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October 2, 2008 – Vol. 2 • No. 14
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Breast cancer:
Young women are not immune

The results of her biopsy came as a shock to Tonia Hines.

She was told that she had calcium deposits in her right breast, but was not quite sure what that meant. She had seen the results of her mammogram and saw the white specks on the film that her doctors considered suspicious.

But word that she had breast cancer was the last thing she expected to hear.

“She can’t be talking to me,” Hines recalled, referring to her doctor. “Who is she talking to?”

The doctor was definitely talking to Hines, but Hines was having none of it.

After all, she had no known behavioral risk factors and no family history of breast cancer.

More important, she didn’t have the usual symptoms.

“How could I have cancer?” Hines said. “I didn’t have a lump.”

But there are many misperceptions surrounding breast cancer.

”Breast cancer is not a single disease,” said Dr. John K. Erban, the director of clinical programs and co-director of the Gillette Center for Breast Cancer at Massachusetts General Hospital. “It’s many diseases. There are many types of breast cancer.”

Breast cancer is the second deadliest cancer in women, trailing only lung cancer. More than 40,000 women are expected to die from the disease in 2008.

Most breast cancers develop in the lobes of the breast, where milk is produced, or in the ducts that transport milk to the nipple. Cancer can be invasive, meaning that it has spread, or non-invasive, or in situ, meaning that it has remained in its original site.

According to the American Cancer Society (ACS), more than 182,000 estimated cases of invasive breast cancer and 68,000 non-invasive cases will be diagnosed in this country this year.

Age and race are significant risk factors for breast cancer. The median age at diagnosis is 61. Almost 42 percent of the cases occur in women 65 and older, and only 12.5 percent in women under the age of 44. The incidence of breast cancer is highest in white women, but the death rates tell a different story.

As reported by the National Cancer Institute, an arm of the National Institutes of Health, death rates in blacks are 37 percent higher than those in whites and twice the rate of Asians, American Indians and Hispanics.

The reason for the disparity is unclear. Erban attributes it to many factors.

“It is probably due in part to the stage of breast cancer at which some blacks receive treatment,” Erban said. “Some blacks may not have access to optimal care. It may also be biological — that blacks tend to get a more aggressive disease.”

One such aggressive disease is a basal-like cancer that, according to the Carolina Breast Cancer Study in 2006, was shown to be more prevalent among pre-menopausal African American women.

Luisa Knight was 33 years old when she was diagnosed with triple-negative breast cancer, a type of basal-like cancer that disproportionately affects black and Hispanic women.

It is so named for its lack of “receptors” for estrogen and progesterone — both hormones — and HER2, a growth-promoting protein. Because of its triple-negative status, the disease does not respond to receptor-targeted treatments, such as tamoxifen and herceptin, that have proven successful in treating breast cancer and have largely contributed to increased survival rates.

Fortunately, standard chemotherapy is still effective for many women with triple negative cancer.

When Knight was told of her diagnosis, she, too, had an out-of body experience.

“OK,” she said she thought to herself. “It can’t be bad because it’s negative. It seemed like a positive thing to me.”

It wasn’t.

Knight’s problem started two years ago. Her mother had died of breast cancer at the age of 44 and Knight was extremely diligent in performing self-examinations. One day, while in the shower, she felt a lump in her left breast.

She went to her primary care physician and a mammogram was done. The mammogram was negative.

But according to Knight, “the lump kept growing.”

Four months later, she went back to her doctor and was told that she was too young and that nothing was wrong.

She finally went to see a gynecologist, who had the opposite opinion. “I’m very concerned about this lump,” Knight said her gynecologist told her. “I’m going to send you to a breast specialist.”

The breast specialist ordered a biopsy, which confirmed cancer.

“That’s the last thing I heard,” Knight recalled. “I started crying and didn’t hear anything after that.”

A few moments later, Knight said she started to pull together. “Why am I crying?” she asked herself. “It won’t make it better, but I was hoping it was a lie.”

She decided to go to Dana-Farber Cancer Institute for her treatment. They offered her a clinical trial that consisted of chemotherapy followed by a mastectomy, another bout of chemotherapy and radiation.

She jumped at the chance. “I wanted to do that,” she recalled. “I would have done anything.”

Knight, 34, has recently completed her radiation and is now an ambassador with the Pink and Black campaign, sponsored by the Boston Public Health Commission to raise awareness of breast cancer among minorities.

The exact cause of breast cancer is unknown, but several factors increase its risk — age, gender, familial or personal history of breast cancer and genetic factors, such as a mutation in BRCA1 and BRCA2, two genes that normally suppress the production of cancerous cells.

The most common symptom of breast cancer is a lump, but not all breast cancers begin that way.

Just ask Tonia Hines.

Hines said she only learned of that medical reality when her doctor told her she had ductal carcinoma, but instead of a tumor, she had calcium deposits that included cancerous cells. The cancer hadn’t spread, but the extent and shape of the calcifications caused the doctors concern.

Hines had a mastectomy and opted for reconstructive surgery. “The breast doesn’t make me, but it’s part of my life,” she explained.

She is now on hormone therapy to reduce the risk of recurrence.

Of greater concern to Hines were her two sons. “They were scared and nervous,” the single parent said. “There was always the fear that the cancer could be elsewhere.”

Survival rates of breast cancer have increased, largely because of early screenings and improvements in treatments. If caught very early, the five-year survival rates are 98 percent, but plunge to 27 percent if the cancer has spread to distant parts of the body.

There are over 2.5 million breast cancer survivors in the U.S. and the number is climbing. A recent study by M.D. Anderson Cancer Center in Houston revealed that the recurrence of breast cancer after five years is low, even in women with more advanced cases.

Many cancers can be caught in the early stages when treatment is most successful. The ACS recommends that yearly screening with mammograms start at the age of 40. More often than not, mammograms can detect changes in the breast or tumors before they are felt and before they invade surrounding tissue.

“For those of very high risk, a yearly magnetic resonance imaging (MRI) is also recommended in conjunction with a mammogram,” said Erban.

An MRI uses magnetic fields instead of X-rays to produce a detailed cross-section of the breast. This combined approach increases the sensitivity in detecting cancers.

A yearly breast exam by a health professional rounds out the annual requirements for breast health.

It is not always possible to prevent breast cancer, but certain lifestyle changes have been found to reduce its risk or recurrence.

“There is strong evidence that both diet, especially decreased consumption of total calories, and exercise can decrease the occurrence and risk of dying from breast cancer,” Erban explained.

Research has borne that out. The Nurses’ Health Study, sponsored by Harvard University, determined that women who gained weight in their adult years, particularly after menopause, increased the risk of breast cancer compared with those who maintained or lost weight. After menopause, fat tissue is a chief source of estrogen, which fuels many breast cancers.

The benefits of exercise cannot be overlooked. Researchers found that exercising for five or more hours a week throughout life can reduce a woman’s risk of breast cancer by more than 47 percent.

Alcohol has a negative impact. It has been determined that just two drinks a day of any type of alcohol can increase the risk by 21 percent.

The Nurses’ Health Study also revealed that prolonged use of hormone replacements, prescribed to reduce the risk of cardiovascular disease after menopause, also increased the incidence of breast cancer. Women should discuss with their doctors the risks and benefits of continuing use of hormone replacements.

Hines put it well: “It’s a lot of information to process.”


(top) Tonia Hines discovered her breast cancer during her first mammogram at the age of 40. Hines, now 42, is a participant in The Wellness Community support group at The Dimock Center.

(bottom) Luisa Knight was 33 years old when she was diagnosed with triple-negative breast cancer, a form of breast cancer that disproportionately strikes young black and Hispanic women.

John K. Erban, M.D.
Director of Clinical Programs and Co-Director
Gillette Center for Breast Cancer
Massachusetts General Hospital

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