all areas. The research and strategies in development today will provide even greater promise in the decade to come.
Just as I stood before the 7 foot wall of shoveled snow wondering how I would ever get to my garden, I could appreciate the challenges ahead of us in facing breast cancer. As the snow continues to fall I grab the old beaten shovel and begin to shovel with earnest, slowly but surely making a dent. Others come over to help out and with a combined effort we eventually manage to create a path to the garden.
Despite the formidable task before us, with effort, the help and support of our friends, and faith, sometimes blind faith, we can get things done.
So too with Shades of Pink Foundation. Times are tough for us in Michigan and so our challenge is even greater - the challenge to continue our efforts so that we can help any woman who seeks us out who needs financial assistance at the time of her breast cancer diagnosis.
Breast cancer impacts every one of our lives. Participating in Shades of Pink Foundation activities, helping with the goals of our Foundation, participating in the luncheon as you are today, the upcoming Walk at the Zoo on April 17th, Cruising for a Cause at the Woodward Dream Cruise at Wild Birds Unlimited, or by turning to the woman next to you and telling her that you will go with her for her mammogram appointment are all ways to make a difference.
When we tend to our gardens in early spring, tenderly planting seeds and sprouts, protecting young seedlings from late frosts, we are really saying that we believe…we believe that we can nurture a young seed to blossom, bring beauty to our world, and make a difference.
Gardening is a way of showing that you believe in tomorrow so let us get out there and create gardens of uncalculated beauty maintaining the promise of spring and creating a garden of hope.
Together we can fight this weed called breast cancer, enrich the soil of survivorship, and share in the beauty of a garden without breast cancer.
THANK YOU
Pamela R. Benitez, M.D.
General Surgeon -
Specializing in Breast Cancer and Diseases of the Breast
William Beaumont Hospital
Beaumont Cancer Center
Suite #201
Royal Oak, Michigan 48073
248-551-8890
Pamela R. Benitez, M.D.
| 
