In February 2003, Jill Wiechert—34 years old with a full head of hair and a three-week-old baby girl—showed up at Johns Hopkins Hospital for her first round of chemotherapy. It was a scenario she could have hardly imagined less than a year earlier, when she got married and became pregnant soon after.
Six months later, she found a lump in her breast and called her obstetrician, who sent Wiechert for a sonogram.
“From there, I went to a surgeon, who believed there was a 90 percent chance that this was just a cyst, and I had a biopsy,” says Wiechert. “Three days later, my husband and I were listening to people recommend that I have both breasts removed.”
Weichert ended up taking a more conservative route: She quickly had a lumpectomy and a sampling of the lymph nodes—and was heartened to know that none of the nodes had been affected. Still, she had several harrowing months ahead of her: She would not begin chemotherapy until after her baby arrived.
“The good news was that I was able to wait until the baby was born and I was very grateful for that,” Weichert says. “I could pretend that this was a normal pregnancy.”
If there is one cancer that
instantly terrifies women, it would most likely be breast cancer. “Even though the survival rate for breast cancer is about the same as for other cancers, it has a different impact on women,” says Neil B. Friedman, M.D., director of the Mercy Medical Center’s Hoffberger Breast Center.
In 2002, 194,000 American women were diagnosed with breast cancer; the average age of diagnosis is 55. And the number of cases is expected to rise dramatically. According to a study conducted by Charles Cox, M.D., of Florida’s Lee Moffitt Cancer Center, the number will be 500,000 by 2010. However, Miles Harrison Jr., M.D., a partner with Sinai Lifebridge’s Sinai Surgical Associates, does not expect the numbers to go up that dramatically—or at least, he says, he hopes they don’t.
“With early-stage detection today, we’re able to pick up breast cancer at Stage 1 or 2, which typically has a survival rate of 10 or more years,” says Harrison. “The mothers of the baby boomers typically had their cancer detected in later stages, frequently when it had spread to the bones, liver, and lungs, or other distant vital organs. That really reduced the chance of survival.”
While such numbers seem discouraging, the news is not as bad as it first sounds. “The reason for those numbers is that more and more women are getting mammograms, and that there is that huge number of baby boomer women,” says Lillie Shockney, R.N., B.S.N., M.A.S., director of education and outreach at the Johns Hopkins Breast Center, and an 11-year breast cancer survivor. “But mammograms remain the best method of early detection, and early detection translates into the best chance for survival.”
Whether it is mammograms, needle biopsies, medication, or lumpectomies, procedures every year are becoming less invasive and more effective. For instance, mammography is more sophisticated these days, says Shockney, especially with the use of digital mammography. Nevertheless, she counsels that it is crucial that a specialist in breast radiology reads the mammogram.
Most breast cancer patients undergo chemotherapy, and that, too,
“You do get medicine to counteract the nausea and, except for losing my hair, I really felt pretty well,” says Wiechert, who underwent four rounds of adriamycin cytoxan. “The idea is that chemo will kill any cancer cells that might have escaped to other parts of the body, while radiation will treat anything that is left in the breast.”
Still, the process is definitely disruptive. As Wiechert, who had chemo at Hopkins and radiation at Mercy, puts it, “Radiation is a five-day-a-week process that goes on for six weeks. It only takes 10 minutes, but it’s every day.
“I finished in July 2003 and, even though the people at Mercy were absolutely wonderful, I hope I never see them again.”
Not every woman needs radia-tion, notes Friedman; those who have a mastectomy often don’t. However, among women undergoing lumpectomies—and these days, more and more women are opting for more conservative surgery—virtually all need radiation. If one has an invasive cancer and does not have radiation, the risk of recurrence of the cancer within the breast in the next 10 years is 30 to 40 percent.
Friedman also points to a new drug, Arimidex, which appears to be particularly promising.
“There was a big study that came out in December 2001, and I suspect that when all the long-term studies are completed, Arimidex will be shown to be even better than Tamoxifen,” he says.
The other hopeful news for women is that breast surgery—as with other areas of medicine—is dramatically less invasive than 25 years ago.
“You still hear horror stories of women being diagnosed and waking up with their breasts and chest muscle removed,” says Shockney, “but that is no longer the case.”
Fewer mastectomies are being performed today, in favor of the much less invasive lumpectomy. Even the biopsy that precedes the lumpectomy is less invasive and often performed with ultrasound-guided needles instead of the one-inch incision of 10 years ago.
Another bonus for some women: Standard wisdom used to hold that as many as 10 to 25 lymph nodes would be removed—malignant lymph nodes being a good indicator that the cancer had spread to other parts of the body— but today it is more likely to be two or three nodes. “A sentinel lymph node biopsy—or a sort of lumpectomy for the lymph nodes—can examine those three lymph nodes and if they are negative, we’ll go no further,” says Friedman. “But, if they are positive, then we still have to remove the rest as we did before.”
Reconstruction is also far more advanced than in the past. “It used to be that we’d take muscle from the abdomen to fill in the breast,” he continues. “Now we don’t take any muscle, but just fat from the abdomen, transplanting it to the chest and there connecting it with the blood vessels under the arm. The cosmetic results are just as good, if not better . . . there is less morbidity, fewer long-term issues, and recovery is quicker.”
This new reconstructive procedure, Deep Inferior Epigastric Perforator Flap (DIEP), may not be recommended by all physicians. But if it isn’t, both Shockney and Friedman say, warning flags should go up.
“If a physician does not recommend DIEP, ask why?” says Friedman. “To do this takes significantly more skill on the part of the doctor.”
Shockney, who underwent DIEP in December 2002, agrees that it is a far better technique. While a physician can do the mastectomy, DIEP requires a plastic surgeon who has been trained and has experience in micro-vascular surgery and breast reconstruction.
As a result of all these advances, 85 percent of women diagnosed at an early stage survive more than five years—Shockney points to one 51-year survivor—compared to 75 percent in 1975. But the news is not so positive for African-American women.
“Back when I was in medical school, we were told that breast cancer was a disease of white women,” says Claudia Baquet, M.D., associate dean for policy and planning and director of cancer disparities research at the University of Maryland School of Medicine. “That’s just not true.”
If one looks at all women, regardless of race, ethnicity and age, the incidence of breast cancer is higher in white females. But when women are separated by age group, there is a significantly higher breast cancer incidence in African-American women under the age of 40.
And the mortality rate is higher for black women than for white women in every age group. Although there are a number of explanations, including later detection and less follow-up, particularly in lower-income groups, and less access to quality treatment, one gene—BP1—found in 80 percent of tissue from breast cancer patients may be part of the problem for African-American women.
In a recent small study, says Baquet, BP1 expression was found in 57 percent of white patients; it was found in 89 percent of African-American patients. This is especially troubling because BP1 was found in every single one of a certain kind of tumor called estrogen-receptor-negative. These tumors, as their name suggests, don’t respond to the anti-estrogen breast cancer therapies that are currently being used. African-American women, says Baquet, tend to have a much higher rate of difficult-to-combat breast cancers. They may be genetically or biologically predisposed not to respond as well to these medications.
“Right now, combined with early detection and follow-up, the best hope is research into new therapies that will be more effective for black women and other estrogen-receptor-negative women,” says Baquet. She adds that other research is working on the possibility of changing a woman’s receptor status from negative to positive, which would make them able to benefit from anti-estrogen therapies.
In Wiechert’s case, the surgery, chemo, and radiation are completed and she’s back at work in the sales department of a beverage company. “I feel strong, but I’m always afraid that it will come back,” she says. “Still, I do feel I’m cured and I’ve once again got hair.”
And she looks forward to spending many years with her new daughter, with more hope than she’d had a year ago.
“My mother had breast cancer, now I had it, and one of my biggest fears was my own daughter would come down with the disease,” Weichert says. “When I spoke with my oncologist about that, she said, ‘Don’t worry, I’m very hopeful that there will be a cure in the next 20 years.’”