What does it mean to have dense breasts?

Effective April 1, 2013, California State Law SB 1538 requires radiologists to inform women if they have dense breast tissue on screening mammography.  Under the new law, about 50% of women will receive the following statement with their mammogram results:

“Your mammogram shows that your breast tissue is dense. Dense breast tissue is common and is not abnormal. However, dense breast tissue can make it harder to evaluate the results of your mammogram and may also be associated with an increased risk of breast cancer.

This information about the results of your mammogram is given to you to raise your awareness and to inform your conversations with your doctor. Together, you can decide which screening options are right for you. A report of your results was sent to your physician.”

Breasts are composed of a mixture of fat, glandular tissue and fibrous tissue.  If breasts have little fat but a lot of glandular and fibrous tissue, they are considered dense.  Currently, breast density is qualitatively classified by radiologists into four categories:

• Almost entirely fatty (10% of women)
• Scattered areas of fibroglandular density (40% of women)
• Heterogeneously dense breasts (40% of women)
• Extremely dense breasts (10% of women)

Women with breasts categorized as heterogeneously dense and extremely dense are required, under the new law, to receive notification of this classification.

The implications of having dense breasts are two-fold.  First, the sensitivity of mammography is lower in dense breasts.  Cancer can be masked in dense breasts because both cancer and dense breast tissue appear white on a mammogram.  Second, women with dense breasts have an elevated risk of getting breast cancer.  If a woman has heterogeneously dense breasts, her risk is 1.2 times greater than a woman with average breast density, and if a woman has extremely dense breasts, her risk is 2 times greater.

Having dense breast tissue does not mean that a woman should stop getting yearly mammograms.  Instead, she should speak with her doctor about her risk factors and discuss whether other screening modalities would be appropriate complements to mammography.  These tests include breast MRI, breast ultrasound and 3D mammography.

Sources/More Information:

Breast Density.info

Stanford Breast Density

American College of Radiology

State Senator Joe Simitians’ website

Routine follow-up care is important for breast cancer survivors who have completed active treatment.  Six years after its last update, the American Society of Clinical Oncology (ASCO) has re-reviewed its recommendations on breast cancer follow-up care.  After considering 14 new publications, the committee concluded that no revisions to the previous guidelines are needed.  The following is a summary of ASCO’s recommendations for breast cancer follow-up care, as well as a summary of tests that are not recommended.

KEY RECOMMENDATIONS:

• Regular medical history and physical exam

- every 3-6 months for 3 years after primary treatment

- every 6-12 months for years 4-5

- annually year 6 and beyond

• Patient education about signs/symptoms of recurrence

• Referral to genetic counseling when appropriate

- Ashkenazi Jewish Heritage

- patient history of ovarian cancer

- history of ovarian cancer in any first or second degree relative

- history of breast cancer before age 50 in any first degree relative

- two or more first or second degree relatives with a history of breast cancer

- patient or relative with a history of bi-lateral breast cancer

- family history of male breast cancer

• Monthly breast self-exam

• Mammography, for women treated with lumpectomy

- 1 year after the initial mammogram, but no sooner than 6 months after radiation therapy

- yearly thereafter (unless otherwise indicated)

• Regular pelvic exam

 NOT RECOMMENDED:

The following tests are NOT RECOMMENDED for routine follow-up care of asymptomatic patients:

• Routine blood tests (i.e. complete blood counts or automated chemistry studies)
• Chest X-rays
• Bone Scans
• Liver Ultrasound
• PET Scans
• CT Scans
• Breast MRIs
• Tumor markers (i.e. CEA, CA 15-3, CA 27.29)

 

Source:  “Breast Cancer Follow-Up and Management After Primary Treatment:  American Society of Clinical Oncology Clinical Practice Guideline Update”

 

By Rebecca Olson, Life Science Research Assistant, Stanford Cancer Institute and Breast Cancer Connections Volunteer

The FDA recently approved a breakthrough cancer drug that represents an exciting new direction in breast cancer treatment. T-DM1 (Kadcyla, Roche) is the first “armed antibody” on the market. This novel antibody-drug conjugate allows for the targeted delivery of chemotherapy to cancer cells without producing concurrent toxic effects on normal cells. The T-DM1 conjugate consists of a stable linkage between the well-known antibody trastuzumab (Herceptin) and the chemotherapeutic molecule DM1 (emtansine)¹. This new drug holds great promise for many patients with HER2-positive breast cancer, and has opened the floodgates for a new wave of cancer research.

Chemotherapeutic drugs cause damage by impairing cell division, and produce cytotoxicity in fast-dividing cells like those in tumors. Many other types of cells are susceptible—including those responsible for hair growth and intestinal lining—leading to severe side effects. T-DM1 was developed by Roche (Genentech) and represents a major step in the creation of safer chemotherapy drugs.  Trastuzumab (Herceptin) works by binding to the HER2 protein on the surface of tumor cells, slowing the cell’s growth and marking it for destruction by immune cells². With T-DM1 treatment, the trastuzumab antibody still binds the tumor cell but also delivers a toxic chemo payload. “Kadcyla is an antibody-drug conjugate representing a completely new way to treat HER2-positive metastatic breast cancer, and it helped people in the EMILIA study live nearly six months longer,” said Hal Barron, Roche’s chief medical officer and head of global product development³.

The EMILIA study specifically looked at a patient population of 991 women with metastatic or locally advanced HER2-positive breast cancer. These patients had previously been treated with a standard treatment regimen of Herceptin and a taxane chemotherapy, but had stopped responding to therapy. Half of the women received T-DM1 and the other half received another HER2-blocking drug, lapatinib (Tykerb) in addition to the chemotherapeutic agent capecitabine (Xeloda)⁴. T-DM1 recipients survived longer without disease and experienced far fewer side effects than those who received the standard of care. Incidences of low platelet count and increased liver enzyme levels were higher with T-DM1; side effects that were higher with lapatinib plus capecitabine included diarrhea, nausea, vomiting, and low red blood cell count. In addition, and particularly important to patients, treatment with T-DM1 is not associated with significant hair loss⁵.

T-DM1 is currently FDA approved as a second line therapy for HER2+ metastatic disease, but ongoing trials will determine its use as a first line therapy and perhaps in early-stage breast cancer. In short, T-DM1 is a promising new therapy for patients with advanced breast cancer. It is the first such antibody-drug conjugate explored in breast cancer, and will certainly shape future research into exciting new cancer treatments.

References:

1. www.ncbi.nlm.nih.gov
2. www.ncbi.nlm.nih.gov
3. www.fiercebiotech.com
4. www.roche.com
5. www.targetedhc.com

A report issued last month by the federal Interagency Breast Cancer and Environmental Research Coordinating Committee called for increased funding of research aimed at determining the environmental causes of breast cancer.  The report concludes that reducing exposure to environmental risk factors is key to preventing the disease.  One such environmental factor under scrutiny is Bisphenol A (BPA).

BPA is a synthetic estrogen that is used to make polycarbonate plastics and the epoxy linings of food cans.   BPA can leach out of plastics and linings, contaminating food and beverages.  There is rising concern, based on preliminary laboratory studies, that exposure to BPA might be linked to a variety of health problems including obesity, infertility, and breast cancer.  Human studies investigating the link between BPA and breast cancer are lacking.  Despite its potential health risks, the FDA still allows BPA in food cans.

For tips on how to reduce your exposure to this chemical, visit these links:

• Environmental Working Group’s (EWG) guide to BPA
• 10 Canned Foods to Avoid to Reduce BPA Exposure

Sentinel lymph node biopsy (SLNB) is an established technique to accurately assess the status of the axillary lymph nodes in women who undergo surgery for breast cancer.  This technique often spares women from a full axillary lymph node dissection.  For women who have chemotherapy prior to surgery (neoadjuvant chemotherapy), however, it is unknown whether the SLNB accurately reflects the lymph node status.

The ACOSOG Z1071 trial investigated the accuracy of the SLNB post-neoadjuvant chemotherapy.  The trial enrolled 756 women with clinically positive lymph nodes who underwent chemotherapy prior to surgery.  At the time of surgery, a SLNB was performed, followed by removal of all of the axillary lymph nodes.  SLNB correctly identified the nodal status in 91.2 percent of patients.  In 12.6 percent of patients, the SLNB was negative, but disease was found in other axillary lymph nodes.  This false-negative rate is higher than the 10 percent false-negative rate considered safe by the study standards. Better accuracy was obtained when three or more sentinel lymph nodes were identified, and when the SLNB was performed with both a blue dye and a radioactive tracer.  In a related trial, the SENTINA trial, the false-negative rate for a sentinel lymph node biopsy performed after neoadjuvant chemotherapy was 14.2 percent.

Sources:

“The role of sentinel lymph node surgery in patients presenting with node positive breast cancer (T0-T4, N1-2) who receive neoadjuvant chemotherapy – results from the ACOSOG Z1071 trial.”  Oughey JC et al.  The San Antonio Breast Cancery Symposium, 2012, Abstract S2-1.

“Sentinel lymph node biopsy before or after neoadjuvant chemotherapy – final results from the prospective German, multiinstitutional SENTINA-trial.”  Kuehn T et al.  The San Antonio Breast Cancery Symposium, 2012, Abstract S2-2.

By Rebecca Olson, Life Science Research Assistant, Stanford Cancer Institute and Breast Cancer Connections Volunteer

The ancient practice of yoga originated in India some 5,000 years ago and has evolved into a discipline with well-documented healing effects. Yoga practice enhances physical, mental and spiritual well-being, and is proven to have significant clinical outcomes in patients struggling with cancer (Woodyard 2011).

The common view of yoga generally involves a variety of poses and stretches. The word “yoga” is derived from a Sanskrit root “yuj” which means union, or yoke, to join, and to direct and concentrate one’s attention. Modern yoga is a form of mind-body fitness that involves a combination of muscular activity and an internally directed mindful focus on awareness of the self, the breath, and energy (Woodyard 2011). Physical exercise is combined with traditional elements of Hindu philosophy to unite the body and mind.

Relaxation and meditation are the core elements of yoga practice. Most yoga classes conclude in ‘Savasana’ pose, a time spent laying relaxed on your yoga mat, calm and at peace. In my own yoga experience, mental relaxation and tranquility were difficult concepts to embrace. At the end of an evening class I would lay stretched out on my yoga mat in Savasana, reflecting on the worries and problems of my life. The concept of relaxation would fade to a distant memory behind the whirring of my preoccupied mind. Until one evening, my yoga instructor quietly offered one simple statement that stilled my busy thoughts:

“Know that you’ve done enough today…that you have enough…you ARE enough.”

I began to understand that the power of yoga comes through acceptance. To practice yoga is to unite the fragmented body and mind and regain the feeling of wholeness. Yoga is self-empowering; it teaches that healing comes from within, and shows the student how to play an active role in their journey toward health (Woodyard 2011).

Receiving a diagnosis of breast cancer and undergoing treatment can create a high level of sustained emotional distress. Whether newly diagnosed or a long-term survivor, many cancer patients struggle with symptoms of pain, anxiety, depression, and fatigue. These individuals suffer from widespread impairment in physical, emotional, social, and spiritual well-being over  long periods of time (Smith and Pukall 2009).

Culos-Reed and colleagues reviewed the clinical significance of yoga in cancer therapy across 25 published works. Cancer survivors who practiced yoga demonstrated clinically significant improvements in health-related quality of life.  Clinically significant outcomes included reduced anxiety, depression and stress, as well as improved mood and sleep (Culos-Reed et al. 2012). Another study investigated the effectiveness of yoga in breast cancer patients through a randomized controlled trial. In comparison to a control group of 584 women, a group of 544 breast cancer patients participating in yoga reported greater quality of life, increased emotional, social, and spiritual well-being, and reduced distress and fatigue (Moadel et al. 2007). Other studies report positive effects on physical parameters such as lowered blood pressure and altered cortisol levels (Woodyard 2011).

The physical effects of therapeutic yoga can be traced to the body’s classical “fight or flight” response. The body deals with physical or psychological stress by firing up two major neuroendocrine systems called the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system (SNS). When triggered, these systems rapidly increase levels of the stress hormone cortisol, resulting in widespread effects throughout the body such as increased heart rate, reduced digestion, and immune suppression. Repeated firing of the HPA axis and SNS and heightened cortisol can produce a state of hypervigilance that takes a severe toll on overall health. Chronic stress increases blood pressure, heart attack and stroke risk, vulnerability to anxiety, depression, and immune weakness.

Regular yoga practice can counteract the severe physical injury created by chronic HPA/SNS activation and heightened cortisol. A review by Ross and Thomas describes the physical effects of therapeutic yoga:

“Numerous studies have shown yoga to have an immediate downregulating effect on both the SNS/HPA axis response to stress. Studies show that yoga decreases levels of salivary cortisol, blood glucose,  as well as plasma rennin levels, and 24-hour urine norepinephrine and epinephrine levels. Yoga significantly decreases heart rate and systolic and diastolic blood pressure. Studies suggest that yoga reverses the negative impact of stress on the immune system by increasing levels of immunoglobulin A as well as natural killer cells. Yoga has been found to decrease markers of inflammation such as high sensitivity C-reactive protein as well as inflammatory cytokines such as interleukin-6 and lymphocyte-1B” (Ross and Thomas 2010).

In the Western world, yoga is now widely regarded as a holistic approach to health and is classified by the National Institutes of Health as a form of Complementary and Alternative Medicine (Woodyard 2011). Yoga is not a cure for cancer, but can promote healing and substantially improve overall wellness in cancer patients. In teaching one to unite the mind, body, and spirit for health and self-awareness, yoga can bring about a sense of peace.

Surya Namaskar (the Sun Salutation) is a familiar sequence of eight poses that express the essence of Yoga. The second pose of the Sun Salutation is the upward salute, in which the feet remain rooted to the earth while the arms reach upward to infinity and the heart opens toward the horizon. The Sun Salutation exemplifies the true purpose of yoga: to be grounded while simultaneously stretching into the vastness of the unexplored self. To do yoga is to be fully rooted in the present while embracing the endless possibilities of the future (Rosen 2013).

REFERENCES

Culos-Reed, S. N., M. J. Mackenzie, S. J. Sohl, M. T. Jesse, A. N. Zahavich & S. C. Danhauer. “Yoga & cancer interventions: a review of the clinical significance of patient reported outcomes for cancer survivors.” Evid Based Complement Alternat Med, 2012, 642576.

Moadel, A. B., C. Shah, J. Wylie-Rosett, M. S. Harris, S. R. Patel, C. B. Hall & J. A. Sparano. “Randomized controlled trial of yoga among a multiethnic sample of breast cancer patients: effects on quality of life.” In J Clin Oncol, 2007, 4387-95.

Rosen, R.  ”Here Comes the Sun. That most familiar of asana sequences, Surya Namaskar (Sun Salutation)  is as rich in symbolic and mythic overtones as it is in physical  benefits.”  Yoga Journal, Cruz Bay Publishing, Inc., 2013.

Ross, A. & S. Thomas. “The health benefits of yoga and exercise: a review of comparison studies.” J Altern Complement Med, 2010, 16, 3-12.

Smith, K. B. & C. F. Pukall. “An evidence-based review of yoga as a complementary intervention for patients with cancer.” Psycho-Oncology, 2009, 18, 465-475.

Woodyard, C. “Exploring the therapeutic effects of yoga and its ability to increase quality of life.” International Journal of Yoga, 2011, 4, 49-54.

Leukemia is a rare but severe side effect that can occur as a result of breast cancer treatment.  The National Comprehensive Cancer Network conducted a study to assess the incidence of leukemia in 20,533 patients diagnosed with early-stage breast cancer who were treated at NCCN cancer centers.  The ten year cumulative incidence of leukemia in the population as a whole was 0.46%.  When treatment subgroups were compared, women treated with surgery alone had a lower risk (0.2%) compared to women treated with radiation (0.44%), chemotherapy (0.52%), or chemotherapy and radiation (0.51%).  Of note, the frequency of myelodysplatic syndrome (MDS) is likely under-represented in this study due to the under-reporting of this condition until recently.  Furthermore, very few patients in this population were prescribed docetaxel/cycolphosphamide (TC) chemotherapy, so the risk of leukemia for this regimen cannot be inferred from this study.

Source:  “Myelodysplatic syndrome and/or acute myelogenus leukemia (MDS and/or AML) after a breast cancer diagnosis:  the National Comprehensive Cancer Network (NCCN) experience.”  Presented at the 2012 San Antonio Breast Cancer Symposium by Karp et al., abstract S3-5.

WINNER

Breast Cancer Connections recently held an essay contest asking people to write about their personal experience with breast cancer. The following three essays: Rejuvenation, In the Pink, and Seeking Solace in the Hills have been selected as finalists. The winner is In the Pink by Randy Hale and will be published in BCC’s March 2013 Newsletter. Voting ended on Jan 26, 2013.

In the Pink

By Randy Hale

She’d been feeling good lately.  You might even say she was in the pink.  After all it was October – pink t-shirts, pink ribbons, pink gloves on the Seahawks, pink, pink, pink.  Actually some of her favorite things were pink:   sunsets over the Olympics, Cosmopolitans, salmon, the pretty blush that made her skin glow, and that impossibly cute pink sweatshirt in her closet.  None of which had anything to do with breast cancer.

She’d never much cared for October except for the changing leaves and Indian summers.  She especially disliked Halloween – where was the fun in being scared?  And then, on October 31, 2011, she was diagnosed with breast cancer.  Boo!

A year later, once again surrounded by pink, she receives an email angrily venting about how buying and wearing pink things is an empty token, a huge money making, promotional push that does nothing of  substance for breast cancer.  The author is full of rage, and to a degree she gets it.

She knows that nothing huge is accomplished by the small, enameled pink ribbon pin on her jean jacket.  She wears it because it was made for her by a jewelry designer with breast cancer — one of her clients in NY.  The woman spoke poignantly about her disappointment in a lumpectomy that, while conserving her breast, left it deformed and virtually unfixable due to radiation treatments — information that wasn’t volunteered beforehand.  Cancer free, she’d been left to fend for herself emotionally.

She also wears it for the lovely upper eastside volunteer who gave hope to women in post surgery breast cancer groups.  Well into her 50’s, she was stunningly beautiful and happily married. But under her Chanel suit she sported a radical mastectomy she’d had since she was 28, after which her then husband had left her.

She wears it for Linda, so delighted with her reconstruction after double mastectomies, that she’d open her blouse and display her new breasts to anyone who so much as mentioned it.  And for the handsome, athletic young man who had a mastectomy with reconstruction so he’d look more normal with his shirt off in the gym.

And she wears it for Kim, one of her best friends, whose breast cancer was left to fester for 6 months by a doctor who didn’t have a keen enough level of suspicion, thinking she was too young, too athletic, too healthy for that lump to be cancer.  After 4 years of treatment, she died at 39, leaving her husband and two small children.

She wears it because breast cancer isn’t just a case of bodacious tatas gone bad.  It’s personal — a vicious assault on men and women who are known and loved – a life threatening, body changing,  out of control attack.  The solidarity displayed in a show of pink can render that experience less frightening, more mainstream, rather than shameful and damaging.  It may even create an opening to start the conversation about having a life altering diagnosis.

She also wears it because pink can give a voice to those without cancer too.  A way to say they care no matter how awkward or scared they are.  A way to say they, too, have feelings about it – fear, confusion, grief over losing a friend, or joy and relief when a loved one makes it through alive and well.

But this year she’s feeling a bit protective of herself and her breast cancer experience.  She doesn’t want to be the center of attention that way anymore.  She’d like to pass.   Breast cancer will always be a part of her, but only a part.  It doesn’t define her this October the way it did last year.

A lot of people already know.  Others may find out over a late night glass of wine, when everyone is telling tales and sharing truths about themselves.  Some may never hear.

For now she just wants to get on with her life.  She thinks about that cute pink sweatshirt – maybe she’ll wear it tomorrow.  Or maybe she’ll wait until November.  She’ll see.

______________________________________________________________

Rejuvenation

By Sally Nettleton

I’ve made quite a dent on my side of the sofa and it’s not because I’ve been playing too many video games.

My dent comes from hours of looking out of the picture window at my garden, watching the flowers grow and the seasons change.  Not a pastime I would normally spend so much time on, but that dent in the sofa became my haven, through the formidable time on chemo.

There were days when my body was paralyzed and unable to move; with the comfort of a soft warm blanket covering me and protecting me, life was bearable.  Still the plants flourished outside with the sun and water on their backs.  There was no sun on my back, as my dent continued to grow deeper.

Life goes on around me but my life has stood still.  Will this feeling of helplessness ever go away?  I need sympathy; nobody knows how I really feel so how can they sympathize?

My veins are pulsating, the poison inside flows slowly like mercury in a thermometer creeping up the tube. Still that dent gives me a sense of security and starts engulfing me.

Hair is coming out in chunks and lines my dent like a nest.  That part of me which categorizes me as a woman has gone.  I can’t bear to look at myself; I look like an alien, that’s if aliens look like that.  With a bald head, a port to the right of my chest and a large scar on my left breast, I have aptly named it the triangle of hate.

The days pass slowly and nighttime even slower.  I’m so tired but I can’t get any sleep.  I close my eyes, how I wish I could sleep.  All that happens is my mind races and I am provided with a full length movie beneath my eyelids, as images race before me. My eyes spring open, still dark, those darn drugs and that dent is feeling more like a permanent home.  Slowly the sun comes up to welcome another day but I don’t welcome another day of feeling like my world is caving in on me.  As the light strains through the side of the blinds, I do start to feel better.  These alien feelings are beginning to pass and I can dig myself out of my dent that has become more of a hole by now.

Finally after 16 weeks of emotionally charged treatment, drugs and doctors visits, it has come to an end.  A glance in the mirror and a normal person starts to re-emerge. The color in my cheeks has returned and I rejoice in a much healthier complexion.  Hair begins to show and I never thought I would celebrate the day when I shaved my armpits once again. Potatoes and bread became my staple, but as my appetite returns to normal no more bland tasting food.

What will happen next?  Chemo, as cruel as it is, has gone but so has my safety net.  Nothing will happen to me while treatment is in progress but now it has come to an end, I enter the unknown.  An unknown world of what’s in store for the future years.  As I have discovered my brain is a weird phenomenon, as time passes the chemo becomes a distant memory.  It reminds me of childbirth, you quickly forget the pain but unlike childbirth where you go back for more, this is an experience not be repeated.  As I return to a normal life, thoughts of the cancer start to drift to the back of my brain but it never strays too far.  There are times when my emotions still flood my brain, I just want the thoughts and cancer to dry up and remain in a drought forever.  I so wish the doctor could give me a graduating certificate; check – surgery, check – chemo, check – radiation plus reassurance that I will stay strong, but no such reward just the reward to wait and see what life has in store for me.

Time is a healer I’m told, in which I am beginning to believe.  Listening to survivors stories, helps to know that there is light at the end of my journey. Being here for my family, appreciating every minute, every hour and every day that life has to offer, is a gift that is precious and not to be sniffed at.  It’s unfortunate that I have had to encounter this disaster to appreciate what really matters.

That dent in the sofa has recovered and so has my body for now.  I look out the window and fall is in the air and the leaves are starting to drop.  The cancer has also fallen away from my body.  No more sofas for me… there is a life out there waiting to be grasped firmly and lived to the fullest.  Most importantly living, alongside all the precious people that have supported me through my dark times and guided me with their candles.

I don’t know if there are more tough times ahead of me but I must stay focused on my life’s goals.  I have so much I need to accomplish and share in an unknown amount of time.  It’s critical for me not to waste time on irrelevant activities or thoughts.  I must use my time wisely and try not to forget my purpose here.

I must make my life count in a way that pleases me and no one else.

______________________________________________________________

Seeking Solace in the Hills

By Carol Taggart

He took my hand in his.  Together we walked along the path, the same winding path we had walked so many times before, under grand oaks and eucalyptus trees with peeling bark, among squirrels darting to and fro, and woodpeckers busily drilling holes in dead tree stumps, stashing their winter’s supply of precious acorns. It was all so familiar, but today was different for my husband and me.

We couldn’t look at each other or speak a word for a long distance.  Then we paused. Tears welled up in both our eyes, streaming down our cheeks. He pulled me closely to his body, hugging me as if never wanting to let go.

“I don’t want to lose you,” he emotionally cried.

Not fully comprehending the terrible new circumstances that had recently encompassed my world, in denial I found relief to my insurmountable fears.  It made me feel better.

“What do you mean? Lose me. You’re not going to lose me. I feel fine.  Look, I am feeling so fine I’m climbing the hills, all the way to The Dish”, referring to a popular climb to the Stanford Satellite Dish sitting on a high hill overlooking the university and environs.  “Further,” I said, “I’ve been referred to a special oncologist who can save me.  You’re not going to lose me.”

Tears streamed down my cheeks. I knew the denials belied my true, most inner feeling. I knew the prognosis was not good. I had Cancer! Breast Cancer! Triple-Negative Breast Cancer! Stage III Cancer! Lymph nodes involved! These were the truths that faced me.  I wondered if there was more.  Had the cancer travelled from my lymph nodes into my brain? my bones? I tried to rescue these unspeakable thoughts with more denial.  “I feel fine,” I wept.

********

A month earlier, following a diagnostic biopsy, my personal physician called. “Are you someplace where you can sit down?” she tactfully asked. Then I knew. Sinking slowly into a chair, I heard her softly say, “It’s Cancer.”  The words shot through my whole being like a knife, hardly believing, not wanting to believe.

Then, within days, I received more bad news. “It’s gone from bad to worse,” I told my husband. “The lymph nodes are involved, all the way up to my neck. From there, the cancer can spread to anywhere in my body – bones, brain, liver –anywhere.”

To add to my troubled mind, I was later to learn that Triple Negative Breast Cancer is a particularly vicious form of cancer, difficult to treat, with no known cure.

This was the troubled world in which I found myself.

********

On this particular day we had decided to walk up to the rolling hills behind Stanford University, with its seemingly never-ending winding hiking trails and far-reaching vistas.  Somehow I felt by going out into nature, I could forget my dreadful dilemma.  I would find solace in the hills.

Wiping tears from both our faces, we trudged on.  “You go ahead,” I told my husband.  As he ran up the hill, I found myself alone with my most inner thoughts.

Why cancer?  Why me?  Is this all a bad dream? Will the doctors save me? Will I live? Will I die? Does it hurt to die? How many more sunsets will I see? Will I be able to see cows grazing in the grass or birds singing their melodic songs one more time in these beautiful hills?

As I looked beyond the hills, I saw the sun was setting. Thinking I may never again see another sunset, this sunset became more dramatic than ever with its hues of oranges and reds, reflected on drifting pink clouds in the distance and above me.  With the sun dipping further behind the distant hills and the first minutes of darkness approaching, I wanted to cry out, “Don’t go, Sunset! Stay a little longer! Don’t you understand? I may never see you again!”

Massive oaks with their far-reaching branches were silhouetted like great massive sculptures against the darkening sky.  A lone bird flew to its tree, settling in for the night.

Contemplating being there for the last time, tears once again welled up in my eyes, as I turned away from other hikers, suffering in moments of private silence.

********

That was three years ago now.  Months of painful chemotherapy, a mastectomy with lymph node removal, and a month of daily radiation was behind me.

Now I climb those same hills with extra energy in my step. I deeply breathe in the air, so happy to be alive.  Cows roam the hills, lazily eating grass while squirrels dart in and out of their earthly holes. Each blade of grass moves silently in the breeze while white, billowy clouds drift above me. Birds provide melodic songs to my ears and colorful beauty to my eyes.  The cows, squirrels, grass, birds, and clouds represent life and I am a part of it!

I’m told that I’m cancer-free, that I have won the odds against me. The words are hard to believe.  Is it possible? Do I dare to believe, only to sink later into depths of despair finding out the cancer has returned? When will I hear the cancer has returned? Tomorrow?  A month from now?  A year from now?  Never? How do I know?

Returning to the same paths we have so often walked before, he holds my hand in his. We both smile, greeting other walkers. There are no more tears.  I am alive and cancer-free – at least for now.

______________________________________________________________

Voting ended Jan 26, 2013.

Traditionally, whole breast external beam radiation for breast cancer involves 25 treatment sessions over the course of 5 weeks.  During each session, 2 Gy doses of radiation are given, totaling 50 Gy by the end of the 5 weeks of treatment.  An outstanding question in the field of radiation oncology has been whether slightly larger daily doses given over a shorter treatment time is a safe and effective strategy for treating early-stage breast cancer.

To answer this question, researchers in the United Kingdom initiated the START B trial.  This trial compared the traditional 50 Gy delivered in 25 sessions over 5 weeks scheme to 40 Gy delivered in 15 sessions over 3 weeks.   After a median follow-up of almost 10 years, the results show no difference in the rate of local-regional breast cancer recurrence between the groups.  Furthermore, there were fewer side effects on normal tissues in the 40 Gy group.  The results of this trial have changed the standard of care in the United Kingdom to 40 Gy given in 15 doses over 3 weeks.   Clinicians at the 2012 San Antonio Breast Cancer Symposium, where the results of the START trial were presented, commented that the standard of care in the United States may be resistant to change, mainly due to the way that radiation therapy is billed to health insurance in the United States.

For women with estrogen receptor-positive breast cancer, treatment with 5 years of tamoxifen is known to substantially reduce the risk of breast cancer recurrence and breast cancer mortality.  Results of the international Adjuvant Tamoxifen:  Longer Against Shorter (ATLAS) trial, reported recently at the San Antonio Breast Cancer Symposium and published online in The Lancet demonstrate that extending tamoxifen therapy to 10 years results in a further reduction in breast cancer recurrence and mortality.

The ATLAS trial recruited 12,894 women with early-stage breast cancer who completed 5 years of tamoxifen therapy and randomized them to either 5 additional years or no further treatment.  Of these women, 6,846 had estrogen receptor-positive disease.  After following these women for 10 years, the investigators reported their breast cancer outcomes and side effects.

Women who took tamoxifen for 10 years were 3.7% less likely to have their breast cancer recur compared to the women who took Tamoxifen for 5 years (617 recurrences versus 711).  They were also 2.8% less likely to die from breast cancer (331 deaths versus 397).  However, extended treatment with tamoxifen increased the incidence of endometrial cancer from 1.6% in the control group to 3.1% in the treatment group.  This translated into a slight increase in endometrial cancer-related death, from 0.2% in the control group to 0.4% in the treatment group.

Results from the ATLAS trial are expected to impact the clinical care of some women with estrogen receptor-positive breast cancer.  According to Dr. Peter Ravdin, director of the Comprehensive Breast Health Clinic at the University of Texas Health Science Center, the finding from ATLAS “will have a major immediate impact on premenopausal women” who are at high risk for recurrence.  Ten years of tamoxifen may not provide much benefit to women with small, slow-growing cancers and negative lymph nodes, since their risk of recurrence is already quite low.  While post-menopausal women were included in the ATLAS trial, it is unlikely that these findings will change their standard of care since most post-menopausal women are prescribed aromatase inhibitors (AIs, i.e. Arimidex, Aromasin or Femara) and not tamoxifen.  There is currently no data to support the idea that 10 years of an AI is better than 5 years of an AI, although ongoing clinical trials seek to address this question.