Breast Cancer
October 2016
Fact Book
How We Stand Up to Breast Cancer
• Cheryl Olson • Stacy Witte • Mitzi Roberts • Kathy Langdon
Plus:
Breast Screenings Reconstruction Personalized Treatment Events Brought to you by Home Magazine
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Page 2
Breast Cancer Fact Book 2016
Contents Breast Cancer Fact Book, October 2016
5 Breast Cancer Screenings
5
Dr. Suresh Devineni
Five simple steps for early detection.
9 Breast Reconstruction
12
14
13
15
Elizabeth SaterenZoller P.A.-C.
Breast reconstruction options.
12 Surviving Breast Cancer
Four Women = Four Stories
• Page 12, Kathy Langdon
• Page 13, Mitzi Roberts
• Page 14, Stacy Witte
• Page 15, Cheryl Olson
17 Early Stages of Breast Cancer
17
Breast Cancer Awareness Events
Google these events: • Tutu Run Tutu Run: Mankato, Oct. 2017 Race Information
• Relay for Life Events Blue Earth County • Nicollet County
Breast Cancer Fact Book 2016
Choosing Your Personalized Treatment Plan
(Event Organized by Mitzi Roberts)
• Making Strides Against Breast
American Cancer Society
Page 3
Welcome to the First edition of the Breast Cancer
Breast Cancer Fact Book
The Breast Cancer Fact Book is a Publication of the Home Magazine, Mankato, MN. A Property of Community First Holdings, Inc.
Fact Book…
Publisher Kelly Hulke
Sales Manager Mary DeGrood
Welcome to the very first edition of the
men tend to delay going to the doctor until they have more severe symptoms, such as
Breast Cancer Fact Book!
Sales Executives Yvonne Sonnek Deena Briggs Dorothy Meyer Editorial Sara Gilbert Frederick Graphic Designer Sirena Tanke
bleeding from the nipples and at that
This is the brain child of the
point the cancer may have already
staff at Home Magazine, our anchor publication. As a staff
spread.
made of women, it was very
important for us to get the
You bet I am...this is deadly
Am I trying to scare you?
message to our readers of how
disease and the only prevention is
important this topic is to our lives.
self examination, knowing your body
I remember many years ago, sitting at a
and making that appointment! A 10 minute
conference and being asked...”Raise your hand
mammogram can change your life, just as it
if you, your friends or your family has been
did with the four women on our cover.
affected by cancer.” Every single hand was
Office Julie Bundy Jolynn Kurtz
raised in the room. It was humbling and sent
and Kathy are an inspiration and have a clear
shivers down my spine.
understanding of their mission concerning
breast cancer.
Advertising Information:
this disease and talk about breast cancer. Did
appointment, get your mammogram done
Home Magazine 1400 Madison Ave., Suite 610 Mankato, MN 56001 (507) 387-7953 fax 387-4775
you know that 1 of 8 women in their lifetime
now! Kudos to them for willing to share their
will be diagnosed with breast cancer? Alarming
journey and also a huge thanks to our writer,
as that is, there is hope since in recent years
Sara Gilbert Frederick.
homemag@homemagonline.com
there has been a decrease in mortality. This is
Breast Cancer
due mainly from a combination of increased
awareness, not only in October...but year round
breast cancer screening with mammography
in the fight against breast cancer. Call me and
and improvement in this cancer’s medical
share your story...and watch for another edition
management
of this fact book. My prayer is to find a cure.
Production Heather Zilka Julie Dempster
October 2016
Fact Book
Let’s move on to be more specific about
processes.
However,
breast
Our cover girls: Cheryl, Mitzi, Stacy
Don’t delay, make that
Let’s make it our mission to raise
cancer is still the second leading cause of How We Stand Up to Breast Cancer • Cheryl Olson • Stacy Witte • Mitzi Roberts • Kathy Langdon
death among women.
And let’s not forget about the men.
Plus:
Breast Screenings Reconstruction Personalized Treatment Events Brought to you by Home Magazine
Cover photo courtesy of Braunshausen Photography
Page 4
Although this is a rare type of cancer for men,
Kelly Hulke, Publisher
in 2016 the odds are 1 in 1,000 for a man to be diagnosed with breast cancer. Unlike women,
Breast Cancer Fact Book 2016
Breast Cancer Screenings Provide Early Detection W 1: Perform at the same time
3: Exam the whole breast
becoming diagnosed with breast cancer in
Perform check at the same time each month.
Perform the monthly exam from the whole
their lifetime, it’s increasingly important that
You should look for breasts that are their
breast, up to your collar bone and into the
females get regular screenings for breast
usual size, shape and color and breasts that
armpit. Move the pads of your fingers around
cancer.
are evenly shaped without visible distortion or
Breast cancer screenings, like a mammogram
swelling.
and clinical breast exam, can help find breast
2: Lying down
cancer early, when the chances of survival are
Examine your breasts lying down with one
ith a startling one in eight women
highest. A mammogram is an x-ray that allows a radiologist to examine the breast tissue for any suspicious areas. Often times, mammograms can show a breast lump before it can be felt. A clinical exam is performed by your healthcare provider, who is trained to recognize many different abnormalities and warning signs. National
guidelines
recommend
adult
women get a clinical breast exam at their yearly check-up and to have mammograms performed yearly beginning at age 40. Breast cancer screenings are important for all women, those at higher risk may need screenings earlier and more often than women at average risk. Talk with your provider to set up your screenings and remember to do your selfcheck once a month! Your self-check can be done in just five easy steps: Breast Cancer Fact Book 2016
arm behind your head by making small, circular motions with the pads of your three
your breasts gently in small, circular motions covering the entire breast area and armpit.
4: Perform a check in front of a mirror Check your breasts in front of a mirror, looking for changes in shape and in the nipple. Visually inspect your breasts with your arms at
middle fingers. Use light, medium and firm
your side. Raise your arms overhead. Look for
pressure.
any changes in the contour, any swelling, or dimpling of the skin, or changes in the nipple. Squeeze the nipple; check for discharge and lumps.
5: Check breasts in the shower In the shower, use the pads of your fingers and move your entire breast in a circular pattern moving from the outside to the center, checking the entire breast and armpit area. Check both breasts each month while feeling for any lumps, thickening or hardened knots. Notice any changes and get lumps evaluated by your healthcare provider. Suresh Devineni, MD Oncology-Hematology Main Street, Mankato Page 5
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Breast Cancer Fact Book 2016
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Breast Cancer Fact Book 2016
Breast Reconstruction Following Breast Cancer: Options and Recovery
O
ne in eight women will be diagnosed with breast cancer in their lives. For the vast majority, this is difficult, frightening and overwhelming. In addition to digesting the information about cancer, there’s the option for breast reconstruction to consider.
What is breast reconstruction?
Breast reconstruction is a series of optional procedures designed to restore the appearance of natural breasts following mastectomy (the surgical removal of breast tissue). Options include: • No reconstruction • Mastectomy with immediate reconstruction • Mastectomy with delayed reconstruction Reconstruction involves, at minimum, one surgery, but often two to five surgeries.
What are the differences in reconstruction options?
Immediate reconstruction occurs in conjunction with the mastectomy. It can be done with either your own tissue (autologous) or with implants. Usually, a general surgeon performs the mastectomy and a plastic surgeon performs the reconstruction. In implant-based reconstruction, a tissue expander will be placed under the skin where the breast tissue had been. The tissue expander is an implant that has a port within it so that it can be injected with saline after surgery in order to restore your pre-operative breast size. After healing, a second surgery is required to replace the expander with a permanent implant. In autologous reconstruction, your own tissue is moved from one area of the body (donor site) to the breast. The donor site is often the abdomen, but can also come from the back or other areas. Mastectomy with delayed reconstruction is another option. The delayed reconstruction techniques are the same as for immediate Breast Cancer Fact Book 2016
By Elizabeth SaterenZoller, P.A.-C. reconstruction, but they may require a longer timetable for processes like tissue expansion to accommodate an implant.
If I have reconstruction, what is the recovery like? It depends. Autologous reconstruction is a more difficult surgery, lasting many hours. The hospital stay is several days, as relocating tissue from one area to another requires close surveillance. The following weeks include assuring the blood flow to the newly relocated tissue is adequate, removing postoperative drains and assessing healing. Recovery time is four to six weeks, with the limiting factor generally being the donor site healing. The hospital stay following implantbased reconstruction is generally one day. The next few weeks include assessing healing, expanding the tissue expander and removing drains. Women often return to their daily activities relatively quickly. For both procedures, a series of surgeries can be required. For autologous, further procedures address issues with shape and or size. For implant-based, subsequent surgeries include exchanging the expander for a permanent implant and contouring with fat grafting (liposuctioning fat from the abdomen or thighs and injecting it into the breasts). Many surgeons wait three months or longer between each of the procedures. These subsequent procedures are done after the breast cancer therapy (radiation, chemotherapy) is completed.
Surgical nipple reconstruction consists of taking skin from the front of the breast and rearranging it to resembles a nipple. This doesn’t recreate the coloration of the nipple and areola. Coloration may be done with tattooing, with or without the surgical nipple reconstruction. Tattooing is done with medical-grade ink and requires touch-ups every five to 10 years. Nipple reconstruction and tattooing is submitted to insurance, just like all aspects of the reconstructive process.
What is involved in long-term follow up? The breast reconstruction process can vary from approximately six months to one-and-ahalf years. This includes initial reconstruction through nipple reconstruction and tattooing. After, you should receive yearly checkups. If the reconstruction is silicone-implant-based, MRIs of the breasts every two to three years are recommended to assure the implants are intact. Both silicone and saline breast implants may require replacement in 10-15 years. Breast reconstruction is an option that can help you feel whole again after the arduous experience of breast cancer. Every surgeon has her or his own set of recommendations and areas of expertise, so asking your surgeon these questions — and more — can help you make the difficult decisions that accompany overcoming breast cancer.
What about nipple reconstruction? Nipple reconstruction, like breast reconstruction, is completely optional. Procedures include: • Surgical nipple reconstruction Elizabeth SaterenZoller is a Plastic and • Nipple and areolar tattooing • Combination surgical nipple reconstruction Reconstructive Surgery physician assistant at Mayo Clinic Health System in Mankato. and tattooing Page 9
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Breast Cancer Fact Book 2016
S
Do It Now By Sara Gilbert Frederick
everal weeks before I started work on
decide if she wanted to have a mammogram
who attend classes at her dance studio know
the stories for this Breast Cancer Awareness
or not. She decided to go ahead and do it. “I
how important early screening is too.
publication, I left my doctor’s office with an
always think about what would have happened
Cheryl Roberts had passed her annual
admonition to schedule a mammogram. I had
if I had skipped that appointment,” she says
mammogram with flying colors when she
delayed making the appointment, more out of
now. “There was a monster in my body and I
discovered what felt like a hard lump in her
laziness and forgetfulness than anything else,
didn’t know it.”
breast. She went right back in for another one
and had been reminded yet again that I needed
Like me, Mitzi Roberts had put her
and found out she had cancer. Now she not
get in.
appointment off—but she was compelled
only promotes regular appointments but also
But earlier this month, as I was scheduling
to call in after talking to a friend who was
regular self-examinations.
interviews with Stacy Witte, Cheryl Olson,
going through cancer treatments. Now she
Kathy Langdon also felt a lump in her breast,
Mitzi Roberts and Kathy Langdon—four
makes sure that all of her friends make their
just weeks before her scheduled appointment.
women who have and will continue to
appointments on time, and that the young girls
Even after she was told it
battle breast cancer—I had
was nothing to worry about,
not yet called to make my
she followed her gut and
appointment.
scheduled another exam—and
As soon as I started talking
caught cancer before it had
to these women about their
spread. “If I had waited until
breast-cancer
my next appointment,” she
journeys,
I
realized how foolish I had
says, “who knows?”
been.
Before these stories were
Each of their stories starts
written, I had called the clinic,
with what they expected to
scheduled a mammogram and
be a routine mammogram.
been in for the exam. It took
Although the details diverge from
there,
the
common
thread was following through on that annual appointment. Because they went in when they did, each of them is able to share their story with others—and each of them are intent on encouraging friends, family and complete strangers to make and keep their annual exams. In 2012, Stacy Witte’s doctor had told her she could
Breast Cancer Fact Book 2016
less than 10 minutes, and I hadn’t even made it home before the clinic called to tell me everything looked good. But next year, I will not wait to make an appointment. That is the least that any of us can do to honor these four women—and everyone else who has been through the same diagnosis and treatment that they have—who have been gracious enough to share their stories with us.
Page 11
Kathy Langdon
Kathy Langdon Photo courtesy of Braunshausen Photography
Keeping the Faith
The power of prayer has helped Kathy Langdon get through breast cancer. By Sara Gilbert Frederick athy Langdon wasn’t too surprised when she found a lump in her breast in October of 2014. For decades, she had been finding cysts in her breasts, and for decades, her doctor had been able to quickly aspirate them without trouble. But this time, the lump felt different. “It was hard,” she says. “It was very obviously different from the others.” Her annual exam was just a week or so away, so she brought it up to her doctor then. When her mammogram came back negative, Langdon was relieved. “I thought wow—this was the first time I was ever concerned, but it turned out fine,” she remembers. “That was that.” But when she noticed that the lump was still there when spring rolled around, she decided she needed to follow up. She had learned from her mother, who had been diagnosed with cancer four times, not to ignore things. So she called the clinic again and set up an appointment to have it aspirated. “The doctor tried to aspirate it five or six times, but nothing happened,” she says. “As I Kathy Langdon sat there, I got hot from head to toe.” Photo courtesy of Braunshausen Photography So as she and her husband prepared to sell their house and close on a new one, Langdon for the positive results thus far. Langdon had another mammogram and a needle biopsy knows that if she hadn’t followed up with her of the lump. Her phone rang on Friday, June clinic when the lump didn’t go away, things 12, confirming that the lump was malignant might not have turned out quite as well. and that she needed to schedule surgery. Two “If I had waited until my next weeks later, on June 24, she had a mastectomy. appointment, who knows what would have “They felt quite confident that they were happened,” Langdon says. “It just goes to able to get it all,” Langdon says. “And they show that sometimes you need to take the bull confirmed that it was not in my lymph nodes. by the horns. It’s too important not to.” So that was quite a relief.” Now Langdon is trying to share the lessons After surgery, Landon spent every Friday that she learned from her mother’s battles with morning for 12 weeks at the Andreas Cancer cancer with her children, grandchildren and Center for chemotherapy. Although she was given a bottle of anti-nausea pills when she great-grandchildren. She reminds them to started the treatment, she never opened it. “I take care of themselves, to be aware of what’s happening in their bodies and above all, to be was so fortunate,” she says. But Langdon can’t give luck all the credit thankful for all that they have.
K
Page 12
“I have always been appreciative of my life and have always tried not to take anything for granted,” she says. “But boy, this sure makes you stop and thank God. When I think about the fact that I just dodged a bullet and truly had a miracle, I know that I just have to hold on to my faith.” Her faith, Langdon says, has been a critical part of her healing process. “I believe in the power of prayer,” she says. “My mom beat cancer three times when there were no answers, medically. When the doctors asked her what she was doing, she told them it was her faith—and they told her it was working.” Faith is working for Langdon, too. “It gives you a reason to go on,” she says. “I’ve got things to do yet. Maybe I can do some good things with the time I have now.”
Breast Cancer Fact Book 2016
Mitzi Roberts Taking the Lead
Mitzi Roberts is using her experience with breast cancer to educate young women and to support other cancer patients. By Sara Gilbert Frederick itzi Roberts remembers the day she ran into one of her dance student’s mom at Kohls. “She was going through breast cancer,” Roberts says. “She told me how horrible it was and how much pain she was in. The side effects of the treatment had been very hard on her.” As she walked out of Kohls, she was thinking about her friend—and about the fact that she had delayed her own annual exam longer than she should have. “I got in my car and called to make an appointment right there in the parking lot,” she says. That phone call led to a series of appointments and, eventually, to a diagnosis of breast cancer in October 2013. Now, three years later, Roberts uses that experience to educate others about the importance of regular exams and mammograms. “I truly believe that I have been put in this role for a reason,” says Roberts, who owns Dance Express in Mankato. “There are 450 little girls who will be so aware of breast cancer and how to take care of themselves now. I can preach that message until the cows come home.” Roberts was 48 when she was diagnosed with stage 3 cancer. Her mammogram had revealed a suspicious spot, which was then biopsied and ruled benign. Her doctor recommended that she have the lump removed, which she did. She laughs as she remembers how calm she was throughout that whole process. “I wasn’t even sweating it,” she says. “I thought it was nothing.” Only at her follow-up appointment after the lumpectomy did it become clear that things were more complicated than she had first thought. “I was thinking that it was no big deal,” she remembers. “Then the doctor said, ‘You know you’re dealing with full-blown cancer
M
Breast Cancer Fact Book 2016
here, right?’” Roberts admits that the news surprised her—but she told herself that she wasn’t going to let herself sit in the clinic and cry. Instead, she listened carefully and started thinking through the next steps in the process. She made a decision early on not to get down about it. Even as she went through surgery and chemotherapy, she reminded herself to focus on the positive and to remain confident about her future. “I decided that breast cancer was not going to get me,” she says. “As soon as I could, I went back to work. I didn’t want to stay at home worrying. I knew that wasn’t going to help me.” Now, Roberts funnels much of her tremendous energy into helping others. Last year, she started the Tutu Run—a 2.2 (twotwo—get it?) mile run that loops around the neighborhood surrounding the Dance Express studio. Each of the 460 runners received a pink tutu, which they wear during the race. Everyone who registers for the second race, which will take place Oct. 2, will also receive a tutu.
The proceeds of that run helped create Angels of Breast Cancer, a nonprofit group that Roberts started to reach out to anyone going through breast cancer treatment. The group’s first project will be to put together baskets full of gas cards and gift certificates that can be shared with patients who need assistance. Roberts will pass the third anniversary of her diagnosis this fall. She still takes a daily medication to block the hormones that could feed the growth of her cancer and has regular appointments to check for any signs of cancer returning. But although those can be a bit nerve-wracking, she doesn’t spend time fretting about her future. “When I wake up every morning, it’s out of my mind,” she says. “I’m not worrying about it. I totally feel great.” Ultimately, she hopes that her experience can have an impact on other women. “My hope and dream is to help other women to not have to go through this,” she says. “Do the screening early. That’s what I tell everyone.”
Mitzi Roberts Photo courtesy of Braunshausen Photography Page 13
Stacy Witte
A Reason for Everything Stacy Witte knows there’s a reason she’s survived her breast cancer diagnosis. By Sara Gilbert Frederick
I
n August 2013, Stacy Witte’s father died of Lewy Body Dementia. Helping to take care of him during this time was physically and emotionally draining—but it helped prepare her to deal with the news that she received less than a year later. She was with her mom at the Mayo Clinic in Rochester—standing at the bottom of the stairs below the Cancer Center—when her phone rang. She had had a biopsy on a lump
Stacy Witte Photo courtesy of Braunshausen Photography Page 14
in her breast the day before and was expecting the clinic to call at some point. She wasn’t really expecting them to tell her it was cancer, but she was ready for it. She was ready for the reality of surgery, the pain of chemotherapy and radiation, and the uncertainty of her future. “After my diagnosis, I understood why I had to go through what I went through with my dad,” she says. “That got me through my battle with cancer. Now I ask, what am I supposed to take from my breast cancer journey? What did this prepare me for?” Four years have passed since her diagnosis. Four years have passed since the lumpectomy that removed her cancer. And four years have also passed since her first chemotherapy treatment, when she couldn’t
imagine what life would be like on the other side of cancer. Now, even as she waits to reach the important fifth-year mark, she knows that she’s made it to the other side. “I can say that I came out on the other side as a better person,” Witte says. “I’m more patient and more compassionate. And I can say no now. I don’t have to do everything anymore. I’m learning to take care of me, to take time for me.” She admits, however, that it has been hard to get to this point. She remembers sitting in her first appointment with the surgeon, feeling absolutely empty and unsure if she would live or die. “All I wanted was to fast forward a year so that I didn’t have to go through all of that,” Witte says. “But it doesn’t work that way. You have to go through the sludge and the mud to get to the other side.” She also remembers that in that initial appointment, her surgeon told her that she wasn’t going to die. That was a critical message for Witte to receive. “Once I figured out that I wasn’t going to die, it became a physical game for me instead of an emotional game,” she says. “I knew what I had to do, I knew the rules of the game, and I just put my head down and got going.” Instead of getting upset when her hair staring falling out two weeks to the day after starting chemo, she had a party with her husband, her two boys and her daughters-inlaw. “We had a good time,” Witte laughs. “We shaved my head, and then my boys and my husband shaved their heads too. It wasn’t so bad.” Instead of succumbing to the nausea and pain that came along with her six long months of chemotherapy, she started seeing an acupuncturist. “I was eating the anti-nausea meds before I starting doing acupuncture,” she says. “After I started, I didn’t need anymore of the medicine.” And instead of worrying about whether or not the cancer will come back, she has chosen to be thankful for the time she’s already be given. “I am so grateful to have survived this far,” Witte says. “The coming back—I can’t let that control my life. I try hard not to let it run my life. Sometimes that’s hard to do. But I know that there’s a reason for everything.” Breast Cancer Fact Book 2016
Cheryl Olson
Counting Her Blessings Even in the midst of fighting cancer, Cheryl Olson still finds reasons to be thankful. By Sara Gilbert Frederick
W
hen Cheryl Olson was diagnosed with breast cancer on August 7, 2015, she set a goal: to be done with her surgeries and treatment by the one-year anniversary of that diagnosis. When August 7 rolled around this year, Olson wasn’t done—but she also wasn’t discouraged. “Every day, there are blessings to count,” she says. “This is the hand I’ve been dealt, so I deal with it. There are good things that come out of this, too.” It would be easy for Olson to dwell on the not-so-good parts: the infection two months after her double radical mastectomy that led to a five-day hospital stay; the blood clots that developed in her lungs as a side effect of chemotherapy and led to another lengthy hospitalization; the devastating skin problems caused by radiation; the staph infection that required emergency surgery and five weeks of intravenous antibiotics; and the lymphedema that caused her arms to swell with retained fluid. But even after those complications delayed her reconstructive surgery and pushed her past her one-year goal, Olson remained positive. “I’m alive,” she says. “Even throughout all the complications and the pain, I have never considered myself sick. You just have to focus on the positive, find reasons to laugh and count your blessings.” One of the blessings has been her husband. As Olson was going through treatment, he was out of work with an injury himself, which allowed him the flexibility to go along to almost every appointment, to take her to the emergency room when complications arose and to help her heal at home as well. “Up until a month ago, I had him fooled that I couldn’t cook or do the dishes,” she laughs. “He did all of that for me. He has been such an amazing support to me.” Breast Cancer Fact Book 2016
Cheryl Olson Photo courtesy of Braunshausen Photography He even painted his fingernails pink for her—and has kept them painted, with a pink ribbon stenciled on his fourth finger, in her honor. “Two days before my first surgery, my granddaughter told her mom that she wanted to do something for grandma,” Olson explains. “She wanted everyone to paint their nails pink for me, so that when they looked at their nails they’d remember to pray for grandma.” Olson’s husband was eager to participate— and hasn’t been shy about sharing the story behind his pink nails, either. Olson loves the story of the time he ran into a rather large, burly man in the grocery store who noticed his pink nails. “He said to my husband, ‘You must know someone with breast cancer,’” Olson says. “And my husband told him that he had painted
them for his wife. So the guy says, ‘I admire you for doing that. I don’t know if I could do it, but I admire you.’” Olson, who was 56 at the time of her diagnosis, has used her experience to encourage her daughter, her sisters and her nieces to take care of themselves and to schedule regular mammograms. She wants them to be aware of their bodies and to stay on top of any changes—but she also hopes that none of them have to go through what she’s been through. “Back when I went in for my mammogram, I remember thinking that breast cancer strikes one in eight women,” she says. “I was calculating the odds that it would happen to someone in my family—and it turned out to be me. So I’m happy to take this one for the team, if it will keep the rest of them from getting it.”
Page 15
Early Stage Breast Cancer: How to know whether to forgo chemo
By Valerie Malyvanh Jansen Clinical Instructor, Ingrid Mayer Associate professor of medicine Vanderbilt University
Chemotherapy There has been substantial publicity about the MINDACT trial, which could lead to changes in breast cancer treatment. The study’s results suggest that women with a certain genetic profile would have a good chance of survival and cure regardless of chemotherapy. While the results are encouraging, breast cancer treatment decisions are complex, and this study does not necessarily provide a clear yes or no answer about the need for chemotherapy. As oncologists, we see this latest scientific development as yet another powerful tool in assessing a patient’s risk of developing cancer recurrence. However, the study results cannot be used as a sole tool to help guide treatment decision making. It does not tell you that if a patient has a genetic profile associated with high risk of recurrence, taking chemotherapy would change that risk. In essence, this trial is one more tool to inform patients and physicians about a tumor’s biologic behavior (more or less aggressive, more or less chance of development of a cancer recurrence). But the take-home message is that these results still do not help physicians and patients decide if chemotherapy can be skipped or not.
A Treatment Mainstay For years, surgery was usually the first step to remove a breast cancer tumor from the body. Both surgery and radiation (needed in certain cases) are helpful in promoting “local control” of the breast cancer. Treatments such as chemotherapy and/or hormone-blocker Page 16
pills are considered as additional or adjuvant treatments, to help “sterilize” the rest of the body (“systemic control”) from potential microscopic cancer cells that can break off from the original tumor in the breast, and ultimately may be responsible for the socalled distant recurrence of the breast cancer. The decision of whether a breast cancer patient will receive chemotherapy and/or hormone-blockers is based on many factors, including tumor size, grade, lymph node status, and presence or absence of hormone receptors or HER2 receptors. In years past, chemotherapy was given to most women. It often brings unpleasant side effects, including nausea, hair loss and fatigue. Some of the toxic drugs used in chemotherapy can sometimes cause health issues years down the road, such as thinking or memory problems called chemo brain. In addition, chemotherapy requires a great deal of time. It is also expensive, often costing tens of thousands of dollars, US. The decision of whether to have chemotherapy or not is, thus, a very important choice for hundreds of thousands of women receiving treatment for breast cancer. It is understandable that many women prefer not to have chemotherapy. The good news is that many women with early stage disease are now potentially cured, sometimes without chemotherapy given after surgery.
Better Understanding of a Complex Disease Breast cancer is the most common cancer diagnosis and the second leading cause of cancer-related deaths in American women. Only lung cancer kills more women. Not all breast cancers are alike. In fact, we are finding that many are much more aggressive than others. Many respond well to new therapies. In a new era of personalized medicine,
we, as oncologists who specialize in breast cancer, have much more information than ever to guide us in helping our patients. Research has found that more than 75 percent cases of breast cancer express what we call hormone-receptors, which are proteins in the cancer cell that are “fed” by the hormone estrogen. This “fuel”, in turn, causes the cells to grow and divide. These cancers are called estrogen-receptor positive, or ER+. Treatment of early stage ER+ breast cancer consists of surgery, sometimes radiation, and hormoneblocker (endocrine) therapy with or without chemotherapy. After a woman’s tumor is examined in a biopsy, some of the recently developed profiling tools can be used to help assess risk of recurrence and death in a more precise way. First, there is Adjuvant! Online. This software provides an estimation of chemotherapy effectiveness when added to endocrine therapy, based on clinicalpathologic features, or what we see in a patient upon exam, or what we learn through laboratory tests. Second, there is Oncotype DX, a 21-gene test, that actually has the ability to predict chemotherapy benefit and the likelihood of distant breast cancer recurrence, or metastasis. More recently, a third tool called MammaPrint was developed. This 70-gene signature examines 70 genes involved in breast cancer growth and survival, and was the one tested in the MINDACT trial. Unlike Oncotype DX, it only provides risk assessment (low risk or high risk) for distant recurrence, or metastasis, but it does not predict chemotherapy benefit. The purpose of the MINDACT (Microarray in Node-Negative and 1 to 3 Positive Lymph Node Disease May Avoid Chemotherapy) trial, an international, prospective, randomized phase 3 study, was Breast Cancer Fact Book 2016
to determine the clinical utility of the addition of the 70-gene signature (MammaPrint) to standard criteria in selecting patients for chemotherapy. The analysis focused on patients with discordant risk results. These included those with cancers that showed high clinical risk but low genomic risk. High clinical risk would include a woman who had a larger tumor size and more lymph node involvement. Low genomic risk refers to those cancers lacking the genes that signify aggressive growth. The women were randomly selected, based on high or low clinical risk, or on high or low genomic risk. The women that had both low clinical and genomic risk did not receive chemotherapy and were not evaluated in the trial. The women with both high clinical and genomic risk all received chemotherapy in addition to endocrine therapy, and were also not evaluated in the trial. The women with discordant risk (i.e. high genomic risk but low clinical risk, or low genomic risk and high clinical risk) were all treated with endocrine therapy, but were randomized to either receive chemotherapy or to not receive chemotherapy. In the group of women with high clinical risk but low genomic risk who were treated with chemotherapy, there was only a 1.5 percent increase in the five-year survival rate, without the cancer spreading to another organ in the body, the authors reported. (95.9 percent in the chemotherapy group vs 94.4 percent in the no chemotherapy group). Since the fiveyear survival is very similar in both groups, it Breast Cancer Fact Book 2016
is still unclear who are the women that actually can truly be spared of chemotherapy. Similar results were seen in the group of women with low clinical risk but high genomic risk (i.e. the five-year survival rate was very similar between the patients randomized to chemotherapy or not).
Bringing All The Information Together So what does this mean for our patients in the clinic? Let us consider two hypothetical clinical scenarios. Patient 1 is a 55-year-old woman with a 1.5 centimeter tumor that is ER+, low-grade, low proliferative rate with 0 of 3 sentinel lymph nodes, or nodes to which the tumor is most likely to have spread. Proliferative rate refers to the rate of growth of cells within the tumor; less than six percent is low, and greater than 10 percent is high. Based on these clinical-pathologic features of her tumor, she is considered to have low clinical risk. According to results from the MINDACT trial, her clinical risk would trump her genomic risk, therefore, getting a MammaPrint test would be a waste of time and money. Patient 2 is a 55-year-old woman with a 3.0 cm tumor that is ER+, high-grade, intermediate proliferative rate, with 2 to 5 positive sentinel lymph nodes. The patient is adamant about not receiving chemotherapy. Based on the clinical-pathologic features of her tumor, she is considered to have high
clinical risk, and chemotherapy followed by endocrine therapy would be the standard of care recommendation. If her MammaPrint test returns as low genomic risk, we could counsel the patient about her risk of distant metastasis without chemotherapy and breathe a sigh of relief if she had low genomic risk. She would certainly benefit from endocrine therapy, a daily, oral medication, for five to 10 years to reduce her risk of distant recurrence, or cancer that has spread, or metastasized. It is not clear, however, whether she would be in the 1.5 percent of patients who might have benefited from chemotherapy but did not receive it, or in the group of patients who were spared the toxicity of chemotherapy based on the MINDACT trial. These cases illustrate the complexity of clinical decision making in an era when we have a growing amount of data about the biology of each patient’s cancer. The MammaPrint test as used in the MINDACT trial suggests but does not predict a patient’s benefit from chemotherapy. It is merely a prognostic tool that tells us that the biology of the tumor matters. We already knew this. For this reason, we believe the MammaPrint test is another tool which may help patients understand their risk of recurrence better. It is important that patients continue to have active discussions with their physicians about treatment options based on these gene panel tests in an effort to achieve personalized care. Page 17
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Breast Cancer Fact Book 2016
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Female Breast Cancer Breast cancer is the most commonly diagnosed cancer among women in the United States. Based on current rates, 1 of 7 women in Minnesota will be diagnosed with this cancer in their lifetime. Female breast cancer rates have changed markedly since cancer reporting was implemented in Minnesota in 1988. Breast cancer incidence among women began declining significantly around 2000, and accounted for 31% of all cancer diagnoses among women in 2009 compared to 34% in 2000. Due to steady declines in mortality, breast cancer accounted for 15% of cancer deaths among women in 2009 compared to 20% in 1988. The breast cancer incidence rate among non-Hispanic white women over the most recent five-year period was 2% lower in Minnesota than reported by the 17 geographic areas participating in the Surveillance, Epidemiology, and End Results (SEER) program, and the mortality rate was 7% lower in Minnesota than in the US. About 20% of breast cancers in Minnesota were diagnosed at the earliest, in situ, stage, when SEER program data indicate that five-year relative survival is 100%.
Trends in Breast Cancer Incidence and Mortality Incidence rates of invasive female breast cancer in Minnesota decreased significantly, by 3.9% per year, from 2000-2004 and then increased significantly, by 1.4% per year, from 2004-2009. The average trend (AAPC) from 2000-2009 was a decline of 1% per year, which is not statistically significant. The mortality rate decreased significantly, by 2.5% per year, from 1988-2009. These are similar to national trends. The decline in incidence may have resulted from a decrease in the use of menopausal hormone therapy (MHT), the documented reduction in the use of mammography, and/or other factors. The sharp decrease in mortality among women has resulted from a combination of increased breast cancer screening with mammography and improvement in this cancer’s medical management.
Demographics of Breast Cancer While breast cancer risk increases with age, it has a younger average age at diagnosis than many common cancers. From 2005-2009, about 58% of breast cancer diagnoses and 40% of deaths in Minnesota occurred among women younger than 65 years of age.
Female Breast Cancer Incidence and Mortality, Minnesota, 1988-2009 150 Incidence Mortality
Rates per 100,000
120
90
60
30
0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year of Diagnosis (Incidence) and Year of Death (Mortality) Source: Minnesota Cancer Surveillance System (MCSS), December 2011 (incidence) and Minnesota Center for Health Statistics (mortality). Rates are age-adjusted to the 2000 US population.
Page 20
Breast Cancer Fact Book 2016
In Minnesota and nationally, non-Hispanic white women are the mostly likely to be diagnosed with breast cancer, but African American women are more likely to die of the disease. From 2005-2009, female breast cancer incidence rates in Minnesota were 15% lower among African American women compared to non-Hispanic white women, but mortality rates were 30% higher. Female breast cancer incidence rates were somewhat lower in Minnesota than in the SEER 18 areas for each race/ethnic group except American Indians. Among American Indian women statewide, breast cancer incidence was 40% higher.
Percent of Female Breast Cancers Diagnosed at Late Stage by Race/Ethnicity, Minnesota, 2003-2007 Average Number of Cases Diagnosed/Year
Race/Ethnicity
African American 62 American Indian Statewide 22 American Indian CHSDA residents 13 Asian/Pacific Islander 32 Hispanic (all races) 30 Non-Hispanic White 3,325
In general, the rate of late-stage disease should decline as breast cancer screening becomes more widely adopted.
*Late Stage
50% 33% 29% 41% 50% 35%
Source: Minnesota Cancer Surveillance System (May 2010). * Late-stage cancers have extended beyond the breast (regional or distant stage) when diagnosed. The denominator is all invasive cancers, including those that were unstaged (2.2%).
Female Breast Cancer by Race/Ethnicity, Minnesota, 2003-2007 150 African American AI/AN* statewide
126.7 120
AI/AN CHSDA* 108.0 103.4
Asian/Pacific Islander
Rate per 100,000
97.0 90
Hispanic (all races) 80.4 Non-Hispanic White
60 53.4
30
27.1 21.9 12.7
13.8
17.1 9.7
0 Incidence
Mortality
Source: Minnesota Cancer Surveillance System (MCSS), May 2010. Rates are age-adjusted to the 2000 US population. *AI/AN is American Indian/Alaska Native. CHSDA is Contract Health Service Delivery Area.
Risk Factors Cumulative exposure of breast tissue to the naturally occurring hormone estrogen is a strong predictor of risk. Therefore, early age at menarche, late onset of menopause, late childbearing, and having fewer children increase risk. Other established risk factors include: benign breast disease with atypical hyperplasia, obesity, alcohol consumption, physical inactivity, and higher
Breast Cancer Fact Book 2016
socioeconomic status. Family history, especially of premenopausal breast cancer, is strongly associated with increased breast cancer risk. Mutations in the BRCA1 or BRCA2 gene are specific inherited risk factors. However, known risk factors only account for 50% of breast cancers. The Women’s Health Initiative (WHI) is a large, randomized clinical trial of the effects of MHT on the risks of many diseases
Page 21
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