Should You Be A Human Guinea Pig?

ssmayIn September of last year, Anne Dyson found a lump in her breast. It wasn’t her first cancer scare–four years earlier, the 52-year-old pediatrician from Millbrook, New York, had what turned out to be a benign cyst diagnosed in the same breast. Hoping this was another false alarm, Dyson rushed to the medical center where she’d had a mammogram six months earlier. At first she was told there was no change. “Then I got the dreaded call to come back,” she remembers. At that point, she turned to a doctor she knew at the Dana-Farber Cancer Institute in Boston, who arranged for a repeat mammogram and breast biopsy.

The results were grim: Dyson had cancer in both breasts-which had been missed in previous mammograms because her dense, lumpy breasts made X rays hard to read. Also, two lymph nodes were positive, indicating that the cancer had spread. “You can’t imagine my terror,” she says. Dyson kept thinking about her family: “I’d just gotten married-literally the week before. My two sons from my first marriage, Mac and Roberto, were only nine and thirteen, and I had a new stepson, Ben, also thirteen. I had a lot left to do in life.”

Determined to beat the disease, she spent seven months undergoing the full range of treatment: a double mastectomy, lymph node removal, chemotherapy, and radiation. Dyson now seems to be in remission and is back at work. “Not a day goes by that I don’t worry about recurrence,” she admits. “But I feel very hopeful that I’ll be all right.”

Dyson and other women with breast cancer have good reason to be optimistic. Although the disease remains the second most common cancer in women (after skin

malignancies)–predicted to strike an estimated 183,000 U.S. women this year and kill 41,000–the death toll for those under 70 has plummeted by nearly 20 percent during the past decade, according to a recent report in The Lancet. The researchers credit breakthroughs in diagnosis and treatment for saving the lives of thousands of women annually in this country. These are the advances all women should know about.

Prevention

Eat your fruits and vegetables Last year the famed Harvard Nurses’ Health Study found that eating five or more servings of fruits and vegetables a day significantly reduces breast cancer risk. This is especially true for women who have a family history of the disease. It’s also a good idea to avoid or limit alcohol: The American Cancer Society reports that having two to five drinks a day ups risk by 50 percent.

Stay slim The Nurses’ Health Study shows that after menopause, overweight women are more likely to develop breast cancer than their thinner sisters. A good way to keep the pounds off?. Regular exercise. Working out cuts your risk of the disease, possibly by affecting hormones and boosting immune system functioning.

Be cautious about hormone replacement therapy Two new studies link HRT to higher rates of breast cancer. Last January a large National Cancer Institute (NCI) survey found that taking estrogen and progestin (the usual combination) raised the risk by 8 percent for each year a woman is on the therapy, while using estrogen alone increases annual risk by 1 percent. Then in June, a study published in Cancer showed that the two-drug therapy more than doubled postmenopausal women’s risk of lobular breast cancer, a relatively uncommon malignancy of the milk-producing glands.

Does that mean you shouldn’t use HRT to relieve the hot flashes of menopause? Taking hormones for a few years poses little overall danger, says Ed Liu, M.D., the NCI’s director of clinical sciences. “I’m comfortable with the fact that my wife is taking them,” Dr. Liu says. “True, the risk of breast cancer goes up the longer you use the therapy, but it offers other, very positive health benefits, especially protection against osteoporosis.” To make the best decision, he stresses, every woman should discuss the potential risks and advantages with her doctor.

Detection and diagnosis

Quicker mammograms In the future, you could be out of the radiologist’s office in ten minutes if your doctor uses the GE Senographe 2000D mammography system, which won FDA approval in January and will be available at 100 medical centers by year’s end. Because the device creates digital images, instead of film, there’s no developing time; also, the doctor will be able to e-mail the pictures to a distant medical center for an instant second opinion.

Gentler mammograms At the University of Virginia, Jennifer Harvey, M.D., is now testing a new CT laser screening technique that requires no breast compression and also uses no radiation.

More reliable mammograms If your dense breasts or implants make your X rays hard to read, you may soon have two additional technologies for more accurate screening. Research by Susan G. Orel, M.D., associate professor of radiology at the Hospital of the University of Pennsylvania, has shown that magnetic resonance imaging (MRI) can detect some cancers that mammograms miss. New York City radiologist Thomas Kolb, M.D., obtained similar results with ultrasound. (Right now, ultrasound and MRIs are sometimes used to help diagnose breast cancer, but aren’t yet part of routine screening.)

A computer-aided detection method, the ImageChecker M1000 system, which received approval two years ago, acts like a spell check for your mammogram. It scans the X ray and pinpoints suspicious areas for the radiologist to look at again. Before February, however, the device was available at only 30 medical centers; now, both doctors and patients themselves can order a review of a mammogram (for $75) through the company’s Web site: iMammogram.com.

A Pap test for breasts? Almost all breast cancer originates in the milk ducts. In the future, ductal lavage–which w ashes fluid through the ducts, then checks it for abnormal cells–could help doctors detect cancer years earlier, reports Patricia Ganz, M.D., director of cancer prevention and control at the UCLA Jonsson Comprehensive Cancer Center.

Easier biopsies Mammotome, a surgical instrument guided by either mammography or, now, ultrasound, allows doctors to perform more accurate minimally invasive biopsies on women whose lumps can’t be located by touch. The device uses a probe (to pinpoint the abnormal area) and a tiny rotating blade (to remove a sliver of tissue for study). The outpatient procedure, which takes less than an hour, requires no stitches because the incision is only as big as a match head.

Less grueling lymph node sampling In the past, doctors removed a large number of lymph nodes from the arm and chest to check if cancer had spread. As a result, many women–up to 20 percent–developed painful, chronic swelling from fluid buildup in their arm. Now, however, surgeons can inject special dyes near the tumor to identify which few nodes the dyes drain into first. If the cancer hasn’t spread into those sentinel nodes, the others don’t have to be removed because chances are at least 98 percent they’re cancer-free too.

Treatment

Skin-sparing mastectomy This new technique minimizes scars: Surgeons remove the cancerous breast tissue through a circular incision around the nipple (which is also removed, to prevent a recurrence), leaving a shell of skin that can be filled with tissue from the abdomen or buttocks, or with an implant. A new areola and nipple may be later created from fat and skin from the reconstructed breast, then can be tattooed to match the other side.

Women who have Paget’s disease of the breast–a rare form of breast cancer that causes an eczemalike rash on the nipple–can usually avoid mastectomy, reports Stephen Edge, M.D., chief of breast surgery at Roswell Park Cancer Institute in Buffalo, New York. “In the past, doctors assumed the more extensive surgery was necessary, but if there’s no evidence of a tumor inside the breast, women can be treated with nipple removal alone,” Dr. Edge says.

New medicine Herceptin, a drug that attacks the HER2 protein (found in excess quantities in about 30 percent of tumors of women with the most aggressive form of breast cancer), could be a less toxic alternative to chemotherapy. Research has shown that women with advanced cancer live 25 percent longer when the drug is added to standard chemotherapy. Now it seems that Herceptin alone may produce the same results–without the hair loss, vomiting, and other severe side effects of chemo.

Chemo is also improving. Last year, the FDA approved epirubicin, a drug that significantly lowers recurrence and increases survival of women whose breast cancer has spread to the lymph nodes.

a 5 percent chance of survival

in 1992, a few days after her fortieth birthday, Madeline Crivello got a terrifying phone call. “You have inflammatory cancer in the left breast, with skin and lymph node involvement, and ductal carcinomain-situ in the right breast,” said the surgeon who had performed a biopsy on Crivello, also a doctor. She pressed the surgeon: What does this mean? When she heard, she literally dropped the phone and came close to fainting. “The doctor said my odds of living another five years were less than five percent.”

Five percent. Crivello and her husband, Edward Nardell, a doctor as well, were terrified for their children, only eight and three at the time. Frantically, she consulted other oncologists. All gave her the same grim prognosis. One, however, suggested a course of high-dose chemotherapy, followed by a bone-marrow transplant. Knowing it was her only hope, Crivello immediately entered a clinical trial of the therapy at the Dana-Farber Cancer Institute in Boston.

The side effects were awful, she says. “I lost every hair on my body and got such terrible mouth sores that it was hard to eat anything.” But she kept on. “I just wanted to live–for my children.”

After the transplant, Crivello underwent a double mastectomy and radiation. Then doctors told her they’d done all they could, that she should come back in three months to see if it had succeeded. “I was devastated,” she says. Crivello, who’d never believed in alternative therapies, turned to acupuncture, vitamins, prayer, meditation, and visuallization, spending hours imagining herself alive at various milestones in her children’s lives.

This year she celebrated a day doctors said she’d never live to see: her forty-eighth birthday. The regimen had worked. (The jury is still out on the effectiveness of bone-marrow transplants. Last year, a study concluded that they were no more effective than standard chemotherapy. But the National Cancer Institute, suspecting the treatment may help those with less advanced disease than the patients in the original studies, is now conducting a large trial.)

“It was very emotional for me, knowing I’d beaten the odds,” Crivello says. “I feel God isn’t done with me–He wants me to use my experiences as a patient to help other women.” She’s doing just that. Formerly a radiologist specializing in angiography (mapping blood vessels), Crivello switched her practice to mammography and is now director of women’s imaging at Mount Auburn Hospital in Cambridge, Massachusetts. If a patient has breast cancer, she can offer more than information. “I can offer her hope.”

now, we talk

Until Betty Rollin broke the silence with her 1976 memoir, First, You Cry, women rarely talked about breast cancer. And so, the NBC News contributing correspondent remembers, she had felt completely alone when she had had a mastectomy the year before. “For all I knew, I was surrounded by one-breasted women like myself,” she says, “but we were all hiding.” Twenty-five years later, as her best-seller is being reissued in a revised edition, Rollin notes the enormous shift in attitude: “The trauma of being diagnosed with breast cancer hasn’t changed, but no one has to worry that her feelings are crazy, as I did.”

Should you be a human guinea pig?

the women featured here–Anne Dyson and Madeline Crivello–both received care at the Dana-Farber Cancer Institute in Boston, a leading research and treatment facility. Frequently, patients at such centers are invited to participate in studies of new drugs or surgical procedures. But you don’t have to be treated at a large cancer hospital to be in a clinical trial; doctors all over the country are involved in research.

If you have breast cancer, it’s a smart move to learn about current studies. Not only could participating in a clinical trial advance scientific knowledge about the disease (potentially helping other women), but it could also improve your own odds of survival. That was the conclusion of a study (in this case, of patients with early-stage disease) released at recent meetings of the American Society of Clinical Oncology. Trials compare the best current therapy with new treatments doctors believe may be even better (though they do carry the risk of not working or having troubling side effects). For information about state-of-the-art care, call the National Cancer Institute: 800-4-CANCER. Or log on to NCI’s Web site: cancer.gov.

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