Angelina Jolie Writes about Prophylactic Mastectomy

Actress Angelina Jolie has authored an opinion piece in the New York Times about her choice to have a prophylactic mastectomy to reduce her risk of breast cancer. Ms. Jolie says her family and genetic history gave her an 87% risk of having breast cancer, and that the surgery reduced that risk to under 5%. She says she chose “not to keep my story private because there are many women who do not know that they might be living under the shadow of cancer. It is my hope that they, too, will be able to get gene tested, and that if they have a high risk they, too, will know that they have strong options.”

We asked Otis W. Brawley, M.D., chief medical officer, for his reaction to the piece.

“While only a small number of breast cancers are linked to known genetic risk factors, women facing such a high risk need to know that, and need to be able to discuss their options with genetic specialists and knowledgeable health professionals so they can have all the information and expertise at their fingertips to do what’s right for them.

“This does not mean every woman needs a blood test to determine their genetic risk for breast and/or ovarian cancer. What it does mean is women should know their cancer family history and discuss it with their regular provider. If appropriate, they should be referred to and have the opportunity to discuss their risk and their options with a genetic specialist.

Otis Brawley, MD, Chief Medical Officer, American Cancer Society

“Insurance plans created before the passage of the Affordable Care Act are not required to cover the costs of genetic counseling, testing, and any surgery to reduce the risk of breast cancer. Under the Affordable Care Act, new plans are required to cover the costs of counseling and testing for breast cancer risk. There is no such mandate for the coverage of surgery.

“A prophylactic (preventive) mastectomy, removing both breasts before cancer is diagnosed, can greatly reduce the risk of breast cancer, by as much as 97%. It does not completely prevent breast cancer because even a very careful surgeon will leave behind a small amount of breast tissue, which can go on to become cancerous.

“Women with BRCA mutations associated with a high risk of breast cancer, confirmed by testing, and with a strong family history of breast cancer, a previous breast cancer, and who show signs of certain pre-cancerous conditions are among those who could benefit from the surgery. A woman with a mutation of known significance must consider her quantifiable risk in making the very personal decision to have her breasts and ovaries removed or pursuing other options, such as more extensive screening for breast and ovarian cancer. Experts recommend women proceed cautiously, and receive a second opinion before deciding to have this surgery. The American Cancer Society Board of Directors has stated that ‘only very strong clinical and/or pathologic indications warrant doing this type of preventive operation.’ Nonetheless, after careful consideration, this might be the right choice for some women.”

For more information, please see: “Can Breast Cancer Be Prevented?” on cancer.org.

“I used to believe a mammogram saved my life.”

“I used to believe a mammogram saved my life.” So begins a remarkable article in this Sunday’s New York Times Magazine (“Our Feel Good War on Breast Cancer“), which asks provocative questions about the battle against breast cancer, questioning awareness efforts and saying mammography has not been as effective at reducing mortality as claimed.

We asked Otis W. Brawley, M.D., the Society’s chief medical officer for his thoughts.

“This is a powerful and important article, one I believe every breast cancer advocate, and frankly even advocates for prostate and other cancers, should read. It lays out the challenge that lies before us in reducing death and suffering from breast cancer, while demonstrating the challenge that we in public health face in how to accurately and truthfully administer information.

Otis Brawley, MD, Chief Medical Officer, American Cancer Society

“In her article, Ms. Orenstein asks a stunning question: whether the mammogram she had even mattered, or whether her outcome would have been the same had she detected the cancer herself years later. She, like millions of American women who have been diagnosed with breast cancer, will never know the answer to that question.

“Many experts agree that not every breast cancer detected early will go on to cause serious disease and even death. But we do not yet have the means to predict whether a small localized tumor will grow or spread, or whether it will potentially remain small and never cause harm.

“There is considerable disagreement as to how many breast cancers actually are what we call ‘over-diagnosed.’ Studies have come up with estimates ranging anywhere from none of them to more than one in three. The most credible evidence suggests the rate of over-diagnosis is somewhere between ten and 20 percent.

“While the rate of over-diagnosis is unsettled, we do have a number of clinical studies that consistently show that appropriate treatment of early-stage breast cancer saves lives. Observation, what in prostate cancer has been termed ‘watchful waiting,’ is not appropriate for breast cancer. A woman who is diagnosed with breast cancer should always receive treatment.

“There is little question that over time we will continue to refine and improve our ability to determine which women are more or less likely to benefit from different approaches to screening and treatment. Genomic research has already proven valuable in identifying which women in certain groups are more or less likely to benefit from intensive chemotherapy, and it holds our best hope moving forward. This problem is due to the fact that our definitions of cancer are based on microscopic description from the 1850′s. It is only through additional research and clinical trials that we can develop a 21st century definition of breast cancer.

“Meanwhile, the view that mammography has only marginally reduced the rate at which women present with advanced cancer must be viewed with caution. Reductions in deaths from breast cancer are due to a number of factors, including increased awareness, the rise of mammographic screening, and better treatment. However, we do not and cannot know with precision today how much these contribute to decreasing deaths and at what proportion.

“There has been a 35% decline in the female breast cancer death rate since 1991. This decline is due to several factors:  increased awareness; an increased openness that allows us to talk about breast cancer; and improvements in diagnosis and treatment. One can argue about the proportions contributing to the decline, but we can say mammography has clearly contributed to the decline in death rate.

“The Society believes existing evidence shows that the benefits of screening mammography every year beginning at age 40 outweigh the risks and harms, which are an unavoidable part of breast cancer screening. The Society also recommends that women have careful and thorough discussions with a health care professional as they consider screening, including the benefits, limitations, and potential for adverse events such as false positive findings and the possibility of over-treatment.

“Women should understand that breast cancer screening is imperfect, and does have limitations. Nonetheless, one can be ‘pro-screening’ without resorting to exaggeration or over promising its effectiveness. This is our challenge. We must be able to give women a choice regarding screening without condescension. And while clinical studies consistently show that breast cancer screening has significant limitations, including some over-diagnosis, we also know that mammography screening does save lives.”

Physicians’ Group Releases Prostate Screening Recommendations

New prostate screening recommendations from the American College of Physicians (ACP) released today say men between the ages of 50 and 69 should discuss the limited benefits and substantial harms of the prostate-specific antigen (PSA) test with their doctor before undergoing screening for prostate cancer.

The guideline says only men between the ages of 50 and 69 who express a clear preference for screening should have the PSA test.

Chief Medical Officer Otis W. Brawley, M.D. was very pleased with the new guidance.

Otis Brawley, MD, Chief Medical Officer, American Cancer Society

“This new guidance for internists and other clinicians from the American College of Physicians is very consistent with recommendations from the American Cancer Society. In 1997, the Society was the first organization to recommend that patients be informed of the known risks and potential benefits of screening. We were also the first organization to recommend that physicians go through a process of shared decision-making concerning prostate cancer screening.

“The current ACS statement notes that ‘[m]en should have an opportunity to make an informed decision with their health care provider about whether to be screened for prostate cancer, after receiving information about the uncertainties, risks, and potential benefits associated with prostate cancer screening.’ Most professional organizations now recommend for such informed decision making. While the US Preventive Services Task Force recommends against prostate screening. the group does recommend that men who request screening be informed of its risks and possible benefits, and then receive screening only if they still want it.

“Virtually every cancer screening test has limitations. Often those limitations involve harms. Several screening studies have failed to show a benefit in terms of a decrease in mortality from screening using PSA, while two studies do show it may be associated with a small decrease in risk of death. All published prostate cancer screening studies have some flaws in them that make them in no way conclusive.

“One thing prostate cancer screening studies consistently show is that a significant number of men are diagnosed with tumors that never would have been a problem and that a significant number of men receive unnecessary treatment with the accompanying side effects. The most serious of these treatment related side effects is death from cardiovascular disease due to hormonal therapy or post-operative complications.

“The American Cancer Society applauds all efforts at explaining these limitations to patients and the physicians who care for them. We also applaud efforts to increase the use of active surveillance as a treatment of low grade localized disease.”

For more information, see “Can Prostate Cancer Be Found Early?” on cancer.org.

TLC’s Lori Allen Helps to Fight Cancer In Style

Lori Allen of TLC’s Say Yes to the Dress: Atlanta

On a Friday the 13^th almost a year ago, bridal shop owner, Lori Allen, got the dreaded call from her doctor that she had breast cancer.  “At first, I was in shock. I couldn’t even say the words “breast cancer” for days,” recalls Allen, who was taking her husband Eddie to the hospital to have a cancerous tumor removed when she got the news.

The day and the diagnosis may have been unlucky, but Allen, famous for her sassy approach on TLC’s Say Yes To The Dress: Atlanta, was determined to turn her situation around. She blogged about her experience, and had her entire journey filmed and broadcast on TLC’s Say Yes to the Cure: Lori’s Fight.

Now, just a few days before her one year anniversary of diagnosis, Allen will be joining the American Cancer Society® and over 100 wives of NCAA® men’s college basketball coaches involved in the Coaches vs. Cancer® program at a Fight Cancer In Style Event on April 6, during NCAA Final Four weekend in Atlanta, Georgia.

“I realized I had an opportunity to give hope to other women by sharing my story publicly,” Allen says. “My mammogram and the early detection of my cancer made such an impact in my life, I want to inspire other women to get checked.”

Fighting Cancer In Style

Fight Cancer in Style is an exclusive luncheon, networking opportunity and boutique shopping event hosted by coaches’ wives to raise awareness about how everyone can help to finish the fight against cancer. For Allen, the event was a perfect fit — for more reason than one. During her own cancer journey, she realized the importance of feeling good even when you’re sick.

“Throughout my treatment and even after my double mastectomy, I still dressed up, wearing makeup and my favorite outfits and accessories. It lifted my spirits and made me feel special,” she says.

According to a 2012 Harris Interactive Survey, of more than 1,200 women surveyed nationwide, 37 percent of women with cancer said that they avoided leaving the house because of the way they looked after going through treatment. But, it doesn’t have to be that way.

Louanne Roark, executive director of the Personal Care Products Council Foundation and spokesperson for the Look Good Feel Better program — a public service program that teaches beauty techniques to cancer patients to help them manage the appearance-related side effects of cancer treatment — says efforts to help women boost their appearance are about “more than eyeliner and lipstick.”

“Many of the women who come through our workshops have told us that after undergoing treatment, they simply don’t recognize the person looking back at them in the mirror. We understand the incredible stress that cancer causes beyond the diagnosis: self-esteem, control, relationships and many of the aspects that define normalcy come under attack,” Roark explains.

“We know there is a cascade of emotions following a cancer diagnosis and cancer treatment. What many don’t realize is that these outward signs of cancer also rob one’s sense of self and self-confidence,” she says.

And that’s what Lori Allen has been encouraging women to avoid.

“If you’re facing a cancer diagnosis, don’t give up on yourself! Keep doing whatever it is that makes you feel beautiful, because you are,” Allen says.

Look Good Feel Better is a collaboration between the American Cancer Society, the Personal Care Products Council Foundation, and the Professional Beauty Association. Additional resources for women are available in the breast cancer information and resources guide on cancer.org/fightbreastcancer and in the Society’s Tender Loving Care catalogue.

Study: Mammography Screening Every Two Years Does Not Increase Risk of Advanced Stage Tumors

A study appearing early online in JAMA Internal Medicine (formerly Archives of Internal Medicine) suggests that women  50 to 74 years old who undergo biennial screening have a similar risk of advanced-stage disease and a lower cumulative risk of false-positive results than those who get mammograms annually.

The study, by Karla Kerlikowske, M.D., of the University of California, San Francisco, and colleagues sought to determine whether the benefits and risks of screening mammography differ according to age, breast density, and the use of hormone therapy (HT). The authors found that biennial vs. annual mammography for women ages 50 to 74 was not associated with an increased risk of advanced-stage or large-size tumors regardless of a women’s breast density or HT use. However, the results indicate that among women ages 40 to 49 with extremely dense breasts, biennial mammography vs. annual was associated with an increased risk of advanced-stage cancer and large tumors.

The authors conclude that women aged 50 to 74 years can undergo biennial rather than annual mammography and that women aged 40 to 49 years with extremely dense breasts who choose to undergo mammography should consider annual screening to decrease the risk of advanced-stage disease but should be informed that annual screening leads to a high cumulative probability of a false-positive result.

Below are comments from Robert A. Smith, Ph.D., American Cancer Society director of cancer screening.

“This new study adds to mounting data that older women can be screened at a wider interval, and that a shorter interval does increase the false positive rate without much additional advantage. The fact is, screening guidelines tailored to individual characteristics really need a more precise tool than age alone (example: ages 40 to 49 versus 50 and above). The question for individual women becomes when to move screening from an annual procedure to every 2 years, and which women are most likely to benefit from continuing with annual screening. We may see a time when that age is moved from the current, age 50, to something like age 55, an age when most women have passed through menopause.

“The benefits of a shorter interval for most women in their 40s is fairly well established. The screening interval should probably be shorter for women with very dense breasts, women with a family history of breast cancer, and women who are taking menopausal hormone therapy.

“What has been shown consistently is that for women in their 40s, the risk of a cancer developing in between mammograms, what we call an interval cancer, is much higher in the first 6 to 18 months after a normal mammogram than it is for women over 50. It may very well be that this higher rate is attributable mostly to breast density, and if so, then perhaps some women in their forties could begin screening at a wider interval based on density. But we’re not there yet; we would need to do quite a bit of analysis to figure out this complicated equation. We cannot say with certainty what level of density might benefit from annual versus longer screening intervals, which may be 18 months or two years.

“Also we are moving towards a day when we will have personalized screening. Some women based on age and other risk factors may be told to get a mammogram every two or perhaps three year; others will be told to get one annually; some may be told to get mammography or MRI imaging even more frequently. We have not reached that day.”

“Until then, if we advise a woman that it is safe to follow a less aggressive preventive health regimen, like waiting longer between mammography screenings, you want to be very sure you are giving her the right advice. So far, surveys show that women prefer safety, and are more willing to live with the consequences of a false positive than risk a missed tumor.

“The American Cancer Society continually reviews emerging data as we create and update our own screening guideline. This study and many others will be included in the evidence review a panel of independent experts will review as a routine part of that work.”

Study Finds Increase in Advanced Breast Cancers Among Younger Women

A new study finds a small but statistically significant increase in the rate of advanced breast cancer in women 25 to 39 years of age, raising questions about what may be causing the apparent increase.

The study was led by Rebecca H. Johnson, M.D., of Seattle Children’s Hospital and University of Washington, Seattle, and appears in the Journal of the American Medical Association. Researchers looked at breast cancer incidence and age in three U.S. National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) registries.

They found that since 1976, there has been a steady increase in the incidence of distant disease breast cancer in 25- to 39-year-old women, from 1.53 per 100,000 in 1976 to 2.90 per 100,000 in 2009. While the increase in relative risk is high, the researchers note that this is an absolute difference of 1.37 cases per 100,000, or 2.07 percent per year over the 34-year interval, a relatively small increase. Importantly though, the trend continues, indicating the need for further study and monitoring.

Len Lichtenfeld, M.D., deputy chief medical officer, had this to say about the study.

Len Lichtenfeld, M.D.

“This study makes the important observation—not previously documented—that the incidence of advanced breast cancer at the time of diagnosis has been significantly increasing over time in women between the ages of 25 and 39, and appears to be accelerating in recent years. Although the numbers of women impacted are small, we must never forget that for these women, their loved ones, friends, colleagues and communities, this is a devastating event.

“If the trend continues to increase over time, we cannot predict what will happen over the next ten or twenty years. As a result, it is important we continue research to understand what is contributing to this observation. Although the study’s authors and other experts—including those from the American Cancer Society—may have some thoughts, the reality is that at this point we do not have the facts to answer the question as to cause. Some reasonable areas for investigation may include childhood obesity, environmental exposures and delayed childbearing among others.

“It is important to point out that this increase is only in the diagnosis of advanced disease, not in localized or regional stages of breast cancer in women under age 40. And of particular importance is that there is nothing in this study that suggests routine breast cancer screening for women in this age group at average risk is either appropriate or justified.

“If there is a message for young women as a result of this study, it is that they should always be aware of changes in their breasts, and consult a health care professional if they discover such changes. For health care professionals, it is important to remember being under the age of 40 does not mean that a woman cannot develop breast cancer. Therefore, changes in the breast should be carefully evaluated.”

You can find comprehensive information on breast cancer, its risks, and the latest trends on the Detailed Guide at cancer.org.

Scientists Receive First-Ever Breakthrough Prize in Life Science

We learned this week that eleven scientists have been named as the first-ever recipients of research prizes given by four technology giants, including Facebook founder Mark Zuckerberg and Google co-founder Sergey Brin, and that among them are some familiar names to people working in our research program.

The Breakthrough Prize in Life Sciences recognizes innovation in medicine and biology and the amount awarded, $3 million each, is more than double the amount of the Nobel Prize. Some of you may know that 46 Nobel Laureates were once recipients of American Cancer Society research grants, pointing the the Society’s strong track record of identifying, and helping make possible, the most promising work in cancer medicine.

Well, we’re proud to say more than half of the recipients of this new prestigious prize were also once ACS grantees.

• Cornelia Bargmann received the first of four ACS research grants in 1991
• David Botstein – was awarded ACS grants in 1969 and 1977, very early in his career
• Lewis Cantley – received the first of two ACS grants in 1994
• Charles Sawyers - received the first of two ACS grants in 1994
• Titia De Lange – became an ACS Research Professor in 2010
• Robert Weinberg - became an ACS Research Professor in 1985
• Bert Vogelstein – became an ACS Research Professor in 1993

Anne Wojcicki, the founder of the genetics company 23andMe and one of the four who created the award told the New York Times the new prize is meant to reward scientists “who think big, take risks and have made a significant impact on our lives.”

We are so proud to be reminded of the important role the American Cancer Society plays  in making sure the most promising research is supported, allowing researchers to help us find answers. And we hope those of us who have supported us along the way, as well as those who want to join the fight will be proud, too.

You can read more about our research program on our website.