New York Times Magazine article, titled "Our Feel-Good War on Breast Cancer," raises the important question, among others: When it comes to breast cancer, are we doing more harm than good? The Breast Cancer Research Foundation's Director of Communications and Engagement, Sabrina Dupré, asked BCRF scientific leaders, Drs. Larry Norton (Scientific Director) and Clifford Hudis (Chairman, Scientific Advisory Board), a few questions of her own.
Q: Lately, a number of critics assert that the breast cancer awareness movement has achieved its goal of awareness and is now at the point of unnecessarily heightening fears. How do you respond?
A: LN: The goal of universal awareness that breast health is important is far from having been achieved. Only about 60% of women who should be getting screened are doing so. In addition, behaviors that we know with certainty increase one's risk of getting and dying of breast cancer - such as using post-menopausal combination hormone replacement or being obese - are still not connected in everyone's mind as dangerous. It is critical that we continue to educate people about such dangerous behaviors.
CH: I agree. Further, just a few decades ago, the word "cancer" itself could hardly be uttered. Thanks to the awareness movement, and I've heard this many times from patients themselves, millions of people have been comforted simply by knowing that they are not alone in what can be an incredible isolating journey. In addition, one of the positive outcomes of the breast cancer awareness movement is that it has demonstrated that there is less to fear from the diagnosis of cancer than people used to think. Frankly, only by confusing "knowledge" with "fear" could one conclude that awareness could be harmful.
Q: You mention screening, currently a widely-debated topic in terms of its efficacy and value. What's being done to improve diagnostic screening?
A: LN: Many people might not realize that there is much research going on to try to make detection more sensitive, accurate and accessible - by improved imaging technologies, identification of individuals at higher than average risk, and even development of new screening methods including blood tests.
CH: The Breast Cancer Research Foundation, for example, is currently supporting two kinds of research to accomplish this. First, the investigators supported by the BCRF are developing better (that is, more accurately predictive) imaging tools to improve upon mammography. Second, we are enabling the development of what are called "predictive tests" or molecular diagnostics. These tests can "interrogate" the cells that are obtained at biopsy so that doctors can more accurately predict their future behavior. The goal is to identify a potential problem and then, in the least intrusive way possible, either confirm that it has the potential to adversely affect health or confirm that we can safely avoid or limit treatment. In the end, all of this depends on two things: a willingness to invest more resources, and an informed general public that is educated about risks and benefits and is engaged with us in seeking accurate answers.
Q: The most commonly talked about screening tool is the mammogram. Is it 100% effective?
A: CH: No test is 100% effective, and there are many factors that contribute to the challenge of detecting breast cancer: the density of a patient's breast, the sensitivity of the diagnostic tool itself, and so forth. An additional complication is that breast cancer itself is not one singular disease, but instead a collection of related diseases that may appear differently using screening tools. The only solution is continued research. At the same time, the one thing we know is that the increased use of mammography has been associated with the discovery of smaller cancers that are more easily treated and with improved survival, even if some cancers are still missed.
Q: So why do people still endorse mammography when we know it's imperfect?
LN: Here's the biology: at some time between the second a single cell turns cancerous and when it has grown into a large mass, it will spread, or metastasize, to other parts of the body and become life-threatening. The objective of the mammogram is to find the cancerous process before that dire moment. The fact is that mammograms are still the best general screening test we have. Just because something is good but imperfect doesn't mean we should abandon it! The time to replace mammography will be when we have a more perfect test, and that is exactly why BCRF, for example, is involved in funding research to improve the sensitivity and accuracy of screening tests like mammograms. We all want to get to that day as soon as possible.
CH: Agreed. And research has shown, time and again, that mammograms are indeed effective in detecting many cancers for which early therapy makes a major difference in the cure rate.
Q: Okay. But the possibility remains that mammograms sometimes "miss" detecting breast cancer or, at the other end of the spectrum, produce unnecessarily worrisome false positive results. True?
A: LN: It is true that some cancers are missed by mammograms because of the combination of factors that Cliff mentioned earlier.
CH: Still, a mammogram is the simplest way to lower one's risk of premature death from breast cancer - in other words, to save lives. The way a mammogram saves lives is by identifying abnormalities in the breast that may represent cancer so we can intervene early on. The only way to prove whether or not these abnormalities are, in fact, cancer is to then perform a biopsy. The biopsy, in turn, produces either one of two possible outcomes - the result is "positive" (meaning it confirms cancer), treatment ensues and lives are saved, or it is "negative" (meaning it confirms a benign diagnosis) and treatment is either unnecessary or limited.
LN: Yes, biopsies are invasive and therefore sometimes unpleasant. But the question is: which is worse? Having a biopsy that turns out not to show cancer or not having a biopsy and missing a potentially curable cancer? The term "unnecessary" is a post-hoc judgment. I sometimes explain it this way: If someone fires an arrow at you, do you choose to not step out of its way because sometimes that arrow will miss its mark? If you do not step out of the way and then the arrow does hit you, would you feel that you had made a good decision? Alternatively, had you chosen to step away, and the arrow misses you, would it be rational to assume that it would have missed you anyway, that stepping away was "unnecessary"?
Q: Back to the breast cancer awareness movement. Another critique is that many awareness activities, particularly social events like walks, seem to focus on the faces of "survivorship." Do you think these campaigns are doing so at the expense of excluding those with metastatic disease?
A: LN: First of all, making the claim that all breast cancer organizations or campaigns focus only on people who have survived after a diagnosis of primary breast cancer (cancer in the breast only) and ignore those with metastatic breast cancer is an erroneous generalization. Many organizations, including BCRF, make a point to include and be relevant to people - men and women - with all stages of breast cancer, from those whose disease has spread to those without disease who are interested in prevention. And for many of those people, the public statement that they have had breast cancer and are leading full, rich, and productive lives is very important and it would be cruel and unfair to deny them that opportunity. We applaud efforts to bring people with metastatic disease into the circle of survivorship, camaraderie and mutual support that has proven so valuable to many who have had only primary disease.
CH: The groups that provide support, fundraising, access to care, scientific education, and awareness, all have their own specific missions and goals. Some or many may have previously concentrated on patients with earlier stages of the disease because their focus was, for instance, the benefits of screening. In recent years, because of advances in treatment (many of which have been supported directly by BCRF), more patients are surviving and living well despite a diagnosis of metastatic breast cancer, and this group of patients is increasingly visible and vocal. Are they as visible and vocal as others in all of these advocacy groups? Possibly not. But this can be addressed organically as groups respond to all of the needs of our community.
Q: What is being done to address metastatic breast cancer?
A: CH: Everyday, we increase our understanding of even smaller subsets of breast cancer, defined by ever more sophisticated tools. That's why we've been able to achieve advances in treatment that have been proven to extend life and that have reduced toxicity compared to what we were able to do in the past. BCRF, for example, is constantly looking at where the next most promising steps lie and is substantially increasing its investment in this area.
LN: The bottom line is simple: more research is needed. We have yet to identify with 100% accuracy which breast cancers will metastasize. We have yet to develop cures for 100% of people with metastatic disease. That is why metastasis is such a focus of BCRF grant making. In fact, BCRF has invested almost half of its $40 million in 2012 grants to this topic. Furthermore, we have earmarked the entire $27 million in a new initiative called the Evelyn Lauder Founder's Fund for a global collaborative investigation of the molecular underpinnings of metastasis.
Q: So many women (108 women in the US alone) still die of breast cancer each day. Many people can't help but wonder-is research doing enough?
A: CH: For someone facing a serious diagnosis, traditionally incurable, it has to be true that not enough is being done. But we need to recognize the advances that have been made. Because of research, we have emerged from a world of "one-size-fits all" treatment, recognizing, for example, that some cancers are better controlled by blocking estrogen while others are best treated with anti-HER2 drugs. And the ability to customize treatment for each individual continues to improve thanks in part to the research that BCRF supports.
LN: Just because much remains to be accomplished does not mean that we should denigrate the progress that we have already made. Indeed, the scientific process that has brought us this far is pointing in profoundly exciting new directions. Sometimes this progress is not evident in national statistics on mortality because, unfortunately, not every American has access to the best screening or best care. We need to do better in that area, too. But progress, which is never rapid enough, will not accompany resignation to the status quo or despondency. Accomplishing all of our goals, including the defeat of metastatic cancer, demands our enthusiasm, energy and optimism.
Q: What can individuals or institutions do to make an impact, be it their own health or the breast cancer movement?
A: CH: We are learning how a number of lifestyle and behavioral changes can help reduce an individual's chance of dying from breast cancer, and so I encourage every person to take ownership over their wellness, whether it be through maintaining a healthy body weight, exercising, avoiding hormone replacement therapies, and also by obtaining the best possible care including maintenance of screening standards.
LN: Most people are not aware of how underfunded cancer research is when compared to the magnitude of the cancer problem. One-third to one-half of all Americans will die of cancer unless we continue to make progress. Yet, as a nation we spend about a seventh of what we spend on soft drinks and about a third of what we spend on tobacco advertising on all forms of cancer research from all sources - philanthropic, government and industry. To eradicate cancer we do not need a massive sacrifice, but rather a mass commitment. We can find the answers in science-the opportunities have never been greater - if only we dedicate ourselves to that mission.