Breast Cancer: Treatment and Prevention
Hosted by Abigail Trafford
Washington Post columnist
Tuesday, May 29, 2001; 1 p.m. EDT
Welcome to Second Opinion, a weekly column and Health Talk discussion with Post Health columnist Abigail Trafford.
This year an estimated 175,000 women and 1,300 men will develop breast cancer. Approximately 44,000 women and 400 men will die of it. Breast cancer is the leading cancer site among American women and is second only to lung cancer in cancer deaths.
Our guest is Dr. Carolyn Hendricks, a recognized oncologist and breast cancer advocate, who will be online Tuesday, May 29, at 1 p.m. EDT, to answer your questions and comments about the treatment and prevention of breast cancer.
Hendricks participates in multidisciplinary risk assessment consultations at the Suburban Breast Center and is actively involved in clinical trials in breast cancer. She has spoken to many community groups including Race for the Cure, the Relay for Life and many breast cancer support groups. She has been seen nationally on The Oprah Winfrey Show and Montel Williams.
The transcript follows.
Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.
Hello everybody and welcome to Health Talk. Got a question about breast cancer? Send us your comments and questions.
Dr. Hendricks, welcome to Health Talk. Breast cancer is on every woman's mind. Men's, too. What have been the major developments on diagnosing and treating the disease in the last year?
Dr. Carolyn Hendricks: The most important developments in breast cancer diagnosis are occuring in the area of breast imaging. This year, there has been a tremendous amount of excitement about digital mammography and MRI imaging of the breast. In terms of breast cancer treatment, "targetted breast cancer therapy" such as Herceptin has really changed the way that oncologists are thinking about and treating breast cancer.
We hear a lot about the genetics of cancer--does breast cancer run in families? How can you find out if you have a familial risk of breast cancer?
Dr. Carolyn Hendricks: Approximately 5-10% of breast cancer occurs in families with a genetic predisposition for breast cancer. The most common known genetic changes are mutations in BRCA1 and BRCA2. It is important for women to learn as much as they can about their own family history of breast cancer to relay to their primary physicians so they can ascertain their breast cancer risk. Breast cancer that occurs on a genetic basis occurs in younger women and is more likely to be bilateral that sporadic breast cancer. Ovarian cancer is more common in BRCA1 and BRCA2 families. Male breast cancer occurs more commonly in BRCA2 families. Mutations in BRCA1 and BRCA2 are more common in families of Ashkenazi Jewish descent (with approximately 2% prevalance in this community. So, it's important to try to find out age at diagnosis, bilaterality, gender and ovarian cancer history to get the most accurate estimate of genetic breast cancer risk.
Are the death rates for breast cancer coming down? Why?
Dr. Carolyn Hendricks: An estimated 40,6000 deaths (40,200 women and 400 men) from breast cancer are expected in 2001. Breast cancer ranks second among cancer deaths in women. According to the most recent data, mortality rates declined significantly during 1990-1997. The largest decreases occurred in younger women - both white and black. These decreases are probably the result of both earlier detection and improved treatment.
The mammogram question: it's pretty clear that women over 50 benefit from mammogram screening. What about women aged 40 to 50 and younger women. What's your recommendation? And is there a danger in getting too many mammograms over a lifetime?
Dr. Carolyn Hendricks: I adhere to the American Cancer Society recommendations for mammography: women age 40 and older should have an annual clinical breast examination by a health care professional and an annual mammogram and perform monthly breast self-examination. The benefits of mammography far outweigh the theoretical risk of the radiation involved in screening and diagnostic mammograms.
A followup on mammography--should women bypass the old technology and ask to have MRI imaging or the newer digital technology? The old mammography machines had such high rates of false positives--and false negatives.
Dr. Carolyn Hendricks: Although there is tremendous excitement about new modalities to image the breast and detect breat cancer, film screen mammography remains the "gold standard." As the new techniques are introduced, it is important that they be compared directly to high quality mammography to determine whether they can improve breast cancer detection rates. In spite of the false negative and false positive rates, film screen mammography is still the best tool we have. I am strongly encouraging women to participate in clincal trials as the new modalities are introduced so the comparison data is available as soon as possible!
We tend to think of breast cancer as one disease--but aren't there many types of breast cancer? Isn't the breast cancer that strikes premenopausal women very different from the breast cancer that occurs in older women? Please explain.
Dr. Carolyn Hendricks: There are many types of invasive breast cancer, but the two most common types are ductal (about 80%) and lobular (about 10-20%). There are some types referred to as "favorable types" because the prognosis is better than with the ductal and lobular types. These include tubular, medullary, colloid and mucinous breast cancer. These types of breast cancer occur with equal frequency in younger and older women. If the important prognostic factors (size, lymph nodes, grade, and estrogen/progesterone receptor status and stage) are the same, then the prognosis for younger and older women is equal. Unfortunately, younger women have a tendency to be diagnosed with more advanced stage disease and so can have a worse prognosis on that basis.
Another mammogram question that I get all the time: why does it hurt so much? Would men stand for a similar kind of screening tool?
Dr. Carolyn Hendricks: Film screen mammography can be uncomfortable because there are a lot of nerves in normal breast tissue and compression of the breast tissue is required for good imaging. It's important for women to communicate their concerns about breast pain with mammographic imaging to the technician doing the study. The best technicians are very sensitive to the breast pain that can be associated with the procedure and help to minimize it. On rare occasions, men do need to undergo mammography for evaluation of breast masses and diagnosis of breast cancer. I imagine they have the same concerns.
Please explain the significance of estrogen/progestin receptors? How does that influence treatment and prognosis?
Dr. Carolyn Hendricks: Estrogen and progesterone receptors are proteins that are found on the surface of all normal breast cells and some breast cancer. When a breast cancer stains positively for the estrogen and progesterone receptors, the prognosis is more favorable than if it does not. If the tests are positive, then tamoxifen (which targets the receptors) can be considered as a form of treatment to reduce the risk of recurrence or to treat advanced disease. Whether women have taken oral contraceptives or hormone replacement therapy does NOT influence the results of the estrogen and progesterone receptor tests.
What about alternative remedies? Where do they fit in with the treatment of breast cancer?
Dr. Carolyn Hendricks: Alternative and complentary therapies are very commonly used by breast cancer survivors (on average 2 or 3 are explored during treatment). These range from dietary changes, nutritional supplements, accupuncture, and many, many others. Alternative and complementary therapies help breast cancer survivors take an active part in their care. Many of them are directed at relieving the side effects of surgery, chemotherapy, and radiation. They help women cope with treatment. There are very few examples of alternative/complementary therapy interfering with the effects of treatment. I encourage women to speak openly about it to their physicians and to network with other survivors for support in pursuing them.
What is the story on bone marrow transplants for women with advanced disease. There was so much hope. . . . and then the studies came out that they did not improved recovery.
Dr. Carolyn Hendricks: Bone marrow transplantation for breast cancer is the administration of high dose chemotherapy with "rescue" by stem cells from the bone marrow or peripheral blood. When it was first developed, the theory was that standard dose chemotherapy could not cure women with advanced disease but escalating the doses might achieve a cure. In spite of the enthusiasm by oncologists and patients, so far, high dose chemotherapy is no better than standard therapy for advanced disease, only more toxic. Bone marrow transplantation remains an active area of research, but I encourage women to pursue it only in the context of a clinical trial.
Should all women with breast cancer go to a comprehensive cancer center to get treated--rather than to their local community hospital? If so, why?
Dr. Carolyn Hendricks: Breast cancer is so common with an estimated 192,200 new cases expected in 2001 that most women are treated in the community setting. In our community, the quality of mammography, breast surgery and radiation is very high. I think it is important for physicians who practice in the community to maintain ties with their comprehensive cancer centers (for example Johns Hopkins and Lombardi), so they are up to date in terms of treatment recommendations. Fortunately, new information about breast cancer treatment is typically disseminated very widely and rapidly to community physicians and their patients. For second opinions on radiology, pathology or treatment, or when there are significant differences in the opinions rendered by community physicians, the comprehensive cancer centers are ideal.
Is is harder to detect lumps if you have bigger breast. I am a D cup. I have asked about the viens and other things I feel during my self exam, and have been told that I have normal breat tissue. But should I be more careful because I my breasts are bigger?
Dr. Carolyn Hendricks: Large breast size does not increase the risk of breast cancer. For women with larger breasts, it is important to feel comfortable with your own normal exam. If you have concerns, have your physician or other health care provider help you perform a breast exam during a visit. Many of the breast centers in this area also have nurses who are trained to teach self-examination. Keep doing self-examination until you are comfortable with your breasts!
Dr. Hendricks, what do you think is the current status of HRT after breast cancer? I am 5 years out from DCIS and 15 years out from endometrial CA, both stage 0 cancers. I was on HRT for 9 years during the intervening period. Both my gyn and I are convinced that estrogen will be rehabilitated with respect to breast cancer. With the recent study from the National Cancer Institute, would you say that that has that happened? I believe strongly in the health benefits of HRT, and if I had 3 days to live and HRT were cleared for breast CA survivors, I swear I would ask for a 3-day prescription.
Dr. Carolyn Hendricks: The relationship between hormone replacement therapy and breast cancer is a very complicated one! Prolonged exposure to hormone replacement therapy (particularly more than 10 years) is known to increase breast cancer risk. For that reason, physicians (particularly in the U.S.)have been reluctant to prescribe HRT to survivors for fear of increasing their risk of recurrence. However, short term HRT (for example 2 or 3 years for the management of menopausal symptoms) is not associated with any known cancer risk. Physicians in Europe have been fairly liberal in prescribing HRT to their survivors (even in combination with tamoxifen), but there has been significant reluctance in the US to do so. The new reference you mentioned is changing the way US physicians think about HRT for survivors. It is still very controversial, but the limited studies done so far do no show any harm associated with it. I have recommended very short course HRT in survivors who have very severe menopausal symptoms, but so far have not recommended longer term use.
My mom is 3 years in remission of breast cancer. Had a mastectomy instead of radiation and chemo. She is pre-menapause. Obviously my risk is high of getting breast cancer, but what can I do at the age of 31 to help myself? Is it too early for a mamogram? Thanks for your help! Some day we will beat this disease!
Dr. Carolyn Hendricks: I would recommend that you do monthly self-examination and have a clinical breast examination once or twice yearly. For women with a family history of breast cancer, mammography should be started ten years younger than the youngest women in the family is diagnosed, or at age 40 which ever is earliest. These recommendations may change over time.
Someone just told me that underwire bras cause an increase in breast cancer risk because they interfere with the workings of the lymphatic system. I have heard this before, but have never seen any studies on this, so I don't know if it's true or not. Is it?
Dr. Carolyn Hendricks: In spite of a tremendous amount of research, the cause of breast cancer is not known. What is known with 100% certainty, however, is that underwire bras are not related in any way to breast cancer risk. Please spread the word!
What are the major risk factors for the development of breast cancer?
Dr. Carolyn Hendricks: The major risk factors for breast cancer are age, a personal or family history of breast cancer, biopsy-confirmed atypical hyperplasia or lobular neoplasia, a long menstrual history (menstrual periods that started early and ended late in life), obesity after menopause, recent use of oral contraceptives or postmenopausal hormone replacement therapy, never having had a child or having a first child after age 30 and the daily consumption of alcoholic beverages (two or more per day).
Is the incidence of breast cancer going up? Why?
Dr. Carolyn Hendricks: An estimated 192,200 new invasive cases of breast cancer are expected to occur among women in the US during 2001. After increasing about 4% per year in the 1980s, breast cancer incidence rates may be continuing to increase slightly in white women. In addition to invasive breast cancer, 46,400 new cases of in situ breast cancer are expected to occur among women during 2001. Of these, approximately 88% will be ductal carcinoma in situ. The increase in the detection of DCIS is a direct result of increased use of mammography screening, which is also responsible for detection of invasive cancers at a less advanced stage than might have occurred otherwise.
How many men get breast cancer? Should they check themselves the same way women do?
Dr. Carolyn Hendricks: About 1,500 new cases of breast cancer are expected to be diagnosed in men in 2001. Typically, breast cancer in men presents with a lump in the breast.
Will there be a cancer cure in our lifetime?
Dr. Carolyn Hendricks: I hope that there will be. The best hope for a cure for breast cancer is at the level of basic science research to determine the cause of breast cancer. There have been very significant strides in terms of determining the steps involved in the development of colon cancer, so I'm hopeful that some of that research will spill over into the area of breast cancer research.
I have read some recent studies that say diets high in tomatos and tomato products reduce the risk of some cancers. Is this also true for breast cancer? Is there a viable preventative diet that a high risk woman can adhere to?
Dr. Carolyn Hendricks: Surprisingly little is known about diet and breast cancer risk. A variety of fruits and vegetables in the diet has been shown to reduce cancer risk in general, so I encourage survivors to try and get at least five servings daily. A diet that is very high in one fruit or another would not be beneficial. It is important to get micronutrients from a variety of food sources to derive benefit.
I appreciate the great strides made in your field, particularly as someone with a mom who's six years past surgery without a recurrence but I wondered, at the time that happened in l995, I got a lot of mailings from people like American Cancer Society saying things like "so I guess you'll give now"? Isn't that ghoulish and do they do that a lot? I didn't just out of principle.
Dr. Carolyn Hendricks: There are so many organizations that support cancer research and request donations that it's hard to single out the American Cancer Society. I'm thrilled that your mother is now a long term survivor.
Let's talk about the politics of breast cancer. Women advocates have been very successful in getting research dollars and changing treatment. Some critics say, too successful in that the focus on breast cancer for women has distracted attention on bigger killers such as heart disease. What's your answer?
Dr. Carolyn Hendricks: Because my medical practice is focused on breast cancer, I rely heavily on the research dollars that are devoted to breast cancer to improve the treatment that I offer my patients. It is true that lung cancer has long surpassed breast cancer as the number one cause of death in women, but in my view the politics of lung cancer are far more influential than in breast cancer. I focus on breast cancer primarily because there is such a tremendous interest from many sources, and I hope it continues.
If you have a friend or family member who is diagnosed with breast cancer, what can you do to help them the most?
Dr. Carolyn Hendricks: Friends and family form a backbone of support for breast cancer survivors, right from the time of diagnosis. The best ways to help are to accompany women through the process of diagnosis and treatment, to serve as a "navigator," or to help women with homecare and work needs while they navigate the process on their own. I am always concerned when a new patient comes in for consultation alone. It is a very isolating and frightening experience. If a woman brings family and friends to the consultation and treatments, then I know she is well supported.
Are you involved with Race for the Cure?
Tell us about the Race for the Cure and its purpose.
Dr. Carolyn Hendricks: I have walked in both the National Race for the Cure and the Baltimore Race for many years. The Susan B. Komen Foundation uses the funds from the Races to support breast cancer outreach and research in our community. I have received grant money to to breast cancer research that was raised through the Races. I have also participated in some terrific breast cancer symposia in Baltimore and Washington, D.C. that are funded by the Races. I hope to see you on Saturday!
Our time is up. Thank you Dr. Hendricks. Thank you all for your questions. We'll talk about this again soon.
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