The Art and Science of Detection
Even before she began taking medication to ward off breast cancer, Bonnie Krull made sure she had mammograms every year. If she couldnt prevent it, she thought, at least she could catch it early, when a womans chance of survival is greatest. Sandra Mascorro, too, was usually religious about getting mammograms and exams. But one year, she missed her check-up. On her next visit to her community physician, the doctor felt a lump in her breast. It turned out to be cancer.
Mammography is a practical and important tool today, says Russell. We all have bad health habits, but the greatest tragedies I encounter are the women who have denied themselves access to physicians or an examination. If they had just taken the time to do this routine test, or had come in when they first felt something was wrong, it could have made all the difference.
Most agree that annual mammography, recommended for women 40 and older, is the best opportunity women have for detecting a curable disease. X-ray mammography, as it is officially known, has a sensitivity of about 90 to 95 percent for the detection of breast cancer ? with about as little radiation exposure as a dental X-ray.
Mammography is much more sensitive than a routine physical examination and can detect many cancers before they can be found through self-examination. For example, early cancer of the milk ducts inside the breast is rarely palpable ? perceivable by touch ? but it can be detected by mammography. The earlier tumors of the breast are detected, the better the chance is that they can be cured.
Yet, the majority of women who should get mammograms dont, says Russell. For some, it is a matter of access. Although mammograms are covered by many insurance companies and Medicare, their cost can be prohibitive. In addition, there are a com-plex set of reasons why such a large number of women avoid the subject altogether, says Russell. Cancer is frightening. Theres a fear of dying, a fear of disfigurement and of losing a breast. Our culture places a lot of emphasis on breasts as a defining feature in sexuality, and up until now, women havent been taught to think in terms of breast health.
Mammographys power to detect tumors also sometimes turns up false positives ? benign growths. Among the new technologies being investigated at USC is thermal imaging, which senses heat in an area where a tumor is growing. Because cancerous tumors emit more heat, physicians theorize that the thermal imaging technology may help them discern between malignant and benign tumors in the breast ? and in turn reduce unnecessary surgical biopsies. So far, the thermal imaging technique shows promise as an adjunct to traditional mammography.
Surgeon Melvin J. Silverstein expects profound changes in the ability to make accurate diagnoses of breast cancer as new tools enable physicians to better detect tumors. An internationally respected surgeon who has spent his career improving the treatment of breast cancer, he recently came to the USC/Norris as co-leader of its breast cancer research program and director of the Lee Breast Center.
We want to continue development of new diagnostic technologies because the 10-year cure rates for non-palpable tumors are as high as 95 percent, he says. For tumors you can feel with your fingers, those rates drop to about 60-75 percent.
We want to meet the cancer as early as we can in its life. When its still a little kid, you can do something about it, but when its an adult, its often too late.
Treatment: Youve Come a Long Way, Baby
Sandra Mascorro recalls that when her mother and aunt were diagnosed with breast cancer, the treatment of choice was radical mastectomy ? surgical removal of the breast and lymph nodes. By the time she was diagnosed, the way physicians treated breast cancer had changed for the better. Today, many women are offered a surgery that conserves more of the breast, called lumpectomy, followed by radiation therapy. Reconstructions are routinely offered to most mastectomy patients, and this can often be done with the surgery to remove the cancer. In addition, chemotherapy and hormone therapy, including tamoxifen, have helped more breast cancer patients survive longer.
Silverstein foresees therapies that are even less invasive, less costly and less daunting for patients, and at the same time more effective than what is now available.
There have been dramatic changes in breast cancer research and treatment over the past 10 years, and that will certainly continue, he says. In the future, I see more reliance on minimally invasive procedures and more use of drugs to prevent breast cancer. There will also be more emphasis on genetic counseling of patients.
I see for the future almost all breast cancer treatment being performed on an outpatient basis, except in cases of major reconstructive surgery. A lot of thats happening now.
Silverstein decided to devote his career to better breast cancer treatment after meeting with a distraught patient more than 30 years ago. He had performed a technically flawless radical mastectomy on a French patient in her 40s, and considered the operation a success until he discovered that the woman was inconsolable.
This is in the context of the 1960s before patients played a significant role in their own care and made informed decisions, he says. Doctors would just say, This is breast cancer, and youre going to have a radical mastectomy. A patient often didnt know if she was going to wake up with a Band-Aid from a biopsy or with a radical mastectomy.
The incident made him start thinking of the breast as more than just diseased tissue, but also an important part of a womans self-image. Doctors at the time didnt appreciate what a terrible shock losing a breast was, he says. What I learned from that is that I really needed to be less of a surgeon and more of a human being.
It has been nearly a decade since Sandra Mascorro was diagnosed with breast cancer. Like many patients, she arrived at the USC/Norris in the middle of her treatment ? she had already undergone surgery and wanted a second opinion about follow-up therapy. On her first visit, oncologist Darcy Spicer sat down with her to discuss her options.
He spent an hour and a half with me, she says. I liked that he gave me the choice about what to do next. Together, Mascorro and Spicer agreed on a relatively aggressive plan using chemotherapy, radiation and hormone therapy (tamoxifen). She has been free of breast cancer ever since.
Depending on the severity and stage of the disease, many women take a combination of anti-cancer drugs after surgery to kill off any remaining cancer cells. Oncologists study the best ways to use these drugs ? the right combinations, timing and doses ? to improve cure rates for these patients.
We keep trying to find the best ways to use existing and emerging drugs for breast cancer, Russell says. For example, Taxol has been used to treat ovarian cancer for years, but was only recently approved to treat women with breast cancer. Now, Russell and others are studying whether the drug should be offered to women with early breast cancer as well.
Despite chemotherapy, women whose breast cancer has spread to many of the nearby lymph nodes or those with inflammatory breast cancer have a high relapse rate and an increased risk of developing metastatic disease. Physicians have tried to reduce the number of relapses by giving higher doses of chemotherapy, but the toxic effects of these drugs severely limit this option. A refined version of bone-marrow transplant offers some hope.
The USC/Norris program currently focuses exclusively on a version of bone-marrow transplant called stem-cell rescue, during which a patients own blood and immune stem cells are collected and then frozen, stored and returned to the patient following intensive chemotherapy. This treatment can reduce the recurrence rate by half, says Dan Douer, who directs the bone marrow transplant program at the USC/Norris.
As more treatments become available, physicians hope to finally be able to help women who have been hardest to cure ? those with the most advanced disease. However, Russell says, we can now put women with metastatic cancer into remission for long periods of time, but we cannot promise them a cure. That is why we need to push people toward prevention and early detection.