Amber E. Johnson
2010-2011 SNMA Academic Affairs Co-Chair
M.D./M.B.A. Candidate 2011
Jefferson Medical College
According to the German writer and philosopher Goethe, “the most beautiful discoveries are made not so much by men as by the period.” History has shown that the methods of diagnosing and treating breast cancer have mirrored the thoughts of clinicians during the eras in which they have practiced. Indeed, breast cancer has been conceptualized within social and cultural norms over time. Today as we continue to strive for cures, we consider new treatment options based on the context of the period.
In the United States, breast cancer was mostly suffered in silence until the 1980’s, when women such as First Lady Nancy Regan and actress Shirley Temple Black began speaking publicly about the impact of their disease and treatment. After that, advocacy, fundraising, and publicity increased substantially. During October 2010, the National Football League recognized Breast Cancer Awareness Month by incorporating hot pink into their uniforms, equipment, and team paraphernalia. This marked the first time that a national organization such as the NFL made such an obvious stand for breast cancer advocacy. The rapidity with which breast cancer has gained awareness likely reflects societal views of the disease. Some suggest that this sensationalization has lead to inappropriate resource utilization and overzealous reporting.
Today more women are being diagnosed earlier thanks to better screening tools. However, historically speaking, patient modesty and clinician reluctance often delayed breast cancer diagnosis and screening, thus leading to dire outcomes. Cases of breast cancer have been documented in medical writings for over 5,000 years. Clinicians as far back as Imohtep and more recently Hippocates and Galen, would diagnose breast cancer by touch. Cool, hard tumors were differentiated from warm, soft ones. The former were considered to be cancerous for which no treatment was known. Galen (b. AD 121) was the first to encourage the “surgical excision of a pathologic tumor in a circle in the region where it borders on the healing tissue.” In much of Europe, therapeutic methods eventually began focusing on removal of the diseased tissue. Other early treatments included exorcism, laying on of the hands by royalty, and wearing amulets to ward off “infected air.”
Breast cancer surgery proliferated in the middle ages and continues today. Yet, it was not until the 1950’s when surgeons like William Halsted began to receive backlash. Some clinicians touted new scientific evidence against Halsted’s radical mastectomy. Until then, statistical measures had not been performed on patient outcomes. After World War II, the rate of radical mastectomies decreased as more localized surgery was initiated. These actions were supported by data from clinical trials (Aronowitz). This era saw a shift in how doctors acquired and applied knowledge. Researchers became proponents of statistical methods like randomized controlled trials, thus rejecting the antiquated rules of medical decision-making. The rise of modern, conservative surgery made the ablation of localized lesions possible and gave hope that breast cancer was a curable disease.
As we have become better at understanding the mechanisms of disease, our treatments and managements have improved. There exists a biological variability between patients with different types of breast cancers. The understanding of oncogenesis may further promote individualized therapies for each patient. As an example of the changing tide in research, one needs only to look at the largest not-for-profit contributor of research funds for breast cancer, the Susan G. Komen Foundation. According to the Komen website, the organization’s initial research was focused on the biology of breast cancers. However, since oncogenesis is better understood, much of their funding now goes towards risk reduction, identifying earlier stages of cancer, new treatments, and prevention.
Today, therapeutic options often depend on the grade and stage of disease. Treatments for breast cancer may include lumpectomy, local radiation, mastectomy, standard chemotherapy, high dose chemotherapy, stem cell transplant, or hormone therapy. Scientists are currently working to discern the best of these strategies and combinations thereof. Additionally, clinicians are using cutting-edge imaging modalities to evaluate the size and location of axillary lymph nodes in order to guide treatment planning. As imaging becomes more advanced, it is likely that treatment plans will become more cutting-edge as well. For example, traditional mammograms are only able to display images in 2 dimensions, but as newer imaging studies are applied to breast cancer patients, the field of radiation oncology is ever evolving. Additionally, one of the latest techniques, breast-specific gamma imaging, or BSGI, uses radioactive dye to detect metabolically active cancer cells, allowing breast cancer to be diagnosed earlier and without some of the limitations that occur with mammography. Whereas mammography cannot discern cancerous lesions in young women who have dense breast tissue, BSGI can pick up cancer cell activity in young women with early disease. Despite these advances, treatment options for such early disease remain controversial (http://www.jeffersonhospital.org/methodist/services/radiology_gamma.html).
Furthermore, future discoveries will examine the role of genetic mutations in the diagnosis and treatment of breast cancer. At present, genetic testing is used mostly for risk assessment. For example, genetic mutations that predispose to breast cancer could be as frequent as one out of 40 Ashkenazi Jewish women. Women who have the BRCA gene mutation carry a lifetime risk as high as 60-90% for developing breast cancer. Options for reducing the risk of invasive cancer include frequent screening via imaging surveillance, chemoprevention with hormone therapy like tamoxifen, prophylactic mastectomy, or prophylactic oophorectomy. Among women who test positive for a BRCA mutation, prophylactic surgery at a young age significantly improves survival. Yet, the benefits to the patient’s quality of life are not as convincing. Additionally, there now exists a genetic assay for women who have been diagnosed with breast cancer that helps predict response to chemotherapy. The Oncotype DX assay is indicated for women with tumor size of one or more centimeters as an added decision-making tool. It helps to predict disease recurrence after surgery and can therefore help determine if chemotherapy should be added to the treatment regimen.
This last example is one of scientific research being applied within the social constructs in which we live. Genetic testing is certainly an exciting topic today. Now that the human genome has been elucidated, scientists are discovering genetic factors of disease that were never before imaginable. As we continue to better understand breast cancer, clinicians are more capable of treating it earlier and with more ability to cater to a patient’s needs or preferences. This will likely decrease medical waste and over-expenditure as well as increase patient satisfaction.
It is estimated that over 40,000 people died of breast cancer last year. Over the last 20 years, though incidence has been increasing, mortality has been decreasing. This discrepancy could possibly be reflective of better screening and treatment, as well as the discontinuation of hormone therapy among postmenopausal women, and may also reflect a delay in diagnosis from less frequent mammography use. Because breast cancer is a screenable diagnosis, the use of tools such as mammography must be tempered with the reluctance to over diagnose. For instance, while breast self-exam does lead to increased detection of breast cancer, it does not lead to decreased mortality. Promotion of breast self-exam to adolescent girls has been shown to increase knowledge and encourage this screening behavior in the future. Some suggest that disease prevalence and risk of developing breast cancer is over emphasized and that “social forces” (such as corporate marketing campaigns during Breast Cancer Awareness Month) have led to a shift in the perception of breast cancer and health-seeking behaviors. The most recent recommendations from the American Cancer Society state that: Women 40 and up should have a mammogram and clinical breast exam every year as long as they are in good health.
In African Americans, breast cancer incidence is lower but mortality is higher. According to the 2010 Cancer Statistics Report by the American Cancer Society, this could represent a disparity in mammography rates and delayed reporting amongst black women. Furthermore, African Americans are less likely than whites to be diagnosed at a localized stage, when the disease may be more successfully treated. Some evidence suggests that African Americans who receive cancer treatment and medical care similar to that of whites experience similar outcomes. Rates for other racial groups are lower than in blacks. Black women also have the lowest 5-year cancer survival rates. They are followed by American Indians, whites, Hispanics, and Asians. To help combat disparities in cancer care, the Komen Diversity in Oncology Initiative was formed. The Susan G Komen for the cure and the American Society of Clinical Oncology (ASCO) teamed up in 2008 to devote $4 million towards screening initiatives and community outreach.
There is no doubt that breast cancer awareness is at an all time high. Organizations that have been committed to raising funds and publicity will certainly continue to do so. The Komen Foundation has issued a statement that it “will invest an additional $1 billion… by 2017” with the promise of one day curing breast cancer. This begs the question, though, of what does cure mean? Is a cure the prevention of recurrence, the lengthening of the patient’s life? Some argue that such a myopic focus on early detection and aggressive treatment has “deflected attention from the more important goal: primary prevention through cleaning up the environment and encouraging women to lead healthier lives.” Nevertheless, the major themes within the field have focused heavily on genetics and screening, especially over the last few years. Yet given the changing medico-economic landscape that we now face, is it too much to wonder if the emerging theme might not be disease prevention and wellness — moving from a reactive society to a proactive one. Moreover, given the disparaging rates at which minority women receive cancer therapy, wouldn’t it be nice to obviate treatment altogether? Perhaps we must look to the future of medicine in order to tell.
Filed Under: Global Health
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