By Ellen Gilbert

October is Breast Cancer Awareness Month, an annual campaign to draw attention to the principle cause of death from cancer among women globally. WHO (World Health Organization) and the National Breast Cancer Association get behind the October endeavor, and smaller, local groups participate as well. The color pink, which has become associated with the campaign, is in particularly wide evidence as people sport pink ribbons, tee-shirts and other accessories to announce their support of the fight against breast cancer.

Actress/activist Angelina Jolie didn’t wait for October (it was May, 2013) to announce that after receiving genetic counseling indicating that she had the “faulty” BRCA 1 gene, she had chosen to have a preventive double mastectomy.

Although it was already on the rise, Breast Cancer Oncologist and Assistant Professor of Medicine at New York University Medical Center Komal Jhaveri acknowledges that, as a result of Jolie’s disclosure, “there has certainly been an uptick in the interest for genetic testing that can help predict a person’s potential risk of developing breast cancer.” Most inherited cases of breast cancer and/or ovarian cancer are associated with two abnormal genes: BRCA 1 (Breast Cancer gene 1, the faulty gene in Jolie’s case) or BRCA 2 (BR Cancer gene 2). Women who test positive for the BRCA mutations may consider preventive surgeries to remove their breasts and/or ovaries in a shared-decision with their breast surgeon, to reduce their risk of developing breast and/or ovarian cancer.

While any woman newly diagnosed with breast cancer or with a strong family history of breast and/or ovarian cancers should consider genetic testing, only five to ten percent of all breast cancers are actually hereditary, notes Jhaveri, who completed medical school at the University of Mumbai, trained in nuclear medicine where she was introduced to the field of nuclear oncology. In the U.S. she pursued a residency in Internal Medicine followed by a fellowship in Hematology/Oncology at Memorial Sloan-Kettering Cancer Center in New York.

If the genetic test is positive for the mutation, there are several alternative steps one can take to lower the risk of breast and/or ovarian cancer or to try to detect their early development. In addition to preventive surgery, a woman can lower risk through medications such as tamoxifen or aromatase inhibitors. Women at high risk are advised to increased monitoring (self breast exams and clinical breast exams), and screening every six months using mammography and MRI. “Each woman’s physical and emotional needs are her own,” says Jhaveri. “Testing allows a woman to make a choice that is right for her as a shared-decision making process with the help of a genetic counselor, breast surgeon, and/or an oncologist.” She notes, however, that even if the genetic test is negative, one could still be at increased risk due to some other inherited gene yet to be discovered or not detectable by currently available tests.

GREAT STRIDES

In the Introduction to the most recent (2010) edition of Dr. Susan Love’s Breast Book, (“the bible for women with breast cancer”), the widely-acknowledged authority on breast cancer points to two recent “paradigm shifts” that have dramatically altered perceptions of the disease. The first is recognition of the fact that all breast cancers are not the same, and that the five or six different subtypes that can occur need to be addressed differently, with customized treatment for each woman.

The second big shift, notes Love, is “the realization that cancer cells do not function in isolation.” This means that a mutated cell’s “local environment” can make a difference, and while there is no sure way to prevent breast cancer, there are things that a woman can do to reduce the risk. Early detection and good lifestyle choices can be key.

MULTIDISCIPLINARY APPROACH

At New York-Presbyterian Hospital/Weill Cornell Medical Center, medical oncologist Tessa Cigler emphasizes the use of a multidisciplinary approach to any form of breast cancer. “It is a complicated disease that requires a lot of health care professionals,” she observes. Input from oncologists, geneticists, pathologists, surgeons, specialists in reconstructive surgery, fertility experts, physical therapists, nutritionists, and mental health professionals can all factor into decisions about any patient. While there is no formal system or coordinator to insure that this collaboration takes place at New York-Presbyterian. “It’s nice when everyone cooperates, though,” says Cigler, who received her undergraduate degree from Harvard College, and her medical degree from Duke University School of Medicine and also holds a Master's degree in Public Health from the Harvard School of Public Health. She completed her residency in Internal Medicine at New York Presbyterian Hospital Weill Cornell Medical Center, followed by a fellowship in Medical Oncology and Hematology at the Dana-Farber Harvard Cancer Center.

For non high-risk women, the question of when to begin getting mammograms and how often to get them has been the subject of some debate in recent years. Mammograms can detect breast abnormalities early in women over 40. Findings from a large study in Sweden of women in their 40s who underwent screening mammograms showed a decrease in breast cancer deaths by 29 percent. On the other hand, another study concluded that despite more women being diagnosed with early breast cancer due to mammogram screening, the number of women diagnosed with advanced breast cancer hasn't decreased. The study suggested that some women with early breast cancer were diagnosed with cancer that may never have affected their health. It’s a bit of a gamble, but most doctors recommend annual mammograms after the age of 40. “Regular screening is the most effective way of ensuring that these cancers are detected at early stages,” says Jhaveri.

Women with a strong family history, a known genetic mutation in the BRCA gene, or those diagnosed with precancerous conditions that put them at greater risk for developing breast cancer, can consider taking medications such as tamoxifen or aromatase inhibitors. Regardless of these medications, notes Jhaveri, these women should remain up-to-date with recommendations for screening and surveillance including breast self-exams, clinical breast exams every six months and appropriate breast imaging.

LIFESTYLE

Obesity has been linked with the development of postmenopausal breast cancer, and both Jhaveri and Cigler encourage women of all ages to maintain a healthy weight, and to eat a “heart healthy” diet rich in fruits and vegetables, and low in saturated fats. Avoiding hormone replacement therapy after menopause, they say, can also help reduce the risk.

Other modifiable variables include getting at least moderate exercise (Cigler suggests walking for 30 minutes at least three times a week) and limiting alcohol consumption. Women who choose to breast feed for several months may get an added benefit of reducing breast cancer risk. Recent research suggests that low vitamin D levels can be linked to breast cancer risk, and that adequate levels can prevent breast cancer recurrence. “Women should discuss checking VIT D levels with their physicians for general health reasons,” says Jhaveri. Books like The Pink Ribbon Diet by Mary Flynn and Nancy Verde Barr provide recipes for what is largely a plant and olive oil-based Mediterranean-style eating plan for women at any level of risk for breast cancer.

TREATMENT

Jhaveri is very encouraged by the “landmark accomplishments” and “enormous advances” in the way the medical profession manages breast cancer with both local and systemic treatments during the last two decades. With respect to local therapy, she points to less radical surgical interventions and better radiotherapy techniques that have ameliorated the physical and psychological morbidity for some women with this disease. Like Susan Love, she points to the fact that a better understanding of the underlying tumor biology has enabled doctors and researchers to move from the “one-size fits all” approach to an era of personalized medicine wherein an individual patient’s tumor cells are analyzed to determine if a particular drug could be an effective treatment.

One of the really positive stories of the modern targeted therapy in breast cancer has been the approval of Trastuzumab (Herceptin), says Jhaveri. “Not only did we have a new drug that dramatically changed the outcome of a deadly type of breast cancer known as the HER2 positive breast cancer, but we also learned the importance of having a reliable companion diagnostic (in this case the expression of HER2 protein on the cancer cells), which can determine which patients are likely to benefit from this treatment.” Since Herceptin, three additional drugs—Lapatinib (Tykerb), Pertuzumab (Perjeta) and T-DM1(Kadcyla) have been approved for patients with HER2 positive metastatic breast cancer.

GOOD-BYE TO HAIR LOSS

Women diagnosed with breast cancer who face chemotherapy have a reassuring new option for preventing hair loss. “Cold caps” have been used in Europe for many years with what Cigler describes as “surprisingly successful results,” and they are finally coming into wider use in this country. The idea behind cold packs is to keep the patient’s head cold enough to prevent chemotherapy from destroying healthy scalp tissue. There are some “theoretical risks” to the procedure, says Cigler, “it’s a lot of work”: cold packs need to be changed frequently during a single chemotherapy session in order to maintain low temperatures. Doctors and technicians are excited about the potential of a new, more efficient cold pack machine that is about to be tested.

BEYOND THE WEST

While the news about breast cancer in the Western world is encouraging, its incidence in developing countries is on the rise. Some suggest that this is may be partially due to the adoption of unhealthy western lifestyles that include smoking, insufficient physical activity, and unhealthy diets. In more rural areas, there is a serious lack of resources for early detection and treatment. Increased awareness, infrastructure improvements, and more funds to support better-educated health providers are badly needed, and it will take more than a month-long campaign to do it.

ADDITIONAL INFORMATION

The National Cancer Institute Fact Sheet www.cancer.gov/cancertopics/factsheet/Risk/BRCA

National Comprehensive Care Cancer Network www.nccn.org

Memorial Sloan Kettering Cancer Center www.mskcc.org/cancer-care/adult/breast

New York-Presbyterian www.nyp.org/services/oncology/breast-cancer.html

New York University Cancer Institute www.cancer.med.nyu.edu

Cold cap use www.cornellbreastcenter.com

Appendices in the book, 100 Questions and Answers about Advanced and Metastic Breast Cancer by Lillie D. Shockney and Gary R. Shapiro, include: a useful list of American resources for information on cancer; a chart that details drugs used in the treatment of breast cancer, their actions, and common side effects; and a glossary of clinical terms.