More than 230,000 American women and almost two million women worldwide will be diagnosed with breast cancer this year.
Of that number, 40,000 American women and more than 500,000 women around the globe will die from the disease that has become these condleading cause of death for women in the United States.
These women will come in all shapes, sizes and ages; some will have children, some won’t; they will come in all colors and speak many different languages; some may be neighbors, or they may be separated by thousands of miles—but as diverse as they may seem, they are very much the same, sharing a common hope that someone, somewhere will discover a cure for their illness.
The National Cancer Institute, a component of the National Institutes of Health, spends almost $5 billion each year for cancer research, and breast cancer research receives more funding than any other form of cancer. What direction is breast cancer research heading, and what are the most promising avenues for discovering a cure or prevention?
NCI Director, Harold Varmus, speaking to the U.S. House of Representatives concerning new avenues of cancer research said, “To make ‘precision medicine’ a reality in cancer treatment, the NCI is reorganizing the conduct of its clinical trials to include genetic characterization of each patient’s tumor and reference to large databases of clinical information to guide the choice of drugs to be tested.”
Personalized Cancer Care
One of the main components of precision medicine is customized, individual care that takes into account not only the type of cancer present but every aspect of the individual affected, all the way down to her DNA. Oncogenomics, the field of research dedicated to identifying cancer-causing gene mutations specific to each of the 200 known types of cancer, is leading the way to tailored therapies that will be as individualized as a patient’s fingerprint.
The Cancer Genome Atlas, which was started in 2005, when completed, will have a tremendous impact on the early detection, prevention and treatment (especially the use of targeted therapy) of all types of cancer. To date, researchers have discovered five separate gene anomalies associated specifically with invasive and in situ ductal carcinoma, and these discoveries are stimulating further research into how to cure and prevent this type of cancer. This is significant because invasive ductal carcinoma is responsible for between 50 and 75 percent of all invasive breast cancers.
Although chemotherapy has been around for more than 60 years, the medications and combination of medications being administered is constantly being modified. Chemotherapy acts by inhibiting the growth and survival of cancer cells. The major drawback to this therapy is that it also similarly affects the body’s healthy cells, which leads to unpleasant side effects such as hair loss, nausea, fatigue, etc. The biggest breakthroughs recently have come in the production of medications that can dramatically reduce these side effects.
Targeted therapy is arguably the most promising of all cancer therapies for the near future. The bulk of cancer research funding is presently being used to produce targeted-therapy medications. Using information gleaned from genetic studies of cancer formation, targeted therapy drugs zero in on specific cancer cells while having no effect on healthy cells anywhere in the body. Any side effects are fairly mild, and this group of drugs, unlike traditional chemotherapy medications, aren’t toxins designed to kill cells. Instead, these medications are designed to bind with cancer cell receptors, thereby inhibiting growth and replication.
Types of targeted therapies include apoptosis inducers, immunotherapy, gene modulation, angiogenesis inhibitors and signal transduction inhibitors.
Over three-fourths of all breast cancers are hormone-positive (tumors that are fueled by estrogen or progesterone), and hormonal therapy is a specific type of targeted therapy used for women diagnosed with this type of breast cancer. This type of therapy is designed to lower hormone levels in the body and thereby slow or completely stop the growth of existing tumors.
This works several different ways. Certain medications diminish ovarian production of estrogen by blocking stimulating signals sent to the ovaries by the pituitary gland. Other medications block estrogen production by inhibiting the actions of the enzyme aromatase, which is vital to building estrogen in the body.
A group of medications called selective estrogen receptor modulators (SERMs) bind to estrogen receptors on the tumor itself, blocking any estrogen from binding with the tumor and fueling its growth. (Tamoxifen is the most recognized drug name in this group.)
A newer drug, Fulvestrant, is an estrogen receptor downregulator that not only binds to the estrogen receptor and blocks it but also destroys the receptor. It is administered by monthly injection. (This therapy is only available for postmenopausal women.)
Aspirin As A Therapy?
Recent research has shown that non-steroidal anti-inflammatory drugs, such as aspirin, lower the risk of breast cancer recurrence in obese postmenopausal women. Meta-analysis shows that premenopausal obese women have a slightly lower risk of having breast cancer, and, paradoxically, postmenopausal obese women have a higher risk. This increased risk may possibly be lowered through regular aspirin use in women who have been previously diagnosed with breast cancer (possibly more so for hormone-positive cancers). These findings are currently being scrutinized, and women are warned against self-medicating. Please consult your physician for more information concerning aspirin therapy.
Too Young For Breast Cancer
In 2002, Tobey Phillips was diagnosed with breast cancer at the age of 24. The lump in her right breast was discovered during a routine gynecological exam by her physician, Dr. Tara Connor.
Following a mammogram and a follow-up ultrasound, the tumor was removed during an excisional biopsy, and it was determined she suffered from hormone-positive ductal carcinoma in situ (DCIS).
In situ means “in place” signifying that this form of cancer, which formed in the milk duct, had not spread to outlying breast tissue. This is the earliest stage and most easily treated of all breast cancers. What made this diagnosis unusual is that it was hormone-positive, meaning that the cancerous cells were being fueled by the presence of either estrogen or progesterone in Tobey’s body.
The tumor was located on the far right side of Tobey’s breast near her armpit and because of its proximity to her lymph nodes, doctors decided to perform a lymph node dissection two months later. The dissection showed that her lymph nodes were clear but in an effort to make sure the cancer would never return, her doctors decided to treat her with 10 weeks of radiation therapy.
“When I heard the initial diagnosis, I really didn’t know what to think,” Tobey says. “For the next two months, life was just a blur. As time went on, there were many times that I was sad or angry. Angry at the fact that this happened to me,” she says, her voice taut with emotion. “All my girlfriends were leading ‘normal’ lives, and I wasn’t. I was sick. Why couldn’t I just be normal like everyone else? But, being a spiritual person, I also realized that something good would eventually come out of this. Somehow I would learn from it and benefit from the experience of breast cancer.”
Following radiation treatments, which left her with a side effect similar to a severe sunburn, Tobey lived cancer-free for seven years. Although the cancer left her with physical scars, the worst scar was emotional when doctors told her she couldn’t risk getting pregnant because the increase in hormones that accompany pregnancy could trigger a recurrence of breast cancer.
“I would attend baby showers for my friends, and I would come home and sit down and cry,” she says. “I love children, and I wanted children of my own. Instead I just became ‘Aunt Tobey’ to everyone else’s children, and it was very hard to accept that I would never be a mother.”
The biopsy, which had extra margins, left Tobey with the need to wear a slip-in prosthetic in her bra, and she decided in 2009 to have a breast reduction performed on her left breast to make her breasts more even in size. During a follow-up visit, the plastic surgeon felt something unusual in her right breast, and she was sent for a needle biopsy.
The biopsy came back positive for atypical ductal hyperplasia (ADH), a precursor to breast cancer, and doctor’s recommended a double mastectomy.
At the time, Tobey was in a serious relationship and she thought the diagnosis and subsequent surgery would surely end the couples’ hopes for the future. It didn’t. Her then-boyfriend supported her in every way.
“Casey told me that he didn’t love me for my breasts… he loved me. He said he knew what I went through with the first diagnosis and that he didn’t care about my breasts, all he cared about is that I was there next to him. He was absolutely wonderful.”
Just prior to the surgery, Tobey and Casey were married. Following the double mastectomy, doctors surprised her with the news that she and Casey could then have children. The couple decided to have one child. Their son, Casey Jr., was born in 2012.
“When I was first diagnosed with this, I just knew that something good would come from it and look at the blessings I have now. I have a wonderful husband and a beautiful son. What more could I have asked for?” she says.
Too Healthy For Breast Cancer
“While I’m here, can I get a prescription to have a mammogram?” she asked, almost as an aside. “Sure, we can take care of that,” her physician answered.
And that short exchange almost assuredly saved 35-year-old Lynn Sardinas’ life.
Mistakenly, Lynn thought that present National Institutes of Health guidelines suggested women begin having regular mammograms at 35 years of age. Actually, the guidelines suggest they start at 40.
Shortly after her screening mammogram she was called back to have another mammogram performed on her right breast, followed by an ultrasound and then a biopsy. The biopsy showed that Lynn had two types of breast cancer: high grade ductal carcinoma in situ (DCIS) and Grade 3 infiltrating ductal carcinoma (IDC).
“When I tell someone that I have breast cancer, it doesn’t sound real. It’s seems as if I am talking about someone else,” Lynn says “I’m too healthy to have breast cancer. The hardest part for me is that I have no symptoms, no pain, no anything… I’m going to have major surgery and lose both breasts and I feel as if I’m not sick at all. It is hard for me to wrap my head around this thing.”
Lynn is a mother of two with no family history of breast cancer. She works out regularly, maintains a healthy diet, doesn’t smoke or use recreational drugs and only has an occasional alcoholic drink.
Even though she is healthy in all other respects, the grading of both types of breast cancer indicate it will have a tendency to spread. This was a major factor in Lynn’s decision to have a double mastectomy.
“I opted for a double mastectomy because I don’t want to go through this again and I don’t want to put my family through this again,” she says. “I only want to go through it once. This will take the fear of having breast cancer again totally away. I won’t have to have a mammogram done every year and wonder if it will show that I have breast cancer in my left breast.”
Lynn has chosen to have oncoplastic surgery, which is two surgeries in one. She will have both breasts removed and a sentinel lymph node biopsy performed… and have skin stretchers inserted to immediately begin the reconstruction process. Once the skin has been stretched to the breast size of Lynn’s choosing, she will receive breast implants and then have nipple reconstruction surgery. The entire process can take up to one year.
One unknown that Lynn is facing with her upcoming surgery is whether or not she will have to undergo chemotherapy.
“The doctors told me that only after they biopsy the breast tissue, tumor and the surrounding lymph nodes will they be able to determine if I need to take chemo or not,” Lynn says. “To be honest, I am far more concerned with chemo than with having the mastectomy. I know that chemo may be necessary to completely rid me of cancer, but it is hard to accept putting those toxic chemicals inside my body.”
Lynn is also concerned about how her children, Tyson, 5, and Ava, 21 months, will react to her illness… especially Tyson.
“Tyson is a very sensitive child, and he just started kindergarten in August. This means there will be a lot of sudden changes in his life. I know that he will be worried when he sees his mommy lying in bed unable to hold him or take care of him,” she says with emotion in her voice. “I have read that it takes four to six weeks to recover, but I hope to be back taking care of my children in three.”
In light of her early detection, Lynn suggests that every woman begin having annual mammograms at 30 years of age.
“If I hadn’t had a mammogram until I was 40, I might not have been alive to have one,” she says. “I think every woman should have a baseline mammogram at 30, and if all is clear, she should start having annual mammograms at 35. It’s like my doctor told me, ‘We can never be sure how long it takes for cancer to develop. It could start at 35, and you could be dead at 36.’”
Editor’s note: Lynn underwent a double mastectomy on August 22. The surgery went well and her surgeon biopsied one lymph node. The biopsy came back negative, and physicians will determine soon if Lynn will be required to undergo chemotherapy and/or start a regimen of hormone therapy for an undetermined time period.
Sources: ncbi.nlm.nih.gov, cancerres.aacrjournals.org, cancer.gov, komen.org