Shades of Pink Foundation

A Promise of Spring Luncheon 2009

Update on Breast Cancer Care

Pamela R. Benitez, M.D.

Co-Founder and Medical Director of SOPF

General Surgeon Specializing in Breast Cancer and Disease of the Breast

Hello. 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.

What unifies us today is our commitment to make a difference; to help someone in need at a difficult time in their life; and to enjoy the camaraderie of friends in a celebration of spring’s arrival.

Spring reminds us of new awakenings. With the initial thaw, the thought of spring spurs us on to challenge the soil. We envision a garden of astonishing blooms, fragrant herbs, and the lush green of perennials.

These are tough times for all of us. As we anticipate the coming of spring, we keep alive the hope that we will see a better future for us and our neighbors here in Michigan, a state hit hard by these economic times. I want to take a moment and celebrate you for being present; for contributing to a cause near and dear to our hearts; for making a difference.

Without your commitment and belief, Shades of Pink Foundation would not be the successful, homegrown Foundation that it is today. I thank you for continuing your support. Beautiful gardens don’t just appear. They require hard work, sweat and tears. And so does preparing for and creating this beautiful luncheon. 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.

I am always thrilled to present the annual update for our Shades of Pink Foundation Promise of Spring Luncheon. It is exciting to be a part of the research and clinical trials as a breast cancer physician, realizing the tremendous progress that we are making in understanding breast cancer in all aspects.

Breast cancer is the second leading cause of cancer death in women in the United States, with approximately 180,000 cases diagnosed each year. Despite these numbers, by combining offensive and defensive strategies with early diagnosis and therapies, the overall 5-year survival is now 88% for all patients. 

Let’s Look at Risk Assessment

The importance of establishing specific risks of developing breast cancer is to gain an understanding of how best to monitor women so that breast cancer may be detected and treated in its earliest stages while minimizing false-positives and over-screening.

 We are at risk because we are women. When we hear that we have a 1 in 8 chance of getting breast cancer, it is to the age of 85. Breast cancer is more common as we mature.

 Remember, of all breast cancers 80% happen out-of-the blue- with no family history. Only 20% have a family history and of that 20%, only 5% have a gene for breast cancer.

 The Women’s Health Initiative clinical trial of estrogen plus progesterone explored the relationship between estrogen plus progestin and risk of breast cancer. The results confirmed that users of estrogen plus progestin were more likely to develop breast cancer than non-users.

o This increased risk declined markedly and fairly rapidly, however, once women stopped using hormones.

o Patients’ risks were at baseline at approximately two years following discontinuation of hormone therapy.

o This study suggests that although breast cancer risk is increased among women who take estrogen plus progestin, these breast cancers have a tendency to be less deadly than breast cancers that develop in women who have never used postmenopausal hormones.

 And a word about assessing risk with genetic counseling and testing. We have discovered two major genes that place one at increased risk – BRCA 1 and 2. There are nuances of these genes that are also now known and can be tested for. With risk factors in our family history, we should explore our risk with a genetic counselor to determine our potential risk so that interventions could be entertained.

Screening

MRI continues to be in the limelight. We need to remember that mammography is still the number one test for diagnosing breast cancer. In addition, breast self exam is an important adjunct. As for MRI, The American Cancer Society has recommended annual breast MRI for the following high-risk groups:

•  Women with a BRCA1 or BRCA2 mutation
•  Women who have a first-degree relative with a BRCA mutation (even if they have not yet been tested themselves)
• Women who have a 20-25% or greater risk of breast cancer based on risk assessment tools (which utilize family history)
• Women who received radiation treatment to the chest between ages 10 and 30, such as for Hodgkin’s Disease

In other certain situations, MRI of the breast can be useful. It can be employed in a patient with breast cancer diagnosed to find out if the cancer is just one mass or in multiple sites in the breast.

It may be able to detect other tumors that are not detected using mammography or clinical breast exam if one is diagnosed with breast cancer.

We need to remember that MRI is not a screening tool but used as an aid to help with difficult cases.

 It is a costly technique.

 It must be done at facilities that have experience and that have the ability to do a biopsy off of the MRI while you are in the MRI machine. Many places doing MRI cannot do that so you need to ask before you do an MRI at a facility that cannot do the biopsy.

Just as we use a multitude of tools working our gardens, the same is true with breast cancer treatments. Our tools include the surgeon, radiation, and medical oncologist. Each one has a role treating breast cancer.

Surgical Advances

We continue to move towards performing less surgery. With earlier diagnosis, breast preservation is a greater possibility. Minimal axillary lymph node surgery, called sentinel node biopsy, continues to be the standard of care for evaluation of the axillary area.

Radiation therapy

With breast preservation, radiation therapy is necessary. In the field of radiation therapy, two trends have arisen: a move towards delivering radiation in less time than the standard whole breast radiation over 5 – 7 weeks. Recent studies have shown excellent success with two shorter treatment plans: one is external beam radiation whole breast radiation delivered with a higher dose over three weeks, and partial breast irradiation, a five day treatment delivered to the tumor bed rather than the whole breast, twice-a-day as opposed to whole-breast radiation. Both techniques offer the convenience of a shorter treatment time, which is especially appealing to patients who live far from treatment centers, making it a hardship to come in five days a week for five weeks or more.

Patients who have received these shorter treatments have been shown to have identical survival and recurrence rates and similar rates of side effects as whole breast radiation therapy.

In 2007 I presented the five year results of the initial clinical trial of the 5 day MammoSite partial breast irradiation therapy to the lumpectomy bed alone rather than the whole breast. This showed excellent five year results in the rate of local recurrence in the breast similar and actually better than whole breast irradiation.

Adjuvant Therapy: Anti-Estrogen Hormonal Therapy: ATAC Trial Update and MA 27 Updates:

From several important studies on the use of anti- estrogen therapy for treatment of the body, we have seen significantly lower breast cancer recurrence rates for post-menopausal patients treated with the class of drugs called aromatase inhibitors compared to patients treated with our standard anti-estrogen, tamoxifen.

For post-menopausal women, aromatase inhibitors are recommended as the front line adjuvant therapy over starting with tamoxifen. Tamoxifen is still the number one choice for pre-menopausal women.

In addition, studies have shown that women who took five years of tamoxifen and then switched to an aromatase inhibitor for another five years did better; women who started with tamoxifen and switched to an aromatase inhibitor after two years did better; and now we are looking at whether more than five years of an aromatase inhibitor might be better.

What about Adjuvant Chemotherapy?

Studies launched during the past few years have attempted to extend the value of chemotherapy by exploring different regimens, either more intensive therapy to improve efficacy or, conversely, reduction of intensity to improve tolerance in special groups. Bottom line, chemotherapy works. There are different programs for different subsets of disease so we leave it to the medical oncologist to determine which program is best.

Of note, studies reported this year showed the effectiveness of standard chemotherapy in the elderly (>65) that is well-tolerated with minimal side effects.

It is clear that progress continues to be steadily made in defining optimal chemotherapeutic regimens in the adjuvant setting.

More importantly, we are extending our knowledge of biological therapies – a treatment form very different than chemotherapy.

We are improving therapies in patients with spread of cancer, metastatic breast cancer. No longer do we see spread of cancer as a death sentence. Many years of survival are achievable with the addition of second and third lines of chemotherapy that are very effective with minimal side effects.

Provocative results were presented at meetings this year regarding use of bisphosphonate therapy for improvement in recurrence-free survival, and a trend towards improvement in overall survival -patients had not only fewer bone metastases but also fewer local-regional recurrences, contralateral breast cancers, and non-bone distant metastases – the drug that is used for osteoporosis. 

Remarkable advances continue to be made for patients with more advanced cancers; a testimony to the power of defining a subgroup of patients with a validated biologically important target and multiple approaches to inhibiting growth of that cancer.

We have seen rates that have doubled in the reduction of recurrence with these newer biologic therapies.

We now have a way to individualize therapies, that give us information on both Prognostic and Predictive Analyses

We have made significant advance in individualizing therapies. Oncotype DX® is now a recommended test for women with newly diagnosed, early-stage, estrogen sensitive, invasive breast cancers, and who are node-negative. It quantitatively predicts the likelihood of breast cancer recurrence in these women and assesses the benefit that these patients will achieve from chemotherapy. Oncotype DX® has been included in the NCCN and ASCO guidelines to help guide treatment decisions. The 21-gene assay stratifies patients according to their risk of a recurrence by a Recurrence Score (RS). Patients with a score less than 18 have a low risk of recurrence; those with an RS score between 18-30 have an intermediate risk of recurrence; and those with a score greater than 30 have a high risk of recurrence.

The study of new markers to select appropriate therapies in early breast cancer is the future of breast cancer care.

New Concepts in Breast Cancer

Previous studies ranging from experiments in people to epidemiologic trials have suggested a link between breast cancer and Vitamin D3. This hormone has increasingly been found to play an important role in cell differentiation and could be a regulator of cancer progression.

These intriguing results raise many questions, including whether or not they are representative of women living in lower latitudes with more sunlight exposure and whether Vitamin D3 supplementation might impact breast cancer-specific survival. More studies are eagerly awaited.

Eat your Fruits and Vegetables

And near and dear to my heart, studies were reported this past year linking breast cancer outcome to nutritional status.

A study just reported in the Journal of Clinical Oncology in December reported improved survival in patients who ate a diet rich in fruits and vegetables and whole grains.

As an aside, one of the major sponsors of SOPF is Juice Plus+ (www.wellnessjuiceplus.com) which is whole food–based nutrition in a capsule… think of it as my salad in a capsule. It is supported by significant clinical research with 16 published studies in the medical literature on the benefits of the product, 2 fruit and 2 vegetable capsules taken daily.

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 tangible progress for current and future breast cancer patients.

Keeping vigilant, tending to details, enriching the soil, pruning when needed, and creating space for plants to grow both in your garden and in your life are important to survival and a beautiful, rich garden.

The future of breast cancer care is bright. The strategies developed over the past four decades are yielding improved outcomes that we are seeing today, including earlier diagnosis, a reduced occurrence of axillary node involvement, decreased levels of toxicity from treatment, an increasing number of cures, and a decreasing mortality rate from breast cancer.

As approaches continue to be refined, we will see further improvement in all of these areas. The research and strategies in development today will provide even greater promise in the decade to come.

Breast cancer impacts every one of our lives. Yes, the future is bright, but we need your help. You can do things for yourself, and you do things for others. Participating in Shades of Pink Foundation activities, helping with the goals of our Foundation to help those in need with a breast cancer diagnosis, participating in the luncheon, the annual Walk at the Zoo in April, or by turning to the woman next to you and asking her if she has had her mammogram or has scheduled her mammogram for this year are all ways to make a difference.

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.

Will to Live I think of all things that show a zest for life, the dandelion beats the rest. The little winged seeds from its white fluff ball settle and grow with no urging at all. Settle in most unlikely places and soon there's a crop of dandelion faces. They are man's worst pest, but a child's playthings. Sometimes I wish I had light down wings like a dandelion seed, and could settle at will on a velvety lawn or a sun-spread hill, and live with the eagerness and zest of the wanton little dandelion pest. -MARY TRIPLETT

Thank You,

Pamela R. Benitez, M.D.

Beaumont Cancer Center

Suite #201

Royal Oak, MI

248-551-8890

General Surgeon Specializing in Breast Cancer