Shades of Pink Foundation Promise of Spring Luncheon Talk 2008 Pamela Benitez, M.D. (delivered by Jaime Caughran, M.D. Breast Fellow at William Beaumont Hospital)

As we come together for the Promise of Spring Shades of Pink Luncheon, I will share with you today the promise of hope for women who are diagnosed with breast cancer in 2008 and beyond.

Let's not forget our focus today: that we are individuals who have come together under the reflective glass of this greenhouse to support women who have financial difficulties during breast cancer treatment. We are surrounded by the beauty of tablescapes created by our friends. We have learned how to beautify our environments and live with our feathered friends each in our unique habitats.

    Author, Marina Schinz, tells us:

To create a garden is to search for a better world.

In our effort to improve on nature,

we are guided by a vision of paradise.

Whether the result is a horticultural masterpiece

or only a modest vegetable patch,

it is based on the expectation of a glorious future.

This hope for the future is at the heart of all gardening.

We remain grateful for the advances of science that continue to provide hope for women diagnosed with breast cancer. So let me share what is new in the world of breast cancer.

2007 was again a banner year for the growth of knowledge in breast cancer issues and provided an abundant harvest of new data from research trials in breast cancer care.

For my talk today, I have chosen to identify important advances and match them with a caution flag.

First let's talk about the Incidence of Breast Cancer:

     There were signs that there was going to be a decline in the incidence of breast cancer. Indeed, this has been verified with a reported 7% decline in the incidence of breast cancer since 2003. Although some of the decline may be attributable to women going off estrogen and progesterone hormone replacement therapy, other factors may also have a role. One important point that we learned from the Women's Health Initiative Study is that the increased risk of breast cancer with long'term hormone replacement therapy was with those women who took both estrogen and progesteone. For the women on estrogen alone, there was actually a slight decrease in the incidence of breast cancer. One of the important take-home messages from this study is that we don't yet know the role of progesterone in the development of breast cancer. So the first Caution flag is to not take progesterone supplements or slather on lotions and creams that have progesterone. The fact that breast cancers can be sensitive to both estrogen and progesterone is important and scientists have not studied progesterone alone.

     A second area of advances is in Detection. What I want to share with you includes a few caution flags as to the information that is "out there" and emphasized in the press that we need to get straight:

The #1 reason for getting breast cancer is that we are women!!!

     ~ 80% of the cases of breast cancer are sporadic, in other words, they occur "out-of-the-blue" in women with no family history of breast cancer.

     ~  The remaining 20% of women who get breast cancer have a family history, meaning a first-degree relative- your mother, daughter or sister.

     ~ Of the 20% who have a family history, only 5% have the inherited genetic mutation for breast cancer: BRCA 1 & BRCA 2.

     ~ Let me remind you that the risk of getting breast cancer increases with increasing age such that the statement that a woman has a 1 in 8 chance of getting breast cancer- it is to the age of 85.

Let's talk for a moment about the diagnostic tools for detection.

We are all hearing about Digital mammography

     ~ Digital mammography uses a computer with digital images instead of a film cassette. Therefore, the image can be manipulated. suspicious areas can be magnified which reduces call-backs.

     ~ There are times when digital mammography may be useful in imaging dense breast tissue.

     ~ the caution flag to raise is that digital mammography is not available everywhere; the equipment is more expensive; and we defer to the mammographers to know when a digital study should be done rather than the film technique.

     ~ In addition, even with digital mammography, cancers can be missed.

If we depended on the media to inform us about detection then we would know that MRI is the latest rage.

     ~ MRI of the breast can be useful in certain situations. It can be used to find out if the cancer is just one mass or in multiple sites in the breast.

     ~ It may be able to detect tumors that are not detected using mammography or climical breast exam.

     ~ A caution flag to  raise is that MRI is not a screening tool but used as a 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 and if they don't you need to run fast as you can from that facility.

     ~ Due to the uncontrolled use of MRI, The Americn Cancer Society came out with these indications for MRI imaging. For Screening, one must have:

        a genetic mutation of the gene for breast cancer

        a first - degree relative with a genetic mutation in the gene for breast cancer

        a lifetime risk of breast cancer of 20-25 percent or more using standard risk assessment models*(which is not just ashieved with a personal history of breast cancer).

        received radiaation treatment to the chest between ages 10 and 30, such as for Hodgkin's Disease

        In addition, the American Cancer Society states that the available data are insufficient to recommend either for or against screening MRI's which would include women with a personal history of breast cancer, very early non-invasive breast cancer, early changes in the ductal cells that are atypical or in women with extremely dense breasts on mammogram.

So the cautions here are that adigital mammography and MRI are not for everyone as a screening study.  Rather, they are tools to elp us with more difficult cases or situations.

     Once an abnormaliity is found on the studies or a mass is felt, minimally invasive biopsy techniques are the standard methods to be used for diagnosis.

     ~ The caution flag here is to be wary of someone who does not inform you of the minimally invasive techniques that are available to obtain a diagnosis. It is becoming increasingly uncommon to need an open surgical biopsy for diagnosis.

Now let's look at the advances in the local surgical treatment of the beast.

     ~ The data that showed equal success in saving one's breast with early-stage breast cancer versus having a mastectomy is still holding up at 25 years.

     ~ The less invasive technique for evaluating the status of the axillary lymph nodes, sentinel node mapping and biopsy, is holding its own in terms of ocerall success. this method that  removes only  a few lymph nodes rather than automatically performing a complete lymph node dissection in cases of early-stge breast cancer has been a great advance in the surgical realm.

     ~ Shades of Pink Foundation's medical director, Dr. Pamela Benitez, presneted the five-year results of a shorter method for delivering radiation therapy to the breaawt with early-stage breast cancer at the American Society of Breast Surgeons Annual Meeting in 2007. Her paper was published in October in the American Jouornal of Surgery. The results of the national trial of the MammoSite balloon brachytherapy 5-day course of  radiation therapy, delivering radiation to just the lumpectomy site versus the standard six week course of whole breast radiation therapy, shows the local recurrences to be equivalent.

     ~ Another advance is the development of techniques that decrease radiation exposure to other tissues when radiating the whole breast with breast preservation.

     ~ The caution flag here is to know that there are options for the surgical treatment of your breast and that there are options regarding the radiation that is delivered with breast preservation. It is important for you to ask and understand the options and if they are not given to you to ask why not or why they don't apply to your case.

Advances continue to expand in the treatment of the body.

     ~ the use of anti-estrogen pills such as tamoxifen or aromatase inhibitors, in women with estrogen-sensitive cancers, cn increase overall survival by 5-10%.

     ~ The newer  class of anti-estrogen pills, the aromatase inhibitors- Aromasin,Letrazole,Femara, and Arimadex-have been shown to significantly lengthen disease-free survival in post menopausal women.

     ~ Studies of chemotherapy have now matured and show absolute survival advantages for women who need chemotherapy and this is even in node-negative patients. These benefits range from 3-11% which is significant. Another great statistic is that some of these drugs have allowed for a decrease in the death rate by as much as 27%.

     ~Even better, these regimens can be given in as few as 2-3 months unlike the six months of chemotherapy from years ago.

     ~ These dose-dense regimens show increased disease-free survival and overall survival!

     ~ For women with cancers that express certain specific proteins, there are drug therapies that target these specific cancers. The one most studied drug is Herceptin.  These therapies have given these women great hope with decrease risk of recurrence of about 50%.  The future looks very bright in the development of additional targeted therapies.

     ~ Another great advance is a tool that looks at one's individaul cancer by examining certain genes in the tumor. This tool generates a "recurrence score" to see if your cancer has a low, intermediate, or high risk of recurrence and also assesses the likelihood of the tumor to respond to chemotherapy. It is called Oncotype Dx.  This has been verified in women with estrogen-sensitive cancers who are node-negative.

     ~ We now have drugs that can actually  reduce the number of cancer cells that spread to the bones, called bisphosphonates. This group of drugs can decrease bone pain if it has spread to bones and they can minimize the loss of bone calcium in menopausal women who don't have breast cancer.

     ~ Studies are being conducted on the role of anti-estrogen pills and/or chemotherapy given before surgery is performed to improve outcomes and possibly to allow women an opportunity to save her breast when she might otherwise not be able to preserve her breast.

     ~ Our caution flag here is to become educated by  your doctor in exploring all possible options for treatment of your body and to know that the advances we have talked about truly have made a difference in survival despite side effects that also have greatly diminished.

 The bottom line is always about Survival:

     ~ Indeed the five-year relative survival rate for all stages of breast cancer is now 88%.  However, let me highlight that the five-year survival rate for all women with localized invasive breast cancer is 98%. The caution flag that I raise is that the earlier we can diagnose breast cancer the better.  You have more options and your success rate is so much better. The reasons for this success are early detection, advances in treatment, and the role of prevention strategies.

What are the Prevention Strategies that we need to pay attention to?

     ~ Studies with tamoxifen, an anti-estrogen pill, have shown its ability to reduce by 50% the chance of developing cancer in women who are at increased risk for developing breast cancer and in those women     who have breast cancer to reduce the development of breast cancer in her other breast.

     ~ Studies with another group of anti-estrogen drugs called aromatase inhibitors have also shown a reduction in the risk of breast cancer by 60% in post-menopausal women who are at increased risk for developing breast cancer.

     ~ We now offer risk counseling, genetic testing, and risk management for men and women.

     ~  Research continues to show the benefits of exercise-aerobic exercise, 3 to 5 times a week for 20-60 minutes; limiting alcohol consumption to one glass or one drink a day; controlling one's weight, and paying attention to nutrition, specifically fruits, vegetables, omega 3's, and whole grains, in reducing one's risk of getting breast cancer.

     ~ In the research on prevention, we are seeing more studies showing the benefit of meditation, stress reduction, and a good nights sleep of 7-8 hours on the reduction of the incidence of all cancers.

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 a greater number of cancers diagnosed at an early-stage, a reduced occurence of axillary node involvement, decreased levels of toxicity from treatment, an increasing number of cures, and decreasing mortality rates from breast cancer.

The research and strategies that are being explored today will provide even greater promise in the decade to come.

As gardening brings us great joy and pleasure so does the hard work and research that is being done around the world in breast cancer.

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 A Garden of Hope".

Pamela Benitez,M.D.