Shades of Pink Foundation, Promise of Spring Luncheon Talk 2007, Pamela Benitez,M.D.

As I stand before you as part of this beautifully planned event by Suzanne Krueger and Bev Napier, I want to share some of the things I have learned about gardening as captured by the following five sayings:

     The best way to garden is to put on a wide-brimmed straw hat and some old clothes.  And with a hoe in one hand and a cold drink in the other, find a comfy lounge chair, put your feet up and tell somebody else where to dig.

     When weeding, the best way to make sure you are removing a weed and not a valuable plant is to pull on it. If it comes out of the ground easily, it is a valuable plant.

     A weed is a plant that has mastered every survival skill except for learning now to grow in rows.

     Any self respecting rock will break at least one shovel before accepting its new home.

     Gardening requires a lot of water most of it in the form of perspiration.

In a similar fashion, here are some things that I have learned about breast cancer as a breast cancer surgeon.

     Best way to prevent cancer is to wear your wide-brimmed straw hat and old, easy to change into clothes... to your mammogram appointment.

     There is so much information out there thus weeding is also important- When weeding out good and bad information, good information is going to come from valuable sources- your physician, research sites, and a good cancer center not from My Space.com or U-Tube.

     Cancer, like a weed, has tried to master every survival skill, but we have developed therapies that are more targeted and specific unlike drenching our gardens in Round-Up.

     Breast cancer might break at least one shovel, but with persistence and education we can turn even the toughest soil.

     Breast cancer survivorship requires a lot of nurturing and nourishing both the body and soul.  It is important to tend to the entire self to promote health and well-being through the journey.

WHAT USED TO BE ...... Breast Mass

                                        Sign permit for biopsy and radical mastectomy

                                        Toxic chemotherapy

                                        Top it off with chest wall radiation

                                        And then don't talk about it.

My goal today is for you to leave here with a sense of WOW! Look how far we have come.

There have been a large number of recent advancements in breast cancer care and research in breast cancer.

For my talk today, I have grouped these advancements into five general areas and within each of these five areas I have chosen to speak about the top three in each category.

But first in introducing the subject let me mention some important statistics:

     Despite the incidence that as a woman you have a 1 in 8 chance of getting breast cancer, there is a bright light on the  horizon. Hot off the press, for the first time in years, there is a reported decrease in the incidence of breast cancer.

     Five year survival rate for all women with localized invasive breast cancer is 96%

     Ten-year survival rate is 80%

The first area to discuss is Imaging and Diagnosis

Computer assisted detection and Digital mammography:

    ~ Computer assisted detection is the use of a computer to help the radiologist "read" the film

    ~ May decrease the false positive and negative screening rates and increase identification of areas that need further evaluation

    ~ Digital mammography allows for manipulation of the image since the technology uses a computer rather than film.

     ~Suspicious areas can be magnified; call backs reduced. Faster image retrieval since no film is used.

     ~ Has improved detection rates in certain breast tissues

MRI

     ~ Not a screening tool but as an aid to help in difficult cases

     ~ Find out is the cancer just one mass or multiple sites in the breast

     ~May be able to detect tumors that are not detected using mammography or clinical breast exam.

     ~Costly technique

     ~May be important in examining breast tissue that is dense or in women that are a high risk

     ~Special techniques used in conjunction with MRI that actually can look at the tumor can help determine if lesion is benign or malignant

Minimally invasive biopsy techniques

     Core biopsy by ultrasound and mammogram is the state of the art

In the area of surgery

Breast preservation over mastectomies

     ~We now have 20 year follow-up studies that compared saving the breast with breast cancer to complete mastectomy that show equivalency in reducing local recurrence.

     ~ These are dramatic clinical trials that women like you and me participated in. (Imagine participating in a trial where you would be blindly randomized to either saving your breast or having it removed)

     ~ These studies have also shown that if you saved your breast and do get a recurrence in the breast and then have a mastectomy, your survival is not affected.

Sentinel Lymph Node Biopsy

     ~ Sentinel Node"Only" Option- means removing a few nodes; looking at them while you are asleep in the operating room; and if negative take no more but if a node is positive, then you need a complete axillary node dissection

     ~ Imagine- possible not having to have all of the lymph nodes in your axilla removed!

     ~ Reduce side effects like arm swelling

Immediate reconstruction and skin-sparing mastectomies

     ~ No difference in local recurrence with either of these techniques.

In the area of Radiation Therapy

Techniques have been developed that decrease radiation exposure to other tissues when radiating the whole breast when you save  your breast

Intensity Modulated RT (IMRT)

     ~ A technique thata further modifies the radiation beam allowing for optimal treatment precision and dose delievery

     ~ Beaumont is one of only a handful of sites in the nation to offer IMRT for breast cancer.

     ~ Improves the uniformity of the dose delivered to the breast

     ~ Reduces acute and long-term side effects

Active breating control

     ~ Coordinate radiation treatment delivery with the breathing cycle

     ~ Typically breath-holding

     ~ Beaumont Hospital is a pioneer in this technique

     ~ Reduces volume of heart in the radiation treatment field

Partial breast irradiation

     ~ A technique of giving radiation to the lumpectomy site only rather than radiating the whole breast delivering the radiation to the site where cancer is most likely to recur

     ~ Treatment is twice a day for five days instead of daily for six to seven weeks

     ~ Data at 10 years is as good as the data on breast preservation and radiating the whole breast

     ~ Decreases toxicity and exposure to other structures from the radiation

     ~ Beaumont Hospital has the largest published series on this type of radiation therapy

In the area of Medical Oncology

Endocrine therapies or hormonal therapies

     ~ Tamoxifen has shown, in post-menopausal women with estrogen sensitive tumors, a 10-year reduction in recurrence of 47% and a 10-year reduction in mortality of 26%

     ~ In pre-menopausal women with estrogen sensitive tumors studies showed a 10-year absolute improvement in survival of 5-10%

     ~ And in both groups a 50% decrease in contralateral breast cancer incidence was found in these studies

Now we have a second class of drugs called aromatase inhibitors (AI)

     ~ Studies improved disease-free survival in post-menopausal women starting out with Arimadex or crossing over to an AI after two or three years of tamoxifen, or by taking an AI after five years of tamoxifen

Chemotherapy Advances: We have seen a decreas in the death rate by as much as 27%, and more in certain groups, with these advances

     ~ Better drugs: Adriamycin, Taxanes, Capcitibine (Xeloda)

     ~ Accelerated treatment regimens that are safe versus the obligatory six months of chemotherapy with the older drugs.

             These regimens can give the course of chemotherapy in as few as 12 weeks

             Dose-dense regimens show increased disease-free survival and overall survival

     ~ Drugs to combat side effects of ch emotherapy(minimize toxicities)

             Neulasta for white blood cells 

             Procrit for red blood cells

             Anti-emetics for nausea

Using newer targeted therapies:

    ~ Antibody therapies such as Herceptin for more aggressive cancers that express a Her-2-neu protein. Herceptin is an antibody that blocks the HER2 protein in cancer cells and stops the growth of HER2 positive cancer cell

    ~ Bisphosphonates for bone disease; can actually reduce the number of bone metastases, decrease bone pain and minimize the loss of bone calcium in menopausal women

Oncotype Dx- A gene array that determines individual Recurrence Score in patients with an estrogen-sensitive cancer and negative nodes

     ~ Assays of one's own tumor

     ~ Determines 3 categories of risk recurrence

     ~ Low

     ~ Medium

     ~ High

     ~ Differentiates which tumors are in need of more aggressive systemic therapy

Lastly, and very important, is the area of Prevention and Lifestyle Changes

     Drugs for prevention: STAR Trials/B-35

         ~ STAR P-1 enrollment from 1992-1998

         ~ Over 13,000 women at higher risk for breast cancer participated in this blinded trial

         ~  Tamoxifen vs. Placebo("sugar pill")

         ~   50% reduction in development of breast cancers in women who took tamoxifen

         ~ STAR P-2 enrollment May 1999-April 2004

         ~ Tamoxifene vs. Evista (Raloxifene)

          ~ Raloxifene had fewer side effects but reduced the incidence of invasive ductal cancer not early              non-invasive ductal cancer (DCIS)

         ~ NSABP B-35: just closed to accrual

          ~ Studying the use of tamoxifen vs. exemestane (aromatase inhibitor) in DCIS

Risk counseling

Genetic testing

Risk management

Physical- research has actually shown that these factors can cerease incidence of breast cancer

         Nutrition - a diet rich in fruits and vegetables and fiber; must keep alcohol intake at a minimum (less than 1-2 glasses per day)

         Weight control- obesity is linked to increased incidence of breast cancer

         Exercise- increased excercise decreased incidence; minimum three times a week for 30 minutes

Mental - stuies show how these practices can improve your immune system and therefore your survival

          Faith/spirituality

          Meditation

          Relaxation

Emotional

          Stress Reduction improves your immune system

          Social support

The Future- what's coming

Designer drug treatment

Nanotechnology

Single intraoperative radiation treatment

Cryoablation

Thermal ablation

Targeted therapies; Gene therapies: immunotherapy

The future of breast cancer care is bright. The strategies developed over the past four degades are yielding improved outcomes that we are seeing today, including a greater occurrence of early-stage 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 can do things for others.

Participating in Shades of Pink Foundation activities, helping with the goals of our Foundation to ehlp those in need with a breast cancer diagnosis, participating in a walk, ot 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.

Together we can fight the weed called breast cancer, enrich the soil of survivorship, and share in the beauty of a garden without breast cancer.

Pamela Benitez, M.D.