tag:theconversation.com,2011:/africa/topics/breast-cancer-awareness-month-12695/articlesBreast Cancer Awareness Month – The Conversation2022-10-18T20:19:22Ztag:theconversation.com,2011:article/1919782022-10-18T20:19:22Z2022-10-18T20:19:22ZFinding community online after finding a lump: Social media and younger adults with cancer<figure><img src="https://images.theconversation.com/files/490300/original/file-20221018-20-gqdw2o.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4357%2C2736&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research suggests that supports are more likely to be provided to meet the needs of the majority of people with cancer who are older, rather than to younger people with cancer.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>October marks Breast Cancer Awareness Month. The Canadian Cancer Society estimates that <a href="https://cancer.ca/en/cancer-information/cancer-types/breast/statistics">one in eight women will contract breast cancer in their lifetime</a>, making it the most common cancer among Canadian women. </p>
<p>It is also the most commonly diagnosed cancer in women under 40 years old. <a href="https://breastcancernow.org/about-us/media/statements/younger-women-increasingly-diagnosed-breast-cancer">Incidence of breast cancer continues to increase among these younger women</a>, though <a href="https://doi.org/10.3390/ijerph17134884">scientists do not yet understand why</a>. </p>
<p>Young women (and men) with breast cancer face unique challenges, such as <a href="https://www.youngadultcancer.ca/yacprime/">disruptions to career or family plans, greater likelihood of more aggressive cancers and a lifetime of fears of recurrence</a>. Further, many targeted supports (like support groups and resources) are not always available or accessible for younger people. Research suggests that <a href="https://doi.org/10.3389/fonc.2013.00075">supports are more likely to be provided to meet the needs of the majority of people with cancer who are older</a>. </p>
<p>This was made worse during the COVID-19 pandemic. During this time, access to health-care services of all kinds changed, as did cancer care and support. As a result of pandemic restrictions, many face-to face appointments and support groups offered through local and regional organizations were paused or at best moved online. </p>
<p>These changes to cancer care and support made sense in the context of a virus that poses a major threat to immunocompromised people with cancer. But this move also left many <a href="https://doi.org/10.1111%2Fecc.13385">feeling even more isolated, at a time when their diagnosis already brought feelings of loneliness</a>. This in turn has <a href="https://doi.org/10.1080/07347332.2020.1853653">led to depression for some people navigating cancer</a>.</p>
<h2>Cancer in younger patients</h2>
<p>The authors of this article are both women under age 45 who have experienced a cancer diagnosis. Now we study cancer, <a href="https://healthresearchbc.ca/award_researcher/cheryl-heykoop/">its unique impacts on young people</a> and the ways young people can be better supported during and beyond treatment. </p>
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<img alt="Two women in chairs beside medical equipment. One is middle-aged and one is young." src="https://images.theconversation.com/files/489738/original/file-20221014-17-l36wyf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/489738/original/file-20221014-17-l36wyf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/489738/original/file-20221014-17-l36wyf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/489738/original/file-20221014-17-l36wyf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/489738/original/file-20221014-17-l36wyf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/489738/original/file-20221014-17-l36wyf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/489738/original/file-20221014-17-l36wyf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Young patients often feel out of place navigating cancer care, where they are often a generation younger than the others they see around them at appointments or support programs.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>In both our research work and our personal experiences, we’ve recognized the tremendous potential for digital communication technologies like social media and instant messaging to connect younger cancer patients to one another, and provide information, emotional support and, crucially, hope during difficult times. </p>
<p>Research with young adults with cancer <a href="https://doi.org/10.2196/28234">highlights the benefits of social media</a> to <a href="https://doi.org/10.3390/curroncol29020099">offer support specific to adolescents and young adults</a>. And through talking with younger adults and organizations that serve them (such as <a href="https://www.youngadultcancer.ca">Young Adult Cancer Canada</a>), researchers are learning that digital communication tools have been essential for their emotional and mental support needs, particularly during the pandemic. </p>
<p>Younger adults have shared that the communities they find on social media sites like Instagram or TikTok can help them to feel less alone. They often feel out of place navigating cancer care, where they are often a generation younger than the others they see around them at appointments or support programs. </p>
<p>Digital technologies can offer a community of people at the same life stages. When younger people with cancer find community online they also find others who have the same concerns about having children, interrupting their careers, or managing young families during the course of their illness. </p>
<h2>Digital communities</h2>
<p>Digital technologies make these kinds of communities possible because they allow people to connect across geographical boundaries. There might be only one other person your age with cancer in your city or town, and you might never run into them if your treatment appointments don’t line up. But online you can connect with others from around the world, meaning that even people with rare cancers can find one another.</p>
<p>However, not all online tools are created equal. In a soon to be published study, which was recently presented at the 2022 <a href="https://socialmediaandsociety.org/page/2/">Social Media and Society annual conference</a>, Hodson, one of the authors of this article, learned that Facebook and Twitter are viewed as more negative than Instagram or TikTok, which offer more hopeful and positive depictions of cancer. And different platforms also attract different users. Facebook tends to attract gen X users, whereas Instagram and TikTok skew to gen Y and Z — data that needs to be taken into account when providing digital support to people with cancer, and particularly younger people. </p>
<p>Of course, social media also presents challenges for people experiencing a cancer diagnosis. <a href="https://www.proquest.com/openview/e18614b5f377026155470a24c3c76772/1?pq-origsite=gscholar&cbl=18750&diss=y">Alarmingly, they are a growing source of misinformation</a>. And if misinformation leads to people with cancer rejecting conventional treatments, <a href="https://doi.org/10.1093/jnci/djx145">it can result in deadly outcomes</a>. </p>
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<img alt="A young man wearing glasses and a hospital gown lying with his head on a blue pillow holding a smartphone with an IV line in his hand." src="https://images.theconversation.com/files/490486/original/file-20221018-12-ka32bv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/490486/original/file-20221018-12-ka32bv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/490486/original/file-20221018-12-ka32bv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/490486/original/file-20221018-12-ka32bv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/490486/original/file-20221018-12-ka32bv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/490486/original/file-20221018-12-ka32bv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/490486/original/file-20221018-12-ka32bv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Digital technologies make it possible for young cancer patients to connect with each other.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>In Hodson’s study, participants also indicated that they sometimes experienced harassment or trolling when discussing their disease on online platforms. This results in a less safe space for people with cancer when they are at their most vulnerable, and can prevent some people with cancer from benefiting from these valuable connection tools. </p>
<p>Digital communication technologies are an invaluable resource for young people who experience a cancer diagnosis and are living with cancer, but right now most of these groups are created on the fly, are independent and are not moderated. This means that not everyone who needs them has access to them, and when people do use social media to connect with others, they’re exposed to such problems as misinformation and online bullying. </p>
<p>We recommend that health-care institutions and policy-makers alike consider ways to build out communities on popular social media platforms for younger people with cancer to ensure everyone can connect. We encourage social media platforms to create moderation policies and procedures that allow young people experiencing cancer to connect safely. </p>
<p>This October, we call on social media companies to think beyond pink, and provide spaces for all young people with cancer to connect with each other in safe, inclusive and supportive ways.</p><img src="https://counter.theconversation.com/content/191978/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jaigris Hodson receives funding from the Social Sciences and Humanities Research Council of Canada.</span></em></p><p class="fine-print"><em><span>Cheryl Heykoop receives funding from Michael Smith Health Research BC, Vancouver Foundation, and the Canadian Institutes for Health Research. She was diagnosed with cancer as a young adult and volunteers with BC Cancer, Young Adult Cancer Canada, and Callanish Society.</span></em></p>Younger cancer patients have unique challenges, and resources often target older patients. Social media brings younger cancer patients together to share information, emotional support and hope.Jaigris Hodson, Associate Professor of Interdisciplinary Studies, Royal Roads UniversityCheryl Heykoop, Associate Professor, School of Leadership, Royal Roads UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1908772022-10-05T12:19:56Z2022-10-05T12:19:56ZBreast cancer awareness campaigns too often overlook those with metastatic breast cancer – here’s how they can do better<figure><img src="https://images.theconversation.com/files/487963/original/file-20221004-26-x590oy.jpg?ixlib=rb-1.1.0&rect=64%2C32%2C4217%2C2811&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many stage 4 breast cancer patients say that they don't relate with the pink ribbon.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/pink-breast-cancer-awareness-ribbon-with-copy-space-royalty-free-image/183579195?adppopup=true">AnthiaCumming/E+ via Getty Images</a></span></figcaption></figure><p>Is there anyone who isn’t aware of breast cancer? </p>
<p>Since 1985, cancer-related nonprofits, along with pharmaceutical firms and other businesses, have sponsored an international campaign to <a href="https://web.archive.org/web/20110716123431/http://www.nbcam.org/about_faq.cfm">observe October as “Breast Cancer Awareness Month</a>.” During these weeks, the public is bombarded with awareness and education messaging featuring the campaign’s symbol, a pink ribbon. </p>
<p>A wave of pink products typically appears, too, including clothing – think about <a href="https://greatnonprofits.org/org/save-the-ta-tas-foundation">the “Save the Ta-Tas” shirts</a> – as well as events like marches and walkathons. This onslaught has led some to term the <a href="https://www.fredhutch.org/en/news/center-news/2014/10/Pinktober-breast-cancer-awareness-month-patients.html">campaign “Pinktober</a>.” </p>
<p>These efforts often focus on encouraging women to get screened with mammograms to increase the possibility that the cancer will be detected early. Breast cancer patients are celebrated for “beating” cancer, “winning” the battle, having survived and being cured. But these messages overlook the experiences of millions of breast cancer patients. </p>
<p>I am a <a href="https://www.bsu.edu/academics/collegesanddepartments/sociology/about/faculty-staff/krausrachel">sociology professor</a> who specializes in studying gender as well as how having a serious illness affects identity. These themes also hit close to home for me: In 2009, I was diagnosed with metastatic breast cancer – also referred to as stage 4 on a scale from 0 to 4 – which means a cancer that has spread beyond the breasts to other parts of the body. Since that time, I have participated in face-to-face and online support groups, joined retreats and met myriad health professionals who specialize in oncology while also continuing my research. </p>
<p>In 2019, I began a nationwide study to examine the experiences of women with stage 4 breast cancer. The first of my papers on religion’s role in coping with metastatic breast cancer <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/jssr.12771">was recently published</a> in the Journal for the Scientific Study of Religion. I am now working on research that examines metastatic breast cancer and a range of spiritual experiences. </p>
<p>The seriousness of metastatic breast cancer, which is the only breast cancer that kills, is rarely discussed. This leaves people with this diagnosis feeling ignored and angry – and largely invisible to most of the organizations focused on breast cancer. </p>
<h2>A need for inclusion</h2>
<p>Breast cancer is <a href="https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html#">the second most common cancer in women</a> in the U.S. after skin cancer. <a href="https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html#">One in 8 American women</a> will be diagnosed with breast cancer at some point in her life. </p>
<p>Although <a href="https://doi.org/10.1007%2F978-3-030-20301-6_3">women of color</a> are less likely to get breast cancer, they are more likely to die from it. <a href="https://www.cancer.gov/types/breast/patient/male-breast-treatment-pdq">Male breast cancer</a> makes up less than 1% of all cases of breast cancer. </p>
<p>Nearly <a href="https://www.breastcancer.org/symptoms/types/recur_metast">30% of people with early stages breast cancer</a> will see their cancer metastasize to stage 4, which kills <a href="https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/breast-cancer-facts-and-figures-2017-2018.pdf">about 44,000 American women and men</a> each year. </p>
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<img alt="Georgia Bulldogs football team displays the slogan 'Save The Ta-Tas!' on their backs." src="https://images.theconversation.com/files/426994/original/file-20211018-13-bn7bpw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/426994/original/file-20211018-13-bn7bpw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=319&fit=crop&dpr=1 600w, https://images.theconversation.com/files/426994/original/file-20211018-13-bn7bpw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=319&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/426994/original/file-20211018-13-bn7bpw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=319&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/426994/original/file-20211018-13-bn7bpw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=401&fit=crop&dpr=1 754w, https://images.theconversation.com/files/426994/original/file-20211018-13-bn7bpw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=401&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/426994/original/file-20211018-13-bn7bpw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=401&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Breast Cancer Awareness Month events, like this display by Georgia Bulldogs football fans, often aim to encourage women to get mammograms, which can detect the disease in its early stages.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/georgia-bulldogs-fans-supper-breast-cancer-awareness-month-news-photo/184230633?adppopup=true">Kevin C. Cox/Getty Images Sport via Getty Images North America</a></span>
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</figure>
<p>To find participants with stage 4 breast cancer for my survey, in 2019 I sent out requests through online support groups, cancer organizations and societies, and word of mouth. Ultimately 310 women completed a questionnaire about their experiences with metastatic breast cancer, such as perceived support, feelings about breast cancer organizations and the pink ribbon, and ways of coping. </p>
<p>I selected 33 of those women to participate in in-depth interviews to provide additional information about some of their survey answers.</p>
<h2>Recognizing people with metastatic disease</h2>
<p>I’m a member of several metastatic breast cancer social media groups. For the purpose of this article, I asked people in these groups to share their thoughts about Breast Cancer Awareness Month and specifically the term “survivor.” Most people who responded aren’t overly excited about October: They don’t find terms like survivor and related language relevant. Nor do they feel the pink ribbon represents them. </p>
<p>Of the women who took my original survey, the majority – at least 70% – felt that pink-ribbon events tend to minimize the seriousness of metastatic breast cancer and tend to ignore stage 4 altogether. They also believe that pink-ribbon campaigns focus too much on breasts and selling products and services, <a href="https://www.bcaction.org/pink-ribbon-marketing-culture/what-is-pinkwashing">a practice known as “pinkwashing</a>.” </p>
<p>As one respondent in a social media group wrote, “I don’t like the term survivor. That and October are aimed at early stage cancer, not at supporting people who have Stage 4 cancer. We won’t survive. We aren’t going to be cured. Early detection didn’t save many of us. Removing boobs didn’t save us. All the pinkwashing does nothing to help us.” </p>
<p>Asking women to rate their preferences on a scale of 1 to 4, from “not at all” to “a great deal,” I found that far more metastatic people prefer “patient” and “a person who has cancer” over the term “survivor.”</p>
<p>On average, many participants also say there isn’t much recognition that those with metastatic disease have a different treatment plan. Often, stage 1 to 3 patients can look forward to a treatment end date after they finish radiation, surgery – mastectomy or lumpectomy – and what are called systemic therapies, such as chemotherapy. The vast majority of metastatic patients will be in treatment for the rest of their lives. </p>
<p>For stage 4 breast cancer, <a href="https://www.cochrane.org/CD011276/BREASTCA_breast-surgery-metastatic-breast-cancer">there is some debate</a> as to whether lumpectomy or mastectomy are effective options. The effectiveness of radiation treatment <a href="https://moffitt.org/cancers/metastatic-breast-cancer/radiation/#">is also debatable</a>. So metastatic patients more typically receive chemotherapy and – more recently – immunotherapy, with no surgery.</p>
<p>I also learned that many stage 4 breast cancer patients find it necessary to manage the diagnosis in ways that don’t apply to those with earlier stages. Metastatic patients must go into treatment simultaneously hoping the drugs will calm the cancer and confronting potential end-of-life issues. They may worry about leaving their families. Some may set milestones, such as seeing their children or grandchildren graduate from school or get married. </p>
<p>They may also be contending with issues like how many possible treatment options are left, or maximizing both quantity and quality of life amid a range of side effects. </p>
<h2>Overturning worn-out narratives</h2>
<p>I surveyed participants about the degree to which they feel excluded from breast cancer organizations, and why. They firmly indicated feeling a recognition gap among breast cancer organizations and awareness campaigns. So many seem to emphasize early detection and survivorship, and leave out the concerns and needs of metastatic patients.</p>
<p>One respondent talked about the “early detection mantra.” Another referred to the “ringing of the bell,” a common celebratory ritual when one is done with chemotherapy or radiation. I’ve been known to use the phrase “that damn bell” to express frustration that I will always be on treatment and won’t get to ring that bell. </p>
<p>People echoed these same sentiments when I posed my question in social media groups. One woman wrote, “I am not going to ever be a survivor. Feels like we are the under belly. … No ‘you got this.’ … There is no stage 4 fanfare.” </p>
<p>Many women with stage 4 breast cancer also feel like little is being done to showcase the less optimistic and more frightening aspects of metastatic disease. </p>
<p>Several organizations are starting to fill these gaps. Some are devoting themselves to funding research for breast cancer, while others are now paying more attention to stage 4 patients – or at least moving in that direction. <a href="https://www.metavivor.org/">Metavivor is one organization</a> focused exclusively on serving the metastatic breast cancer community. The Susan G. Komen organization has also begun offering resources and <a href="https://www.komen.org/breast-cancer/metastatic/">information about metastatic breast cancer</a>. </p>
<p>I see hopeful signs that some of these efforts are making a difference. Just the other day, I stopped by my cancer center’s gift shop to buy some mastectomy bras and saw that they were handing out pink-ribbon bracelets. So I asked the woman running the shop if they could get bracelets representing metastatic breast cancer. I was encouraged that – without hesitation – she said it shouldn’t be a problem. </p>
<p><em>This is an updated version of an article <a href="https://theconversation.com/breast-cancer-awareness-campaigns-can-do-a-better-job-supporting-women-whove-received-a-stage-4-diagnosis-instead-of-focusing-only-on-early-detection-and-beating-cancer-168628">originally published on Oct. 29, 2021</a>.</em></p><img src="https://counter.theconversation.com/content/190877/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel Kraus receives funding from the Society for the Scientific Study of Religion and the Louisville Institute. </span></em></p>October is awash in seas of pink T-shirts, balloons and ribbons in honor of Breast Cancer Awareness Month. But this messaging fails to recognize people who are not cured of the disease.Rachel Kraus, Professor of Sociology, Ball State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1475492020-10-14T14:20:12Z2020-10-14T14:20:12ZBreast cancer awareness is not enough: Public health strategies need to be based on prevention<figure><img src="https://images.theconversation.com/files/363282/original/file-20201013-19-1xb0rox.jpg?ixlib=rb-1.1.0&rect=15%2C127%2C5278%2C3028&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A Breast Cancer Awareness sign is seen before an NFL football game between the Washington Football Team and the Baltimore Ravens on Oct. 4, 2020, in Landover, Md. </span> <span class="attribution"><span class="source">(AP Photo/Susan Walsh)</span></span></figcaption></figure><p>I’m tired of <a href="https://www.cancer.ca/en/get-involved/support-us/breast-cancer-awareness-month/?region=on">Breast Cancer Awareness Month</a>. Forgive me, <a href="https://www.uwindsor.ca/dailynews/tags/jane-mcarthur">but as a researcher</a> studying how we understand information on links between environmental and occupational exposures and breast cancer, I’ve grown weary of yet another October decorated in pink, promoting the same message of awareness. The message itself has become tired, and awareness-raising alone is an ineffective solution to the breast cancer epidemic.</p>
<p>Year after year, we miss opportunities for critical interventions into the primary prevention of breast cancer. For my <a href="https://www.cbc.ca/news/canada/windsor/jane-mcarthur-breast-cancer-border-research-1.5622866">dissertation research on awareness of environmental breast cancer risks</a>, I interviewed women workers at the <a href="https://windsorstar.com/news/local-news/investigate-breast-cancer-cases-at-ambassador-bridge-says-customs-union-and-researcher">Ambassador Bridge</a>, where there are <a href="https://doi.org/10.1177/1048291118810900">high rates of breast cancer</a>. Larissa* pointed out:</p>
<blockquote>
<p>“I know it is out there. I know it happens. You see breast cancer awareness everywhere, but it’s pink. That’s what you see. You don’t see information on what we can do to prevent.”</p>
</blockquote>
<p><a href="https://gooselane.com/products/conspiracy-of-hope">Screening and early detection programmes are widely promoted</a>, <a href="https://www.ubcpress.ca/health-advocacy-inc">advocacy for treatments continues</a> and <a href="https://doi.org/10.1016/j.envres.2008.11.005">survival with breast cancer for some groups of women has improved</a>. These are crucial pieces for tackling breast cancers that develop. But <a href="https://www.researchgate.net/publication/291355785_Missing_in_Actions_The_Critical_Role_of_Environmental_and_Occupational_Exposures_in_the_Development_of_Breast_Cancer_in_Women">comparatively little effort seems to go into primary prevention</a>, which means stopping cancer before it starts. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1312053881766117376"}"></div></p>
<p>The focus persists on <a href="https://www.cancer.ca/en/prevention-and-screening/reduce-cancer-risk/make-healthy-choices/?region=on">advising women to exercise, eat well and limit alcohol intake</a>. Messaging about the need for policy, regulation, legislation, <a href="https://doi.org/10.1186/s12940-020-0570-7">strategies and programs that prioritize primary prevention from environmental exposures to breast carcinogens</a> are inconspicuous.</p>
<h2>Lifetime risk is 1 in 8</h2>
<p>I recognize that Breast Cancer Awareness Month provides an opportunity for contribution, engagement and hope. And I understand why women and their allies support these initiatives. It offers a chance to feel some power over a disease that creates so much fear and suffering.</p>
<p><a href="https://www.who.int/cancer/prevention/diagnosis-screening/breast-cancer/en/">Nearly 630,000 women across the globe died from breast cancer last year</a>. The overall <a href="https://doi.org/10.1016/S0140-6736(11)61351-2">global incidence of breast cancer continues to rise</a> with marginal improvements in five-year survival rates. North American women face a one in eight lifetime risk for breast cancer, with almost <a href="https://www.cancer.ca/en/cancer-information/cancer-type/breast/statistics/?region=on">525 new diagnoses of breast cancer each week in Canada</a>. Fourteen Canadian women die each day from breast cancer. Incidence is <a href="https://doi.org/10.1016/S2214-109X(20)30215-1">rising in younger women, specifically in premenopausal women</a>. </p>
<p><a href="https://silentspring.org/why-study-environmental-chemicals-and-breast-cancer">Only five to ten per cent of cases are related to genetics</a>, with family history, lifestyle and behaviour factoring into overall incidence. <a href="http://dx.doi.org/10.2304/pfie.2014.12.7.945">Fewer than 50 per cent of breast cancers</a> can be explained by known or suspected risk factors. <a href="https://doi.org/10.1080/09603123.2011.634386">Research suggests that environmental factors may contribute in 70 to 90 per cent of breast cancer cases</a>.</p>
<p>When I interviewed Annie, she said: </p>
<blockquote>
<p>“I am a big proponent of government taking care of us citizens. To me, that is what government is for. Regulation is important to me. I feel that that’s key.”</p>
</blockquote>
<p>With Annie’s words and <a href="https://www.academia.edu/37856227/INVESTIGATING_WOMENS_NARRATIVES_OF_BREAST_CANCER_RISKS_Exploring_Environmental_Health_Literacy_In_A_Population_At_Risk">those of other women in mind</a>, I recently wrote to governmental leaders, ministries, public health agencies and the Canadian Cancer Society. I conveyed my concerns about the focus on awareness that highlights lifestyle factors and omits exposures in our living and working environments. I suggested we need more action on primary prevention to limit or eliminate exposures to known and suspected breast carcinogens.</p>
<p>My letter also reflected Erin’s thoughts: </p>
<blockquote>
<p>“I think that ensuring that people have the knowledge of what is really going on is a big issue. And then, with the knowledge, change policy or the way that things are being done, so that people are not at risk.”</p>
</blockquote>
<h2>Primary prevention</h2>
<p>To implement practical primary prevention activities, we need to draw on the science of the associations between breast cancer and risky exposures in our social environments. For example, <a href="https://search.proquest.com/openview/e521e94693664ad6cc7f57bdca7bedef/1?pq-origsite=gscholar&cbl=2034827">when we know women are being exposed to identified breast carcinogens in their workplaces</a>, why are we not reducing or eliminating these exposures to prevent breast cancer? </p>
<p>When we know that there are <a href="https://doi.org/10.1016/j.envres.2017.08.045">endocrine-disrupting chemicals</a> in personal care products, and these are associated with an elevated risk for breast cancer, why are we not eliminating or replacing these substances? </p>
<p>When science tells us that women in areas with high volumes of air pollution, especially vehicle exhaust, are at a <a href="https://doi.org/10.5271/sjweh.3923">higher risk of developing premenopausal breast cancer</a>, why are we not putting controls on pollutants or developing alternatives? </p>
<p>When we know there are disparities in breast cancer incidence and survival across groups of racialized women, why are we ignoring <a href="https://dx.doi.org/10.1016%2Fj.jadohealth.2013.02.016">social determinants of health</a> in our strategies to mitigate risk and to prevent the disease?</p>
<p>Science provides the <a href="https://dx.doi.org/10.1186%2Fs12940-017-0287-4">evidence of exogenous exposures that contribute to the development of breast cancer</a>. Many of these exposures are outside of the control of individual women; they are involuntary exposures not modifiable with lifestyle or behavioural changes. Instead, systemic changes — regulations, legislation, policies — with the protection of the public is fundamental to <a href="https://deainfo.nci.nih.gov/advisory/pcp/annualReports/pcp08-09rpt/PCP_Report_08-09_508.pdf">prevention</a>. We need the political will and those with power to enact these critical changes.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1303525608446599168"}"></div></p>
<p>Pink products and awareness-raising are not enough. At this time, when COVID-19, climate change and political turmoil dominate our thoughts, it is tiring even to begin to think of adding yet another struggle to the list. But to effect real change against the breast cancer epidemic, we need more powerful, structural strategies that prevent exposures to known and suspected breast carcinogens in the places we live and work.</p>
<p>*<em>Pseudonyms are used to protect the identities of study participants</em>.</p><img src="https://counter.theconversation.com/content/147549/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane E. McArthur received funding through SSHRC Doctoral Fellowship, SWS Barbara Rosenblum Dissertation Scholarship, and Gail Rosenblum Breast Cancer Memorial Scholarship for her doctoral dissertation.</span></em></p>Awareness-raising alone is an ineffective solution to the breast cancer epidemic. We need more action on primary prevention to limit exposures to known and suspected breast carcinogens.Jane E. McArthur, Doctoral Candidate, Sociology-Social Justice, University of WindsorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1048732018-10-19T10:38:17Z2018-10-19T10:38:17ZStop marginalising men with breast cancer<figure><img src="https://images.theconversation.com/files/241006/original/file-20181017-41153-rleq71.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/male-breast-cancer-269166263?src=Awfnn_kkrnqpechJr1N_Bw-1-0">Hidesy/Shutterstock.com</a></span></figcaption></figure><p>Breast cancer is the most common cancer in the <a href="https://breastcancernow.org/about-breast-cancer/want-to-know-about-breast-cancer">UK</a> and the leading cancer <a href="http://www.who.int/cancer/detection/breastcancer/en/index1.html">in women worldwide</a>. Approximately 150 cases are diagnosed in the UK every day – that’s one every <a href="https://www.breastcancercare.org.uk/about-us/media/facts-statistics">10 minutes</a>. Breast cancer does not discriminate. The illness is undeterred by age, ethnicity, socioeconomic status, sexuality, or even sex. Yes, men get breast cancer, too – although you wouldn’t necessarily think so from much of the breast cancer awareness material around.</p>
<p>Incidence among men is low: there are approximately 390 new cases in UK men presenting each year compared to around <a href="https://www.cancerresearchuk.org/about-cancer/breast-cancer/about">54,800 women</a>. Consequently, breast cancer in men is <a href="https://www.ncbi.nlm.nih.gov/pubmed/16377181">consistently overlooked</a> within both lay and expert health and care systems. This is despite the fact that breast cancer is responsible for proportionally more male deaths annually than some men’s cancers, including penile and testicular forms – <a href="https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/breast-cancer/mortality#heading-Zero">22% of men</a> diagnosed with breast cancer die, compared to 21% of those with penile and 2.5% of those with testicular.</p>
<p>Prognosis for men is similar to that for women, yet outcomes among male patients are typically poorer due to reduced illness awareness and late disease detection. Five-year survival rates vary depending on the stage of the disease at diagnosis, but they are <a href="https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/breast-cancer/survival#heading-Zero">generally poorer for men than women</a>.</p>
<h2>Fe/male breast cancer</h2>
<p>Clinical diagnosis of and methods used to treat breast cancer are currently the same for men and women, as it is assumed that the sexes share some anatomical and oncological similarities. But unlike research with women, large scale studies are comparatively scarce due to the relative rarity of breast cancer in men, and to date, there are <a href="https://www.croh-online.com/article/S1040-8428(16)30041-5/fulltext">no randomised control trials with men</a> published.</p>
<p>The management of male patients and recommendations for treatment are therefore based largely on female data, despite little evidence validating the effectiveness of treatment options used with women in men. Further, recent research claims that breast cancer in men is not wholly the same, biomedically, as the disease in women. In 2016, researchers at Guy’s Hospital London <a href="https://www.croh-online.com/article/S1040-8428(16)30041-5/fulltext">reported key differences</a> in epidemiological risk factors, tumour types, molecular profiling and responses to treatments. </p>
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<p>Such findings pose important implications for treating breast cancer in men and illustrate why the illness warrants greater research attention. If the methods used to treat men are inadequate it could have grave consequences for them, even death. But this could be avoided with appropriate interventions.</p>
<h2>Male marginalisation</h2>
<p>But the more insidious effects of this gender imbalance occur socially. Because although breast cancer is not a sex-specific cancer, it is <a href="https://thepsychologist.bps.org.uk/volume-27/edition-6/psychology-men-and-cancer">consistently gendered</a> as a “women’s illness”. High-profile awareness-raising advocacy and activism around breast cancer in women has, over time, led to a reinforced misconception that it only affects women. </p>
<p>The explicit gendering of breast cancer <a href="https://www.sciencedirect.com/science/article/pii/S0277953615302409">serves as a barrier</a> to men. It deters them from seeking prompt professional care and social support, and increases body image concerns. Men are rarely visible and scarcely discussed within breast cancer-focused communications – and even when the illness receives attention in <a href="https://www.bbc.co.uk/sport/football/45489993">male-dominated arenas</a>, it is typically feminised. Many English Football and Premier League teams, for example, host breast cancer awareness fixtures, where the home team plays in a pink strip and <a href="https://www.liverpoolecho.co.uk/sport/football/football-news/everton-raise-awareness-breast-cancer-13793774">supporters are encouraged</a> (through the use of flyers and half-time talks) to help women to spot signs and symptoms sooner. The risk to men is seldom mentioned at such events.</p>
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<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/26689631">Evidence</a> suggests many survivors of breast cancer, men included, struggle to identify with the non-inclusive nature of “<a href="http://pinkribbonblues.org/">pink ribbon culture</a>”. Related movements – such as “<a href="https://raceforlife.cancerresearchuk.org/">Race for Life</a>”, an annual charitable event, in which men are excluded from participating – foster marginalisation and disempowerment of those, like men, who are <a href="https://link.springer.com/article/10.1023%2FA%3A1009553613564">at the breast cancer periphery</a>. This affects their psychological response to the illness.</p>
<p>Men with breast cancer consistently report <a href="https://www.researchgate.net/publication/327675078_Men_With_a_Woman's_Disease_Stigmatization_of_Male_Breast_Cancer_Patients-A_Mixed_Methods_Analysis">feeling marginalised</a>, most commonly within cancer care systems, and by female patients and survivors. They often find themselves on the fringe of optimal care and support, causing them to feel alienated and emasculated.</p>
<h2>Next steps</h2>
<p>In the last few years, as part of <a href="https://www.dora.dmu.ac.uk/handle/2086/16683">my PhD research</a>, I have interviewed men from across the UK living with, and beyond, a breast cancer diagnosis. My aim is to gain understanding about how men make sense of breast cancer and masculinity, and how this influences their adjustment to the illness.</p>
<p>I have found that the conceptualisation of breast cancer as feminine opposes dominant ideas of <a href="https://thepsychologist.bps.org.uk/volume-27/edition-6/tapestry-oppression">what it means to be a man</a>. This threatens the identities of, and has complex ramifications for, affected men. The marginalisation of men with breast cancer poses additional difficulties for them to contend with beyond the primary cancer challenge. It undeniably influences <a href="https://www.dora.dmu.ac.uk/handle/2086/16683">their sense of self</a>, affecting how they think and behave as men, and as sexual and social beings, during and beyond the illness episode.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/241031/original/file-20181017-41144-114yhjj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241031/original/file-20181017-41144-114yhjj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241031/original/file-20181017-41144-114yhjj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241031/original/file-20181017-41144-114yhjj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241031/original/file-20181017-41144-114yhjj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241031/original/file-20181017-41144-114yhjj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241031/original/file-20181017-41144-114yhjj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Breast cancer in men is so marginalised it is often conceived as make-believe, and patient-survivors feel like they don’t exist: pink unicorns.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pinc-unicorn-619538282?src=xaKAi5ZpbzmAcpg-1kWp1A-2-11">Iryna Reshetyuk/Shutterstock.com</a></span>
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<p>October is breast cancer awareness month, when those affected by breast cancer – directly or indirectly – supposedly unite to raise public consciousness of the serious health threat and to promote breast health. Men – who are arguably the least risk-aware – remain underrepresented, ill-informed and sidelined by current approaches. Greater breast cancer equality is clearly needed. </p>
<p>Several things could be done to improve equality and men’s breast cancer experiences. Clinical settings should be redressed to appear more gender and culturally neutral. This may help to foster greater patient inclusivity. Linked to this, increasing the visibility of men in patient resources, visual displays in clinical waiting areas and at dedicated events would help improve men’s sense of identity and belonging. Shared patient resources should be developed which clearly signpost male-specific needs and concerns (separate literature could unintentionally isolate men further).</p>
<p>Men’s needs and experiences should be made more visible in clinical and support staffs’ training materials in order to improve knowledge and understanding of breast cancer in men, and staff-patient interactions. Ensuring that men have a voice and opportunities to be heard is key. Men should be encouraged to take part in clinical studies and to engage more with support services. Excluding men from participating in cancer awareness events is not advisable. If a holistic rethinking of breast cancer is to emerge, the inequities facing affected men need to be confronted.</p><img src="https://counter.theconversation.com/content/104873/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kerry Quincey does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Men, who are arguably the least risk-aware when it comes to breast cancer, are largely overlooked in awareness material, and remain ill-informed.Kerry Quincey, Lecturer in Psychology, De Montfort UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1037172018-10-17T10:26:17Z2018-10-17T10:26:17ZWe tested women and men for breast cancer genes – only 18 percent knew they had it<figure><img src="https://images.theconversation.com/files/237541/original/file-20180921-129847-e23c75.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are now hundreds of genetic tests that claim to predict the risk of various diseases. All that's needed is a few drops of blood.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/molecule-dna-forming-inside-test-tube-793257808?src=c94fVb_vY4knb-OwBoNing-1-0">Connect world/Shutterstock.com</a></span></figcaption></figure><p>There are diseases and health conditions that are essentially invisible to us until it is too late. </p>
<p>When those problems are life-threatening, such as cancer, and if there is a period when something could be done, then those are instances where an effective screening strategy could prevent illness and save lives. </p>
<p>Once an individual tests positive for one of the “breast cancer” genes, called <em>BRCA1</em> and <em>BRCA2</em>, then screening – mammograms and MRI – and prevention – surgery and medicines – can be used to reduce risk of disease and improve outcomes. In this case the risk is not just for breast cancer; these genes also raise the risk for ovarian, prostate and pancreatic cancer. </p>
<p>Perhaps just as important as the actions to encourage screening and prevention in the person who gets the news, is the opportunity to alert family members. Parents, siblings and adult children all have a 50-50 risk for the carrying the same gene change and might benefit from knowing of the positive screening results. That’s because when one family member tests positive all close relatives should also consider testing. With <em>BRCA1</em> and <em>BRCA2</em> women have higher personal cancer risk, but all have increased cancer risks. </p>
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<a href="https://images.theconversation.com/files/239782/original/file-20181008-72121-5jy3lz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/239782/original/file-20181008-72121-5jy3lz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/239782/original/file-20181008-72121-5jy3lz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=456&fit=crop&dpr=1 600w, https://images.theconversation.com/files/239782/original/file-20181008-72121-5jy3lz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=456&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/239782/original/file-20181008-72121-5jy3lz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=456&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/239782/original/file-20181008-72121-5jy3lz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=572&fit=crop&dpr=1 754w, https://images.theconversation.com/files/239782/original/file-20181008-72121-5jy3lz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=572&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/239782/original/file-20181008-72121-5jy3lz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=572&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A mammogram is an x-ray that allows a qualified specialist to examine the breast tissue for any suspicious areas.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/selective-focus-thoughtful-female-doctor-looking-485474053?src=W10m-l-E-E4zFcexah07tQ-1-52">Chompoo Suriyo/Shutterstock.com</a></span>
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<p><a href="https://medicine.yale.edu/genetics/people/michael_murray.profile">I</a> helped lead <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2703131">a recent study</a> of 50,000 people in Pennsylvania whose DNA had been collected and tested for disease-causing versions of the breast cancer genes <em>BRCA1/2</em>. We discovered that some 267 people carried such genes. But what surprised us was that only 18 percent of these people were already aware of this. </p>
<p>This study highlights the fact that our current approaches to finding individuals with the cancer risk associated with <em>BRCA1</em> and <em>BRCA2</em> miss the majority of individuals who carry those genes, and further research into the use of DNA-based screening is needed if we are to address the missed opportunities to intervene. </p>
<h2>The value of genetic testing</h2>
<p>There are lots of ways to screen. As part of standard primary care, physicians check blood pressure and recommend carrying out colonoscopies on nearly everyone over 50 years old. High blood pressure is invisible, but if not addressed can lead to increased strokes and heart attacks. Polyps in the colon are not visible without a colonoscopy or similar study, and if not removed early some will progress to colon cancer. </p>
<p>In 2013 I left Harvard Medical School to join Geisinger Health System in Pennsylvania, where we saw a unique opportunity to explore ways to use genetic testing in standard primary care to improve the health of the average person. In early 2014, <a href="https://www.nytimes.com/2014/01/13/business/aiming-to-push-genomics-forward-in-new-study.html">Geisinger announced a research collaboration with Regeneron Pharmaceuticals</a> to work together on discovering disease-causing genes and new targets for drug therapies. This project relied on tens of thousands of patient volunteers choosing to link their electronic health records to their DNA code for research. This allowed researchers to carefully study the combined DNA code and health care records to identify harmful genetic changes that raised the risk of particular disorders, and as well as protective genetic changes that lowered them.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/239783/original/file-20181008-133328-16komds.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/239783/original/file-20181008-133328-16komds.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/239783/original/file-20181008-133328-16komds.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/239783/original/file-20181008-133328-16komds.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/239783/original/file-20181008-133328-16komds.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/239783/original/file-20181008-133328-16komds.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/239783/original/file-20181008-133328-16komds.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The <em>BRCA</em> gene test is a blood test that uses analysis of DNA to identify harmful mutations in either one of the two breast cancer susceptibility genes – <em>BRCA1</em> and <em>BRCA2.</em></span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/dna-sample-129794300?src=bau00YMcsxibV7MlOIgvdw-1-30">damerau / Shutterstock/com</a></span>
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<p>Among the Geisinger leadership team, a group of us recognized the opportunity to give something back to these volunteers by using <a href="http://doi.org/10.1126/science.358.6362.436">DNA code as the basis for a screening program</a>. The screening was designed to identify genetic variations in the volunteer’s DNA that might increase their risk of disease and that health care providers could do something about, and then deliver a report to the patient and their physician. In May of 2015 we delivered our first result, and <a href="http://doi.org/10.1016/j.ajhg.2018.07.009">there is now a well-structured system</a> set up to deliver care based on this kind of result to thousands of Geisinger patients who volunteered for the project. Now at Yale, I co-authored the recent paper that reported results from one of the most important projects from my time at Geisinger and is a template for some the work we will do here in Connecticut. </p>
<p>Over the last 20 years, screening strategies to identify risk related to disease-associated changes in the breast cancer genes <em>BRCA1</em> and <em>BRCA2</em> have been developed. Those strategies have focused on the predictive value of family history of cancer. </p>
<p>A lot of careful research has proven that a strong family history of cancer greatly increases the likelihood of a related person having disease causing variations in one of their genes, and the <a href="https://www.nytimes.com/2013/05/14/opinion/my-medical-choice.html?mtrref=www.google.com&gwh=EB80754AD24C87AB000280FBB4B272EB&gwt=pay&assetType=opinion">brave public stories</a> of affected people has helped us all to appreciate that connection. </p>
<p>We also know that family histories don’t always get discussed in enough detail to alert someone that they need to get tested. Then there are those who have DNA changes that increase their risk of disease but are unaware because they fortunately don’t have the family history.</p>
<h2>New findings with <em>BRCA1/BRCA2</em> screening</h2>
<p><a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2703131">Our study</a> showed that of 50,000 people in Pennsylvania whose DNA had been tested as part of the <a href="https://www.geisinger.org/mycode">MyCode project</a> for <em>BRCA1/2</em> genes, 267 people carried such genes but only 18 percent were already aware of this. The other 82 percent were learning it for the first time through the DNA-based screening strategy that we applied. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/239785/original/file-20181008-72110-aofk3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/239785/original/file-20181008-72110-aofk3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/239785/original/file-20181008-72110-aofk3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=855&fit=crop&dpr=1 600w, https://images.theconversation.com/files/239785/original/file-20181008-72110-aofk3z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=855&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/239785/original/file-20181008-72110-aofk3z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=855&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/239785/original/file-20181008-72110-aofk3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1074&fit=crop&dpr=1 754w, https://images.theconversation.com/files/239785/original/file-20181008-72110-aofk3z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1074&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/239785/original/file-20181008-72110-aofk3z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1074&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Breast cancer survivor Alicia Cook holds a letter from the University of Chicago informing her that test results showed she had the <em>BRCA</em> genetic defect linked to breast cancer.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Breast-Cancer-Genes/515728a3630c46448886511e49be9ea8/2/0">AP Photo/M. Spencer Green</a></span>
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</figure>
<p>It’s important to note that not all of these 267 individuals will develop cancer. However, among the volunteers who had died prior to the completion of the study, almost half had developed a <em>BRCA</em>-associated cancer. </p>
<p>In contrast, far fewer of those alive at the end of the study had developed a <em>BRCA1-</em> or <em>BRCA2</em>-associated cancer, suggesting that we have opportunities to intervene with those we have identified.</p>
<p>Early warning provides the chance to apply proven cancer prevention and early detection strategies for those who are now aware of their risk. While long-term follow-up is needed to document how successful this is, <a href="https://doi.org/10.1038/gim.2017.145">we have already detected a number of early cancers</a> that we hope will result in better outcomes for those individuals. </p>
<p>In the decades ahead, medical researchers will work out the details of using DNA-based screening to understand risk, not only for cancer, but for all kinds of health risks. <a href="http://doi.org/10.7326/M18-1722">That information</a> can be used to improve people’s lives by prevention of cancer, heart disease and other diseases. Although we are in the early days still, there are several prominent organizations, including the <a href="http://www.nationalacademies.org/hmd/Activities/Research/GenomicBasedResearch/Innovation-Collaboratives/Genomics-and-Population-Health.aspx">U.S National Academy of Medicine</a>, which are gathering expert groups figure out what it will take to apply what we know now to DNA-based screening programs for large groups of people, perhaps even the entire U.S. population some day. </p>
<p>Large demonstration projects are needed to get a clearer picture of what works best. We need to determine what is the ideal age to do the screening, which set of genes to screen, what are the costs of such large programs and what are the long-term risks and benefits. </p>
<p>Ultimately however, there should be little doubt that preventive health care management in the decades ahead will routinely use DNA-based screening to detect otherwise invisible risks that can be addressed to improve individual and populations health.</p><img src="https://counter.theconversation.com/content/103717/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Murray received funding from Regeneron, InVitae, and Merck in the past. </span></em></p>Individuals who carry the breast cancer genes BRCA1 or BRCA2 are often unaware of the fact. That suggests that physicians need a new way to apply DNA-based screens to identify those at risk.Michael Murray, Professor of Genetics and Director for Clinical Operations in the Center for Genomic Health, Yale UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1024612018-10-09T10:43:06Z2018-10-09T10:43:06ZBreast cancer survivors, who lose muscle mass, can benefit from strength training, studies suggest<figure><img src="https://images.theconversation.com/files/239515/original/file-20181005-72106-10zlw1c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Breast cancer is more survivable than ever. Strength training is a key to helping women survive well. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/breast-cancer-awareness-message-against-fitness-327055655?src=tORRiFA42mOSnL_xJifiiA-1-18">wavebreakmedia/Shutterstock.com </a></span></figcaption></figure><p>Breast cancer research has resulted in treatment that has greatly improved survival rates. As a result, there are <a href="https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-treatment-and-survivorship-facts-and-figures/cancer-treatment-and-survivorship-facts-and-figures-2014-2015.pdf">3.1 million breast cancer survivors</a> alive in the United States today. The <a href="https://www.cancer.net/cancer-types/breast-cancer/statistics/2015">five-year survival rate</a> is about 90 percent. This is great news.</p>
<p>But, survivors are still left to struggle with many <a href="https://www.hopkinsmedicine.org/kimmel_cancer_center/centers/breast_cancer_program/treatment_and_services/survivorship/side_effects.html">adverse side effects</a> from the disease and cancer treatments, which include surgery, radiation, chemotherapy and hormonal suppression drugs that are used to suppress hormones that may have fueled the breast cancer.</p>
<p>Particularly worrisome side effects are accelerated losses in bone mineral density and muscle mass – with gains in fat mass. These changes can lead to <a href="https://www.webmd.com/breast-cancer/breast-cancer-and-osteoporosis#1">osteoporosis and fractures</a>, as well as lower strength, decreases in physical function, and becoming overweight and obese, which can lead to <a href="https://journals.lww.com/co-clinicalnutrition/Abstract/2011/05000/Two_faces_of_drug_therapy_in_cancer__drug_related.7.aspx">poorer survival rates</a>. </p>
<p>These side effects can ultimately reduce overall quality of life and increase the risk for chronic disease and disability in breast cancer survivors.</p>
<p>Over the last 10 years, our laboratory has been evaluating the effects of exercise interventions, specifically resistance-type exercise on muscle mass, fat mass, bone mineral density, strength, physical function and quality of life in breast cancer survivors. </p>
<h2>Survivors, already tough, get tougher and stronger</h2>
<p>One of our first studies found that breast cancer survivors had lower <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4939569/">strength, upper-body bone mineral density and physical function</a> compared to women matched for age and weight who had not had cancer. Many of the breast cancer survivors had limited their activity after breast surgery, especially in the upper body, and were never advised to increase upper-body strength after the surgery site or sites had healed. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/239516/original/file-20181005-72110-1hkr5t0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/239516/original/file-20181005-72110-1hkr5t0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/239516/original/file-20181005-72110-1hkr5t0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/239516/original/file-20181005-72110-1hkr5t0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/239516/original/file-20181005-72110-1hkr5t0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/239516/original/file-20181005-72110-1hkr5t0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/239516/original/file-20181005-72110-1hkr5t0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A woman works with one of the researchers to increase strength. Such exercises have been shown to help women who have lost muscle mass and strength due to breast cancer treatment.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-woman-workout-rehabilitation-center-personal-643134019?src=l4TBgpeF89L1wlcsG4rhWA-1-37">Liderina/Shutterstock.com</a></span>
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<p>In our three-month and six-month intervention studies using resistance machines for both the upper body and lower body, we found about a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4939569/">25 percent improvement</a> in both upper and lower body strength. Physical function and quality of life also improved, with no adverse effects on <a href="https://www.mayoclinic.org/diseases-conditions/lymphedema/symptoms-causes/syc-20374682">lymphedema</a>, or swelling that can occur from damage to the lymph nodes, with either the low- or high-intensity <a href="https://link.springer.com/article/10.1007%2Fs00520-016-3374-0">resistance training</a>. Even the women who participated in high-intensity resistance training tolerated it well and experienced the added benefit of increasing muscle mass in both the upper and lower body after the three months of training. </p>
<p>In these two studies, women performed three or six months of resistance training on two nonconsecutive days each week. In the studies, the participants performed two or three sets of eight to 12 repetitions of each exercise. The exercises included chest press, biceps curl, triceps press down, overhead press, seated row, leg press, leg extension, leg curls, abdominal crunches and lower back hyperextensions. The amount of weight was increased as the women were able to achieve 10 to 12 repetitions on all sets. </p>
<p>Although we did not find increases in bone mineral density in our six-month training study, the women did not experience any decreases in these measures over the training period. <a href="http://depts.washington.edu/osteoed/faqs.php?faqID=34">Bone mineral density</a> has been shown to decrease by 1 to 2 percent each year after menopause, and the losses may be higher in the first few years of menopause in healthy women. Therefore, being able to maintain bone mineral density in breast cancer survivors is a positive outcome, especially in the upper body, which is more susceptible to losses due to cancer treatment and disuse.</p>
<p>There are a limited number of studies that have evaluated resistance training on bone mineral density in survivors. Of those studies, only <a href="http://dx.doi.org/10.1080/23809000.2016.1191318">maintenance in bone mineral density</a> has been found. </p>
<p>In studies with healthy premenopausal women, women have been able to achieve an increase in bone mineral density with resistance training. The benefits are best when resistance training is combined with high-impact activities, such as jumping, hopping and plyometrics. Plyometrics are exercises that require one to jump down and jump up in one continuous movement. It involves repeated rapid stretching and contracting of the muscles.</p>
<p>In postmenopausal women and in some breast cancer survivors, most increases in bone mineral density are seen when <a href="http://dx.doi.org/10.1080/23809000.2016.1191318">resistance training is combined</a> with medications that help to build bone. </p>
<h2>More benefits on horizon with greater choices of exercise</h2>
<p>In our third intervention study, we incorporated high-impact exercises that provided a variety of different loading patterns, since unusual loading patterns have been found to be more beneficial for improving bone mineral density than exercises that provide <a href="http://www.homepages.ucl.ac.uk/%7Eucgatma/Anat3048/PAPERS%20etc/Ehrlich%20Lanyon.pdf">consistent strain</a>, like that of resistance training.</p>
<p>This study incorporated a six-month circuit of functional resistance training exercises that combined different high-impact exercises to provide women with unusual loading patterns. Exercises included lunges, squats, jumping jacks, burpees, push-ups, dumbell rows, mountain climbers, step-ups, biceps curls, triceps extensions, running in place, high knee lifts and planks. The women progressed to more high-impact versions of these exercises through the six months. The exercise sessions lasted 45 minutes and were completed twice a week. </p>
<p>In this intervention, we used a group exercise format, as many breast cancer survivors report that they prefer to exercise with one other person or in a group setting compared to <a href="https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1523-5394.2002.104003.x">exercising alone</a>. </p>
<p>We compared this functional impact training program to a program of <a href="https://www.yogajournal.com/yoga-101/types-of-yoga/yin">yin yoga</a>, or a slower-paced yoga in which postures are held for longer periods, that consisted of non-weight-bearing stretching and relaxation postures. We again evaluated the effects on body composition, bone mineral density, strength, physical function and quality of life over the six-month period. </p>
<p>We are currently analyzing the data for this project, but so far, the results look promising. Both the functional impact training and the yin yoga were effective in improving lower-body strength, physical function and quality of life. The functional impact training had the added benefit of improving upper-body strength, which is very important in the breast cancer population. Unfortunately, the functional impact training program was not effective in improving body composition or bone mineral density.</p>
<p>These findings along with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1482759/">previous research</a> highlight how important it is for health care providers to make sure that their patients get involved with some type of exercise that can improve body composition, strength, physical function and ultimately quality of life. There are a number of exercises and programs available for women to choose from. For women who may want to start off with yoga and then progress to more moderate to vigorous activity as they feel better, our studies provide evidence that benefits can be obtained safely from yin yoga and low intensity resistance training. </p>
<p>The studies also suggest that women can achieve greater benefits with higher-intensity resistance training and high-intensity functional training that incorporates intervals of strength and aerobic exercises.</p><img src="https://counter.theconversation.com/content/102461/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lynn Panton's doctoral student Ashley Artese received funding from the American College of Sports Medicine and the National Strength and Conditioning Association for her dissertation work with breast cancer survivors. </span></em></p><p class="fine-print"><em><span>Ashley Artese received funding from The American College of Sports Medicine and the National Strength Conditioning Association for her dissertation.</span></em></p>Breast cancer, once a death sentence, now has a survival rate of more than 90 percent. This means that millions of women suffer effects of treatment. Recent research shows ways to overcome them.Lynn Panton, Professor, Exercise Sciences, Florida State UniversityAshley Artese, Assistant Professor, exercise science and physiology, Roanoke CollegeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/865842017-11-01T10:16:51Z2017-11-01T10:16:51ZBeyond October: Things to be aware of all year about breast cancer<figure><img src="https://images.theconversation.com/files/192489/original/file-20171030-18720-fe35qf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Inflammatory breast cancer, a pernicious form of the disease. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/inflammatory-breast-carcinoma-cancer-pathology-which-554909224?src=NxZyJE2I4Ca7HwemRcm-DA-1-55">David Litman/Shutterstock.com</a></span></figcaption></figure><p>Almost all of us have a friend or relative who has battled breast cancer, and that is in large part because the disease is so common. One in eight women has a <a href="https://www.cancer.gov/types/breast/risk-fact-sheet">lifetime risk</a> of being diagnosed with the disease. Breast cancer causes about <a href="https://www.cancer.gov/types/breast/risk-fact-sheet">15 percent of cancer-related deaths</a> in the United States, making it the second-largest cancer killer of women in the U.S., <a href="https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2017/estimated-number-of-new-cancer-cases-and-deaths-by-sex-us-2017.pdf">second to lung cancer</a>.</p>
<p>And so, we walk, we run and we donate in October. But beyond the nearly ubiquitous pink that surrounds us in October, there is a lot more going on microscopically with this disease. When we speak of breast cancer, we are actually talking about dozens of different diseases. Many of these have in common only that they originated in the breast, when in fact, on a cellular level, some might have more in common with a cancer in another part of the body, such as ovarian cancer.</p>
<p>Even though breast cancer awareness month is now over, we believe as cellular biologists who study breast cancer that it is important for people to be aware of the disease year-round. About 250,000 women – and 2,500 men – were estimated to be diagnosed with the disease in 2017.</p>
<p>Some women’s fights will be tougher than others. Many thousands will go on to never face the disease again.</p>
<h2>More than one disease, more than one treatment</h2>
<p>Breast cancer is an umbrella term for different types of malignant tumors that arise in the breast. Each tumor may have its own distinct tissue structure, genetics and prognosis. Therefore, researchers aren’t looking for a “silver bullet” that will cure all breast cancers.</p>
<p>Rather, researchers search for ways to identify the specific type of tumor a patient has and to tailor treatments to that diagnosis. To do so, a better understanding of the complexity of breast cancer based on genetic makeup of a particular person’s disease is required.
Tumors from different patients differ from each other in pathological features and molecular signature. This is called <a href="http://www.nature.com/articles/nm.3915">intertumor heterogeneity</a>.</p>
<p>Broadly, breast cancer is divided in two categories based on how the tumor looks under the microscope. This includes the tissue type and the involvement of surrounding cells. Based on whether the cancer is found, breast cancer is classified initially either as <a href="https://www.cancer.gov/publications/dictionaries/cancer-terms?cdrid=44394">ductal carcinoma in situ</a>, commonly called DCIS among doctors and patients who have been diagnosed with this form, or <a href="https://www.cancer.gov/types/breast">invasive breast cancer</a>, which means the cancer has spread from the ducts to breast tissue itself.</p>
<p>DCIS is a pre-malignant and pre-invasive form of breast cancer that is confined in the milk ducts or is found in the lining of milk ducts. DCIS has significant potential of progressing into invasive breast cancer. At this time, however, doctors and researchers do not yet have a way to tell which DCIS cancers might progress into invasive cancers and those that will not.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/192740/original/file-20171031-18686-rcjtgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/192740/original/file-20171031-18686-rcjtgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/192740/original/file-20171031-18686-rcjtgm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/192740/original/file-20171031-18686-rcjtgm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/192740/original/file-20171031-18686-rcjtgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/192740/original/file-20171031-18686-rcjtgm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/192740/original/file-20171031-18686-rcjtgm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Breast cancer doctors cannot know for certain whether DCIS will become aggressive.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/healthcare-medicine-breast-cancer-concept-325908098?src=Gzw3GTxFqoWSdc2W6KP9Iw-1-99">Guschenkova/Shutterstock.com</a></span>
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</figure>
<p>To treat DCIS, doctors typically use lumpectomies, in which the tumor itself and a small amount of tissue surrounding it are surgically removed; or mastectomies, in which the entire breast is surgically removed, to treat the DCIS tumors.</p>
<p>But, a single tumor can have features of the ductal type and invasive type.</p>
<h2>Molecular differences abound</h2>
<p>Researchers have discovered that breast cancer has at least four different molecular subtypes. As a result, pathologists today will perform a biopsy of breast cancer cells soon after a woman is diagnosed. The cancer then is classified into four subtypes by whether certain kinds of receptors that fuel growth are present on the surface of the breast cancer cells.</p>
<p>Growth of certain breast tumors is fueled by estrogen. These are called estrogen receptor-positive (or ER-positive) breast cancers. </p>
<p>Others are fueled by the hormone progesterone. These are called progesterone receptor-positive (or PR-positive). </p>
<p>Some can be both ER/PR-positive, and are also known as luminal tumors. </p>
<p>Others can be negative for both estrogen and progesterone but positive for a hormone called human epidermal growth factor receptor 2 (HER2). These are called HER2-positive breast cancers.</p>
<p>Highly effective targeted treatments are now available for breast cancers that test positive for either ER/PR and HER2. This has tremendously improved their disease outcomes.</p>
<h2>When testing negative is bad</h2>
<p>Among all the molecular subtypes, a disease called triple negative breast cancer is one of the most aggressive subtypes of breast cancer.</p>
<p>They are set apart because they have none of the three receptors that doctors test for in breast tumors – hence the term, “triple negative.” That’s also what makes them hard to treat – because they have no receptors, they have no molecules for the conventional treatments to target.</p>
<p>These cancers are more aggressive, more likely to spread to other parts of the body and more likely to be fatal. They are also two to three times more common in women of African descent than in women of European descent.</p>
<h2>Tumors can be complicated</h2>
<p>We and many others are working to come up with better treatments for triple negative breast cancer and to improve outcomes for those with other breast cancer subtypes. We are learning different parts of the tumor of an individual patient can be different in terms of their inherent characteristics, behavior and response to treatments. This is where things become complicated.</p>
<p>In fact, even a single breast tumor can contain multiple kinds of cancer cells, and the balance of cells can shift with time and treatment. Different parts of the tumor of an individual patient can be different in terms of their inherent characteristics and behavior. This is called <a href="http://www.nature.com/articles/nm.3915">intra-tumor heterogeneity</a> and is a hot research area.
Doctors typically make treatment decisions based on the biopsies that sample one region of the tumor. </p>
<p>If different parts of the tumors harbor cancer cell populations with different traits, there is a chance that some of those cells may be able to resist treatments, expand in numbers and eventually repopulate the tumor - leading to disease recurrence and spread.</p>
<p>Also, a given tumor can change or evolve over the time of its growth within the patients, or due to treatment, or the cancer cells of the tumor change as the disease spreads to new locations in the patient’s body. Therefore, the more heterogeneous a tumor is, the greater the likelihood of a poor outcome for a patient.</p>
<h2>Moving forward</h2>
<p>There are many promising avenues of research related to breast cancer – more than 100 clinical trials are happening right now that attempt to develop more specific targeted treatments. </p>
<p>Other researchers are looking into treatments that will attack different kinds of tumor cells at the same time. Still others are teasing out methods that use the body’s own immune system to create targeted treatments.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/192741/original/file-20171031-18686-1rp6h06.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/192741/original/file-20171031-18686-1rp6h06.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/192741/original/file-20171031-18686-1rp6h06.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/192741/original/file-20171031-18686-1rp6h06.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/192741/original/file-20171031-18686-1rp6h06.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/192741/original/file-20171031-18686-1rp6h06.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/192741/original/file-20171031-18686-1rp6h06.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Doctors are focusing on personalized treatment plans for breast cancer.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/oncology-breast-cancer-concept-female-doctor-728822260?src=d__lkQGuS9ZYIF-E6b2-5A-3-95">Syda Productions/Shutterstock.com</a></span>
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<p>All of these avenues point to the future of research into breast cancer and into cancer more generally. That future does not lie in a single breakthrough, for the simple reason that one size doesn’t fit all.</p>
<p>Instead, we are working toward precision medicine, where treatment for each patient is customized to her body and her specific diagnosis. And every discovery we make moves us closer to the day when breast cancer is a death sentence for no one.</p><img src="https://counter.theconversation.com/content/86584/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Padmashree Rida is affiliated with Novazoi Theranostics, Inc.</span></em></p><p class="fine-print"><em><span>Ritu Aneja receives funding from the National Institutes of Health.</span></em></p><p class="fine-print"><em><span>Karuna Mittal does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Breast cancer awareness month may be over, but don’t put away your pink. The disease is with us year-round. While researchers have found several ways to treat it, here are some things to know.Karuna Mittal, Doctoral Candidate, Cellular and Molecular Biology, Georgia State UniversityPadmashree Rida, Research Scientist, Georgia State UniversityRitu Aneja, Professor of Biology, Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/853792017-10-24T00:14:14Z2017-10-24T00:14:14ZA new clue into treatments for triple negative breast cancer, a mean disease<figure><img src="https://images.theconversation.com/files/191238/original/file-20171020-13963-1w6ykal.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">African-American women are about three times more likely to be diagnosed with triple negative breast cancer, an aggressive form of the disease. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/breast-cancer-awareness-charity-race-multiethnic-152895665?src=qqKkirwMIeqVbzrIa7ABCw-1-15">mangostock/Shutterstock.com</a></span></figcaption></figure><p>When a woman finds a lump in her breast, her doctor’s first move is usually to recommend a biopsy – that is, to remove a small portion of the lump for analysis. If the lump is cancerous, doctors test for three different <a href="https://www.cancer.gov/types/breast/hp/breast-treatment-pdq">clinical markers</a>: estrogen receptor, progesterone receptor and human epidermal growth factor receptor. The results determine what kind of hormone or growth factor receptor treatment the patient receives.</p>
<p>About 15-20 percent of breast cancers, though, don’t test positive for any of the three markers. They’re called <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2868264/">triple negative breast cancers</a>, and they’re big trouble. Treatments developed for cancers that test positive for any of the three different markers will not work on triple negative breast cancers.</p>
<p>Triple negative breast cancers are <a href="http://www.breastcancer.org/symptoms/diagnosis/trip_neg/behavior">more aggressive</a> and more likely to spread throughout the body. </p>
<p>At the 2017 <a href="https://www.tnbcconference.org">International Triple Negative Breast Cancer Conference</a> in Atlanta, I presented findings that show promise of improving treatment and outcomes for some women with the disease, even though more study is needed to confirm my findings.</p>
<h2>Moving the focus</h2>
<p>The <a href="http://www.breastcancer.org/symptoms/diagnosis/trip_neg/behavior">five-year survival rate</a> for women with triple negative breast cancer is lower – 77 percent – than the five-year survival rate – 93 percent – for women whose cancers have one of the three receptors. Also, because there are no hormone-targeted treatments for triple negative breast cancer, women often must endure harsher treatments like radiation and chemotherapy. Black women are about three times more likely than white women to develop triple negative breast cancer, a difference that could be due to their genetics.</p>
<p>Most researchers working on triple negative breast cancers study the tumor themselves. But my research looked at the disease from a different angle – the way the patient’s own body attacks the tumor. </p>
<p>When a woman gets breast cancer, her immune system leaps into gear. Her body sends <a href="https://www.cancer.gov/publications/dictionaries/cancer-drug?cdrid=41004">tumor infiltrating lymphocytes</a> to target and kill the tumor cells. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/191239/original/file-20171020-13995-113b9r1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/191239/original/file-20171020-13995-113b9r1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/191239/original/file-20171020-13995-113b9r1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/191239/original/file-20171020-13995-113b9r1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/191239/original/file-20171020-13995-113b9r1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/191239/original/file-20171020-13995-113b9r1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/191239/original/file-20171020-13995-113b9r1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Lymphocytes attack a cancer cell.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-illustration-cancer-cell-lymphocytes-617973347?src=HaMn3Sbb-AvLldL421pibQ-1-0">Christoph Burgstadt/Shutterstock.com</a></span>
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<p>Researchers and I looked at 103 early-stage patients with triple negative breast cancer, 71 of them African-American and the rest European-American, to see whether there was a difference in tumor-infiltrating lymphocyte count. Tumor-infiltrating lymphocytes were evaluated in hemotoxylin- and eosin-stained tissue sections according to the International TILs Working Group 2014 guidelines by pathologists we collaborate with at Emory University Hospital. We found that the African-Americans had a <a href="http://www.aacr.org/Newsroom/Pages/News-Release-Detail.aspx?ItemID=1090#.We5AEulbzww">significantly higher level of tumor infiltrating lymphocytes</a> in early-stage cancer than white women. </p>
<p>We also found higher tumor infiltrating lymphocyte levels in early-stage African-American patients who were diagnosed at a young age or tested negative for a fourth common clinical marker, androgen receptor. African-American women are more likely to be diagnosed with triple negative breast cancer at younger age and lack androgen receptor, factors associated with more aggressive disease, compared to white women.</p>
<p>Maybe most importantly, we found that we could use the level of tumor infiltrating lymphocytes to predict a greater or lower risk of death: The more tumor infiltrating lymphocytes, the better the survival we found among early-stage African-American cancer patients. High levels of tumor infiltrating lymphocytes also seem to correlate with higher levels of DNA damage within the tumor. If this correlation bears out in further research, doctors could use it to predict response to DNA repair therapies for a specific patient.</p>
<p>Finally, our study pointed to the possibility of an exciting new form of treatment: adoptive T cell therapy. In adoptive T cell therapy, doctors extract immune cells from a patient and genetically engineer them to expand the patient’s T cells. The cells are then infused back into the patient to improve her anti-tumor response.</p>
<h2>Promise in other cancer types</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3315690/">Adoptive cell therapy</a> has already shown promise in melanoma patients, and it is currently in clinical trials as a treatment option for breast cancer patients. From our research, we already know who might be most likely to respond to the treatment: African-American women, in the early stages of the disease, whose tumor infiltrating lymphocyte count is lower than normal. However, we plan to validate these results in additional patient cohorts.</p>
<p>Triple negative breast cancer is a scary disease – aggressive, rapid-spreading and insusceptible to the hormone treatments we use to target most breast cancers. But our next key to fighting it might not be in the tumor at all. It just might be tumor infiltrating lymphocytes, those tiny anti-cancer warriors our own bodies throw into the fray.</p><img src="https://counter.theconversation.com/content/85379/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nikita Wright does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Researchers have long been looking for clues into how to treat triple negative breast cancer. Could fighter blood cells that infiltrate the tumor provide insight?Nikita Wright, Ph.D. Candidate, Biology, Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/842552017-10-04T01:09:26Z2017-10-04T01:09:26ZHow inherited fitness may affect breast cancer risk<figure><img src="https://images.theconversation.com/files/188399/original/file-20171002-3124-1m8j627.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Physical activity has long been considered a way to lower risk for breast cancer. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-cheering-women-supporting-breast-cancer-710585749?src=nJ37oq49Ns6on7zpfk2y8w-1-71">vectorfusionart/Shutterstock.com</a></span></figcaption></figure><p>Repeated studies have shown that physical inactivity, and the occurrence of obesity to which it is linked, increases the risk for many chronic diseases, including breast and other cancers.</p>
<p>In fact, the evidence is so compelling that the <a href="https://www.cdc.gov/cancer/dcpc/prevention/policies_practices/physical_activity/guidelines.htm">lifestyle guidelines</a> of most <a href="https://www.ncbi.nlm.nih.gov/books/NBK11795/">health agencies</a>, both in the United States and abroad, include a recommendation for obesity prevention via maintenance of an appropriate body weight for height and a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1402378/">physically active lifestyle</a>.</p>
<p>However, what if the science behind these recommendations were only about half the story? What if your fitness were influenced not only by your activity level but also by your genes? And, focusing specifically on breast cancer, what if one’s risk of getting breast cancer were influenced by one’s inherited capacity for fitness?</p>
<p>A team of investigators, including me, explored these questions in a recently published <a href="https://academic.oup.com/carcin/article-abstract/38/9/920/3988099/Inherent-aerobic-capacity-dependent-differences-in">study</a> and found a surprisingly large role for genetics in fitness and breast cancer.</p>
<h2>Fit as you can be?</h2>
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<img alt="" src="https://images.theconversation.com/files/188402/original/file-20171002-4693-sz3teu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/188402/original/file-20171002-4693-sz3teu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/188402/original/file-20171002-4693-sz3teu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/188402/original/file-20171002-4693-sz3teu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/188402/original/file-20171002-4693-sz3teu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/188402/original/file-20171002-4693-sz3teu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/188402/original/file-20171002-4693-sz3teu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A woman exercising is likely lowering her risk of breast cancer, but a study suggests that inherent fitness is also a factor.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/627904697?src=paFVFoDXPFcnQ8nclILBbA-1-22&size=small_jpg">Aslysun/Shutterstock.com</a></span>
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<p>We frequently associate a physically active lifestyle and maintenance of an appropriate weight for a given height (measured as body mass index) with fitness, which is sometimes referred to as cardio-respiratory fitness. And individuals with <a href="https://www.ncbi.nlm.nih.gov/books/NBK11795/">high fitness generally fare better</a> not only in having a lower risk for chronic diseases like cancer. Even when they are diagnosed and treated, they have a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1402378/">more favorable prognosis</a> for recovery.</p>
<p>However, what has generally been overlooked is that aerobic fitness, broadly defined as the ability to transport oxygen and nutrients to the muscles, has a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3993978/">heritable component</a>. That explains why individuals engaged in the same training program have a wide range of improvement in their fitness in response to the same amount of exercise.</p>
<p>This inherited capacity for fitness led us to consider whether this capacity affects breast cancer risk.</p>
<p>Our question, while simple, would be problematic to study in people because it requires a lifetime of sedentary behavior, which is contrary to medical advice for health and well-being. So, the team decided to investigate this question in the laboratory. We worked to isolate the effects of inherent fitness and then studied how they affected breast cancer rates. </p>
<p>The fitness model was developed by selecting rats over multiple generations with low or high running activity on a treadmill. Those rats that ran the farthest before tiring were mated with one another and those rats that tired of running early likewise were bred together. This procedure was repeated for many generations, ultimately resulting in pups with large differences in inherited fitness.</p>
<p>To study the effects of these differences in inherent fitness, we took female pups born to mothers with high or low fitness and maintained the pups so that we could assess primarily the effects of fitness related to genetics, not to exercise. Before reaching sexual maturity, the pups were exposed to a chemical that triggers the development of breast cancer. </p>
<p>The animals were then monitored for the occurrence of palpable tumors throughout their lives and for tumors too small to detect without the use of a magnifying glass at the time of their death. What we found was striking. </p>
<h2>Born fit, and born unfit</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/188404/original/file-20171002-18673-1yjy7hf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/188404/original/file-20171002-18673-1yjy7hf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=427&fit=crop&dpr=1 600w, https://images.theconversation.com/files/188404/original/file-20171002-18673-1yjy7hf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=427&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/188404/original/file-20171002-18673-1yjy7hf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=427&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/188404/original/file-20171002-18673-1yjy7hf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=537&fit=crop&dpr=1 754w, https://images.theconversation.com/files/188404/original/file-20171002-18673-1yjy7hf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=537&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/188404/original/file-20171002-18673-1yjy7hf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=537&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Rats born with low fitness were four times more likely to develop breast cancer, and the difference appeared to be linked to cellular signaling.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/workplace-modern-laboratory-molecular-biology-test-188935001?src=nd_Py2qcBVlEDIHF-Gu-2w-4-3">Jakub Stepien/Shutterstock.com</a></span>
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<p>Rats born with low fitness were <a href="https://academic.oup.com/carcin/article-abstract/38/9/920/3988099/Inherent-aerobic-capacity-dependent-differences-in">four times more likely</a> to develop breast cancer, whereas rats born with high fitness not only had fewer cancers but the cancers occurred later in their lives and were smaller in size.</p>
<p>These effects were traced, at least in part, to a network of sensors that occur in essentially every cell in the body. </p>
<p>This system, referred to as <a href="http://jcs.biologists.org/content/122/20/3589">mammalian target of rapamycin</a>, senses the availability of energy and of various nutrients within the cell. When energy and nutrient availability is high, the system is active and promotes the ability of a cell to proliferate; excessive cell division is a hallmark of cancer. </p>
<p>We found that this signaling activity in cells in the breast was high in rats born with low fitness, whereas it was reduced in rats with high inherent fitness. </p>
<p>Efforts to identify hormones or growth factors in the blood that explained this difference were not successful, suggesting that the responses are coming from deep within the cell. </p>
<h2>Next steps: Moving from lab to clinic</h2>
<p>A growing number of studies in women have shown a link between <a href="https://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/physical-activity-fact-sheet">exercise and breast cancer risk</a>, and these findings seem to indicate that aerobic fitness alters the inner workings of cells to confer its protective effects. </p>
<p>However, our study suggests that there is an inborn component to protection that affects one’s exercise performance as well as their risk for breast cancer. </p>
<p>Many questions have been raised by this research. Recognizing that our experiment was done in rodents and that rodents are not people, the stage is set for extending these observations from the laboratory to the clinic. </p>
<p>A great amount of work also remains to be done using the rats with low and high inherent fitness. Current studies are focused on how to reduce breast cancer risk in rats born with low fitness. Key questions revolve around identifying the amount and type of exercise needed to break the link between low inherent fitness and the development of breast cancer, since most of us have the ability to raise our innate fitness capacity with exercise.</p><img src="https://counter.theconversation.com/content/84255/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Henry J. Thompson receives funding from the National Cancer Institute.</span></em></p>Physical activity is considered an important way to lower risk for breast cancer. But what if your ability to be fit is influenced by genes you inherit? Would that raise your risk? In rats, it did.Henry J. Thompson, Director Cancer Prevention Laboratory, Colorado State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/646452016-09-02T01:32:24Z2016-09-02T01:32:24ZEarly stage breast cancer: How to know whether to forgo chemo<figure><img src="https://images.theconversation.com/files/136353/original/image-20160901-1023-1ho483m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Woman receiving chemotherapy.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-171516044/stock-photo-chemotherapy.html?src=zo7sMOyCUrlIlC0YJ1iIzA-1-10">From www.shutterstock.com</a></span></figcaption></figure><p>There has been substantial publicity about the <a href="http://www.aacr.org/Newsroom/Pages/News-Release-Detail.aspx?ItemID=867#.V8cyUDbSfq0">MINDACT trial</a>, 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. </p>
<p>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. </p>
<p>As oncologists, we see this latest scientific development as yet another powerful tool in assessing a patient’s risk of developing cancer recurrence. </p>
<p>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. </p>
<p>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. </p>
<h2>A treatment mainstay</h2>
<p>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 pills are considered as additional or <a href="http://www.cancer.gov/publications/dictionaries/cancer-terms?cdrid=45587">adjuvant</a> 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 so-called distant recurrence of the breast cancer. </p>
<p>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. </p>
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<span class="caption">Woman with hair loss after chemo.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-174191054/stock-photo-cancer-woman.html?src=zo7sMOyCUrlIlC0YJ1iIzA-2-11">From www.shutterstock.com</a></span>
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<p>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 <a href="http://www.mayoclinic.org/diseases-conditions/chemo-brain/home/ovc-20170224">chemo brain</a>. </p>
<p>In addition, chemotherapy requires a great deal of time. It is also <a href="http://www.ncbi.nlm.nih.gov/pubmed/19354340">expensive</a>, 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.</p>
<p>The good news is that many women with early stage disease are now potentially cured, sometimes without chemotherapy given after surgery. </p>
<h2>Better understanding of a complex disease</h2>
<p>Breast cancer is the <a href="http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics">most common cancer diagnosis</a> and the second leading cause of cancer-related deaths in American women. Only lung cancer kills more women.</p>
<p>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. </p>
<p>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. </p>
<p>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 hormone-blocker (endocrine) therapy with or without chemotherapy. </p>
<p>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.</p>
<p>First, there is <a href="https://www.adjuvantonline.com">Adjuvant! Online</a>. This software provides an estimation of chemotherapy effectiveness when added to endocrine therapy, based on clinical-pathologic features, or what we see in a patient upon exam, or what we learn through laboratory tests.</p>
<p>Second, there is <a href="http://www.oncotypedx.com">Oncotype DX</a>, a 21-gene test, that actually has the ability to predict chemotherapy benefit and the likelihood of distant breast cancer recurrence, or metastasis.</p>
<p>More recently, a third tool called <a href="http://www.agendia.com/healthcare-professionals/breast-cancer/mammaprint/">MammaPrint</a> 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. </p>
<p>The purpose of the <a href="http://www.eortc.org/news/mindact-mammaprint-genetic-test-can-reduce-use-of-post-surgery-chemotherapy-among-early-stage-breast-cancer-patients/">MINDACT</a> (Microarray in Node-Negative and 1 to 3 Positive Lymph Node Disease May Avoid Chemotherapy) trial, an international, prospective, randomized phase 3 study, was to determine the clinical utility of the addition of the 70-gene signature (MammaPrint) to standard criteria in selecting patients for chemotherapy. </p>
<p>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.</p>
<p>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. </p>
<p>In the group of women with high clinical risk but low genomic risk who were treated with chemotherapy, there was only a <a href="http://www.eortc.org/news/mindact-mammaprint-genetic-test-can-reduce-use-of-post-surgery-chemotherapy-among-early-stage-breast-cancer-patients/">1.5 percent increase</a> 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 five-year survival is very similar in both groups, it 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).</p>
<h2>Bringing all the information together</h2>
<p>So what does this mean for our patients in the clinic? Let us consider two hypothetical clinical scenarios.</p>
<p>Patient 1 is a 55-year-old woman with a 1.5 centimeter tumor that is ER+, low-grade, low <a href="http://www.breastcancer.org/symptoms/diagnosis/rate_grade">proliferative rate</a> with 0 of 3 sentinel lymph nodes, or <a href="http://www.cancer.gov/about-cancer/diagnosis-staging/staging/s%E2%80%A6">nodes </a>to which the tumor is most likely to have spread. Proliferative rate refers to the rate of growth of cells within the tumor; <a href="http://www.breastcancer.org/symptoms/diagnosis/rate_grade">less than six percent is low</a>, and greater than 10 percent is high.</p>
<p>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. </p>
<p>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. </p>
<p>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 <a href="http://www.hopkinsmedicine.org/breast_center/treatments_services/survivor_care/endocrine_therapy/">endocrine therapy</a>, a daily, oral medication, for five to 10 years to reduce her risk of <a href="http://www.mayoclinic.org/diseases-conditions/cancer/in-depth/cancer/art-20044575">distant recurrence</a>, or cancer that has spread, or metastasized.</p>
<p>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.</p>
<p>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. </p>
<p>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.</p><img src="https://counter.theconversation.com/content/64645/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New tools help doctors and breast cancer patients decide whether chemotherapy is needed. A recent study suggested that many can forgo chemo. But the decision is complicated. Here’s why.Valerie Malyvanh Jansen, Clinical Instructor, Vanderbilt UniversityIngrid Mayer, Associate professor of medicine, Vanderbilt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/317582014-10-22T09:36:40Z2014-10-22T09:36:40ZAwash in pink, but breast cancer awareness isn’t a cure<figure><img src="https://images.theconversation.com/files/59732/original/4q2c8bpd-1411415664.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Participants and guests at a Walk for Breast Cancer decked out in pink.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-104793701/stock-photo-czech-republic-prague-june-participants-and-guests-celebrate-after-the-final-ceremony-speeches.html?src=GskVD3-OuyGt-Go5wVFXQw-1-40">Breast cancer walk image via www.shutterstock.com</a></span></figcaption></figure><p>This month, we are inundated with pink. By wearing pink ribbons, purchasing pink products, and participating in walks and other collective activities, citizens try to raise awareness of the scourge of breast cancer, with the eventual goal of curing the disease. But three decades after October was established as Breast Cancer Awareness Month, we need to ask ourselves: has all our pink paraphernalia really helped improve health?</p>
<p>At best, the results are mixed. <a href="http://asr.sagepub.com/content/77/5/780.short">Studies show</a> these campaigns can put a particular disease on the map, which can be valuable for rare illnesses. The summer of 2014’s <a href="http://www.alsa.org/fight-als/ice-bucket-challenge.html">Ice Bucket Challenge</a> for amyotrophic lateral sclerosis is a perfect example. It raised the disease’s profile and the ALS Association generated <a href="http://www.alsa.org/news/archive/als-association-thankyou-video.html">US$100 million in donations</a> in a month. But dumping a bucket of ice over your head doesn’t teach you anything about the disease or how it affects those who suffer from it. Those who donated money had little sense of how their efforts might improve the health and lives of ALS patients, and a year on, the disease and its sufferers have been largely forgotten.</p>
<p>The longer history of breast cancer awareness efforts gives us a deeper understanding of the benefits and limits of these kinds of campaigns. Without a doubt, the past three decades have generated an enormous increase in public awareness of breast cancer. There have been thousands of consciousness-raising events across the world, and hundreds of targeted initiatives among government agencies, major corporations and nonprofit organizations, to the point that it’s not strange to see even <a href="http://www.nfl.com/pink">NFL players</a> decked out in pink during October. </p>
<p>Breast cancer research funding has grown considerably. In 1990 the US federal government spent <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.0141-9889.2004.00420.x/full">less than $100 million</a> on the disease. Now the government and top private foundations spend <a href="http://pinkribbonblues.org/resources/beyond-awareness-workbook/background/funding-for-research/">at least $1 billion</a> annually. And there has been a massive <a href="http://www.hrsa.gov/quality/toolbox/measures/breastcancer/">increase</a> in mammography screening. </p>
<p>But across the world, breast cancer rates have gone up right along with awareness. In the United States, a woman’s lifetime risk of breast cancer has gone from one in 20 in the 1960s to <a href="http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-042725.pdf">one in eight</a> today. While part of this shift can be explained by increased access to mammography, researchers also point to long-term use of <a href="http://www.cancer.gov/cancertopics/factsheet/detection/probability-breast-cancer">hormone therapies</a> and <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1582-4934.2005.tb00350.x/abstract">lifestyle changes</a>. This year in the US, nearly <a href="http://www.cancer.org/research/cancerfactsstatistics/breast-cancer-facts-figures">a quarter of a million</a> women will be diagnosed with invasive breast cancer. Mammography <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1206809">does not seem to reduce</a> breast cancer mortality. </p>
<p>And while survival rates have improved for white women, women of color have not seen the same gains: today, black women are <a href="http://www.cdc.gov/vitalsigns/breastcancer/">40% more likely</a> to die of breast cancer than their white counterparts. Even women of color who are diagnosed early have more aggressive cancers. Low-income women also have <a href="http://www.biomedcentral.com/1471-2407/9/364">difficulty accessing</a> the expensive treatments that are improving survival rates for middle- and high-income women. </p>
<p>Also problematic is the fact that the breast cancer awareness movement’s enormous success has actually led women to overestimate their risk of getting the disease while underestimating their risks of contracting more common – but at least as deadly – conditions, including <a href="http://www.cdc.gov/heartdisease/facts.htm">heart disease</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/98346/original/image-20151014-879-xsmj7e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/98346/original/image-20151014-879-xsmj7e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/98346/original/image-20151014-879-xsmj7e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/98346/original/image-20151014-879-xsmj7e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/98346/original/image-20151014-879-xsmj7e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/98346/original/image-20151014-879-xsmj7e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/98346/original/image-20151014-879-xsmj7e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/98346/original/image-20151014-879-xsmj7e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">It’s going to take more than a month’s supply of pink ribbons to find a cure.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/susangkomenforthecure/9623480056">Susan G Komen®</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>So while awareness efforts can focus significant public attention and help scientists raise funds for research, the impact on eradicating the disease itself is much less clear. </p>
<p>Does that mean we should abandon such efforts? Absolutely not. But in the fight against a particular disease, we need to understand that awareness efforts are only initial steps down a very long road. The time has come for us to think about other steps we need to take. </p>
<p>We can begin by putting at least as much time and effort into understanding the social, health, economic, environmental and policy-related challenges faced by individuals at risk for and suffering from a particular disease. Then we should help them fight these battles. Imagine “national days of action” in which we work within communities to improve access to the local health infrastructure. Or we could direct fundraising to organizations that serve patients’ practical and emotional needs. In the case of breast cancer, these <a href="http://www.shanti.org/pages/shanti-model.html">organizations</a> provide help in getting to the grocery store, interacting with medical professionals and communicating the patient’s wishes, and providing home care. </p>
<p>If we continue to focus on increasing research funding, then we need to ask questions not only about the percentage of money actually spent on research as opposed to overhead, but also how to ensure that this research will benefit those suffering from the disease. Scholars have suggested, for example, that <a href="http://dx.doi.org/10.1016/j.envsci.2006.10.001">decisions about allocating research funding</a> be tied to the potential for improved health outcomes and the researchers’ track records in achieving them. At the moment, funding is doled out based primarily on scientific priorities that may or may not align with health and social priorities.</p>
<p>Others have argued that in order to ensure that findings turn into widely available new technologies rather than expensive innovations available only to a few, research efforts must be <a href="http://dx.doi.org/10.1016/j.amepre.2008.05.018">truly interdisciplinary</a>. So a breast cancer team could include not only biologists but also social scientists, public health and policy experts, and even patients. They would work together throughout the research process to produce outputs that are acceptable, useful and affordable to the populations most in need.</p>
<p>And we need to pressure research funding organizations and other policymakers to ensure that intellectual property agreements do not hinder access to important treatments, preventive or diagnostic measures. Until 2013, for example, genetic testing on genes linked to breast and ovarian cancer was extremely expensive in the United States due to a <a href="http://www.nytimes.com/2015/01/28/business/myriad-genetics-ending-patent-dispute-on-breast-cancer-risk-testing.html?_r=0">patent-based monopoly</a> held by biotechnology company Myriad Genetics. But public interest lawyers, civil society groups, and other citizens fought against the patent, and now the technology is <a href="http://bcconnections.org/resources/brca-test-providers/">cheaper and more widely available</a>. The competition that has emerged may produce more research and better testing too.</p>
<p>If we continue to focus our advocacy on disease awareness efforts, then we will only make limited progress toward our real goals. We must think strategically about generating the same kind of public engagement in all the other steps down the long road toward better health and cures.</p><img src="https://counter.theconversation.com/content/31758/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shobita Parthasarathy has received funding from the US National Science Foundation and the UK Wellcome Trust. She is on the Board of Directors for Breast Cancer Action.</span></em></p>Awareness efforts can focus public attention and help scientists raise funds for research. But the impact on eradicating the disease itself and helping patients today is much less clear.Shobita Parthasarathy, Associate Professor of Public Policy and Women's Studies, University of MichiganLicensed as Creative Commons – attribution, no derivatives.