Monday, December 18, 2017

OCMA Blog

The Road Ahead: Diagnosis and Treatment of Breast Cancer

Cancer. Just hearing the word can bring you down. For many women, a breast cancer diagnosis is a reality they have to face. The thought of receiving a diagnosis can cause much distress and anxiety in women on top of all the stresses they experience every day. Fortunately, there have been great strides in breast cancer research, treatment and diagnosis. Breast cancer is no longer a death sentence, and more women are living healthy and happy lives after their diagnosis. With death rates down 34% since 1990, breast cancer is no longer a death sentence, and more women are living healthy and happy lives after their diagnosis.

The road to recovery begins with diagnosis. So, how do we do so with confidence and accuracy? Physicians employ a variety of breast imaging services including mammography, ultrasound and MRI to detect breast cancer, depending on various patient factors. However, breast cancer screening guidelines have become somewhat confusing in recent years, with multiple organizations offering different recommendations. The most common advice from radiologists and breast surgeons is for an annual mammogram starting at the age of 40. For women with denser breast tissue, tomosynthesis (3D) mammography may be beneficial and/or consideration of screening breast ultrasound. Those women whose lifetime risk of breast cancer exceeds 20% would also be screened with annual MRI. Still, I find it helpful for women to have a general sense of what is normal for them. For instance, if a new breast lump is identified by a patient that does not go away within one menstrual cycle, it is worth exploring with at least an ultrasound.  In a postmenopausal woman, a new lump warrants diagnostic breast imaging including ultrasound.
  

Once breast cancer is detected, the next step to recovery is treatment. There are three main forms available: medications, radiation therapy and surgery. Which one or ones are right for you is dependent on the type and severity of the cancer. Medications used for breast cancer include chemotherapy agents, hormone blocking drugs like tamoxifen or aromatase inhibitors, and immunotherapy. The biology and behavior of the cancer tend to influence which drugs, if any, would work best for a particular cancer. With radiation therapy, doctors take into account a patient’s age, surgery performed, and pathology characteristics to assess whether radiation is indicated, and if so, what course might be best suited for the patient. Breast surgery procedures range from lumpectomy, which conserves breast tissue, to mastectomy, which removes the majority but not all of the breast tissue. In determining which surgery is best for an individual, several factors are taken into consideration, including the size and location of the cancer, personal and family history, and the patient’s personal preferences. More and more women are benefiting from the use of oncoplastic surgery, where oncologic principles of taking out cancer with, ideally, widely clear margins, are combined with plastic surgery closure techniques. Oncoplastic breast conserving procedures and mastectomy reconstruction options have really revolutionized breast surgery, allowing women to boost their self-confidence and feel more like their usual selves. 

Reconstruction is an option for the vast majority of patients undergoing mastectomy and allows women to retain a natural, feminine appearance after surgery. Two main forms of reconstruction are available: reconstruction with implants and reconstruction with tissue. Reconstruction with implants is the most common technique used in breast reconstruction. It often involves the initial placement of a tissue expander to maximize the ability of the skin to heal, while allowing flexibility in the size of the reconstructed breast, followed by later removal and replacement with a formal implant. Some women may prefer to use their own tissue for reconstruction. In this case, tissue is taken from another part of the body, most commonly the abdomen or the back, and transferred to the mastectomy site, creating a natural texture to the reconstructed breast. 
The thought of being diagnosed with breast cancer can be frightening. Fortunately, great strides have been made in breast cancer research, and new technologies help women get back to their normal lives more quickly. 

For more information on breast cancer imaging, treatment and diagnosis, visit breastlink.com. 


USPSTF Recommendations Ignore Reality of Breast Cancer


This article is brought to you by: Breastlink

visit www.breastlink.com for more information

 

Annual mammogram screening beginning at age 40 saves lives. U.S. Preventive Services Task Force (USPSTF) recommends less frequent screening at a later age, not because screening will not save lives, but because it will not save sufficient numbers of lives when started before age 50. The recommendations are based on outdated, blemished data and do not evaluate cost-effectiveness or any other benefits of early detection. In fact, USPSTF states, “Screening mammography in women ages 40 to 49 years may reduce the risk of dying of breast cancer, but the number of deaths averted is much smaller than in older women and the number of false-positive tests and unnecessary biopsies are larger.”[1]

Women need to empower themselves with accurate information about screening to benefit from early detection.

The Reality of Breast Cancer in Younger Women

Women younger than 50 are diagnosed with and die from breast cancer. Research proves that mammogram screening can prevent breast cancer deaths in these women.

Nearly 65,000 women younger than 50 were diagnosed with breast cancer in 2013, according to the American Cancer Society. Nearly 5,000 women in this age group died from breast cancer.[2] Within its own recommendations, even USPSTF recognizes that mammogram screening contributed to a 15 percent decrease in breast cancer mortality among women aged 39 to 49.[3]

Decreasing mortality is not the only benefit from early detection with screening mammography – it is simply the most important benefit. There are many other potential benefits to identifying and treating cancer in its earliest stages:

·         Prevent chemotherapy

·         Prevent lymphedema

·         Limit surgery

·         Minimize radiation therapy

·         Decrease psychosocial impact

·         Maximize number of treatment options available

Mammogram is superior to clinical breast exam or self-exam at identifying small tumors. Tumors detected under 1cm in size, regardless of their biology, can almost always be treated without chemotherapy. About 20 to 30% of these tumors will have aggressive biology and if left to grow for one to two years, they would certainly require more aggressive treatment. USPSTF has failed to acknowledge the harms of chemotherapy needed for more advanced tumors.

Identifying tumors that have not spread to lymph nodes can minimize surgical and radiation treatments. Breast conservation and partial breast irradiation are options with early stage breast cancers. Surgical complications decrease when radiation can be avoided in the setting of mastectomy with reconstruction. Avoiding lymph node dissections also decreases the incidence of lymphedema. USPSTF has failed to acknowledge the burden of lymphedema when disease has spread to lymph nodes.

Aggressive treatments also represent a cost burden to individuals and to society. The total cost of treating all cancers exceeded $216 billion in 2009, according to the National Institutes of Health.[4] Breast cancer accounts for a significant portion of this. By detecting cancer at its earliest stages, the cost of cancer care can be greatly diminished. This cost burden inevitably has a direct psychosocial and economic impact to cancer patients, their families and society as a whole. The “harms” of a false-positive mammogram are almost trivial in comparison to the burden of advanced cancer care. USPSTF has failed to acknowledge the emotional and cost burden of delaying breast cancer diagnosis.

Due to significant advances in adjuvant therapies, death from breast cancer has improved even at advanced stages of diagnosis. However, USPSTF has failed to acknowledge 10 years’ worth of advancements in breast cancer treatment focused on minimizing surgery and radiation treatment when cancer is detected at early stage. These advancements have helped to decrease morbidity while improving quality of life for cancer survivors.  These benefits depend on early detection enabled by annual mammogram screening.    

It is irresponsible for USPSTF to describe harms of false-positives and anxiety of testing without discussing the benefits of avoiding aggressive treatment. Women should be empowered to make their own decisions about their health care. Failure to provide this information and limiting access to mammogram screening does not help to accomplish this. Furthermore, these “recommendations” made by USPSTF can be inappropriately used to limit insurance coverage for annual screening, prevent primary care providers and OB/GYNs from ordering screening, and discourage women from obtaining routine mammograms. By recommending annual screening beginning at age 40, women are encouraged to begin thinking about their breast cancer risk and breast health.

The Argument Against Mammogram Screening

USPSTF recommendations suggest women should begin screening at the age of 50 and continue screening every two years until the age of 74. This decision was made in 2009, reversing an earlier stance for annual screening beginning at age 40. A recent review of the 2009 decision upheld the reversal. These recommendations are based heavily on data provided by flawed research studies:

Canadian National Breast Screening Study

The Canadian National Breast Screening Study is one of the studies used to support current USPSTF recommendation.[5] Multiple independent researchers who reviewed this study noted multiple problems.[6]

·         Outdated mammogram technology from the 1970s.

·         Women included in the study were not appropriately placed in the screening and control groups.

·         Technicians performing exams did not receive special training in mammogram screening.

·         Radiologists interpreting mammograms were not trained specifically in breast imaging.

USPSTF recommendations also consider harms and risks like patient anxiety, false-positive results, recalls and overdiagnosis. These are important concerns to recognize, but are sometimes overstated. The Swedish Two-County Trial found that two lives are saved for every instance of overdiagnosis.[7] This trial also showed that recalls affected less than 1 in 20 women.

While it is necessary to talk about the harms and risks, physicians should discuss them with patients rather than denying them access to mammogram screening.

The Benefits of Mammogram Screening

The American Cancer Society, Society of Breast Imaging and American College of Radiology all recommend women receive mammogram screening once every year for as long as they are healthy. Numerous studies and data support this position.

National Cancer Institute SEER Data

While cancer treatments have improved, early detection enabled by mammogram has helped to reduce the mortality rate. Data collected by the National Cancer Institute over the last several decades supports this.

Mammogram Screening Rates

Breast Cancer Mortality Rates

1987: 22%

1990: 33%

2010: 67%

2010: 22%

Over a similar period of time, mammogram screening rates skyrocketed while breast cancer mortality rates decreased by one-third.[8][9]

University of Michigan Comprehensive Cancer Center

The ability of mammogram screen to aid early diagnosis is also evident in research published May 2014 in Cancer. Researchers compared data collected from 1977 to 1979 with data collected from 2007 to 2009. While incidences of early-stage breast cancer rose by one-half based on projected rates, incidences of late-stage breast cancer would have dropped 37 percent.[10]

Analysis of Mammogram Screening in Women Aged 40 to 49

Prior to its 2009 reversal, USPSTF recommended annual screening beginning at age 40. These recommendations relied on an analysis of eight randomized clinical trials, published 1997 in Journal of the National Cancer Institute.

Results from this analysis showed that women aged 40 to 49 benefitted from mammogram screening. Incidences of breast cancer and breast cancer deaths were lower among women aged 40 to 49 than for women aged 50 or older. A mortality reduction of 23 percent was noticed in this study when screening in women aged 40 to 49.[11]

More Deaths in Unscreened Women

A failure analysis published September 2013 in Cancer determined that most breast cancer deaths occur in women who do not receive routine screening. Unscreened women accounted for 71 percent of breast cancer deaths. Additionally, approximately one-half of these deaths were in women younger than 50.[12]

Breastlink Position

In summary, we agree with the USPSTF that screening mammography saves lives. We also agree with the American Cancer Society and many others that screening should begin at age 40 for average risk women and should occur annually while women are healthy. We believe this will maximize the benefit of early detection by not only saving lives, but also by reducing the need for more aggressive treatments.

Signed:

Dr. Nimmi Kapoor

Dr. John Link

Dr. John West

Dr. Lisa Curcio

Dr. Amy Bremner

Dr. Samantha Kubaska

Dr. June Chen

Dr. Wade Smith

Dr. Tchaiko Parris

Dr. Justin West

Dr. Mark Gaon

 



[1] U.S. Preventive Services Task Force. “Draft Recommendation Statement: Breast Cancer: Screening.” April 2015.

[2] American Cancer Society. “Breast Cancer Facts & Figures 2013-2014.” 2013.

[3] U.S. Preventive Services Task Force. “Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement.” Annals of Internal Medicine. November 2009.

[4] National Heart, Lung, and Blood Institute. “NHLBI Fact Book, Fiscal Year 2012.” 2013.

[5] Miller et al. “Twenty-five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomized screening trial.” The BMJ. February 2014.

[6] Daniel B. Kopans. “Arguments Against Mammography Screening Continue to be Based on Faulty Science.” The Oncologist. February 2014.

[7] Tabár et al. “Swedish Two-County Trial: Impact of Mammographic Screening on Breast Cancer Mortality during 3 Decades.” Radiology. September 2011.

[8] National Center for Health Statistics. “Health, United States, 2013: With Special Feature on Prescription Drugs.” 2014.

[9] American Cancer Society. “Breast Cancer Facts & Figures 2013-2014.” 2013.

[10] Helvie et al. “Reduction in late-stage breast cancer incidence in the mammography era: Implications for overdiagnosis of invasive cancer.” Cancer. September 2014.

[11] Hendrick et al. “Benefit of Screening Mammography in Women Aged 40-49: A New Meta-Analysis of Randomized Controlled Trials.” Journal of the National Cancer Institute. January 1997.

[12] Webb et al. “A failure analysis of invasive breast cancer: Most deaths from disease occur in women not regularly screened.” Cancer. September 2014.


Understanding Advancements in Genetic Testing for Breast Cancer

Written by Nimmi Kapoor, MD, Surgical Oncologist, Breastlink

Our understanding of breast cancer is rapidly advancing.  Breast cancer is not a single disease entity, but a heterogeneous disease spectrum with numerous genetic alterations involved in its pathogenesis. Some breast cancers are indolent and not life-threatening, while others are very aggressive. Similarly, we find different genetic alterations in different breast cancers. Some of these genetic changes are familial, or the result of genetic mutations passed from parent to child. The BRCA genes were the first to shed light on familial breast cancer genetics. Now we are capable of screening over a dozen different genes for mutations implicated in breast cancer risk. Navigating these new complexities in genetic testing can be challenging. It will be important for all physicians to become more familiar with this expanding area of medicine.

Background to Genetic Testing for Breast CancerIt is the 20-year anniversary since the first BRCA gene mutation was identified. By the mid-2000s, enough data had been collected for the National Comprehensive Cancer Network (NCCN) to issue guidelines on genetic testing. Most insurance plans began to offer some sort of coverage for genetic testing by 2010. In the short time since, genetic testing has become much more widespread and tests have advanced to identify numerous genetic mutations linked to breast cancer.

Two of the most well-known genes associated with increased risk for developing breast cancer are BRCA1 and BRCA2. Between 15 and 20 percent of all breast cancers are familial, with BRCA1 and BRCA2 responsible for approximately half of these familial cancers. These genes have been well described and there are established guidelines for their management. However, there are numerous other genes also known to increase risk for breast cancer. The most updated NCCN guidelines now recommend considering multi-gene testing over single gene testing. Some of these genes, in addition to the BRCA genes, include:
 

• PALB2
• PTEN
• TP53
• CDH1
• ATM
• CHEK2

Of these genes, PALB2, PTEN, TP53 and CDH1 are also well described and guidelines exist for their management. ATM and CHEK2, along with a handful of other genes, explain a significant portion of hereditary breast cancers, but are less understood and guidelines do not exist for their management.

Choice in Genetic Testing
Initially, there was not much choice when it came to testing for genes associated with increased risk for developing breast cancer. However, there are several factors at play today when physicians identify patients who may benefit from genetic testing.

Steps involved in completing genetic testing include assessing patient personal health and familial history, determining an appropriate test, educating the patient and obtaining informed consent, facilitating testing, interpreting results and developing a management plan. Several resources are available, such as the IBIS Breast Cancer Risk Evaluation Tool, to help physicians determine patient risk.

Numerous sequencing panels exist for testing of breast cancer genes, including single gene tests and multi-gene panels. Single gene tests may not reveal the presence of certain genes associated with increased risk for breast cancer, but are straightforward with clear guidelines for management. Multi-gene panels cast a wider net, concurrently testing for multiple genes, but results can include variants of unknown significance and be more difficult to manage.

There are also variables when it comes to choosing a laboratory for the analysis of genes. These include a patient’s insurance status and cost-effectiveness, turn-around time, ease-of-use services and patient tolerance for uncertain answers. For instance, a quick turn-around time may be necessary to inform decisions about surgery.

Breastlink’s Experience with Multi-Gene Panels
Breastlink began to offer multi-gene testing in 2013. Through a high-risk program, physicians working with Breastlink identify patients at high risk for developing breast cancer, a member of the Breastlink medical staff provides a consultation and coordinates genetic testing if necessary, and the physician uses results to inform a management plan.

From July 2013 to September 2014, Breastlink collected data on the multi-gene panel testing results of 398 patients referred to Breastlink through the high-risk program. Of these, 83% had negative results while 6% tested positive for a gene associated with increased risk for developing breast cancer. In the 23 patients with mutations, a mutation in a non-BRCA1/BRCA2 gene was identified in 10 patients, or 43%. In other words, multi-gene testing increased diagnostic yield by 77%.

As knowledge of the relationship between genetics and breast cancer grows, multi-gene testing will likely prove beneficial. It offers efficient sequencing of multiple genes and helps clinicians to better understand the true nature of individual cancers.

Physicians must learn how to talk with patients about genetic testing without limiting discussions to BRCA genes. A better understanding of the relationship between genetics and breast cancer risk will help women to make informed decisions about testing. Also, by identifying patients who are mutation carriers, we can counsel patients on individual risk management options, identify family members who can also be screened and contribute to our understanding of cancer biology.

Management options for gene mutation carriers
Once a patient is diagnosed with a mutation related to an increased cancer risk, they should be given adequate counseling on management options. Ideally, early involvement of a genetic counselor is a good idea. At the same time, all physicians should be aware of options and how to generally guide patients. Some gene mutations, such as those in the BRCA1 gene for example, will lend to an increased risk of multiple types of cancer including breast, ovarian, melanoma, and even pancreas cancer.

Not all gene carriers will necessarily develop cancer and each patient will have an individualized risk based on their personal and family history. There are on-line tools and algorithms such as brcatool.stanford.edu that can help guide individuals with gene mutations on their risk of developing breast or ovarian cancer and dying from cancer depending on how and when they choose particular interventions.  For example, a 35 year-old woman with a BRCA-1 mutation who chooses to have a prophylactic oophorectomy by age 35 and will have a 30% risk of developing breast cancer by age 70 compared to a similar woman who does not remove her ovaries with a 50% risk of breast cancer. This decrease of breast cancer risk by 20% with a prophylactic oophorectomy can be helpful to young women deciding on how to best manage their high risk state.

While preventive surgery is an option for women at high risk, alternatives include high risk screening with MRI or medical prophylaxis. Fortunately, because of advances in surgical technique, many women who choose to have prophylactic mastectomy will be able to undergo nipple-sparing mastectomy with some form of immediate reconstruction. This type of surgery offers superior cosmetic outcome and is ideal for the appropriate candidate.

Upcoming Event
Physicians, nurse practitioners and physician assistants are invited to join Dr. Lisa Curcio and Dr. Nimmi Kapoor, two Breastlink surgical oncologists, to learn more about the genetic testing landscape at a CME course to be held at MASTRO’s Steak House in Costa Mesa on October 23. For more information or to RSVP, please call 714-804-0940 or email events@breastlink.com.  

Click here for the event flyer.


Your Input is Needed: Susan G. Komen Breast Health Needs Assessment

OCMA is partnering with Susan G. Komen® in order to help disseminate a survey regarding Orange County's needs assessment for the 2015 Community Profile on Breast Cancer and Breast Health. The goal and purpose of the Community Profile is to communicate the status of breast health and breast cancer in the Orange County community, as well as to inform planning of programs and grants for the next several years.
 
As part of the data gathering process, Susan G Komen® has developed a brief provider survey to identify existing gaps and barriers to service as well as patients' beliefs and attitudes towards breast health services. Physicians should answer these questions based on their day-to-day interaction/experience with their patients. The survey should take no more than 20 minutes to complete, and all responses to the survey will be kept confidential. As an incentive, providers who complete the survey will have the opportunity to win a $100 gift card.
 
The last day to complete this survey is Friday, September 19, 2014.
 
Please follow the survey link below to participate in the survey:
https://www.surveymonkey.com/s/breasthealthneeds

 
Thank you in advance for your participation.

"Risk Tip" from The Doctors Company - Be Aware of Risks for BRCA-Based Breast Cancer

Avoid Missed or Delayed Diagnosis by Being Aware of Risks for BRCA-Based Breast Cancer

Recent news coverage has brought BRCA gene-based breast cancer into the spotlight. Actress Angelina Jolie's decision to get a preventive double mastectomy after testing positive for the BRCA gene may cause patients to ask physicians if they are at risk. Physicians should be aware of the risk factors for BRCA gene-based cancer in order to identify those who need testing and to avoid delayed or missed diagnosis.
 
A recent malpractice case highlights the failure of missing an early diagnosis. A 33-year-old woman had two female relatives, including her mother, who had breast cancer in their forties. At 31, she began getting annual screening mammograms, which showed dense breasts. She complained of a small palpable mass. However, no mass was seen on a mammogram, and the diagnosis was fibrocystic changes. No additional tests were ordered. Within six months, the mass was enlarging, and she was diagnosed with infiltrating ductal cancer that had advanced from a Stage I to a Stage III. Based on her history, she should have been tested for the BRCA mutation and given various treatment options. Additionally, no ultrasounds or MRIs were done, which possibly could have detected the cancer at an earlier treatable stage.
 
A woman's risk of developing breast and/or ovarian cancer greatly increases if she inherits a BRCA1 or BRCA2 gene mutation. Widespread screening is not required because together these mutations account for only 5-10 percent of breast cancers. Those with the BRCA1 mutation have a 55-65 percent chance of developing breast cancer by age 70, and those with the BRCA2 mutation have a 45 percent chance. Women have about a 2 percent chance of getting ovarian cancer, but if they have a BRCA2 mutation, that risk increases to 40-60 percent.
 
Physicians should watch for the following BRCA mutation risk factors and discuss genetic testing with patients at risk:

  • Maternal or paternal blood relatives with breast cancer diagnosed before the age of 50.
  • Certain cancers in a patient's family, such as pancreatic, colon, or thyroid.
  • Both breast and ovarian cancer in a patient's family, especially in one individual.
  • Women in a patient's family with cancer in both breasts.
  • Patient with Ashkenazi Jewish heritage.
  • A male in the patient's family with breast cancer.     
  • Relative with BRCA1 or BRCA2 mutation.

If the patient does test positive for the BRCA mutation, it is essential to remind her that this does not indicate she will get cancer. Patients can reduce risks of cancer with prophylactic surgery, hormonal treatment, and lifestyle changes.
 
Contributed by The Doctors Company. For more patient safety articles and practice tips, visit  www.thedoctors.com/patientsafety.


Home   |   About Us   |   Membership   |   For Physicians   |   News   |   For Patients   |   Advocacy   |   Events
Copyright (c) 2017 Orange County Medical Association