New breast cancer guidelines raise concerns

By Ana B. Ibarra
aibarra@mercedsunstar.com

The American Cancer Society earlier this week released new guidelines for women with an “average risk” of breast cancer. Mammograms can be delayed another five years, the guidelines say. But those new recommendations have brought concern to some physicians and specialists.

The new recommendations advise women to begin yearly mammograms at age 45. The recommended age used to be 40.

Women are also advised that fewer mammograms are needed. According to the society’s guidelines, at age 55, women could transition to having mammograms every other year, although those who wish to stick to the yearly routine can do so.

“Since we last wrote a breast cancer-screening guideline, there have been the publication of quite a number of new studies that inform us about the benefits and drawbacks of screening with mammography,” said Dr. Richard C. Wender, the society’s chief cancer control officer, in a statement.

Mammograms, as explained by the American Cancer Society in a news release, sometimes find things that turn out to be harmless but that have to be checked out with additional tests that come with side effects, including pain and anxiety. An expert group weighed the benefits and harm to come up with the new guidelines, according to society officials.

“This guideline makes it so clear that all women by age 45 should begin screening – that’s when the benefits substantially outweigh the harms,” Wender said.

The guidelines also state that breast exams by a provider or self-exams are no longer recommended because research does not indicate any clear benefits.

Dr. Dortha Chu, a breast surgeon in Merced, does not agree with the changes. While she understands the guidelines are only recommendations, she said they also can mislead women and provide a false sense of security.

“I’m concerned that women will read this (the guidelines) and take it as a license to delay medical care even more,” she said.

Clinical exams, for example, are not perfect tests, she said, but they help open the dialogue between doctor and patient. These exams provide an opportunity for patients to be educated about breast changes and for the provider to become familiar with a patient’s medical history.

Self-exams are also important, not because they will directly save lives, but because they help women become familiar with their own breasts, Chu said.

“Ignoring breast exams, that part especially doesn’t sit well with me,” she said. “As medical professionals we should be doing an even better job in teaching patients how to do a self-exam properly.”

Changing mammograms from annual to every other year at age 55 is also tricky, Chu said, noting that close to one-third of her patients are in their 70s. Many of those patients, had stopped their regular mammograms because they believed they were no longer at risk of getting breast cancer, she said.

“But as long as you have breasts, you can get breast cancer,” Chu said.

Reaching a consensus in screening guidelines will always be difficult, the breast surgeon said. The best advice for women, she said, is to keep communicating regularly with their doctor.

However, one thing that will improve detection is new technology.

Last month, Mercy Medical Center in Merced announced the addition of a 3-D mammography system that should be ready for use early next year.

Patients currently have to travel to Modesto or Fresno for a 3-D breast screening.

Chu explained that the more in-depth screening works like a CT scan. The new mammography system can take up to 80 photos during the same exposure needed for the conventional 2-D system to take a couple of photos.

Chu said this system is definitely a step forward.

Source from :  http://www.mercedsunstar.com/living/liv-columns-blogs/article41265423.html

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10 Essential Facts About Breast Cancer

Finding breast cancer in its early stages has many benefits.    

Javier Larrea/Getty Images

 

Chances are you have a friend or family member who’s faced breast cancer. After all, 1 in 8 women will be diagnosed with the disease at some point during their lives, according to the American Cancer Society (ACS).

Sometimes a disease doesn’t seem so scary when you know the basic facts, so we talked with a few breast specialists who have in-depth knowledge about the prevention, diagnosis, and treatment of breast cancer. Read on to find out what you should know.

1. Experts differ on when to start getting regular mammograms.

While the United States Preventive Services Task Force (USPSTF) recommends that women ages 50 to 74 get mammograms every two years, the ACS suggests that women begin getting annual mammograms at age 45. And some experts believe 40 is the right age to start getting mammograms.

“Breast cancer is an age-related disease, so if you look at women under 50, they get far fewer cancers than women over 50; but if you look at women in their forties compared to women in their fifties, there’s not that much of a difference,” says Monica Morrow, MD, chief of breast service in the surgery department at Memorial Sloan Kettering Cancer Center in New York City.

“We think the best thing for women’s overall health is to start at 40, because the best way to pick up small cancers is to have annual mammograms so you can see subtle changes in breasts over time,” Dr. Morrow says.

Finding cancer when the tumor is small has many benefits. “If it’s smaller, you can have less surgery — say, a lumpectomy rather than a mastectomy; it’s less likely to have spread to the lymph nodes; and you're therefore less likely to have those taken out with surgery," she says. "You're also possibly less likely to have chemotherapy.”

Talk to your doctor about when you should start getting mammograms and how often you should get them.

2. Breast self-exams may not save your life.

There’s no evidence that giving yourself a monthly breast self-exam (BSE) reduces the risk of dying from breast cancer, or that BSEs help in finding cancer earlier, according to the National Breast Cancer Coalition. Yet many physicians still recommend doing them.

“They allow you to get comfortable with what your tissue feels like, so that if there’s something new, you’ll notice it,” says Allyson F. Jacobson, MD, medical director of the breast program at Northwest Community Hospital in Arlington Heights, Illinois.

“You have more access to your breasts than anyone else. If you find something like a lump in your breast, sure, it can make you anxious," says Dr. Jacobson. "But if you're examining your breasts at regular intervals, you can potentially find something before the next time you see a doctor." She recommends doing a BSE the week after your period (if you still have menstrual periods), and no more than once a month.

Morrow adds that breasts are lumpy by nature, and for women who have especially lumpy breasts, self-exams may not be effective. “Every time they do an exam, they find a lump, and those women should not drive themselves crazy trying to do self-exams — especially if they’re in the age range to receive mammograms,” she notes.

3. Your breast size doesn’t matter.

Jacobson says the size of your breasts has no bearing on your risk for developing breast cancer. The same is true for detecting cancer with a mammogram.

“As long as the technologist can get the tissue within the plates to compress it and get the image done — which they can almost always do — there shouldn’t be a problem, " she says. "Even men can have mammograms, and there is very little breast tissue in the typical male.”

Whether or not you or a physician can feel a cancer depends on how close to the surface the cancer is, how different the texture of the cancer is from your breast tissue, and where the cancer is in the breast, says Morrow. “It’s not purely a matter of breast size.”

4. Breast cancer usually shows no signs or symptoms.

The point of mammograms is to detect cancer before symptoms occur, but sometimes cancer is missed on a mammogram.

The most common symptom of breast cancer is a painless lump or mass. But according to the ACS, other symptoms can include swelling; skin irritation; pain in the nipple or breast; an inward turning nipple; redness, scaliness, or thickening of the nipple or breast skin; and nipple discharge that isn’t breast milk.

“Awareness of your breasts is important. If you find something that’s new or different, whether you discover it in the shower or looking in the mirror or another way, bring it to your doctor’s attention,” says Morrow.

5. Most women who get breast cancer don’t have a family history.

More than 85 percent of women who get breast cancer have no family history of the disease, reports the ACS.

“While family history does increase your risk, not having breast cancer in your family does not by any means get you off the hook,” says Jacobson. Even if you have no family history, your risk of getting breast cancer over your lifetime is 12 percent.

“This is very high for a cancer. I see many women who find a lump and don’t think they need to worry, because no one in their family has had breast cancer,” says Jacobson.

RELATED: What Is the Best Diet for Cancer Prevention?

6. High risk factors are relative.

When the term "high risk" is used scientifically, Morrow says it means higher risk than someone without any risk factors. “Factors increase the risk of getting breast cancer, but there is no standard definition of what truly constitutes high risk.”

Still, in general Morrow says the biggest risk factors for getting breast cancer are being female and getting older. Some other risk factors, according to the National Cancer Institute, include:

    Being obese
    Having a close relative with breast cancer (specifically your mother, sisters, or daughters)
    Carrying the gene mutations BRCA1 and BRCA2
    Getting your first menstrual period before age 12
    Giving birth for the first time after age 30
    Never being pregnant
    Starting menopause at an older age
    Taking hormone therapy
    Drinking alcohol

Not all of these risk factors are equal; they range from questionable to truly high-risk.

7. Genetic testing is appropriate for some women, but not all. 

If you know that a close relative, such as your mother or sister, carries a breast cancer gene mutation (such as BRCA1 or BRCA2), talk with your doctor about genetic testing. If you don’t know whether a family member who had breast cancer was tested for a gene mutation, your doctor can determine if you’d be a good candidate for genetic testing.

“[The number of] women who have this increase in risk is relatively small,” says Morrow. Some other factors that may be markers of a higher risk, and that may merit getting a genetic evaluation, include:

    Having numerous relatives who have had breast cancer
    Having relatives who have had breast cancer at a younger age, before menopause
    Having relatives who have had cancer in both breasts
    Having male relatives who have had breast cancer
    Having relatives with both breast and ovarian cancer

Check with your insurance company about coverage for genetic testing, but note that the Affordable Care Act considers genetic counseling and testing for people at high risk a covered preventive service.

8. Breast cancer treatment is truly individual. 

Even though it’s beneficial to find your breast cancer in an earlier stage before it has spread, doing so doesn’t always mean that your treatment will be less aggressive.

“Sometimes we end up doing mastectomies instead of lumpectomies for stage 0 breast cancer, because the biology of cancer the patient has is more likely to be aggressive and shorten their survival,” says Morrow, adding that the same thing goes for chemotherapy.

“Just because a tumor is small versus large doesn’t mean it’s not serious. The biology of the tumor, no matter its size, is what matters,” she says.

By testing tumors, Morrow says it’s possible to determine how the cancer will behave. “Based on those characteristics, even if it’s a small stage I cancer, the potential of what it can do is what drives the treatment,” she says.

9. Mastectomy is not always the best treatment.

While a mastectomy, which is the removal of one or both breasts, is performed to get rid of cancer from the breasts or to prevent cancer from developing in women who are at high risk, Morrow says there is a myth surrounding the surgery.

“It’s often thought that if you have breast cancer in one breast, the safest thing to do is to have both of your breasts removed. For the average woman with breast cancer — meaning those who don’t have a genetic mutation — removing your other breast does nothing to prolong your life,” she says.

Morrow adds that breast cancer does not spread from breast to breast. “The risk of getting a second breast cancer in your other breast has been going down over time, because the drugs used to treat the first breast cancer reduce the risk of making a new cancer. But a lot of people say, ‘I want to see my children grow up. I want to be safe. I hear celebrities say it’s good to remove both.’ It’s just simply not true,” she says.

10. There are some things you can do to reduce your risk.

There is no proven way to prevent breast cancer, yet Jacobson says living a healthy lifestyle is your best defense.

“You can’t beat your DNA or your family history, so whatever you’re predisposed to, you are predisposed to. But there are things you can potentially control and maximize to your benefit,” she says.

Following a healthy diet rich in fruits and vegetables that contain antioxidants and cancer-fighting nutrients, as well as exercising, minimizing alcohol (more than one drink a day on average increases a woman’s risk), and maintaining a healthy weight can all be beneficial, she notes.

“There’s no magic bullet, or pill, or one specific thing, but these are some factors you can control,” she says.





Source from : http://www.everydayhealth.com/news/10-essential-facts-about-breast-cancer/

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New breast cancer guidelines: screen later, less often

                  

The venerated cancer organization says women should start getting mammograms at 45 instead of 40, and that everyone can skip the routine manual breast checks by doctors.

An exhaustive review of the medical literature shows these measures just aren't very effective, according to the group. "The chance that you're going to find a cancer and save a life is actually very small," said Dr. Otis Brawley, the society's chief medical officer.

Now three key groups -- the American College of Obstetricians and Gynecologists, the American Cancer Society, and the U.S. Preventive Services Task Force -- recommend different ages for starting regular mammograms: 40, 45 and 50 respectively.

While mammograms save lives, they can also cause harm, and each group does a different job of balancing the pros and cons.
In a move sure to befuddle women -- and anger some breast cancer survivors -- the American Cancer Society has issued new guidelines saying less screening for breast cancer is better than more.

Earlier testing is not necessarily better

        The problem with mammograms is that they have a relatively high false positive rate, which means women sometimes have to undergo painful and time-consuming tests only to find out they never had cancer in the first place.

The chances of false positives are especially high for women under 45, as they have denser breasts and tumors are harder to spot on an image. "If she starts screening at age 40, she increases the risk that she'll need a breast cancer biopsy that turns out with the doctor saying 'You don't have cancer, so sorry we put you through all this,'" Brawley said.

He said he knows women who've had false positives year after year. "False positives are a huge deal," he said. "These women are so frightened and inconvenienced they swear off mammography for the rest of their lives."

Six years ago, the federal government's Preventive Services Task Force caused a furor when it declared that women in their 40s didn't need to get routine mammograms. Younger women whose breast cancers were caught by mammograms angrily responded that they would have been dead if they'd followed that guideline.

They said they'd gladly risk a false positive, with all the inconvenient and sometimes painful followup, for the chance of finding a cancer.

Learning from that experience, the American Cancer Society has sought to soften its message, emphasizing that women in their early 40s should still be able to get mammograms if they want them, as long as they understand the risks.

There's the risk of a false positive, plus the risk that a mammogram could catch a very small breast cancer that will go away on its own, or never progress to the point that it hurts a woman. In other words, a mammogram could catch a tumor that isn't really worth catching.

But since doctors can't reliably discern the harmful from the harmless cancers, they treat them all. This means some women are getting potentially harmful treatments, such as radiation, chemotherapy and surgery, when their tumor would never have caused a problem, Brawley says.

A Canadian study looked at 44,925 women who were screened for breast cancer, and 106 of them fell into this category and were treated for breast cancer "unnecessarily," according to a review in the New England Journal of Medicine.

New guidelines have their critics

    While agreeing with the American Cancer Society that mammograms aren't perfect, some advocates for women criticized the group's new guidelines. First, they said the society looked mostly at studies of film mammography, which in the United States has almost been entirely replaced by digital mammography.

Digital mammograms generate clearer images and do a better job of finding cancer and have a lower false positive rate.

"It's like standard versus HD TV," said Dr. Therese Bevers, the chair of the National Comprehensive Cancer Network's guidelines panel for breast cancer screening and diagnosis, and the medical director of the Cancer Prevention Center at the MD Anderson Cancer Center.

Second, critics said the cancer society looked only at whether screening saved a woman's life, and not at whether screening caught a cancer early, so the woman could avoid the most drastic treatments, such as chemotherapy or mastectomy.

"The American Cancer Society made the value judgment that screening is only worth it if improves survival," said Dr. Marisa Weiss, a breast cancer survivor and president of Breastcancer.org. "There's an arrogance to that. Let women decide what's meaningful to them."

Insurance companies also decide

     The new guidelines also state that women over age 55 can choose to get a mammogram every other year, since breast cancers in post-menopausal women tend to develop more slowly.

To a great extent it will be insurance companies that decide at what age women get mammograms. In 2009, they typically continued to pay for mammograms starting at age 40 even though the government's task for force recommended mammograms starting at age 50.

But it's not clear what they'll do now that the American Cancer Society has also raised the age for mammograms.

"(Insurance) plans will certainly take these updated recommendations into account when evaluating their coverage policies," Clare Krusing, a spokeswoman for America's Health Insurance Plans, wrote to CNN in an email.

The new guidelines are meant for women at average risk of breast cancer. The society says women with a family history or who carry a gene that predisposes them to breast cancer may need to start screening earlier and more frequently.

As for the recommendation to discontinue routine manual breast exams by doctors, many advocates for women with breast cancer agree there's a lack of good evidence that they save lives, but some said they saw no reason to get rid of them.

"It's a free and added way of knowing whether or not a lump is there," said Leigh Hurst, founder of the Feel Your Boobies Foundation.

In the end, with so many different opinions on preventing breast cancer, experts are worried women will throw up their hands.

"Our biggest concern is that this will create a lot of potential havoc in the day-to-day practice of caring for women," said Dr. Christopher Zahn, the vice president of practice activities for ACOG.


Source from : http://edition.cnn.com/2015/10/20/health/new-acs-breast-cancer-screening-guidelines/

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What`s new in breast cancer research and treatment?

What`s new in breast cancer research and treatment?

     Research into the causes, prevention, and treatment of breast cancer is being done in many medical centers throughout the world.

Causes of breast cancer

Studies continue to uncover lifestyle factors and habits that alter breast cancer risk. Ongoing studies are looking at the effect of exercise, weight gain or loss, and diet on breast cancer risk.

Studies on the best use of genetic testing for BRCA1 and BRCA2 mutations continue at a rapid pace. Scientists are also exploring how common gene variations may affect breast cancer risk. Each gene variant has only a modest effect in risk (10 to 20%), but when taken together they may potentially have a large impact.

Potential causes of breast cancer in the environment have also received more attention in recent years. While much of the science on this topic is still in its earliest stages, this is an area of active research.

A large, long-term study funded by the National Institute of Environmental Health Sciences (NIEHS) is now being done to help find the causes of breast cancer. Known as the Sister Study, it has enrolled 50,000 women who have sisters with breast cancer. This study will follow these women for at least 10 years and collect information about genes, lifestyle, and environmental factors that may cause breast cancer. An offshoot of the Sister Study, the Two Sister Study, is designed to look at possible causes of early onset breast cancer. To find out more about these studies, call 1-877-4-SISTER (1-877-474-7837) or visit the Sister Study website (www.sisterstudy.org).

Chemoprevention

           Fenretinide, a retinoid, is also being studied as a way to reduce the risk of breast cancer (retinoids are drugs related to vitamin A). In a small study, this drug reduced breast cancer risk as much as tamoxifen.

Other drugs, such as aromatase inhibitors, are also being studied to reduce the risk of breast cancer.

For more information, see Medicines to Reduce Breast Cancer Risk.

Making decisions about DCIS

         In some women, DCIS turns into invasive breast cancer and sometimes an area of DCIS contains invasive cancer. In some women, though, the cells may never invade and remain localized within the ducts. If the cells don’t invade, DCIS cannot spread to lymph nodes or other organs, and so cannot be life-threatening. The uncertainty about how DCIS will behave makes it difficult for women to make decisions about what treatment to have, if any. Researchers are looking for ways to help with these challenges.

Researchers are studying the use of computers and statistical methods to estimate the odds that a woman’s DCIS will become invasive. Some of these methods are based on routinely available clinical information about the patient and her DCIS, whereas others also include information about changes in her tumor’s genes. Decision aids are another approach. They ask a woman with DCIS questions that help her decide which factors (such as survival, preventing recurrence, and side effects) she considers most important in choosing a treatment.

Another approach is to look at genes expressed by the DCIS cells using a test such as the Oncotype Dx DCIS Score. This test can be used to predict a woman’s chance of DCIS coming back or a new cancer developing in the same breast if she does not get radiation. So far, though, it hasn’t been studied well enough to predict how much someone would benefit from radiation after surgery for DCIS.

Another recent area of research and debate among breast cancer specialists is whether changing the name of DCIS to one that emphasizes this is not an invasive cancer can help some women avoid overly aggressive treatment.

New laboratory tests

Circulating tumor cells

       Researchers have found that in many women with breast cancer, cells may break away from the tumor and enter the blood. These circulating tumor cells can be detected with sensitive lab tests. Although these tests can help predict which patients may go on to have their cancer come back, it isn’t clear that the use of these tests will help patients live longer. They may potentially be useful for women with advanced breast cancer to help tell if treatments are working.

Newer imaging tests

   Newer imaging methods are now being studied for evaluating abnormalities that may be breast cancers.

Scintimammography (molecular breast imaging)

   In scintimammography, a slightly radioactive tracer called technetium sestamibi is injected into a vein. The tracer attaches to breast cancer cells and is detected by a special camera.

This technique is still being studied to see if it will be useful in finding breast cancers. Some radiologists believe it may helpful in looking at suspicious areas found by regular mammograms, but its exact role remains unclear. Current research is aimed at improving the technology and evaluating its use in specific situations such as in the dense breasts of younger women. Some early studies have suggested that it may be almost as accurate as more expensive magnetic resonance imaging (MRI) scans. This test, however, will not replace your usual screening mammogram.

Several other imaging methods, including thermal imaging (thermography) are discussed in Mammograms and Other Breast Imaging Procedures.

Treatment

Oncoplastic surgery

      Breast-conserving surgery (lumpectomy or partial mastectomy) can often be used for early-stage breast cancers. But in some women, it can result in breasts of different sizes and/or shapes. For larger tumors, it might not even be possible, and a mastectomy might be needed instead. Some doctors address this problem by combining cancer surgery and plastic surgery techniques, known as oncoplastic surgery. This typically involves reshaping the breast at the time of the initial surgery, and may mean operating on the other breast as well to make them more symmetrical. This approach is still fairly new, and not all doctors are comfortable with it.

New chemotherapy drugs

Advanced breast cancers are often hard to treat, so researchers are always looking for newer drugs.

A drug class has been developed that targets cancers caused by BRCA mutations. This class of drugs is called PARP inhibitors and they have shown promise in clinical trials treating breast, ovarian, and prostate cancers that had spread and were resistant to other treatments. Further studies are being done to see if this drug can help patients without BRCA mutations.

Targeted therapies

Targeted therapies are a group of newer drugs that specifically take advantage of gene changes in cells that cause cancer.

Drugs that target HER2: A number of drugs that target HER2 are currently in use, including trastuzumab (Herceptin), pertuzumab (Perjeta), ado-trastuzumab emtansine (Kadcyla), and lapatinib (Tykerb). Other drugs are being developed and tested.

Anti-angiogenesis drugs: For cancers to grow, blood vessels must develop to nourish the cancer cells. This process is called angiogenesis. Looking at angiogenesis in breast cancer specimens can help predict prognosis. Some studies have found that breast cancers surrounded by many new, small blood vessels are likely to be more aggressive. More research is needed to confirm this.

Bevacizumab (Avastin) is an example of anti-angiogenesis drug. Although bevacizumab turned out to not be very helpful in the treatment of advanced breast cancer, this approach still may prove useful in breast cancer treatment. Several other anti-angiogenesis drugs are being tested in clinical trials.

Other targeted drugs: Everolimus (Afinitor) is a targeted therapy drug that seems to help hormone therapy drugs work better. It is approved to be given with exemestane (Aromasin) to treat advanced hormone receptor-positive breast cancer in post-menopausal women. It has also been studied with other hormone therapy drugs and for treatment of earlier stage breast cancer. In one study, letrozole plus everolimus worked better than letrozole alone in shrinking breast tumors before surgery. It also seemed to help in treating advanced hormone receptor-positive breast cancer when added to tamoxifen. Everolimus is also being studied in combination with chemotherapy and the targeted drug trastuzumab. Other drugs like everolimus are also being studied.

Other potential targets for new breast cancer drugs have been identified in recent years. Drugs based on these targets are now being studied, but most are still in the early stages of clinical trials.

Bisphosphonates

     Bisphosphonates are drugs that are used to help strengthen and reduce the risk of fractures in bones that have been weakened by metastatic breast cancer. Examples include pamidronate (Aredia) and zoledronic acid (Zometa).

Some studies have suggested that zoledronic acid may help other systemic therapies, like hormone treatment and chemo work better. In one study of women being treated with chemo before surgery, tumors in the women getting zoledronic acid with chemo shrank more than those in the women treated with chemo alone.

Other studies have looked at the effect of giving zoledronic acid with other adjuvant treatments (like chemo or hormone therapy). So far, the results have been mixed. Some studies have shown that this approach helped lower the risk of the cancer coming back, but others did not. The results of one study linked the use of these drugs with adjuvant chemo with an increased risk of breast cancer recurrence in younger women. Overall, the data does not support making bisphosphonates part of standard therapy for early-stage breast cancer.

Denosumab

     Denosumab (Xgeva, Prolia) can also be used to help strengthen and reduce the risk of fractures in bones that have been weakened by metastatic breast cancer. It is being studied to see if it can help adjuvant treatments work better.
Vitamin D

A recent study found that women with early-stage breast cancer who were vitamin D deficient were more likely to have their cancer recur in a distant part of the body and had a poorer outlook. More research is needed to confirm this finding. It is not yet clear if taking vitamin D supplements would be helpful. Still, you might want to talk to your doctor about testing your vitamin D level to see if it is in the healthy range.


Source by : http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-new-research

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