Breast Cancer in the News
Are we about to see a breakthrough in DCIS evaluation that will spare women unnecessary treatment? Is there a better way to predict breast cancer risk? Is Taxol losing its effectiveness as a cancer drug? Can a contraceptive pill ward off ovarian cancer?
Below, Breast Cancer Alliance Medical Advisory Board members Dr. Alison Estabrook of St. Luke’s Roosevelt Hospital Center, Dr. K.M. Steve Lo of the Bennett Cancer Center , Dr. David Rimm of Yale University School of Medicine, and Dr. Barbara Ward of the Breast Center at Greenwich Hospital, and contributor Noah D. Kauff, M.D., Director, Ovarian Cancer Screening and Prevention at Memorial Sloan-Kettering Cancer Center, offer their insights on these issues of interest.
Dense breast tissue comes with a higher risk of developing breast cancer. Mammogram reports include a density reading, but doctors don't always share that information with their patients. Should they?
Dr. Estabrook: Dense breast tissue does come with a higher risk of developing breast cancer, and since the tissue is dense on mammography, some of these women may benefit from other screening techniques, such as ultrasound or MRI. Many patients are aware of this and they ask me: “Are my breasts dense, do I need an ultrasound?” Because of the consistent questions, I have now gotten into the habit of telling most women about their breast density as it is described on the mammogram report. Studies have shown that digital mammograms are better for women with dense breasts so I think this information is helpful. Whether women with dense breasts will benefit from other screening techniques is still unknown. At the moment, dense breast tissue by itself is not enough to require ultrasound and MRI; the patient must have a strong family history or be BRCA1/2-positive as well.
Dr. Ward: I show every patient her films, whether they are from our computer or they are films she carries in. I think it helps to demonstrate to patients visually what dense breasts look like. It also helps them to understand why I would be ordering an additional test such as an ultrasound or MRI. If a cancer did not show up on a mammogram, then the patient definitely needs additional testing.
Taxol seems to help women with HER2-positive breast cancer, but not those with Estrogen receptor positive cancer. Should doctors stop giving Taxol to anyone who doesn’t have HER2-positive cancer?
Dr. Lo: There was an analysis recently that suggests that Taxanes have little benefit for women with ER positive breast cancer when used in the older ACT regimen (in which taxanes were given every three weeks in addition to AC - adriamycin and cytoxan). This study does not apply to women with ER negative or Her 2/neu positive breast cancer, and Taxanes should still be considered for these patients. The study does not prove that there is no value to adding taxanes to AC if it’s given every two weeks (which is how it is currently given as part of “dose dense ACT chemotherapy.”) This study may actually not be relevant since we are also moving away from using adriamycin and using combinations such as TC (taxotere and cytoxan) which seem as effective and have fewer side effects compared with AC or ACT.
A new, simpler model for predicting breast cancer risk in post-menopausal women is on the horizon. Dr. Rowan T. Chlebowski at the LABioMed Resarch Institute found that three things determine greater risk: being 55 or older, having had a breast biopsy at any time (regardless of findings) or having a first-degree relative diagnosed with breast cancer at any age. Will this be a good replacement for the traditional GAIL model?
Dr. Ward: I still tend to use the GAIL risk model, which is easy in my estimation. If the new one becomes recognized by insurance companies and used in clinical trials, I may change.
Dr. Lo: The Gail model is what I would consider the “first generation” model. It was an excellent first model, but there is no doubt that better models can and should be developed that will better predict breast cancer risks. I’m looking forward to the second and third generation models that will be more accurate and help women better decide what their risks are, whether to use chemoprevention with Tamoxifen, and even whether to have prophylactic mastectomies.
Dr. Thea Tisty at the University of California - San Francisco says her group's study has discovered a molecular profile that can distinguish potentially lethal cases of DCIS from ones that will not become life-threatening, with the implication that they can save large numbers of women from unnecessary surgery, radiation, and chemotherapy. Is this, as has been reported, "the single most important piece of research to emerge from this year's San Antonio conference?”
Dr. Rimm: This is an interesting observation and very promising, but the data need to be confirmed in a second cohort and then the technology needs to be commercialized. Promising, but probably still years away from translation.
In the January 26, 2008 issue of The Lancet, investigators from the Collaborative Group on Epidemiologic Studies of Ovarian Cancer in England reanalyzed data collected in 45 studies from 21 countries. They confirmed that women who took oral contraceptives at any point in their lives had a 27% lower risk of ovarian cancer than women who had never used these medications. The risk reduction was greater the longer the women used oral contraceptives. Additionally, the protection was long lasting, with measurable decreases in ovarian cancer risk up to 30 years after cessation of use.
Dr. Kauff: While these results suggest a possible role for oral contraceptives as an ovarian cancer preventative, caution is advised before these medications are used just to reduce the risk of ovarian cancer. While there is a long experience and excellent safety profile with oral contraceptives for prevention of pregnancy, the study did not address the key issue of impact on life expectancy when these medications are used strictly as a cancer preventative. Until such studies are available, oral contraceptives are best used for their primary purpose, which is reproductive control. For women interested in both effective contraception and simultaneously reducing their risk of ovarian cancer, these data suggest that oral contraceptives may be a very attractive option.
