Breast Cancer: 10 Years of Progress

10 Years of Research

Janice Fine, a breast cancer
survivor, describes the size of the
tumor in her breast.

She'd felt it. She'd urged doctors to treat it. But it wasn't until she was told that that the 7-centimeter mass inside her left breast was cancerous that Janice Fine felt she was about to face something truly ominous. Hearing the word "cancer" sent her reeling. "Having lost my mother to cancer, and hearing that I had cancer, confirmed my deepest fears," she says today.

But Fine, 43, is now an official 10-year breast cancer survivor and the subject of a new documentary, One in Eight: Janice's Journey. The Bostonian has had no recurrence of the carcinoma for which she was treated with surgery, radiation, and chemotherapy in the early months of 1994. And she is more than a single success statistic.

The last decade has seen improvements in the prevention, diagnosis, and treatment of breast cancer -- and in the amount of money being spent on research. What's more, the breast cancer movement -- the grass-roots efforts by women to see that the disease commands the attention of policy-makers, drug companies, and physicians -- has burgeoned since Breast Cancer Awareness Month was born 20 years ago. The Internet has enabled women from far-flung locations to meet one another virtually and stay in touch, sharing critical information, advice, hope, and well wishes. At the same time, corporate America, from cosmetics chains like Sephora to Fortune 500 companies like 3M to smaller convenience store chains such as Wawa have contributed money, ideas, and products to help individual women and the breast cancer movement. Authors committed to breast cancer awareness have worked with publishers and TV stations to create huge events around the release of their books. And dozens of celebrities have gotten involved in projects as creative as breastcancer.org's Celebrity Talking Dictionary, which helps women learn to say and understand the complex medical terms they need to speak intelligently with their doctors.

"Twenty years ago people wouldn't even say the words 'breast cancer,'" says Nancy Brinker, founder of the Susan G. Komen Breast Cancer Foundation, a leading advocacy organization. "While there is still more work we can do, we have come a very long way in the fight to bring awareness and early detection to top of mind."

According to Marisa Weiss, MD, president and founder of breastcancer.org, a nonprofit organization of medical experts that distributes free, up-to-the-minute information on breast cancer diagnosis and treatment over the Internet, "Women today are busier than they've ever been before. No one has time to get breast cancer. So what women are doing today that they were not able to do in the same ways five years ago is arm themselves with medical information, connect, support each other, and lobby to conquer this disease." The Internet is making such connections possible, says Weiss, who is also a breast radiation oncologist practicing in the Philadelphia area.

Weiss says that the amount of information on breast cancer has doubled in the past 10 years and will double again in the next five, making rapid, fluid communication among women and their doctors more critical than ever. "Gone are the days of Saturday conventions for women to gather and talk about breast cancer," says Weiss. "Women want a 24-7 medical resource, and they want to be able to speak to each other, virtually, any time of day and night."

Activism

In the last few years, efforts to push for more research and to contribute to the cause have surfaced in myriad forms from around the world. Some examples:

After learning breast cancer spread
to her brain, Florence Mink (left)
welcomed 22 breastcancer.org
friends to the New Jersey
shore in 2004.

• 3M this year will erect what the company is calling the World's Largest Pink Ribbon in Times Square, New York City -- a sculpture of sorts that will stand over 70 feet tall and consist of more than 75,000 pink Post-it notes. The sculpture will be unveiled during the first week of October, and 3M will donate $1 to City of Hope Cancer Center in California for each of the first 75,000 people who sign up to show their support for "sticking up" for breast cancer.
• The Susan G. Komen Foundation's Race for the Cure Series this year will include 110 runs and fitness walks across the United States, plus two overseas events, and will draw more than 1.4 million participants. In 1983, the first Race for the Cure in Dallas, Texas, attracted 800 people.
• Last fall, breastcancer.org debuted its Celebrity Talking Dictionary, for which 59 celebs, from Celine Dion to Courteney Cox, pronounce and define more than 1,000 breast cancer medical terms, then talk about the power of knowledge in making decisions with their physicians.
• The new biography, Why I Wore Lipstick to My Mastectomy (St. Martin's Press, October 2004), by Geralyn Lucas, will be published in conjunction this fall with "courage nights" on October 21 in Betsey Johnson stores and other venues around the country. Lucas lost her right breast to cancer at age 28, just months after landing her dream job. But she went on to have a baby and breast reconstruction, opting for a heart tattoo in place of a new nipple. Courage nights are meant to empower women of all ages while they shop for the breast cancer cause.
• To help raise money, more cosmetic companies than ever are donating a portion of their proceeds from the sale of specially created items, as well as existing favorites, for breast cancer research, prevention, and treatment. Joining beauty giants Estee Lauder and Avon, who together have raised over $392 million, are Aromafloria and Essence of Heaven, two up-and-coming cosmetic companies. Sephora, the cosmetics company, also is releasing a range of products -- from a pop-up travel brush to Heart-to-Tarte lip balm -- from which profits will go to various breast cancer awareness and support organizations. Fund recipients include the Breast Cancer Research Foundation, which has raised over $92 million in the last 10 years, and the Susan G. Koman Breast Cancer Foundation, which has raised $600 million since 1982. Likewise, since 1982, the Avon Foundation Breast Cancer Crusade has contributed over $300 million in funds.
• Weiss' heartfelt and humorous performance-speech, "How to Talk to Your Doctor: A Guide to Creating a Great Doctor-Patient Relationship," will be available online and in VCR and DVD formats through breastcancer.org this fall. In the video, Weiss strips from her doctor's coat down to a patient gown while telling women how to speak to their doctors about breast cancer, has been given to tens of thousands of women worldwide, and will be available online and in VCR and DVD formats through breastcancer.org this fall.
• This October 28 marks the fifth annual "WomenRock! Songs from the Movies," a TV concert event dedicated to raising awareness of the fight against breast cancer.
• Ford, the automaker, has united with celebrities Claire Danes, Demi Moore, Jennifer Connelly, and Mary Blige, to create and market a limited-edition silk scarf designed by Lilly Pulitzer that invites women to "put the brakes" on breast cancer. Eighty-five percent of proceeds will go to the Komen Foundation.
• Meanwhile, thousands of women from all 50 states and around the world have sewn 24,504 quilt blocks and assembled 400 quilts as part of the American Patchwork & Quilting 2004 Quilt for the Cure Quilt Block Challenge. The quilts of all sizes, primarily in pink and white, will be auctioned on eBay during October 2004 to raise money for breast cancer research.
  
  "We are so thrilled and touched," said Executive Editor Heidi Kaisand (the quilting magazine is owned by Meredith Corp., which also owns LHJ.com). "And it wasn't just the tremendous number of squares that touched us, but also the stories and messages that were sent along with their works." Quilt blocks came from Girl Scout troops in Maine and from distant corners of the globe, many with highly personal notes about how the sewers' own lives or those of loved ones had been touched by breast cancer. For instance: "Please help Aunty Kim," said the note pinned to one block. One quilt shop in Humble, Texas submitted 901 blocks for the project.

And in recent years, individual women, from tiny towns and major metropolises, have gone public on Internet message boards, a practice almost unthinkable less than five years ago. For instance, with less than a week's notice, 22 cyberfriends of Florence Mink, 53, of North Wildwood, New Jersey, convened at the Jersey shore for a week this past June to support her through treatment for breast cancer that had just spread to her brain. "It was the most wonderful thing," says Mink, who is now undergoing one regimen of chemotherapy to attack the cancer in her brain and another because the cancer has metastasized to her bones. "These were women I'd never met in person, and the outpouring of friendship was truly overwhelming." Mink organized parties, gourmet dinners, casino trips, and dancing; her cyberfriends, all battling breast cancer, range in age from 19 to 67.

Other women have organized charity events to celebrate the lives of loved ones battling the disease. For the past eight years, the family of Debbie Osborne, 49, of Glen Mills, Pennsylvania, has hosted a charity bike ride for family, friends, and bikers far and wide. They have raised more than $50,000. "I can either plan my funeral or work to help plan events like this," says Osborne, a registered nurse whose sister-in-law, Nancy, started the event with 30 bikers; this October, more than 100 will participate. "It's a terrible disease, but I just try to put my scared and frightened thoughts in a dark corner and stay positive and hopeful, trying to help other women." Adds her sister, "It's a day of fun, fellowship, laughter, and family. The fundraising is secondary."

The advocacy movement also has spawned petitions in Congress. Last September, for instance, Lifetime Television delivered more than 5 million petition signatures to Capitol Hill, urging Congress to ban so-called "drive-through" mastectomies -- the practice in which women are forced out of the hospital sometimes only hours after breast cancer surgery.

Numerous organizations now distribute awards to survivors, researchers, physicians, and treatment facilities that are passionately committed to the cause of finding a cure for breast cancer.

Experts are chagrined that there still is no cure, or cures, for breast cancer -- still the leading killer of women between 35 and 50 years of age. But they see immense hope in the decade to come with the mapping of the human genome and the study of so-called protein profiles (proteomics) that may allow the development of new screening tools and targeted therapy that will move patients away from more radical procedures and toxic treatments.

Progress

Breast cancer patient Debbie
Osborne and her husband, Stephen
ride in the family's annual biking
event to celebrate life, family,
and breast cancer awareness.

"To some, the last 10 years may appear to have been sluggish," says Susan Braun, president and chief executive officer of Komen. "But what we've been doing is creating the base of science and information technology and public awareness that will be the springboard from which immense progress will come in the next 10 years."

Adds Dr. Carolyn Runowicz, 53, a breast cancer survivor, gynecological oncologist, member of the President's National Cancer Advisory Board, and Director of the Neag Comprehensive Cancer Center at the University of Connecticut, "We've made major progress in the past decade, but breast cancer is a major and unmistakable health problem in this country. We've made strides but we still see way too many women presenting with advanced stages of the disease. Too many people still are dying."

In fact, the number of deaths each year from breast cancer has declined about 10% since 1996 (from 44,300 to the current 40,110) according to data from the American Cancer Society. However, the number of cases diagnosed has risen -- from 184,300 in 1996 to an estimated 215,990 this year. This may be the result of better diagnostic techniques and early detection.

Growing most rapidly are the number of cases of ductal carcinoma in situ (DCIS), a form of breast cancer in which the tumor has not spread beyond its borders into lymph or other systems. And the number of DCIS cases is expected to grow rapidly as diagnostic techniques continue to improve.

Current data suggest that, based on living to the age of 85 to 90 years, the lifetime risk of developing breast cancer among American women is 1 in 7, up from 1 in 10 two decades ago. "That sounds discouraging," says Braun of the Komen Foundation. "But we think it will level off."

The good statistical news is that survival rates are improving. According to American Cancer Society data, 87 percent of women are still alive five years after diagnosis; 77 percent after 10 years; 63 percent after 15 years; and 52 percent after 20 years.

Research funding for breast cancer, meanwhile, has skyrocketed. Between the National Cancer Institute and the Department of Defense, the federal government this year will spend nearly $800 million on breast cancer, double the amount spent 10 years ago, according to federal statistics. Strides have been made in every phrase of the disease, doctors and patients agree, from prevention and education to diagnosis and treatment.

"The advocacy movement can take a great deal of the credit for the increase in funding," says Weiss. "Women care passionately about this disease, which robs them of life in the prime of their life. They want the cure and they want it now."

Prevention

Being a woman and aging are the two of the strongest risk factors for developing breast cancer. But beyond that, most cancers remain inexplicable, experts say. Even where a woman has a known risk factor, such as possessing the BRCA1 or BRCA2 gene mutation, such cases account for only 10 percent of breast cancer diagnoses, Runowicz notes (99 of 100 breast cancer patients are women). So, an increasing amount of energy and effort are being put into understanding the causes of breast cancer in seemingly healthy women.

"There still just aren't too many things we can tell a healthy average-risk woman to do," Braun notes. "Eating a balanced diet, limiting stress, exercise -- these are important, but we have not proven definitively that even these things reduce risk. They just make common sense." Eliminating alcohol and tobacco are more strongly linked with reducing risk, but these, too, have limited impact, Runowicz says.

One development in the last five years is the creation of the Mitchell Gail breast cancer prediction model, which allows healthy women to assess their risk of developing breast cancer based on a variety of factors. A specific diagnostic technique, ductal lavage, can further characterize a patient's risk by testing cells in the fluid of the breast ducts. However, this procedure is still undergoing assessment, and practitioners generally use it only in high-risk patients such as those with an elevated score on the Mitchell Gail model.

The most intent focus of work in preventing breast cancer is directed at women who have already had one breast tumor or who have a strong family history, or a known genetic mutation, such as the BRCA1 or BRCA2 mutation. One preventive technique that is gaining popularity is risk-reducing mastectomy, the removal of the breasts as a preventive measure. A 2001 study reported by the Mayo Clinic showed a reduction in recurrence of roughly 90 percent when this procedure was performed on high-risk patients. "And it's becoming more cosmetically acceptable to women, especially with modern day reconstructive techniques," notes Braun.

Another radical preventive procedure for premenopausal women with known high risk of developing breast cancer -- for example, the BRCA1 or 2 mutations -- is risk-reducing oophorectomy, the removal of a woman's ovaries. Reducing ovarian function is thought to reduce breast cancer risk by blocking the amount of estrogen in the blood.

Modulating the amount of estrogen is also the goal of the drug tamoxifen, which has been on the market for 20 years and is primarily used to prevent breast cancer recurrence. It also has been approved in the last decade in the prevention of cancer for high-risk women. But soon a new clinical study, code-named STAR, is to report results on the efficacy of tamoxifen compared to the osteoporosis drug raloxifene in reducing the chance of developing breast cancer in postmenopausal women who are at increased risk. The STAR study, involving 19,000 women, is also examining whether raloxifene may have fewer side effects than those from tamoxifen -- notably, vaginal discharge and uterine cancer.

"There is no doubt in my mind that prevention is the key to solving breast cancer," says Runowicz, who will become president of the American Cancer Society in November 2005. "We will make improvements in enhancing treatment and diagnosis, but an ounce of prevention is truly worth a pound of cure."

Diagnosis

Though mammography remains the gold standard for breast cancer screening, doctors are now armed with a sizeable array of new diagnostic options, especially for high-risk women.

• Digital Mammography: Most exciting, doctors say, are the increasingly high-tech options for diagnosing breast cancer. First, there is some interest among clinicians in digital mammography, which, in addition to possible diagnostic benefits, allows physicians to transmit mammograms over the Internet. This technology, experts say, is especially useful in pockets of the country that do not have highly trained diagnosticians to read mammograms, so digital x-rays can simply be forwarded to screening centers. But digital mammography is still very costly, and research has not yet show definitively that it is a more effective diagnostic technique than conventional mammography.
• Ultrasound: In addition, ultrasound is now being used to help distinguish cysts from tumors, thereby preventing invasive, unnecessary surgeries and follow-up procedures. This technique also is thought to be helpful in diagnosing tumors in dense breasts -- dense breasts are especially associated with younger women -- that do not visualize well on more conventional screening tools, like mammography.
• MRI: Another tool, MRI or magnetic resonance imaging, is being used in women at high risk for breast cancer, and has been shown to be a highly effective screening tool. "The negative is it picks up everything," says Runowicz.
• PET Scans: A fourth technology, positron emission tomography or PET scan, also is being tested in women at high risk, though it is expensive. PET scans study the increased uptake of glucose or sugar by tumor cells. The increased uptake is due to the increased metabolic action of the tumor cells. Areas of higher activity on the scan suggest problems in the breast to which doctors can be especially attentive.

But by far the most exciting breakthrough in diagnosis -- one that is sparing needless invasive surgeries -- is sentinel node biopsy, a procedure that has become commonplace in the last decade and has replaced radical lymph node dissections. Traditionally, if a breast biopsy showed cancerous cells, a woman would be brought in for surgery to remove 10 to 15 lymph nodes under her arm. This invasive procedure often required two or three weeks of recuperation. Now, research has shown that the sentinel lymph node is the first to witness a breast cancer spread. So, using dyes and radioactive compounds to identify the sentinel node, doctors can remove only those nodes to determine if the cancer has spread. If the cancer hasn't hit the sentinel node, it hasn't hit the rest of the nearby lymph tissue. On the other hand, if the sentinel node shows evidence of cancer, then the more invasive procedure of removing all of the lymph nodes is done. Removing only the sentinel lymph node can allow breast cancer patients to avoid many of the complications and side effects associated with the traditional so-called axillary lymph node dissection, such as lymphedema (tissue swelling).

Treatment

Chemotherapy is still a treatment option for most types of breast cancer, but it is being used in more creative ways, depending on how advanced a woman's cancer is and the type of cancer doctors believe she has. In women with early breast cancer, chemotherapy is sometimes used after surgery and radiation to eliminate cancer cells that might still be in the body. In women with locally advanced breast cancer, chemotherapy is given prior to surgery to reduce the size of the tumors in the breast and lymph nodes. And in women with metastatic cancer (cancer that has spread), chemotherapy is used to decrease the number of cancer cells elsewhere in the body, to reduce cancer-related symptoms, and to prolong survival. You can learn more about the "alphabet soup" of the various chemotherapies at breastcancer.org.

But even chemotherapies are changing radically. In the last decade, the expansion of the taxane class of drugs, and its proven effectiveness, has led to dramatic improvements in care for breast cancer patients. Chemo dosages have been reduced, as has the length of treatment. "Quality of life today is dramatically better today than a decade ago," Braun notes.

The focus of research now is on both hormonal and biological agents to reduce the size of tumors, or eliminate them, without surgery. For instance, Herceptin, one of a new class of drugs called monoclonal antibodies, was approved in 1998 by the FDA to treat 25 percent of breast cancers. The drug, effective on metastatic or spreading cancers, targets so-called HER2-positive tumors and blocks the growth of these cells. HER2-positive tumors typically grow faster than tumors that don't have an overexpression or overabundance of the HER2 protein. Braun, Runowicz, and others predict an explosion of drugs like Herceptin that go after specific proteins that bind to cancer cells.

"Gone is the one-size-fits-all approach to diagnosis and treatment," says Cheryl Perkins, MD, senior clinical advisor for Komen. "We must be able to tailor therapy to the individual woman."

Another form of targeted therapy, still experimental, is brachytherapy or partial breast irradiation. A radioactive balloon-like device, or seed, is implanted into the tumor bed following surgical removal of the tumor, making for a localized treatment. While brachytherapy has been used to give a "boost" to the standard radiation treatment to kill remaining cancer cells, it is now being evaluated for use instead of traditional radiation treatments, which radiate the entire breast for five to six weeks and can potentially result in skin irritation and heart and pulmonary problems.

Depriving tumors of a blood supply, theoretically to prevent growth and spread, is another form of biological therapy under review.

Researchers also are focused on finding treatments for women who have not responded, or who are no longer responding, to tamoxifen. The most exciting recent news for such patients -- postmenopausal women for whom doctors are trying to prevent recurrence -- is the use of so-called aromatase inhibitors such as letrozole and exemestane. "It's an exciting time, as we learn how to best use these drugs," Runowicz says.

And this past August, a Pennsylvania firm reported that a simple blood test can predict how long a woman may survive with metastatic breast cancer, giving doctors a tool that some suggest will help customize treatment options further in individual patients. The test measures the number of tumor cells circulating in the blood stream; fewer than five cells in a small vial of blood suggests a woman will live more than 18 months, while women with more than five cells died in an average of 10 months, the study found. About 75,000 women a year are diagnosed with breast cancer that has metastasized, meaning the disease has spread beyond the breast. The new blood test, though experimental, could help doctors figure out earlier if a given treatment course is working; if it isn't, they can switch course, perhaps before it's too late.

The Future

The next decade in diagnosis, prevention, and treatment of breast cancer is apt to look startlingly different from the last 10 years, experts say. First, the 2003 mapping of the human genome is expected to cause a burst of exciting therapies. Specifically, doctors expect it will soon be possible to use DNA analysis to uncover patterns in the genes of individual patients with specific types of cancers, then use those patterns to predict the likelihood of disease in other women who are thought to be at high risk. DNA analysis also could be used to select treatments for newly diagnosed patients; doctors would use therapies that have proven effective in patients whose DNA markers are similar to those of newly diagnosed women.

Says Braun: "It's very early for this type of work, but we can imagine the uses. And that's truly the exciting part. We've laid the foundation for an explosion of therapies that may turn the disease on its face."

Experts also have their eye on so-called nano-technology, the use of materials, devices, and drugs that attack individual molecules and atoms. A nano-particle is 1/80,000th the size of a human hair. And if drugs can be found that can hone in on cancerous atomic particles of that size, researchers may stand a prayer of eradicating those tumors without causing damage to healthy cells in a woman's body. One of the first drugs for which FDA approval has been sought to treat metastatic breast cancer is abraxane, a nano-drug. "We're learning to send treatments where they have to go without destroying healthy cells," says Braun.

Meanwhile, patients like Janice Fine are living proof that breast cancer doesn't have to be a death sentence. "It's really important for newly diagnosed women and their loved ones to know that it is possible to cope with breast cancer and to live beyond it," Fine says. "Mine is a hopeful story, and this is why it is an important one to tell, but we need new treatments and a cure so that no woman ever again has to fear death at the hands of breast cancer."

Originally published on LHJ.com, August 2004.

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