However gently a physician informs a woman of test results that indicate the presence of breast cancer cells, she will hear a stark pronouncement: “You have breast cancer.” The fear of breast cancer is a gut-wrenching emotion. “Every woman thinks she is alone with this,” says Dr. Eric Bonnem, an oncologist affiliated with Portsmouth Regional Hospital. He encourages his patients to participate in support groups, citing the importance of education and emotional support during the treatment process and beyond. Dr. Bonnem describes how breast cancer treatment has changed over the years.
From 1900 to about 1970, the approach to treatment was to remove the tumor. Surgery, usually a radical mastectomy, was the only option. If cancer cells reappeared, more aggressive surgery was performed. But in some patients, cancer cells still returned, often in a new location. Oncologists realized that for these women, who had invasive or metastasizing cancer, surgery was not a sufficient answer. Chemotherapy (anticancer drugs) was introduced, in combination with surgery. More recently hormonal therapy (primarily Tamoxifen) has proven effective for certain cancers. Breast-conserving surgery (“lumpectomy”) combined with radiation has become the option preferred by many women for the removal of small tumors. “We have 30 years of experience and clinical research to demonstrate that adjuvant therapy [adjunct to surgery] can extend life,” says Dr. Bonnem.
Not all breast cancers are alike. A woman who has a diagnosis of breast cancer needs to know what type and what stage of cancer she has. Early stage cancers are those that have remained in place and haven’t invaded surrounding tissues. These cancers can usually be treated successfully. Left untreated, they can develop into invasive breast cancer. In invasive breast cancer, cells have gone beyond the duct or lobular wall, into surrounding tissue. The type and stage of the cancer dictate which treatment, which adjuvant therapies will be most effective.
These therapies improve survival. “Women will live longer and have a better quality of life,” says Dr. Bonnem. New drugs help to reduce the common side effects of treatment, such as nausea. Smaller, more targeted dosage is used. The statistics are favorable, though, if a relapse occurs, the odds change. Another episode is likely in two to three years.
Dr. Steven Larmon, clinical director of the Kingsbury Cancer Center at Cheshire Medical Center, is encouraged by recent trends in breast cancer statistics. There has been a slight decrease in the incidence of breast cancer. Breast cancer deaths began a downward curve in the early 1990s. The mortality rate in New Hampshire was 27 per 100,000 in 1981. In 1998, it was 23.4 per 100,000. This good news results, in large part, from early diagnosis and therefore treatment of smaller cancers. The earlier the treatment, the more likely it will be successful. “A small cancer is rarely found by a woman’s own examination,” says Dr. Larmon. This underscores the importance of regular screening mammograms and clinical breast examinations.
The “breast cancer gene” first came to the attention of the public in the mid-1990s. Two identified genes, BRCA-1 and BRCA-2, inhibit the growth of cancer cells. When there is an abnormality in either, this critical function is lost. The announcement brought anxiety to women with relatives who had been treated for breast cancer; many wondered if they should have genetic testing. A sporadic pattern of breast cancer in a family, however, does not indicate the presence of a genetic abnormality. Only a family history with multiple blood relatives with breast or ovarian cancer suggests an inherited genetic abnormality.
About 3-5 percent of breast cancer patients have an inherited abnormal gene. A woman whose family history indicates that possibility should work with her physician and perhaps a genetic counselor, before opting for genetic testing.
The presence of an abnormal BRCA-1 or BRCA-2 gene does increase the risk for breast cancer. The average woman has about a 12 percent risk over a 90-year life span. By contrast, a woman with an abnormal gene has a risk of from 40 percent to 85 percent at age 70. Yet it is important to remember that many women with the gene will not develop cancer. Gene abnormalities are more commonly found in women who are diagnosed before the age of 40. There is evidence that these cancers grow more slowly than others.
Breast cancer is still a formidable foe. But Dr. Larmon speaks of promising new treatments. There are new agents for chemotherapy. There are antibodies to block the growth of cancer cells. Sentinel lymph node biopsy offers an effective, less-invasive diagnostic tool to determine the presence of cancer cells in the lymph nodes. Clinical trials of “dose dense” chemotherapy (reducing the time between successive doses) have shown positive results. The addition of new drugs to prevent the side effects of chemotherapy makes more frequent dosing tolerable for patients. “I’m excited about what’s happening,” says Dr. Larmon. “There are dozens of new possibilities. Some may not work out, but some will. We will have more options and better survival rates.”
This article appears in the October 2004 issue of New Hampshire Magazine