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Looking back on 20 years of breast cancer diagnosis

October 02, 2013
 

Media Contact: Keith.O’Connor@baystatehealth.org, 413-794-7656

 

SPRINGFIELD - In celebration of the 20th anniversary of the Rays of Hope at Baystate Health, which steps off again in Springfield and Greenfield on Oct. 20, and on the occasion of 25 years as a respected oncologist and leading breast cancer specialist,
Dr. Grace Makari-Judson reflected recently in a note to Rays of Hope supporters on the “wins” over the years in the diagnosis and treatment of breast cancer.

“Although we haven’t won the fight yet by finding a cure for breast cancer, there is much to celebrate. Our understanding of breast cancer has evolved over 20 years leading to treatment that is less invasive and more to the target,” said Dr. Makari-Judson, chair, Baystate Health Breast Network and co-director, Rays of Hope Center for Breast Cancer Research.

 

Less invasive approaches
Breast biopsy once involved an operation to remove a lump or mammographic abnormality, resulting in scars and a recovery period for the patient. All that changed in 1994 with the advent of breast core biopsy, a minimally-invasive, outpatient procedure where radiologists localize an abnormal area and sample it with a needle. This new approach to diagnosis was immediately adopted by surgeons and radiologists as the favored approach for breast biopsy.

“Then, in 1996, thanks to Rays of Hope, Baystate acquired sentinel lymph node technology. Before 1996, breast surgery for invasive cancer included axillary dissection, a procedure to remove all lymph nodes under the arm. The new procedure identified the leader or sentinel lymph node, so that women with a negative sentinel lymph node were spared complete axillary dissection,” said Dr. Makari-Judson.

Today, axillary dissection can be safely eliminated in some node positive patients who meet strict criteria. The Baystate Health Breast Network reviews new advances such as this and decides when to incorporate them into daily practice.

 

More personalized treatments
“Not all breast cancers are alike, and not all patients benefit from the same treatments, which is why breast cancers are routinely tested for hormone receptors, specifically estrogen and progesterone,” said Dr. Makari-Judson.

Twenty years ago, tamoxifen was the standard for hormone treatment of early stage
breast cancer. Today, a new class of drugs called aromatase inhibitors, including
anastrozole, exemestane and letrozole, are available for postmenopausal women with hormone positive cancers.

Another target for treatment is called “HER2/neu,” a gene which promotes the growth of cancer cells. The medication called trastuzumab, which many know as Herceptin, took this very aggressive subtype of “HER2/neu-positive breast cancer” and tamed it into one with a more favorable prognosis.

“We participated in this landmark clinical trial a decade ago, and I can still recall the thrill of seeing the overwhelmingly positive data presented at the Annual Meeting of the American Society of Clinical Oncology,” said Dr. Makari-Judson.

The Baystate breast specialist also noted molecular testing helps identify which women with early stage cancers need chemotherapy and which have an excellent prognosis with hormone treatment alone.

“Thanks to these tests, medical oncologists, including myself, are prescribing 20-30 percent less chemotherapy now compared to 10 years ago,” said Dr. Makari-Judson.

 

Preventing some cancers
Doctors today use medications to prevent cancer in some women.

“We started our High Risk Program 20 years ago. Our focus on prevention started with participation in the first national breast cancer prevention trial and, in the follow-up study, we tested medications such as Tamoxifen and Raloxifene. Despite the fact that these readily available medications can reduce the risk of developing breast cancer by approximately 50 percent, they are still underused. Women find it hard to accept a medication for prevention and not all doctors are comfortable talking about it,” said
Dr. Makari-Judson.

She added that genetic testing has seen a rapid rise in interest since more insurance plans now cover testing, and there is less concern about implications, thanks to the Genetic Information Non-Discrimination Act of 2008.

“In those individuals found to carry a mutation, there are proven strategies to reduce the risk of developing breast or ovarian cancers,” said Dr. Makari-Judson.

 

Debunking the old message
Twenty years ago, guidelines were for monthly breast self exam starting at age 20, yearly clinical breast exam at age 30, and yearly mammogram starting at age 40.

“Many cancers are first identified by women, and we have learned that even more important than monthly self-exams is an awareness of changes in the breast and reporting to your doctor any new lumps, skin changes or other signs of cancer,” said
Dr. Makari-Judson, who also noted that yearly clinical breast exams by a health care provider can vary in their benefits, depending on the practitioner.

But, the biggest shift in the old message relates to mammography.

“We believed breast cancer prognosis was solely dependent on the size of the tumor and the number of involved lymph nodes. If a cancer was small, it was less likely to have spread to lymph nodes. If cancers were not in lymph nodes, there was less likelihood of distant spread called metastases and, therefore, better survival,” said Dr. Makari-Judson.

So, it made sense to doctors that finding cancers too small to feel through the use of mammography would lead to better outcomes and less-involved treatment.

“Unfortunately, we now realize this is not entirely true. Today, we base our decisions on biology, meaning that very small cancers that appear aggressive may be treated with chemotherapy, while a larger tumor that appears slow growing may not be,” said
Dr. Makari-Judson.

While it remains true that mammography reduces the risk of death from breast cancer, and is still the gold standard for screening, physicians across the country cannot agree on one set of recommendations as to when to begin mammography screening.

“At Baystate, we agree that it is important for women to be educated on mammography in order to make an informed decision with their health care provider about screening,” said Dr. Makari-Judson. “That means understanding a woman’s breast cancer risk, then deciding when to start screening, when to stop, and how often in between,” said
Dr. Markari-Judson.

As women everywhere begin to don their pink ribbons in support of Breast Cancer Awareness Month in October, Dr. Makari-Judson said that rather than the battle cry of “get your mammogram,” she proposes a new message for the pink ribbon: follow a healthy lifestyle, know your family history, and talk to your doctor about mammography.

And, a healthy lifestyle really matters.

“Exercise at any age reduces the risk of breast cancer. Avoid weight gain after menopause, don’t smoke, and limit your alcohol consumption,” said Dr. Markari-Judson.

As the Rays of Hope begins its third decade of “finding a cure,” the Rays of Hope Center for Breast Cancer Research is continuing in its attempt to better understand what it is about some pre-cancerous cells that drives them into cancer while protecting others from ever becoming malignant.

“If we could just figure out that one….but thanks to Rays of Hope, we’ll keep trying to win the battle,” said Dr. Makari-Judson.

For more information about this year’s Rays of Hope Walk and 8K Run, held rain or shine, call 413-794-8001 or visit baystatehealth.org/raysofhope. Also, for more information on the Baystate Regional Cancer Program, visit baystatehealth.org/bch.

 
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