BREAST CANCER RESEARCH

By Yana Puckett, MD

What is Breast Cancer?

Breast Cancer Statistics

Population affected: all women and men.

Chance of developing breast cancer in a lifetime: 1 in 8 women, 1 in 1000 men

● No. 1 cause of death in women and No.2 cancer overall in the United States ● 2014: 235,000 new cases in the U.S 40,000 deaths ● 2.5 years = Median survival without treatment ● 25% decrease in mortality with screening ● Country with lowest incidence of breast cancer: Japan and Eastern Africa

Current Screening Recommendations

● Annual mammography starting at the age of 40 ● Clinical breast examination every 2-3 years starting at the age of 20 ● Continue mammograms if woman is in good health

Social Determinants of Breast Cancer

● Breast cancer disparities exist ● Higher death rates 27/100 (B) vs 18/100 (W)(1) ● Inequalities in breast cancer screening, follow-up, and treatment after diagnosis, leading to greater mortality

Who Has a Higher Risk of Getting Breast Cancer?

● Use of oral birth control pills ● Not breastfeeding ● Diet high in fat, alcohol consumption ● Obesity ● Nulliparity ● Early menarche or late menopause ● Family history of breast cancer, ovarian cancer ● Smoking

What is Health Disparity?

“A particular type of

health difference

that is closely linked with

social, economic, and/or environmental disadvantage

.” *

* U.S. Department of Health and Human Services. The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Phase I report: Recommendations for the framework and format of Healthy People 2020. Section IV. Advisory Committee findings and recommendations.

Social Determinants Of Health and Breast Cancer

● Racial or Ethnic group ● Religion ● Socioeconomic status ● Gender ● Age ● Mental health ● Cognitive, sensory, or physical disability ● Sexual orientation or gender identity ● Geographic location ● Other characteristics historically linked to discrimination or exclusion

Cause of Disparities

Is it just because of poverty and illiteracy?

Cause of Disparities

● Genetic - Hispanic vs AA Women ● Nutrition and Physical Activity ● Lack of access to care - rural areas ● Lack of knowledge about insurance coverage ● Tobacco use ● Culture/religious beliefs ● Fear or anxiety about mammography

Cultural Beliefs?

● Several latest studies published a recent trend noted in African American women that refuse chemotherapy and radiation treatment (11-13).

● Fatalistic beliefs death!

CANCER

= inevitable

Reason for Lack of Screening

● Lack of knowledge about breast cancer ● Lack of belief in the healthcare system ● Mistrust of doctors -

Tuskegee Trial in 1930s

● Lack of healthcare coverage American Cancer Society.

Cancer Facts & Figures for African Americans 2007-2008

. Atlanta: American Cancer Society: 2007 Retrieved November 12, 2009 from, http://www.cancer.org/downloads/STT/CAFF2007AAacspdf2007

Affordable Care Act Data Collection

● Quality Improvement and Research ● Expected 32 million additional Americans will have health coverage by 2019 ● ACA is the first major step since the implementation of Medicaid which aims to relieve the disparity among minority populations regarding health care coverage and preventative care awareness

Milestones in Breast Cancer Research

● 1913 - X-rays are used to study breast cancer → introduces idea of mammography ● 1947 - First use of chemotherapy for treatment of cancer ● 1955 - Link discovered between estrogen and growth of breast cancer ● 1966 - First targeted breast cancer therapy, Tamoxifen, developed in UK ● 1970s - First use of CT scan to show tumors ● 1976 - American Cancer Society officially recommends use of mammography for breast cancer screening ● 1976 - Discovery of oncogene followed by tumor suppressor gene in 1982

Milestones in Breast Cancer Research Continued

● 1977 - Lumpectomy proven effective → 10 year study by Dr. Bernard Fisher, first randomized clinical trial ● 1994 - Dr. Mary-Claire King discovers location of BRCA1 gene and role in hereditary breast and ovarian cancer; 1995 → BRCA2 ● 1998 - FDA approves Herceptin, first target therapy for breast cancer, used to treat HER2+ ● 2009 - NIH launches The Cancer Genome Atlas following success of Human Genome Project in 2003

Research - Stakeholders

● National Cancer Institute: Federal organization under the National Institute of Health established in 1937 under National Cancer Institute Act funds from Congress - 2011: 625.1 million - 2012: 602.7 million 2013: 559.1 million → overall budget was 4.79 billion ● Grantees are “judged on scientific merit, potential impact, and likelihood of success” by scientific advisory board (7).

● NCI leadership then considers “public health significance, scientific novelty and overall representation of research topic (7).”

Research - Stakeholders

● Breast Cancer Research Foundation: nonprofit organization ● founded in 1993 Funds from donors → Estee Lauder Companies Inc, Play for PINK, Ann ● Inc. Generated over half a billion in breast cancer research since its start - 2013: 50 million - 2012: 40 million - Projected 2014-2015: 70.2 million ● Scientific Advisory Board seeks out researchers to fund 220 researchers across 14 countries and 6 continents

Latest Research: Did you know?

● Self-breast exams have not been proven to be helpful and are now not recommended (14) ● New initiative on the rise to start screening mammograms at the age of 50 instead of 40 or mammogram every 2 years rather than 1. Controversial, more studies needed (16) ● MRI instead of mammogram (15) ● Stopping screening at 70, 75, 80 (17)

Testing for Breast Cancer Genes

What is the breast cancer gene?

● BRCA1 and BRCA2 produce tumor suppressor proteins ● Mutations = proteins not produced, cancer sometimes ensues ● These mutations are inherited genetically ● Responsible for 5-10% of all breast cancers

Testing for Breast Cancer Genes

What does it mean if you have a mutation?

● Your risk for developing breast cancer is

greatly

increased - 90% chance of developing breast cancer overall.

● More likely to have another cancer such as ovarian.

Testing for Breast Cancer Genes

What is the test?

● Blood test detects harmful mutations in BRCA1 and BRCA2

Who should get tested?

● Family history of breast cancer on same side of family ● Immediate family member diagnosed before age 45 ● Family history of bilateral breast cancer ● Ashkenazi Jewish heritage and family history of breast cancer

Testing for Breast Cancer Genes

What does it tell you?

Positive result:

significantly at more risk, and treatment options are available: ● Increase cancer screenings and surveillance ● Preventive surgery (prophylactic mastectomy) ● Preventive medications

Negative result:

not genetically predisposed

Ambiguous result:

detects mutations not necessarily linked to cancer

Testing for Breast Cancer Genes

Benefits

● Knowledge of increased risk ● Increase in access to preventive measures

Challenges

● Cost of test ● Can be emotionally taxing ● Negative test results should not deter future screenings

Connecting Research, Social Determinants, and Treatment

General Benefits of Breast Cancer Research

● A better understanding of risk factors can allow for earlier detection and better prevention methods ● Increased ability for individualized treatment ● Identification of populations at risk allows for targeting screening and prevention towards these populations

Challenges of Research Application

● Treatment of cancer happens at a very individualized level

Questions?

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References

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17.

Eheman C, Henley SJ, Ballard-Barbash R, et al. Annual report to the nation on the status of cancer, 1975 –2008, featuring cancers associated with excess weight and lack of sufficient physical activity. Cancer 2012;118:2338 –66.

Crawford, S. P., & Alder, R. P. (2014). Breast cancer.

Magill’S Medical Guide (Online Edition), B RCA1 and BRCA2: Cancer risk and genetic testing. (2014). National Cancer Institute a the National Institutes of Health.

Genetic Testing. (2014). Susan G. Komen Foundation.

Tests and procedures: BRCA gene test for breast cancer. (2014). The Mayo Clinic.

http://www.bcrfcure.org/sites/default/files/2013-06%20BCRF%20Financial%20Statements.pdf

http://www.cancer.gov/cancertopics/factsheet/NCI/research-funding http://www.bcrfcure.org

http://ww5.komen.org/BreastCancer/1877GOKOMEN.html

http://www.cancer.org/research/acsresearchupdates/breast-cancer-research Simon, C. E. (2006). "Breast cancer screening: cultural beliefs and diverse populations." Health Soc Work 31(1): 36-43.

Thompson, H. S., et al. (2004). "The Group-Based Medical Mistrust Scale: psychometric properties and association with breast cancer screening." Prev Med 38(2): 209-218.

Klassen, A. C., et al. (2008). "A healthy mistrust: how worldview relates to attitudes about breast cancer screening in a cross-sectional survey of low-income women." Int J Equity Health 7: 5.

Grother, J. P. (2003). "Is breast self-exam efficacious?" J Midwifery Womens Health 48(4): 298.

(2014). "Breast cancer screening: options beyond the mammogram. The mammogram remains the foundation of breast cancer screening, but variations on this test can improve detection for some women." Harv Womens Health Watch 21(11): 3.

Saeger, H. D. and M. Hampl (1999). "[Mammographic screening starting in the fifth or sixth decade of life]." Chirurg 70(4): 380-383.

Rich, J. S. and W. C. Black (2000). "When should we stop screening?" Eff Clin Pract 3(2): 78-84.