16 October 2013

This is one of my most comprehensive interviews to date. It aired on Santa Clarita Valley TV and I had the opportunity to discuss a wide range of topics, including breast self-exams, male breast cancer, genetic testing for breast cancer, “pink washing” and more! Many thanks to SCVTV as well as Tami Edwards and Dave Caldwell, for spending so much time on such important topics.

16 September 2013

The following article appeared in Medscape and covered a recent study suggesting that many women base their decision to undergo a mastectomy on fear. I was happy to contribute my thoughts to what is a very complex issue and a very difficult decision for so many women. ~DJA

Fran Lowry

Sep 16, 2013

Women with breast cancer, especially younger women, are choosing to have their healthy breast removed because of mistaken beliefs about the effectiveness of mastectomy and unfounded fears about the risks for contralateral disease.

In a cross-sectional survey of 123 women with early bilateral breast cancer who chose to undergo contralateral prophylactic mastectomy (CPM), the overwhelming majority cited improving their chances of survival (94%) and reducing the risk that cancer will develop in the other breast (98%) as their primary reasons for deciding to have the additional surgery.

The results appear in the September 17 issue of the Annals of Internal Medicine (Ann Intern Med. 2013;159:428-429).

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3 August 2013

What’s in a name? In the case of cancer, there are myths, fears, and misinformation – more than perhaps any other illness.

Cancer encompasses hundreds of different diseases and each one is complex. Even women diagnosed with exactly the same “type” of breast cancer and who undergo the same treatment can have very different outcomes. Not all cancers are equal and not all cancers are lethal.

While early detection and treatment were once equated with improved survival, we now know that tumor biology (characteristics governing the behavior of spread and response to treatment) plays an extremely important role in the prognosis of an individual cancer. There is an increasing recognition that current screening tests, meant to diagnose cancer in the earliest stages, will often diagnose lesions that have minimal potential to become aggressive or lethal. As our screening technology improves, we are detecting more patients in early stages or with pre-cancerous conditions and we are treating those patients with surgery and other potentially toxic therapies.

In 2012, the National Cancer Institute convened a working group to “evaluate the problem of ‘overdiagnosis’ which occurs when tumors are detected that, if left unattended, would not become clinically apparent or cause death.” Unrecognized overdiagnosis, they stated, “generally leads to overtreatment”1.

The recommendations of this panel were recently published in the Journal of the American Medical Association: Overdiagnosis and Overtreatment in Cancer, An Opportunity for Improvement.  The authors provide five recommendations:
1. Physicians and patients alike need to acknowledge that screening results in overdiagnosis – especially in breast, lung, prostate and thyroid tumors.
2.  The term ‘cancer’ should be reserved for describing lesions with a reasonable likelihood of lethal progression if left untreated.
3.  Create observational registries for low malignant potential lesions in order to better understand prognosis and best treatment options.
4. Mitigate overdiagnosis with an ultimate goal of preferential detection of consequential cancer while avoiding detection of inconsequential disease.
5. Expand the concept of how to approach cancer progression by controlling the environment in which cancerous conditions arise.

While these are certainly laudable goals, some important points should be made, especially in regards to breast cancer and ductal carcinoma in-situ – the most important being that we do not currently have biomarkers or other indicators that can clearly distinguish a potentially lethal cancer from a more indolent one. The field of cancer genomics is rapidly changing, and today more than ever, we can obtain very sophisticated prognostic information regarding an individual’s tumor. Despite that, Dr. Larry Norton, medical director of the Evelyn H. Lauder Breast Center at Memorial Sloan Kettering Cancer Center, stated “Which cases of DCIS will turn into an aggressive cancer and which one’s won’t? I wish I knew that. We don’t have very accurate ways of looking at tissue and looking at tumors under the microscope and knowing with great certainty that it is a slow-growing cancer”2.

Regarding the modern management of DCIS, there are three points to remember:
1. When DCIS lesions diagnosed by needle core biopsy are surgically removed (which involves removal of substantially more tissue from the abnormal area), there is an approximately 15% rate of ‘upstaging’ to invasive ductal cancer 3. Put another way, one cannot always reliably predict the behavior of an entire lesion based on a core biopsy specimen.
2. During surgery for DCIS, axillary lymph node metastases have been demonstrated up to 20% of the time, usually indicating missed microinvasion or invasion 4.
3. Finally, if DCIS recurs, 50% of the time it is invasive 5.

What is important to be aware of is that any woman with breast disease, including DCIS, should be presented with the information necessary so that she may gain an understanding of where her diagnosis stands in the biological spectrum and the wide array of choices she has for treatment. DCIS is far from simple, and it is not to be taken lightly. Clearly there are cases where ‘watchful waiting’ is safe – but we cannot always reliably predict who will truly benefit from treatment. Moving forward, we need to be aware of the facts – what medical technology can provide the patient and the physician now, and we need to ask how we can drive this conversation in the future.

Deanna J. Attai, MD, FACS
Michael S. Cowher, MD

14 May 2013
BRCA gene testing and prophylactic mastectomy were thrust into the spotlight when Angelina Jolie announced in May 2013 that she tested positive for a BRCA mutation and underwent preventative surgery. The interview below discusses who should be tested, and some of the issues to consider regarding prophylactic surgery.

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11 May 2013

In May 2013, I was invited to give a talk with my colleague Dr. Carol Connor at the annual meeting of the American Society of Breast Surgeons.  Our topic was “Endocrine Therapy for Breast Cancer”, and we discussed the literature supporting the use of tamoxifen and aromatase inhibitors for breast cancer, as well as adverse effects and treatment of adverse effects. We were then invited to submit a manuscript which was published in the Annals of Surgical Oncology. The following is a summary of our talk and manuscript. I would like to express my appreciation to the #BCSM Community, who responded to my request for information about adverse effects  – it allowed me to discuss not only the literature, but also real patient experiences.

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10 May 2013
Angelina Jolie’s decision to undergo a prophylactic mastectomy has prompted a lot of interest in the options available for immediate reconstruction. Unfortunately, there are a lot of misconceptions regarding the extent of surgery, the recovery time needed, and the potential for complications. The following article appeared in the New York Times on 05/10/2013 and discusses the complicated issue of breast reconstructive surgery.
By RONI CARYN RABIN
A technician helps to create a silicone gel breast implant for Sebbin Laboratories in Paris.
Benoit Tessier/ReutersA technician helps to create a silicone gel breast implant for Sebbin Laboratories in Paris.

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1 March 2013

A study published in JAMA found that there is an increase in the incidence of young women (age 25-39) diagnosed with metastatic breast cancer. Metastatic breast cancer means that the cancer has already spread outside of the breast, most commonly to the lungs, liver, bone, and brain. Metastatic breast cancer is not curable, although newer treatments have improved the survival rates.

This study evaluated the SEER Database from 1973-2009. They found that while the incidence of breast cancer in young women is low, young women are more likely to have metastatic disease when first diagnosed. One criticism of the study is that we did not have the ability to detect metastatic disease in the 1970’s like we do today. So a woman diagnosed in the 1970’s might have been thought to have earlier stage disease, when in reality the cancer was already present in other areas of the body. Today, we are more likely to use a combination of blood tests and imaging scans to get better idea of the cancer stage – metastatic disease is considered Stage IV.

The following interview discussed some of the limitations of the study, as well as recommendations for young women. All women should be aware of their breasts and their bodies. While breast cancer is not common in young women, it certainly does occur. Any changes should be reported to your physician.

The Young Survival Coalition is an excellent resource and support organization for young men and women diagnosed with breast cancer, as well as their caregivers and support team. 

 

30 January 2013

A recent study in the journal Cancer compared patients with early stage breast cancer who underwent lumpectomy with radiation to patients who underwent mastectomy, and found that the patients who underwent lumpectomy had a better overall survival.

It is important to realize that this is an “observational study”, meaning the researchers went back to older data and analyzed the results – in the case of this study, they reported on patients treated between 1990-2004. There are many factors that were not accounted for, most importantly the specific subtype of cancer. It is not clear if the patients who underwent mastectomy had more aggressive tumors, which might in part explain the difference in survival rates.

Randomized clinical trials have demonstrated that the long-term survival is equivalent for patients undergoing a lumpectomy with radiation or mastectomy – in other words – you will not live any longer if the breast is removed. This is important to remember as more women are requesting mastectomy, and even removal of the healthy breast. While there are limitations to this current study, it at least reinforces the point that more surgery is not necessarily better.

The following interview discussed some of the history of breast cancer surgery as well as a discussion of the journal study: