July 2014 Research Highlights

Jamie DePolo: Hello, everyone. Welcome to this edition of the Breastcancer.org podcast. I'm Jamie DePolo, the senior editor here at Breastcancer.org, and as always, our guest today is our medical adviser, Dr. Brian Wojciechowski. He's going to explain some of the most recent Research News articles that we have covered on the site and give us some insights into a little more detail behind them. Welcome, Brian. How are you today?

Dr. Brian Wojciechowski: I'm very well. How are you?

Jamie DePolo: I'm good. I'm good. I think we have some very interesting articles to discuss today. The first one, I think is good because there is not a ton of research on inflammatory breast cancer. So I was very interested to see this study that had come out, and it says that if you treat inflammatory breast cancer with what the researchers call trimodality treatment, which means three treatments, which is chemotherapy, surgery, and radiation, that there's better survival if you have all three treatments compared to only treating inflammatory breast cancer with one or two of those treatments. And so, I was hoping you could explain for us first of all why chemotherapy comes first when you treat inflammatory breast cancer, and also, talk to us a little bit just in case everybody doesn't know what exactly is inflammatory breast cancer and how would that be considered different from invasive breast cancer.

Dr. Brian Wojciechowski: Okay. Well, inflammatory breast cancer is a type of invasive breast cancer, but it's a little different in terms of how it behaves and how it presents. The main feature of inflammatory breast cancer is skin involvement and it is said that the skin looks sort of like an orange peel.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: Yeah. And it's often not a discrete lump but more diffusive involvement of the skin and breast. So, often times you don't palpitate a mass, you just notice that the breast is firm, it's red, and, you know, it's often hard.

Jamie DePolo: Okay. Is it warm, too? Is it almost like it's swollen like infected?

Dr. Brian Wojciechowski: It can be, yeah. That's why they call it inflammatory.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: Okay. And as a general principle, we do chemotherapy before surgery when we're trying to make the breast more operable, basically. Someone with very large breast tumors, for example, can get chemotherapy before surgery in order to shrink it and make it easier to do the surgery.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: So, because of the very nature of inflammatory breast cancer, where it's more of a diffuse process than a discrete lump, doing the chemotherapy before surgery can shrink that and get it under control to make it easier for the surgeon to go in and take it out.

Jamie DePolo: Okay. And then if I'm understanding right, too, surgery to treat inflammatory breast cancer is almost always a mastectomy, correct?

Dr. Brian Wojciechowski: Correct.

Jamie DePolo: There's no lumpectomy because there's no lump.

Dr. Brian Wojciechowski: There's no lump. Exactly. It's diffuse involvement so we always do a mastectomy.

Jamie DePolo: Okay. Okay. And then the radiation is to zap any of the remaining cancer cells behind.

Dr. Brian Wojciechowski: Right. Because inflammatory cancer, besides being a diffuse process where it involves a lot of the skin and soft tissues, is also very aggressive and tends to come back more often than run-of-the-mill cancer, so you really want to hit it with every modality that you can, including hormonal therapy afterward or, you know, Herceptin therapy if the patient's cancer is HER2-positive.

Jamie DePolo: Okay. Okay. And so, if somebody gets diagnosed with inflammatory breast cancer and that particular person's doctor only recommends, say, chemotherapy and surgery, it makes sense for somebody to ask why. Correct? Because it sounds like using all three treatments is really the best way to go and that is the standard of care.

Dr. Brian Wojciechowski: It really is the standard of care for inflammatory breast cancer and has been for quite some time. So if a woman is not getting all three, there really better be a very good reason.

Jamie DePolo: Okay. Okay.

Dr. Brian Wojciechowski: Like some sort of medical contraindication, you know, that she can't get chemo or she can't get radiation, because, as this study shows us, there's good reasons for not getting the treatments, such as comorbidities and other medical problems that preclude it, and there's bad reasons, such as socioeconomic status or insurance.

Jamie DePolo: Okay. Okay. Our second study I thought was interesting because I had never read anything about this before. There were two studies that looked at a relationship between moles, which doctors apparently call nevi, a single is a nevus — I learned a lot when I was reading about the study. And they are linked to a higher risk of breast cancer. And I want to be clear that moles do not cause breast cancer. It really seems to be that having a lot of moles is linked to having more estrogen in the body, which can also be linked to breast cancer. So to start, Brian, for those of us who have a lot of moles and/or freckles, can you tell us the difference between a mole and a freckle so people aren't freaking out?

Dr. Brian Wojciechowski: So a freckle is a flat, pigmented area on the skin, and a mole is, generally speaking, a raised area with a distinct border that you can feel when you run your finger over it.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: And it's moles that generally can progress to, you know, skin cancers, and not freckles.

Jamie DePolo: Okay. Yeah, because I learned that, too, that moles aren't... if you have a lot of moles, you have a higher risk of skin cancer, too, because they can become cancerous.

Dr. Brian Wojciechowski: Right.

Jamie DePolo: So, there were two studies. One was a French study and one was a Nurses' Health Study, and the French study showed that the link between having a lot of moles and a higher risk of breast cancer was only in premenopausal women. The Nurses' Health Study was only looking at white women. So there were some sort of limitations to these studies, correct?

Dr. Brian Wojciechowski: That's true, they were limited in their scope. However, they were prospective studies so, based on that, they are relatively strong.

Jamie DePolo: Okay. And can you remind us again what a prospective study means. What does that mean?

Dr. Brian Wojciechowski: A prospective study is when you take, for example, two groups of women, one with a lot of moles, one with no moles, and follow them over time looking for differences of a particular outcome. And that's generally considered the strongest study design, as opposed to a retrospective study, where you're starting after the fact, after all the outcomes have already occurred, and you're looking back in time.

Jamie DePolo: Okay. Okay. So, yeah, a retrospective study in this case would be women who are diagnosed with breast cancer and then the researchers went back and looked at how many moles they had.

Dr. Brian Wojciechowski: That's right. And by doing it that way, you introduce more opportunities for bias and therefore, the validity of the study is in question.

Jamie DePolo: Okay. And so, as we were talking, the strongest point from these studies is that we don't want people to get very, very concerned if they have moles because moles, again, moles don't cause breast cancer. Correct? But they seem to be an indication of higher levels of estrogen. Correct? And so is it that the estrogen is causing more moles to form? Is that what it does?

Dr. Brian Wojciechowski: Well, I don't think we know for sure, but that's what these studies seem to suggest, that higher levels of estrogen are associated with more moles.

Jamie DePolo: Okay. And higher levels of estrogen can cause hormone-receptor-positive breast cancer to develop and grow, so that's where the concern is.

Dr. Brian Wojciechowski: Exactly.

Jamie DePolo: But ultimately, it sounds like we're not quite sure how this could all fit in to any sort of risk assessment yet because it's so new.

Dr. Brian Wojciechowski: Yeah. Women who have a lot of moles shouldn't get worried at this point because there's really nothing actionable for them here. It doesn't mean that they have to get mammograms more frequently or anything like that because we just don't know that yet. We don't have that data.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: We don't really know how to apply this information and, you know, I think a lot more studies have to be done before women who have a lot moles are treated any different from any other woman. Okay. So the same guidelines apply to women with more moles that apply to, you know, any other woman in the general population.

Jamie DePolo: Okay. Just somebody with an average risk of breast cancer.

Dr. Brian Wojciechowski: Exactly.

Jamie DePolo: Okay. Okay. Well, that's good to know. Now, we had another study that was looking at women with abnormal BRCA1 and BRCA2 genes, and the researchers found that if these women were diagnosed with breast cancer, women with an abnormal BRCA1 gene who had their ovaries and fallopian tubes removed were more likely to survive the breast cancer. And it was interesting to me that the protective effects of the surgery were found primarily in women with the abnormal BRCA1 gene as opposed to the abnormal BRCA2 gene.

There were two studies: so there was that one that found that result of the benefit, but then there was another study that found that women who did have this protective surgery, their quality of life was affected because you immediately get thrown into menopause. You're a premenopausal woman and all of a sudden you may have sleeping problems, you may have problems thinking and remembering, you may have hot flashes, probably do, and there may be problems with sexual function. So, Brian, if you could talk a little bit about the differences between having an abnormal BRCA1 gene and an abnormal BRCA2 gene and what that means for an individual woman, like what she may want to consider.

Dr. Brian Wojciechowski: Yeah. So everyone has a BRCA1 and 2 gene. It's when they are abnormal and there's genetic changes to those genes that a woman's risk of breast or ovarian cancer goes up considerably. Now in this study, the benefit was seen mostly in woman with BRCA1, and that could be because, generally speaking, women with BRCA1 are at higher risk of breast cancer anyway. But it's just an abstract form so it hasn't been published yet, so I'm only speculating there.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: Because of the poor quality of life that happens when you get your ovaries out, there has been some doubt or reluctance among physicians to recommend this surgery at times. This is a very helpful study because it provides a very strong reason, a very strong rationale, to now recommend having that surgery. Because there's no better outcome in medicine than, you know, something that increases your survival.

Jamie DePolo: Right. Right. And we should point out that these women with the abnormal genes were already diagnosed with breast cancer. So this study does not apply to women who are at high risk because they know they have one of these abnormal genes but have not been diagnosed.

Dr. Brian Wojciechowski: That's correct. You know, women with BRCA1 who've never had breast cancer can still opt to get their ovaries removed, and there's nothing wrong with that, but this particular study applies only to women who have had breast cancer.

Jamie DePolo: Right. Right. Okay. And again, we do want to emphasis that this is a very personal decision and you do need to be aware that there are side effects. You know, you are going to have an effect on your quality of life and you just need to sit down and talk to your doctor, talk to your family, think about it, and see if it's the right decision for you. It could be, it could be or it could be not. It's the right decision for some women and it's not the right decision for other women, but it is an option.

Dr. Brian Wojciechowski: Exactly.

Jamie DePolo: And this study does, as you said, Brian, gives us some pretty strong evidence that if a woman has this abnormal gene and it has been diagnosed, there are some benefits, too. So, again, as with any treatment or any procedure that you have, we always say on Breastcancer.org you need to weigh the risks and the benefits and see how that fits with your personal preferences and your tolerability of risk in what you want to do. But at least we have evidence now that there are some benefits, which is good. Right?

Dr. Brian Wojciechowski: I couldn't have said it better myself.

Jamie DePolo: Well, that's good because you're the expert!

Dr. Brian Wojciechowski: I'm just riding your coat tails, Jamie!

Jamie DePolo: No, no, no. Now our third – our fourth and final study, I thought this was also very interesting. It got quite a bit of coverage in the media. I know there were stories in the New York Times. There were stories all over the web. This is talking about using 3-D mammograms, which are also called digital tomosynthesis -- and Brian and I were talking before we started here that that's very confusing to have two names for the same procedure. And you combine that with digital mammography, and this technique, both techniques find more cancers and with fewer false positives. So, to start with, Brian, can you sort of explain what a 3-D mammogram is and how it's different from a digital mammogram?

Dr. Brian Wojciechowski: So let's start from the beginning.

Jamie DePolo: Way back when.

Dr. Brian Wojciechowski: When mammograms were first born, they consisted of, really, two X-rays of the breast from different angles. So that was called a 2-D mammogram, and this was in the days when, you know, when you read an X-ray, it was on actual films.

Jamie DePolo: Okay. Okay. Films. A giant sheet of film.

Dr. Brian Wojciechowski: Yeah. A giant film that you held in your hand and stuck up on the wall in front of a light.

Jamie DePolo: A light box.

Dr. Brian Wojciechowski: Yeah, a light box, and you read it that way. So, fast forward decades into the future and you had the development of digital mammography, where instead of putting the X-ray picture on a piece of film, you put it on a computer image. So the radiologist could manipulate that image. He could zoom in or zoom out and you could change the brightness of it, that sort of thing, and it, you know, it improved on the accuracy.

Jamie DePolo: Okay. Okay. The accuracy.

Dr. Brian Wojciechowski: Yeah. So three dimensional mammograms are basically looking at the breast from three angles. So you have that additional dimension and of course, because it's 2014, they're digital. It's not the old film mammography.

Jamie DePolo: Okay. Right. So it actually takes more images of the breast.

Dr. Brian Wojciechowski: Yeah. And therefore you get a little bit higher radiation exposure.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: Okay. But we know beyond a shadow of a doubt that this technique leads to less false positives.

Jamie DePolo: Okay. And can you... that was going to be my next question. Can you just sort of give a brief synopsis of what a false positive is?

Dr. Brian Wojciechowski: Yeah. A false positive is basically when they find something on the mammogram that looks concerning and you get a biopsy and it's benign.

Jamie DePolo: Okay. And it's usually stressful, because I've had them, and you get called back, and you're wondering what they saw, you know, “Are they going to see it again? Are they going to tell me I've been diagnosed with cancer?” So it is stressful and you may have to have another scan. You may have to have a biopsy which is surgery. You may have to have several more visits. So I can see why false positives are a problem.

Dr. Brian Wojciechowski: Yeah. Yeah. It's extremely stressful. So it decreases the rate of false positives, and it detects more cancers than conventional mammograms. And those are two really important advances with this technique.

Jamie DePolo: Okay. Absolutely. Because the false positives, too -- and if people are regular readers of our website, there's been some controversy over mammograms -- do all women need mammograms? And invariably, people point to either false positives or overtreatment as the problem with mammograms, because they're finding things that either look suspicious and aren't, they turn out to be fine, or they're finding things that don't need to be treated. So, in a sense, this is kind of improving on mammograms. Right?

Dr. Brian Wojciechowski: Exactly.

Jamie DePolo: It's a step forward.

Dr. Brian Wojciechowski: It's a better mammogram. No doubt.

Jamie DePolo: Okay. And it's also my understanding, too, that they're available at a lot of places but not everywhere. So if you happen to live in an urban area with university hospitals, teaching hospitals, research hospitals, you could probably get a digital 3-D mammogram if you wanted one.

Dr. Brian Wojciechowski: And add affluent communities to that list.

Jamie DePolo: Okay. Okay. Because they are more expensive. Right.

Dr. Brian Wojciechowski: Yeah. It requires more of an upfront investment from the hospital.

Jamie DePolo: Okay. But if you, say, lived in a very remote area that perhaps wasn't as affluent, you're probably not going to have this piece of equipment at your local mammogram center.

Dr. Brian Wojciechowski: Yeah. You would probably have to travel a considerable distance.

Jamie DePolo: Okay. So let's talk about that. Do you think that every woman needs to have a 3-D mammogram?

Dr. Brian Wojciechowski: I don't think so. I don't think we have enough information on what are the long-term outcomes. Now, we know it's a slightly higher dose of radiation. Most doctors are not concerned about that because it's still a very low dose, but still, we don't know the long-term impact of that. We also don't know if it changes any particular outcomes, say, you know, do women who have 3-D mammograms have a better survival than women who have conventional 2-D mammograms? So I would not say that women listening to this podcast have an imperative that they need, they absolutely have to go get a 3-D mammogram. We really can't say that yet.

Jamie DePolo: Okay. Okay.

Dr. Brian Wojciechowski: But suffice it to say what we do know, and this is beyond a doubt, is that 3-D mammograms are slightly better in terms of decreasing the rate of false positives and detecting more cancers. So my feeling is that if I were a woman who was mammogram age, I'd probably want to get it.

Jamie DePolo: Okay. Okay.

Dr. Brian Wojciechowski: But I don't think it's written in stone that you have to at this point.

Jamie DePolo: Okay. And if you don't have the option of getting one, you're not getting substandard care with a digital mammogram? You're still getting a good test.

Dr. Brian Wojciechowski: Yeah. You're still getting a very good, very effective test that I will reiterate, as I have many times in the past, does save lives, okay. We know that there are a lot of false positives associated with mammograms. But women's lives will be saved by getting mammograms. So, to me, that is the most compelling argument that mammograms are good and should be done routinely.

Jamie DePolo: Okay. Okay. From the age of 40 on, annual mammogram. That's your position, I know that's Breastcancer.org's position. And I would add if anyone's listening out there, and you don't get a mammogram because you don't know where to go, or you don't think you can afford it, or you find them painful, there are ways to overcome all those things and any other reasons that you might have for not getting one. And if you go to our website, we have a whole page on mammograms that will talk all about that and where you can get one at low or no cost, how you can have the procedure be less painful, how you can find a center that does mammograms. So there's lots of information there. And I guess we'll wait, too, to see if there's more research that comes out, and ultimately, if it turns out that 3-D mammograms do have better outcomes, then it seems like probably everyone will be switching. I mean, it sounds like a lot of hospitals are getting the equipment because, as you say, it is better and people want to have the best care possible.

Dr. Brian Wojciechowski: Exactly. Yeah.

Jamie DePolo: All right. Anything else about that, Brian?

Dr. Brian Wojciechowski: I don't think so.

Jamie DePolo: All right. Well, thank you so much. This is always a very informative podcast. Thank you for stopping in. We thank everybody for listening, and we'll probably be back again next month with another Breastcancer.org Research Newscast. Thanks everyone for listening.