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Running For More…

The personal blog and website of Kristen Cincotta

Archive for the ‘About Cancer’ Category

Gone, But Never Forgotten

Friday, April 5th, 2013

I know that I still owe everyone a recap on my first half marathon and an update on the results of my Running for the ROC fundraiser. Those posts will be coming, soon. But tonight, I wanted to talk for a minute about Bridget Spence.

Bridget, featured in an ad for Komen for the Cure

Bridget was a member of my pink family. I never had the privilege of meeting Bridget, but as part of the extended 3 Day family, I felt like I knew her. I think a lot of us felt that way. She was so open and honest in her blog, My Big Girl Pants, it was hard not to feel like she was an old friend. Today, we all received word that after a long battle with breast cancer, Bridget passed away last night surrounded by those who truly did know and love her best.

Bridget’s cancer was similar to my mom’s. As similar as a cancer can be, I guess, when it strikes a woman in her early 60s and a young lady in her early 20s. Both of their cancers were/are HER2+, a protein marker that we didn’t even know was a thing until the last two decades. The discovery of HER2+ cancers quickly led to the development of Herceptin, the drug that both my mom and Bridget credited with extending their lives far beyond what used to be expected for Stage IV metastatic breast cancer.

Herceptin is a different kind of drug. The HER2 gene causes cells to express extremely high levels of cell surface receptors that promote improper, aggressive cell division. Herceptin is an antibody that gloms onto those receptors, effectively blocking them from promoting cell division. Unlike other chemo drugs, which interrupt universal cell division processes (and therefore target ALL dividing cells in the body, leading to those side effects that are commonly associated with cancer treatments), Herceptin only affects the cancer cells that are over-expressing these receptors. As a result, it is tolerable for far longer than most chemo drugs. My mom was on Herceptin for the entire first 18 months she was being treated and has been on it continuously since her cancer came back in early 2010. From what she wrote, Bridget was on it for most of her 6+ years of treatment. Herceptin is not a cure in and of itself. Instead, Herceptin keeps the cancer at bay so that individuals like Mom and Bridget can live their lives. Herceptin turns metastatic breast cancer into a chronic condition rather than an immediate death sentence.

Herceptin first gained FDA approval 15 years ago. That’s not that long ago, as far as biomedical breakthroughs go. But scientists aren’t generally the sort to be contented with one breakthrough. Herceptin isn’t perfect. So scientists and the organizations that fund them started asking “What’s next?”. And what was next is TDM-1. TDM-1 is a new drug that is a hybrid of two cancer drugs that we already had: Herceptin plus a super potent molecule of traditional chemotherapy. On its own, that chemo molecule is too damaging to be used in medical care, even for metastatic cancer. It just wouldn’t be tolerable at the doses you’d need to give to get full coverage of a cancer that has spread throughout the body. But! Stick that molecule of super chemo onto a Herceptin molecule, and it’s the equivalent of adding a honing device to missile. Suddenly, the chemo bomb is delivered directly to the cancer cells. That means that far less of the chemo needs to be given to have the same anti-cancer effect. All of the potency, relatively minimal cellular collateral damage. This is what a I truly believe is the future of chemotherapy. And because of Herceptin, HER2+ breast cancer is the first one to have a specific antibody-chemo conjugate that targets it.

TDM-1 was approved for use by the FDA on February 22nd, 2013, when it was rechristened “Kadcyla”. It was in clinical trials last summer when my mom was told that the current treatment she was on might be the last one available to her once her cancer outsmarted it. These last few months have been stressful, wondering what would happen first: would Mom’s cancer would wisen up to the taxotere she was taking and become resistant or would TDM-1 get approved? Thankfully, the clinical trials were successful and the FDA, recognizing the potential in TDM-1, expedited the approval just in time. Mom’s cancer hasn’t yet outsmarted the taxotere. But a few weeks ago, the taxotere outsmarted her lungs and caused significant fluid accumulation, making it unsustainable as a cancer treatment.

Mom will start Kadcyla in a few weeks, if not sooner. And because of Bridget, my mom knows what to expect of this brand new drug. That’s because brave, strong Bridget was in the clinical trials for TDM-1.

When your parent is diagnosed with cancer and you are told that it will be okay, because there are treatments available, you are relieved. You probably don’t give much thought to the people who came before you, who tried all of those experimental drugs and surgeries before we knew what they would do. When you’re told there may not be any more treatments available, it is terrifying. You are obsessed with the clinical trials: who’s in them, what are they experiencing, is it going to work???

You almost never get answers to those questions. Because of Bridget and her honesty, I did. And more importantly, my mom did. That kept Mom fighting so that she would be here for the day that TDM-1 became a reality for her. That’s why Mom is still here, feeling strong and optimistic about this next phase of treatment.

Bridget gave me the greatest gift I have, and probably will ever receive: more time with my mom. That is a priceless gift. In her final blog post back in December, Bridget asked that we not forget her. I know that I absolutely never will.

When I Ran for the ROC at the Publix Half Marathon in March, I dedicated one of my miles to Bridget, knowing that she had made the courageous decision to end her treatments. Tomorrow morning, I will run the Northwestern Mutual Road to the Final Four 5K benefitting the American Cancer Society’s Coaches vs Cancer program in Bridget’s name. It is the very least I can do to honor someone who has given me so much.

#NHBPM Post 3: Stomach Cancer Awareness Month!

Wednesday, November 7th, 2012

Note: This post is a part of WeGo Health‘s National Health Blog Post Month: 30 posts in 30 days challenge. The prompt for Day 3 that I’m responding to is “I don’t know about this, but I’d like to…”. To see the rest of my #NHBPM posts, please click on the image at the bottom of this post.

So, as noted in my #NHBPM header introduction, the prompt for “Day 3” was “I don’t know about this, but I’d like too… ” which seems like the perfect time to write another post in my Cancer Awareness Months series. As I’ve written before, while I choose to focus my efforts primarily on breast cancer awareness and advocacy, I feel that it is important for all cancer advocates to have some familiarity with each of the major cancer subtypes. So using the “Awareness Months” as my guide, I’ve been researching and writing brief synopses on different subtypes of cancer, which can all be found filed under the blog category “Cancer Awareness Months”. The month of November serves triple duty as Lung Cancer Awareness Month, Pancreatic Cancer Awareness Month, and Stomach Cancer Awareness Month, which is what I’m going to be writing about today.

Stomach Cancer Awareness Month was started in 2010 by the group No Stomach for Cancer. They chose November because it is “a month known for the pleasure of eating”. With so many of us thinking about our bellies this month, this is the perfect month to shine a spotlight on this widely overlooked type of cancer. In fact, while mortality has been declining over recent decades (especially here in the United States), stomach cancer is still the second leading cause of cancer death word wide.

About Stomach Cancer

Stomach cancer, which is also commonly referred to as gastric cancer, is any cancer that forms in the tissues lining the stomach. The stomach itself is actually made up of five distinct tissue layers:

  1. Inner layer/lining (or mucosa): the site of digestive enzyme production and the most common origination site for stomach cancers.
  2. Submucosa: the supportive tissue layer for the inner layer of the stomach.
  3. Muscle layer: the location of the muscles responsible for digestive contractions that keep food moving through the GI tract.
  4. Subserosa: the supportive tissue layer for the outer layer of the stomach.
  5. Outer layer (or serosa): the tissue that covers the exterior of the stomach and holds it in place within the abdomen.
Per the NCI page on stomach cancer, this type of cancer usually begins in the cells of the inner layer of the stomach and can, over time, grow and invade the deeper tissues of the stomach wall. This type of stomach cancer is called adenocarcinoma and accounts for 90-95% of all malignant stomach tumors. The other three less common types of cancer found in the stomach are:
  1. Lymphoma, which is a cancer of the immune system that is sometimes found in the wall of the stomach. Lymphomas (which I wrote about in more detail here) account for ~4% of all stomach cancers.
  2. Carcinoid tumors, which start in the hormone -making cells of the stomach. These tumors account for ~3% of all stomach cancers.
  3. GI stromal tumors (or GIST), which originate in a specific type of cell in the stomach wall known as the interstitial cells of Cajal. These types of tumors can be found anywhere along the GI tract, although they are most commonly found in the stomach. Even so, GI stromal tumors are very rare among stomach cancers.
Risk Factors for Stomach Cancer
While we don’t know the direct cause (or more likely, causes) of stomach cancer, a number of risk factors have been identified, the management of which has led to the aforementioned decline in stomach cancer mortality here in the United States. I’m going to go through a number of these risk factors in more depth, but in general, factors that contribute to gastric inflammation and poor nutrition (which itself contributes to gastric inflammation) can have a large impact on a person’s risk for developing stomach cancer. As a result, stomach cancer is much more prominent in less developed countries (and in the less well off segments of developed countries as well) where healthy food, clean water, and proper refrigeration are not widely available.
Some of the recognized risk factors for stomach cancer include:
  • Infection with Helicobacter pylori bacteria. H pylori is a very common infection of the inner lining of the stomach. It is estimated that up to two-thirds of the world’s population is harboring H pylori at any given time, the majority of whom will suffer no ill consequences of this infection. In order to survive within the acidic environment of the stomach, these bacteria actively convert nitrites/nitrates from our food into ammonia, which can irritate the stomach lining resulting in peptic ulcers, among other complications. When left untreated over the long term, this irritation to the stomach walls can leave those tissues at a greater risk for developing cancer. H pylori is spread from person to person via contaminated food and water or through mouth to mouth contact. While H pylori is still very common around the world, the increasingly widespread use of antibiotics to treat other infections in developed countries has had the incidental effect of reducing H pylori infection rates in those countries. You can read more about the connections between H pylori and cancer here.
  • Eating a poor diet consisting of high amounts of smoked/pickled/salted foods and low amounts of fresh fruit and vegetables. This type of diet is thought to increase risk for stomach cancer due to the high amounts of nitrites/nitrates in foods that have been preserved using these methods, which again can contribute to lower stomach acidity and long term inflammation of the stomach tissues. Fruits and vegetables, with their plethora of good for you vitamins and minerals are thought to counteract some of these ill effects and are generally easier on the stomach. The advent of refrigeration has led to a significant decrease in preservation via smoking/pickling/salting and, when coupled with the increased ability to keep fresh fruits and vegetables on hand year round, has led to a significant reduction in stomach cancer around the world, and especially here in the United States and in Europe.
  • Pernicious anemia. Pernicious anemia is a form of anemia that is caused by a deficiency in vitamin B12.
  • Previous stomach surgeries or illnesses. Because these operations or conditions can alter the enzymatic balance within the stomach and leave the tissues irritated, having a history of GI surgeries or distress is associated with a higher risk for developing stomach cancer. This includes having a personal history of other forms of stomach cancer, including lymphoma and GIST.
  • Smoking. Smokers have twice the risk of developing stomach cancer as non-smokers, likely to due increased irritation of the stomach tissues.
  • The usual suspects. As with most other forms of cancer, age, obesity, lack of physical activity, and a family history of stomach cancer are also considered risk factors for stomach cancer.

To learn more about the risk factors associated with stomach cancer, I highly recommend the American Cancer Society’s webpage on the topic, here.

The Statistics

It is estimated that 21,320 people will be diagnosed with stomach cancer in 2012, with the majority of those diagnoses (13,020) occurring in men. 10,540 people will die of stomach cancer in that same time period. 26.9% of all people diagnosed with stomach cancer live at least five years following initial diagnosis. One in 116 people will be diagnosed with stomach cancer at some point in their lifetimes, with diagnoses in men being more common. Thankfully, for reasons discussed in the previous section, the incidence rate has been steadily dropping since the 1930s when stomach cancer was the leading cause of cancer death here in the United States. However, due to lack of refrigeration, unhealthy diets, and contaminated water, stomach cancer is still very common in other parts of the world where it remains the second leading cause of cancer death. It is estimated that the United States spends ~ $1.6 billion annually on treating stomach cancer.

The NCI allocated $14.5 million (or 0.29%) of their budget for stomach cancer research in 2010, the most recent year for which those statistics were available.

Recommended Resources

If you would like to learn more about stomach cancer, I highly recommend reading through the NCI’s web pages dedicated to stomach cancer, which can be found here. Their “What You Need To Know” section is particularly informative, as is the “snapshot” report on stomach cancer, especially the section discussing recent research investments and findings. I also found the American Cancer Society’s Learn About Cancer: Stomach Cancer section to be very useful. All of the statistics cited in the post were from the Surveillance Epidemiology and End Results (SEER) fact sheet on thyroid cancer, which can be found here. These webpages were my primary sources of information for this blog post.

The American Association for Cancer Research does not have any specific recommendations for organizations dedicated to stomach cancer research, stomach cancer advocacy, or patient support for those diagnosed with stomach cancer. However, the following organizations are (to the best of my knowledge) considered to be leaders in the field and may be worth consulting:

No Stomach for Cancer, the founders of Stomach Cancer Awareness Month

Can’t Stomach Cancer

The Gastric Cancer Foundation

The Life Raft Group, an organization that focuses on GI stromal tumors.

As with all of these cancer awareness posts, I hope that everyone reading this found it helpful and informative. I know I learned a lot researching it and will be a more effective cancer advocate for it!

Note: While I am a biomedical scientist, I am not considered an expert (medical or otherwise) on stomach cancer. This post, as with all of my “awareness month” posts, is not meant to be an in depth review of stomach cancer. Rather, I only wanted to provide a brief overview of stomach cancer in order to help further the larger cancer community’s awareness of this common cancer. Moreover, while I provided links to a number of stomach cancer organizations at the end of this post, I have not researched these organizations to the extent that I do for my “Spotlight On” series of posts. Until I can research them further, I am not explicitly advocating financial donations to these organizations (although I certainly won’t advise you against it either should you find them worthy!). Instead, I am recommending them here because each organization is a well respected leader in these specific areas and is considered a reputable source for further information on stomach cancer.

 

Thyroid Cancer Awareness Month!

Thursday, September 27th, 2012

September was a busy month full of cancer awareness observances and I’m not quite done yet!

As I’ve mentioned in the introductions to the other “cancer awareness month” posts that I’ve written, I believe very strongly that even though I identify myself as primarily a breast cancer advocate, it is important for me to have some level of understanding of the other major cancer types. To help broaden my knowledge, I’ve been using the various cancer awareness observances as my guide for which cancers to research and write about. And as it turns out, there are A LOT of them in September. Over the course of the last few weeks, I’ve written posts touching on Childhood Cancer Awareness Month, Blood Cancers Awareness Month, Ovarian and Gynecological Cancers Awareness Month, and Prostate Cancer Awareness Month. Today, to wrap things up, I’m going to write a little bit about thyroid cancer in honor of Thyroid Cancer Awareness Month.

Thyroid Cancer Awareness Month was first initiated by ThyCa: Thyroid Cancer Survivors Association back in 2000. When it was originally founded, it was only a week long observance that was extended for the full month of September in 2003. As ThyCa puts it on their website:

Thyroid Cancer Awareness Month promotes thyroid cancer awareness for early detection, as well as care based on expert standards and increased research to achieve cures for all thyroid cancer.

In my reading, I came across some assertions that due its relatively low mortality rates, thyroid cancer was the “good” cancer to get. Well, that’s just ridiculous. All cancer sucks because all cancer can and does kill people. There is no such thing as a “good” cancer to get. And with the fastest increasing incidence rate of all cancers in both men and women, it’s time to pay more attention to thyroid cancer!

About Thyroid Cancer

Thyroid cancer, following the traditional naming conventions in oncology, is any cancer that forms in the thyroid gland. That part should be pretty straightforward by now. But what exactly is the thyroid gland? Well, the thyroid gland is a small organ at the base of the throat, just below the larynx (voice box) that makes hormones to regulate the rate of metabolism. The thyroid is shaped sort of like a butterfly, with two larger lobes connected by a small piece of tissue called the isthmus. In healthy individuals, the thyroid is a little larger than a quarter and can’t be felt manually through the skin. The thyroid is composed of two primary hormone producing cells:

  1. Follicular cells, which use iodine from the blood to make the not so creatively named thyroid hormone (TH). TH is produced in response to increasing levels of the also not so creatively named thyroid stimulating hormone (TSH), which is generated and released from the pituitary gland. Because TH is required for metabolism, improper levels of TH can have a whole host of side effects. Someone who has too much TH (called hyperthyroidism), for example, often experiences irregular heartbeat, trouble sleeping, nervousness, hunger, weight loss, and feeling to warm. Having too little TH (which is called hypothyroidism), on the other hand, can cause a person to feel slow and fatigued and to gain weight.
  2. C cells, or parafollicular cells as their also called, which are responsible for producing calcitonin, a hormone that helps regulate how the thyroid uses calcium.

Thyroid cancer can develop in either thyroid cell type, giving rise to four major subtypes of thyroid cancers: papillary carcinoma, follicular carcinoma, medullary thyroid cancer, and anaplastic thyroid cancer. Let’s go through each one, one at a time.

The most common subtype of thyroid cancer is papillary carcinoma, which develops from the follicular cells. Because these are glandular cells, this type of thyroid cancer is also sometimes referred to as papillary adenocarcinoma. Papillary carcinomas, which account for 86% of all thyroid cancers, are generally slow growing, although they are prone to spreading into the lymph nodes of the neck. These cancers are usually isolated to only one lobe of the thyroid, although not always. Papillary carcinomas can usually be treated and are rarely fatal.

The second most common subtype of thyroid cancer is follicular carcinoma, which accounts for 9% of all thyroid cancer diagnoses. Follicular thyroid cancer is very similar to papillary thyroid cancer in that both types of cancer originate in the follicular cells and are relatively slow growing. However, unlike papillary thyroid cancer, follicular thyroid cancer generally doesn’t spread to the lymph nodes. Follicular thyroid cancer is most common in countries lacking dietary iodine. The prognosis for individuals diagnosed with follicular thyroid cancer is generally good, although not quite as strong as for those with papillary carcinoma. This is at least in part due to the relatively poor prognosis for the Hürthle cell carcinoma subtype of follicular cancer. Because Hürthle cell follicular carcinomas do not readily absorb radioactive iodine, they are often diagnosed at later stages and are much more difficult treat.

The third major subtype of thyroid cancer is medullary thyroid cancer, or MTC. Unlike the previous two subtypes, MTC develops from the c-cells of the thyroid. MTC, which accounts for 2% of all thyroid cancers, often results in abnormally high levels of calcitonin. MTC is usually slow growing and is treatable if caught before the cancer spreads to other parts of the body. MTCs can be linked to inherited mutations in the RET. This form of MTC, which I’m going to talk about more later in this post, is known as familial medullary thyroid cancer and accounts for 25% of all MTCs.

The most rare form of thyroid cancer is anaplastic thyroid cancer, which accounts for approximately 1% of all thyroid cancers. Anaplastic thyroid cancer also develops in the follicular cells, and is thought to sometimes develop from an existing papillary or follicular cancer. Because anaplastic cancer cells are highly dysmorphic and do not resemble healthy thyroid cells when examined under a microscope, anaplastic thyroid cancer is sometimes described as “undifferentiated” thyroid cancer. Anaplastic thyroid cancer is the most aggressive form of thyroid cancer, rapidly invaded the neck and then spreading to other parts of the body. Because of this, anaplastic thyroid cancer is relatively hard to treat.

Finally, while it is not technically a form of thyroid cancer, I wanted to just briefly write about parathyroid cancer, which is any cancer that develops from the four tiny parathyroid glands located at the back of the thyroid. Parathyroid cancer is very rare (with less than 100 cases occurring in the US each year) and generally results in elevated levels of calcium in the blood due to calcium dysregulation. Parathyroid cancer is much more difficult to cure than thyroid cancer.

While the cause of every form of thyroid cancer remains unknown, there have been a handful of risk factors that have been identified. For as yet unknown reasons, thyroid cancer is three times more common in women than in men. Moreover, women tend to be diagnosed with thyroid cancer at a younger age, with the peak rate of diagnosis for women occurring in their 40s and 50s while the peak rate of diagnosis occurring in their 60s and 70s. Eating a diet that is low in iodine has also been shown to increase the risk of developing thyroid cancer, although due to dietary supplements like iodized table salt, this isn’t generally a concern here in the US. While exposure to radiation can increase your risk of developing cancer in general, radiation exposure seems to be particularly strongly linked to an increased risk for thyroid cancer. This includes both exposure to medical radiation as a child and nuclear fall out from living near atomic bomb testing sites and disasters such as the meltdown of the Chernobyl nuclear power station. Finally, there have been a number of genetic mutations linked to the various subtypes of thyroid cancer, which I’m going to talk about in the next section.

The Genetics of Thyroid Cancer

There are two primary types of genes that, when mutated, can result in cancer:

  1. Oncogenes: These are genes that promote growth and cell division. These types of genes are usually turned “off” and are only switched on under highly regulated circumstances. When an oncogene becomes mutated, it becomes permanently turned on (and in some cases turned way up!), resulting in uncontrolled cell growth and division.
  2. Tumor suppressor genes: These are genes that are normally responsible for turning off the oncogenes and stopping cell growth and division before it gets out of control. When tumor suppressor genes become mutated, the off switch essentially is broken, allowing cells to continue growing and multiplying. The rate of cell growth and division isn’t higher, it’s just that the stop light is busted. As a result, mutations in tumor suppressor genes generally result in less aggressive forms of cancer.

Different cell types in the body seem to have certain genes that are more vulnerable to cancer-causing mutations than others. These mutations can be either inherited (meaning you were born with a bum form of the gene) or acquired (meaning you picked up that damage at some point during your life). Cancer due to inherited mutations is known as familial cancer and cancer that is due to acquired mutations is known as sporadic cancer. One of the great challenges in cancer research, then, is to identify both the vulnerable genes associated with each cell type (and therefore associated with each cancer type) and to identify the source of the mutations in those genes. In the case of thyroid cancer, and especially MTC, we actually have uncovered the answers to a few of these genetic questions.

The primary gene that has been associated with thyroid cancer is the gene RET. The mutated form of RET is the oncogene PTC. Acquired mutations in RET have been found to play a role in some papillary thyroid cancers as well as in approximately 10% of sporadic MTCs. Inherited mutations in RET, though, underly almost all cases of familial MTC. Nearly everyone who inherits a mutated form of RET ultimately develops MTC. As a result, if someone has a strong family history of MTC, many doctors will recommend genetic testing and potentially prophylactic removal of the thyroid as a means of preventing thyroid cancer.

Other oncogenes that have been associated with thyroid cancers include:

  • BRAF (oncogene) – mutations in BRAF have been associated with 30-70% of papillary thyroid cancers
  • NTRK1MET (oncogenes) – less common than BRAF mutations, mutations in these two genes have also been linked to papillary thyroid cancer
  • RAS (oncogene) – mutations in RAS have been linked to follicular thyroid cancer
  • p53 (tumor suppressor gene), CTNNB1 – mutations in these two genes have been linked to anaplastic thyroid cancer.

Hands down, the most important breakthrough in cancer research has been the recognition that cancer is ultimately a disease caused by genetic mutations. While we still have a lot of questions still to answer when it comes to the genetics of cancer, seeing how far we’ve come in understanding the genetic basis of thyroid cancer gives me hope that those elusive answers for all cancers are closer to being discovered than ever before.

The Statistics

It is estimated that 56,460 people will be diagnosed with prostate cancer in 2012, with 43,210 of those diagnoses occurring in women. 1780 people will die of thyroid cancer in that same time period. 97.5% of all people diagnosed with thyroid cancer live at least five years following initial diagnosis. One in 97 people will be diagnosed with thyroid cancer at some point in their lifetimes. The NCI allocated $16.2 million (or 0.32%) of their budget for thyroid cancer research in 2011, the most recent year for which those statistics were available.

Recommended Resources

If you would like to learn more about thyroid cancer, I highly recommend reading through the NCI’s web pages dedicated to thyroid cancers, which can be found here. Their “snapshot” report on thyroid cancer is particularly informative, especially the section discussing recent research investments and findings. I also found the American Cancer Society’s Learn About Cancer: Thyroid Cancer section to be very useful. All of the statistics cited in the post were from the Surveillance Epidemiology and End Results (SEER) fact sheet on thyroid cancer, which can be found here. These webpages were my primary sources of information for this blog post.

The American Association for Cancer Research recommends ThyCa: Thyroid Cancer Survivors’ Association for additional thyroid cancer advocacy and patient support information. I also recommend the Light of Life Foundation for more information about thyroid cancer in general and to learn how you can get more involved in advocating for thyroid cancer research.

As with all of these cancer awareness posts, I hope that everyone reading this found it helpful and informative. I know I learned a lot researching it and will be a more effective cancer advocate for it!

Note: While I am a biomedical scientist, I am not considered an expert (medical or otherwise) on thyroid cancer. This post, as with all of my “awareness month” posts, is not meant to be an in depth review of thyroid cancer. Rather, I only wanted to provide a brief overview of thyroid cancer in order to help further the larger cancer community’s awareness of this common cancer. Moreover, while I provided links to a number of thyroid cancer organizations at the end of this post, I have not researched these organizations to the extent that I do for my “Spotlight On” series of posts. Until I can research them further, I am not explicitly advocating financial donations to these organizations (although I certainly won’t advise you against it either should you find them worthy!). Instead, I am recommending them here because each organization is a well respected leader in these specific areas and is considered a reputable source for further information on thyroid cancer.

Prostate Cancer Awareness Month!

Tuesday, September 25th, 2012

Pushing on with my series of cancer awareness months, today I’m going to be writing about prostate cancer in observance of Prostate Cancer Awareness Month. After writing long posts for Childhood Cancer Awareness Month, Blood Cancer Awareness Month, and Ovarian/Gynecological Cancer Awareness Month, this post is hopefully going to be a bit more concise. However, that doesn’t mean prostate cancer isn’t as important as these other cancers. In fact, prostate cancer is the most common cancer in men outside of non-melanoma skin cancer and is the second leading cause of cancer death in men. So as a cancer advocate, I think it’s important to learn a bit more about this very common form of cancer!

About Prostate Cancer

The prostate is a gland within the male reproductive system that is located in front of the rectum and just below the bladder, where it surrounds the urethra. The prostate is responsible for producing the liquid component of the seminal fluid that helps to carry the sperm out of the body as part of the semen. The prostate grows rapidly during puberty in response to a testosterone derivative called dihydrotestosterone (or DHT). The healthy adult prostate is generally the size of a walnut and does not continue to grow larger with age, although a variety of conditions can result in an enlarged prostate. The most common of these conditions is called benign prostatic hyperplasia (or BHP), which generally only results in serious medical complications when the enlarged prostate begins to squeeze and constrict the urethra.

Prostate cancer, then, is any cancer that develops in the tissues of the prostate. Almost all prostate cancers are adenocarcinomas; that is, cancers that develop from the glandular cells of the prostate. Other (very rare) subtypes of prostate cancer include sarcomas (soft tissue cancers), small cell carcinomas, and transitional cell carcinomas. It is important to note that BHP is NOT a form of prostate cancer. While some prostate cancers can grow and spread very rapidly, the majority of prostate cancer grow incredibly slowly. These slow progressing cancers are often present within the prostate for years to decades before they begin to have any kind of symptomatic effects on the individual harboring the cancer.

While prostate cancer is not known to be caused by HPV infection, the slow growth of prostate tumors results in a long precancerous stage that is similar to that seen in cervical, vaginal, and vulvar cancers. These precancerous changes are known as prostatic intraepithelial neoplasia (or PIN) and can be classified as either high- or low-grade PIN. It is estimated that nearly half of all men will develop some degree of PIN by age 50. Men with high-grade PIN have a 20-30% chance of harboring prostate cancer at another site within the gland. The relationship between low-grade PIN is much less clear and may not be related to prostate cancer at all.

The primary risk factor for prostate cancer is age, with two-thirds of all prostate cancers being diagnosed in men over the age of 65. Prostate cancer is very rare in men under the age of 40. Certain races also appear to have a higher risk of prostate cancer. For example, prostate cancer is more common in African American men, who are also twice as likely to die from the disease. The reason for this increased risk is unknown at this time. A family history of prostate cancer is also linked to a higher risk of developing prostate cancer, with 5-10% of prostate cancers having a known genetic basis. Interestingly, while mutations in the BRCA1 and BRCA2 genes are most commonly associated with an increased risk of developing breast and ovarian cancer in women, mutations in these same genes also appear to be associated with an increased risk of prostate cancer. Finally, it appears that a diet high in red meat and dairy and low in fruits and vegetables may lead to an increased risk of prostate cancer, although the specific components of that diet that underly this increased risk are unknown.

Prostate Cancer Screening

Because there has been a lot of confusion surrounding prostate cancer screening tests, I felt like a section dedicated to the topic was warranted. There are currently two methods for screening for prostate cancer that are generally used in tandem:

  1. The prostate specific antigen (PSA) blood test, which detects elevated levels of the prostate-produced substance PSA in the bloodstream. A healthy prostate will generally (but not always) produce PSA levels between 4ng/ml of blood and 10ng/ml of blood. Men with PSA levels in this range have a 1-in-4 chance of harboring prostate cancer, while men with PSA levels above 10ng/ml have a greater than 1-in-2 chance of harboring prostate cancer. It is important to note that low PSA levels do not mean that a man is cancer-free; rather, approximately 15% of men with PSA levels below 4ng/ml are found to have prostate cancer on biopsy.
  2.  The digital rectal exam (DRE), which is a physical examination in which the doctor manually inserts his fingers (or digits) into the rectum to directly check the prostate for changes that may be related to cancer. DREs are generally used to confirm or dispute PSA test results.

These tests have unequivocally been shown to find more prostate cancers, especially in the early stages of the disease, than would otherwise be diagnosed without regular screening, resulting in a significant decline in the death rate from prostate cancer since their implementation. So why is regular screening for prostate cancer not recommended for every man over the age of 40? Well, it’s complicated. Let’s try to sort through it all.

First and foremost, while the PSA and DRE tests are good at detecting cancer, the range of biological variability inherent in the prostate (and the levels of PSA produced by it) means that they can also be inaccurate. Some men have very low PSA levels even in the presence of cancer, resulting in false negative tests. Otherwise healthy men may have elevated PSA levels due to a host of other, non-cancer, conditions, resulting in false positive tests. And the DRE suffers from anatomical limitations, again resulting in a number of inaccurate test results. So while these screening tests can be useful, they are by no means ideal.

Moreover, as noted above, prostate cancer grows VERY slowly. Many otherwise healthy men are walking around with undiagnosed prostate cancer that due to its slow rate of progression, will never cause them medical problems during their lifetimes. Regular screening, then, leads to what many in the medical community consider to be an overdiagnosis of prostate cancer. While many of these men would likely opt to treat an asymptomatic cancer should they become aware of it, the reality is that a large portion of those treatments are medically unnecessary. Ultimately, there is a growing belief that because the side effects of treating prostate cancer can have a significant impact on a man’s quality of life (much more so than the cancer ever would!), the benefits of identifying and treating these cancers in their earliest stages are not sufficient to warrant those risks for the majority of men.

In May of 2012, the United States Preventive Services Task Force (USPSTF) updated their recommendations for prostate cancer screening. The USPSTF currently does not recommend PSA screening for any men, stating that there is “moderate or high certainty that the service has no benefit or that the harms outweigh the benefits”. You can read their full report here.

The Prostate Cancer Foundation strongly disagreed with the USPSTF recommendations, and summarized both their response to the USPSTF and their position on prostate cancer screening here. They also noted, in this synopsis of the prostate cancer screening debate, that, “in contrast [to the USPSTF], physician-led groups, such as the American Society of Clinical Oncology and the American Urological Association, maintain that PSA screening should be considered in the context of a man’s life expectancy and other medical conditions.” They further note that “most experts agree that there is no role for PSA screening for men expected to live less than 10 years”.

The official position of the American Cancer Society on prostate cancer screening is in agreement with the physician-led groups cited by the Prostate Cancer Foundation. Specifically, they state that:

At this time, the American Cancer Society recommends that men thinking about prostate cancer screening should make informed decisions based on the available information, discussion with their doctor, and their own views on the benefits and side effects of screening and treatment.

The ACS specifically recommends that men of average risk for developing prostate cancer and who otherwise have every reasonable expectation of living for at least another decade should discuss screening with their doctors starting at age 50. Men of above average risk (i.e. African American men, men with one first degree relative with prostate cancer) should start having these discussions at age 45 and men of high risk (that is, men with multiple first degree relatives with prostate cancer) should start having these discussion at age 40. For men who choose to undergo regular screening, the ACS recommends that men with PSA levels below 2.5ng/ml have follow up tests every two years while men with PSA levels above 2.5ng/ml should have follow up tests annually. Men should make decisions about biopsies and additional treatments based on marked and persistent changes in these test results in consultation with their doctors.

The Statistics

It is estimated that 241,740 men will be diagnosed with prostate cancer in 2012 and that 28,170 men will die from the disease. 99.2% of all men diagnosed with prostate cancer live at least five years following initial diagnosis, primarily due to the slow rate of progression of these cancers. One in six men will be diagnosed with prostate cancer at some point in their lifetimes and one in 36 men will die from the disease, making prostate cancer the most common non-skin cancer in men and the second leading cause of cancer death. The US spends an estimated $9.9 billion on treating prostate cancer annually. For comparison, the NCI allocated $300.5 million (or 5.9%) of their budget to prostate cancer research in 201o, the most recent year for which those statistics were available.

Recommended Resources

If you would like to learn more about prostate cancer, I highly recommend reading through the NCI’s web pages dedicated to prostate cancers, which can be found here. Their “snapshot” report on prostate cancer is particularly informative, especially the section discussing recent research investments and findings. I also found the American Cancer Society’s Learn About Cancer: Prostate Cancer section to be very useful. The Prostate Cancer Foundation’s section on prostate screening recommendations, which can be found here, summarizes this complicated topic very well. All of the statistics cited in the post were from the Surveillance Epidemiology and End Results (SEER) fact sheet on prostate cancer, which can be found here. These webpages were my primary sources of information for this blog post.

If you would like to read more about the current prostate cancer screening recommendations of the USPSTF, you can find that information here.

The American Association for Cancer Research also recommends the following prostate cancer advocacy and patient support organizations:

Finally, while they weren’t listed on the AACR website, I also recommend the Prostate Cancer Foundation for more information about prostate cancer in general and to learn how you can get more involved in advocating for prostate cancer research.

I hope that every reading this found this informative. I know I learned a lot researching it and will be a more effective cancer advocate for it!

Note: While I am a biomedical scientist, I am not considered an expert (medical or otherwise) on prostate cancer. This post, as with all of my “awareness month” posts, is not meant to be an in depth review of prostate cancer. Rather, I only wanted to provide a brief overview of prostate cancer in order to help further the larger cancer community’s awareness of this very common cancer. Moreover, while I provided links to a number of prostate cancer organizations at the end of this post, I have not researched these organizations to the extent that I do for my “Spotlight On” series of posts. Until I can research them further, I am not explicitly advocating financial donations to these organizations (although I certainly won’t advise you against it either should you find them worthy!). Instead, I am recommending them here because each organization is a well respected leader in these specific areas and is considered a reputable source for further information on prostate cancer.

 

Ovarian and Gynecologic Cancers Awareness Month!

Wednesday, September 19th, 2012

A busy September of cancer awareness continues!
Cervical, Ovarian, Uterine, Vaginal, Vulvar. Get the facts about gynecologic cancer.

As a part of my efforts to become the most effective cancer advocate that I can, I have challenged myself to expand my working knowledge of cancer beyond just breast cancer. Using the assorted cancer awareness month observations as my guide, I have been using my blog to share what I’ve been learning about a number of different types of cancer. I have already dedicated posts to Childhood Cancer Awareness Month and Blood Cancer Awareness Month, and I’m planning to dedicate posts to Thyroid and Prostate Cancer Awareness Months as well. Today, though, I am going to focus on ovarian and other gynecological cancers in honor of Ovarian Cancer Awareness Month as well as the more broad Gynecologic Cancer Awareness Month. With more than 80,000 women expected to be diagnosed with a gynecological cancer in this calendar year, I think this awareness month is one that all women need!

Gynecologic Cancer Awareness Month was first established back in 1999 by the Foundation for Women’s Cancer. The goal of this month, which is marked every September, is to increase awareness of these cancers in order to enable earlier detection, better treatment, and a greater chance of recovery for individuals diagnosed with a gynecologic cancer. With the exception of cervical cancer, there are no established, reliable screening tests for any of these gynecologic cancers. Moreover, the symptoms associated with these types of cancer overlap significantly with other common infections and diseases, including urinary and bladder infections, common STDs, kidney stones, and even PMS. Because of this, gynecological cancers are often diagnosed at a more advanced stage, making it much more difficult to treat these cancers. Therefore, it is critically important that all women are familiar with what is normal for their own bodies and are knowledgeable about the range of cancers that can occur in the female reproductive system. To that end, I am going to use this post to give a brief overview of each of the five primary gynecological cancers (ovarian, uterine, cervical, vaginal, and vulvar cancers), some important stats for each, and a list of links where you can find additional information. Even if you are familiar with these cancers, it can’t hurt to review this information again!

Ovarian Cancer

As you might have intuited, ovarian cancer is any cancer that develops from the cells within the ovary. There are three general cell types that make up the ovary: epithelial cells (which make up the general structure of the ovary), germ cells (which give rise to the eggs), and stromal cells (the cells that produce the female hormones estrogen and progesterone). Each of these cell types can develop into one of three corresponding ovarian cancer subtypes. The most common subtype of ovarian cancer is epithelial ovarian cancer, which accounts for 90% of all ovarian cancers. Germ cell and stromal cancers are both significantly more rare, accounting for less than 2% and approximately 1% of ovarian cancers, respectively. There is no recommended screening test for ovarian cancer and the symptoms associated with ovarian cancers can be especially hard to discern from those associated with more common gynecological and renal disorders, making ovarian cancer very difficult to diagnose. As a result, while ovarian cancer accounts for just 3% of all cancer in women, it is the fifth leading cause of cancer death.

While the cause of most ovarian cancers remains unknown, a number of risk factors for the disease have been identified. In general, it appears that the more ovulations that a woman experiences over the course of her lifetime, the higher her personal risk for developing ovarian cancer, likely due to increased exposure to estrogen. Therefore, a history of taking fertility drugs or estrogen therapy is considered a risk factor for ovarian cancer. The flip side of that coin, though, is that anything that reduces the number of lifetime ovulations a woman experiences can lower her risk. This includes having multiple pregnancies, breast feeding, taking birth control pills, or having a tubal ligation. Women who are obese are also at increased risk for ovarian cancer because fat cells are capable of converting certain other hormones into estrogen. A family or personal history of ovarian, breast, uterine or colorectal cancer is also a risk factor for ovarian cancer because the genes that predispose individuals to those cancers (including BRCA1 and BRCA2) are often associated with an increased sensitivity to estrogen. As with breast cancer, older women are at an increased risk of ovarian cancer, as are women who have a history of smoking and/or alcohol use. However, while each of these risk factors may increase risk of ovarian cancer, having these factors does not guarantee that an individual will develop the disease, just as the absence of these risk factors does not guarantee that a woman will not develop cancer.

In terms of the numbers, it is estimated that 22,280 women will be diagnosed with ovarian cancer in 2012 and 15,500 women will die of the disease in that same time period. One out of every 72 women will be diagnosed with ovarian cancer in their lifetimes. The 5-year survival rate for ovarian cancer is just 43.7%. In the US, we spend approximately $4.4 billion treating ovarian cancer every year.

The National Cancer Institute (my primary source for this information, along with the American Cancer Society) allocated 2.2% (or $112.3 million) of its budget in 2010 for ovarian cancer research.

The information in this section was provided to the public courtesy of the NCI and the American Cancer Society. The ovarian cancer homepage of the NCI can be found here and the ACS ovarian cancer section can be found here. All of the statistics came from the Surveillance Epidemiology and End Results (SEER) fact sheets on ovarian cancer, here.

Uterine Cancer

Uterine cancer, as follows logic, is cancer that develops in the tissues that make up the uterus. There are two primary layers of the uterus that each give rise to a corresponding subtype of uterine cancer:

  1. The inner layer (or lining) or the uterus is called the endometrium. This is layer that thickens and grows each month in preparation for gestation. Cancers of this layer account for 98% of all uterine cancers and are known as endometrial cancer.
  2. The outer layer of the uterus is made of muscle tissue and is known as the myometrium. Cancers of this soft tissue are known as uterine sarcomas and are very rare.
Endometrial cancers are the most common gynecological cancer and account for 6% of all cancers in women. Endometrial cancers can be sub-classified based on the specific types of cells involved and then further graded based on the degree of “abnormality” in the cellular phenotype (phenotype = what it looks like). Because endometrial thickening normally occurs in response to estrogen, it follows logic that many endometrial cancers occur as a result of an improper response to normal estrogen stimulation and/or an over-exposure to estrogen. These estrogen-sensitive endometrial cancers (which are classified as “Type I” endometrial cancers) are generally not very aggressive and are commonly diagnosed at less advanced stages. Type II endometrial cancers, then, are endometrial cancers that are not related to estrogen. Type II endometrial cancers are generally more aggressive and are more likely to metastasize.
Because many endometrial cancers are estrogen-sensitive, anything that results in a shift in the balance between estrogen and progesterone towards estrogen is considered a risk factor for endometrial cancers. Examples of these types of risk factors include:
  • The use of estrogen therapy to treat menopause without a concomitant use of progesterone.
  • Being obese.
  • Taking tamoxifen. Tamoxifen acts as an anti-estrogen in breast tissue, but acts as a pro-estrogen in the uterus.
  • A history of certain subtypes of ovarian tumors that are capable of producing estrogens.
  • Poly-cystic ovary syndrome (PCOS)
  • A high lifetime number of menstrual cycles, due to early puberty, late menopause, never being pregnant/breast feeding, or some combination thereof.
Because of the lifetime accumulation of residual estrogen in the tissues of the uterus, estrogen imbalances are particularly potent in post-menopausal women, making age a risk factor for endometrial cancer. Other non-estrogen risk factors for endometrial cancer include a family or personal history of breast or ovarian cancer and endometrial hyperplasia, a condition in which a woman naturally produces a very thick endometrium. There are currently no screening tests for endometrial cancer and as with ovarian cancer, the symptoms of endometrial cancer can be hard to detect, making early diagnosis very difficult.
Uterine sarcomas are a rare type of uterine cancer that forms in the muscles or other soft tissues of the uterus. There are two primary subtypes of uterine sarcomas:
  1. Uterine stromal sarcomas, which develop in the supporting connective tissues (or stroma) of the uterus and account for less than 1% of uterine cancers. Stromal sarcomas are generally low grade (not very abnormal, slow growing) and the prognosis for this type of cancer is generally good.
  2. Uterine leiomyosarcomas (LMS), which develop in the muscle cells of the uterus and account for approximately 2% of uterine cancers.
Unlike endometrial cancers, uterine sarcomas are not influenced by estrogens or lifestyle/genetic factors that influence estrogen. The only known risk factors for uterine sarcomas are a history of pelvic radiation and race (with uterine sarcomas being twice as common in African American women as in white/Asian women, although the reason for this remains unknown). As with endometrial cancer, there are no screening tests for uterine sarcomas either.
It is expected that 47,130 women will be diagnosed with one of the two major types of uterine cancer in 2012 and 8,010 will die from these cancers in that same period. Uterine cancer will affect 1 out of every 38 women, with more than half of all uterine cancer diagnoses occurring in women aged 50 – 69 years. The five year survival rate for uterine cancer is 81.5%. The US spends $2.3 billion annually treating uterine cancer.
The NCI allocated $14.2 million (or 0.28%) of its budget in 2010 for research on uterine cancers.

The information in this section was also provided to the public courtesy of the NCI and the American Cancer Society. The endometrial cancer homepage of the NCI can be found here and the uterine sarcoma homepage of the the NCI can be found here. The ACS endometrial cancer section can be found here and the ACS uterine sarcoma section can be found here. All of the statistics came from the Surveillance Epidemiology and End Results (SEER) fact sheets on uterine cancer, here.

Cervical Cancer

Cervical cancer is any cancer that develops from the tissues of the cervix, which is the organ that connects the uterus and the vagina. There are two primary subtypes of cervical cancer:

  1. Squamous cell carcinoma, which develops from the outer layer of the cervix (or exocervix) and accounts for 80-90% of all cervical cancers.
  2. Adenocarcinoma, which develops from the mucus-producing gland cells that line the inside of the cervix (which is also known as the endocervix).

Cervical cancer is generally slow growing and unlike the other gynecologic cancers that I’ve covered thus far in this post, can be detected even in the pre-cancerous stages of the disease with regular pap tests. In addition, we also know that virtually all cervical cancers are caused by infection with the human papilloma virus (HPV), making cervical cancer one of the only cancers with both a known cause AND a reliable screening test. As a result, while cervical cancer used to be one of the leading causes of cancer death in women, the mortality rate of cervical cancer has declined by over 70% since 1955.

While cervical cancer is generally pretty rare, infection with HPV is not. In fact, over 50% of all sexually active people have been infected with HPV at some point in their lives, making HPV the most common sexually transmitted infection in the United States. While we often talk about HPV as if it is a single virus, the reality is that there are actually more than 150 genetically unique but highly related HPVs, more than 40 of which are capable of being spread via skin-to-skin contact. These viruses can be divided into two primary categories of HPVs: low risk HPVs that do not cause cancer and are primarily associated with genital/skin warts and high risk HPVs that are known to cause cancer. There have been at least 12 high risk HPVs identified to date. Infection with a high risk HPV accounts for approximately 5% of all cancers worldwide, including virtually all cervical cancer (as I noted above), 85% of anal cancers, and more than half of all vaginal, vulvar, penile, and oropharyngeal cancers. There are currently two FDA-approved vaccines targeted at preventing high risk HPV prevention. Safe sex practices are also important and effective for preventing HPV infection of any kind.

It is important to note that most high risk HPV infections have no symptoms and go away on their own with no medical treatment. However, occasionally, the body is unable to clear the infection on its own, resulting in a chronic HPV infection. Chronic HPV infection can result in cellular changes and abnormalities that, if left to grow and reproduce unchecked over a long period of time, can result in cancer. This process can take as long as 10-12 years after the initial HPV infection, resulting in a lengthy “pre-cancerous” phase. Fortunately, regular pap tests, in which the doctor scrapes cells from the cervix and examines them under the microscope for cellular abnormalities, can detect the majority of pre-cancerous cervical changes that can then be treated well before they ever develop into full blown cervical cancer. A pap test that is positive for abnormal cervical cells coupled with a positive test for HPV is very effective at identifying both cervical cancer and pre-cancerous cervical cells. As a result, the American Cancer Society currently recommends the following cervical cancer screening guidelines, even for those who have been vaccinated against HPV:

  • For women aged 21 to 29: Pap test every three years. No HPV screen.
  • For women aged 30 to 65: HPV test every five years or pap test every three years.
  • For women over the age of 65, regular screening can be stopped unless the individual has a history of abnormal pap tests and/or detection of precancerous cervical cells.

In terms of statistics, it is estimated that 12,170 women will be diagnosed with cervical cancer in 2012 and 4, 220 women will die from the disease. One out of every 147 women will be diagnosed with cervical cancer in their lifetimes, a number that has been markedly reduced over the past few decades due to the development and improvement of pap tests and behavioral modifications to prevent HPV transmission. The US spends $1.4 billion treating cervical cancer every year.

The NCI allocated $76.5 million (or 1.5%) of it’s annual in 2010 for cervical research, with large portions of that research focused on better understanding how HPV causes cancer and the detection and treatment of pre-cancerous cervical cell changes.

The information in this section was also provided to the public courtesy of the NCI and the American Cancer Society. The cervical cancer homepage of the NCI can be found here and the ACS cervical cancer section can be found here. I also found this overview of HPV and cancer from the NCI to be particularly informative. All of the statistics came from the Surveillance Epidemiology and End Results (SEER) fact sheets on cervical cancer, here.

Vaginal and Vulvar Cancer

Because there are a lot of similarities between vaginal and vulvar cancers and because both of these cancer types are fairly rare (together, they only account for 6 – 7% of all gynecologic cancers), I’m going to tackle these two cancers together. Vaginal cancers are, as you would imagine, any cancer that forms in the tissues of the vagina. Vulvar cancers are any cancer that develops in the tissues of the vulva (the external female genital organs including the clitoris, the vaginal lips, and the opening to the vagina itself). There are four major subtypes of both vaginal and vulvar cancers:

  1. Squamous cell carcinomas, which develop from the epithelial cells of both organs and are the most common subtype of both vaginal and vulvar cancers. In both organs, squamous cell carcinomas are generally slow to develop and include a long pre-cancerous phase as in cervical cancer. In the vagina, these pre-cancerous changes are known as “vaginal intra-epithelial neoplasia” or VAIN and in the vulva, these changes are known as “vulvar intra-epithelial neoplasia” or VIN. The stage of VAIN/VIN is used to describe the extent of cellular abnormalities present, with Stage I VAIN/VIN being the least abnormal and Stage III VAIN/VIN being the most abnormal.VAIN/VIN can be detected using a pap test, as in cervical cancer.
  2. Adenocarcinomas, which develop in the glandular cells of the vagina or vulva. Adenocarcinomas account for 15% of vaginal cancers and 8% of vulvar cancers. In the vulva, adenocarcinomas generally arise in the Bartholin glands, which are located just inside the vaginal opening or in the sweat glands of the skin.
  3. Melanoma, which develops from the pigment-producing cells of the vagina or vulva. Melanomas account for 9% of vaginal cancer and 6% of vulvar cancer. Melanomas are generally more aggressive than squamous cell carcinomas or adenocarcinomas. Basal cell carcinomas, a common but less aggressive type of skin cancer can also occur on the vulva, although they are very rare.
  4. Sarcomas, which develop in the soft structural tissues of the vagina or vulva. Sarcomas account for 4% of vaginal cancers and less than 2% of vulvar cancers.

Approximately half of all vaginal and vulvar cancers are caused by HPV infections and as with cervical cancer, these cancers can often be detected via pap test in the pre-cancerous stage. The risk factors for both vaginal and vulvar cancer are highly similar and include HPV or HIV infection, a personal history of other gynecological cancers, and a history of smoking and/or drinking alcohol. The risk of developing either of the cancers increases with age, with over 50% of all vaginal and vulvar cancers occurring in women over the age of 70. Other risk factors for vaginal cancer include exposure in utero to diethylstilbestrol (DES, a hormonal drug given between 1940 and 1971 to prevent miscarriage) and vaginal adenosis (a condition that affects 40% of all women where there are hormonal glands present within the vagina). Other risk factors for vulvar cancer include Lichen Sclerosis (a disorder that causes the vulvar skin to become very thin and itchy) and a family or personal history of melanoma/atypical moles.

It is estimated that 2,680 women will be diagnosed with vaginal cancer in 2012 and 840 women will die from the disease. During that same time period, it is estimated that 4,490 women will be diagnosed with vulvar cancer and 950 women will die from the disease. One out of every 368 women will be diagnosed with vulvar cancer at some point in her lifetime. The equivalent statistic for vaginal cancer was not available. Details about the annual cost of treating these cancers in the United States and the NCI research budget for these cancers was not available.

The information in this section was also provided to the public courtesy of the NCI and the American Cancer Society. The vaginal cancer homepage of the NCI can be found here and the ACS vaginal cancer section can be found here. The vulvar cancer homepage of the NCI can be found here and the ACS vulvar cancer section can be found here. The statistics on vulvar cancer came from the Surveillance Epidemiology and End Results (SEER) fact sheets on vulvar cancer, here. The equivalent statistics from SEER were not available for vaginal cancer.

Recommend Resources

If you would like to learn more about gynecological cancers in general, or one of these types of cancers in particular, I highly recommend reading through the NCI’s web pages dedicated to ovarian, uterine/endometrial, cervical, vaginal, and vulvar cancers. The “snap shot” reports linked to in each subsection are particularly informative, especially the sections discussing recent research investments and findings. I also highly recommend the CDC’s section on gynecologic cancers, especially the Inside Knowledge fact sheets.

The American Cancer Society also has the following subsections of their “Learn About Cancer” webpage dedicated to gynecologic cancers:

The American Association for Cancer Research also recommends the following cancer advocacy and patient support organizations for each type of gynecological cancer that I’ve covered here:

 

Note: While I am a biomedical scientist, I am not considered an expert (medical or otherwise) on any of these types of cancer. This post, as with future planned “awareness month” posts, is not meant to be an in depth review of these types of cancer. Rather, I only wanted to provide a brief overview of each type of cancer in the gynecological cancer family in order to help further the larger cancer community’s awareness of each of these cancers. Moreover, while I provided links to a number of gynecological cancer organizations at the end of this post, I have not researched these organizations to the extent that I do for my “Spotlight On” series of posts. Until I can research them further, I am not explicitly advocating financial donations to these organizations (although I certainly won’t advise you against it either should you find them worthy!). Instead, I am recommending them here because each organization is a well respected leader in these specific areas and is considered a reputable source for further information on gynecological cancers.

Blood Cancer Awareness Month!

Saturday, September 15th, 2012

As I mentioned in this post about Childhood Cancer Awareness Month and CURE Childhood Cancer, September is a busy month in terms of cancer awareness. While I consider myself primarily a breast cancer activist, I recognize that at the heart of every type of cancer is the same thing: formerly normal cells behaving badly, growing out control, and becoming malicious. To that end, I think that any type of cancer activist should take some time to familiarize themselves with the other major types of cancer that exist in the world and take innocent lives every day. Because today is officially World Lymphoma Awareness Day, and because the rest of the month of September is more broadly recognized as Blood Cancer Awareness Month, I thought today was a great day to write a little more about blood cancers.

Two Important Stats About Blood Cancers Worth Knowing

  1. Someone in the United States is diagnosed with a blood cancer every four minutes. (per the Lymphoma Research Foundation)
  2. Blood cancer is the third leading cause of cancer death in the US. (per the Leukemia and Lymphoma Society)

Did you know those stats? Until I started researching this post, I didn’t. I guess this is one cancer awareness month that I really need!

Blood cancer as a group is actually made up of three major types of cancer: leukemia, lymphoma, and myeloma. Each of these cancers begin as a different type of white blood cell that ultimately begins accumulating at an above normal rate, either due to increased cell production or decreased cell death. As a result of this rapid accumulation, those cells quickly become abnormal, resulting in different types of cancer, depending on the type of cell the cancer originated as. Because each of these types of cancer are such different diseases, I’m going to talk about each of the major types of blood cancer individually.

Leukemia

Leukemia is a type of cancer that starts in the bone marrow, the site of blood cell production in the body. There are three primary types of blood cells that the body produces: red blood cells (or “erythrocytes”, the cells that carry oxygen to the rest of the body), white blood cells (or “leukocytes”, which fight infection in the body), and platelets (which are responsible for clotting). In general, leukemia is the type of cancer that arises when the body accumulates cancerous leukocytes/white blood cells, or WBCs, as I’m going to abbreviate them here on out.

[Science reading comprehension tip: The prefix leuk- is derived from latin word for white, and in science/medical parlance, generally refers to white blood cells. Any term that ends in the suffix “-cyte”, is a specific type of cell. Therefore, a leukocyte is literally a white blood cell. The suffix -emia is used when referring to anything blood-related. So a blood cancer of white blood cells = leukemia.]

The body makes a huge number of different WBCs, each of which performs a different role within the circulating immune system. WBCs develop from one of two types of stem cells, depending on which type of WBC they are meant to become: myeloid stem cells (which are also the precursor cells to red blood cells and platelets) or lymphoid stem cells. Leukemias can develop from either of these stem cell types. Based on the type of stem cell that the cancer developed from and the rate at which the cancer progresses, the majority of leukemias can be classified as one of four types:

1. Chronic Lymphocytic Leukemia (CLL) – leukemia originating from lymphoid stem cells that progresses slowly. CLL affects primarily adults.

2. Chronic Myeloid Leukemia (CML) – leukemia originating from myeloid stem cells that progresses slowly. CML also affects primarily adults.

Chronic leukemia cells usually retain some degree of functionality as WBCs, at least at the beginning of the disease. Because of this, the decline in health of individuals with chronic leukemias is relatively slow. As a result, chronic leukemias can be more difficult to diagnose.

3. Acute Lymphocytic Leukemia (ALL) – leukemia originating from lymphoid stem cells that progresses rapidly. ALL is the most common leukemia in children, although it is also found in adults.

4. Acute Myelod Leukemia (AML) – leukemia originating from myeloid stem cells that progresses rapidly. AML affects both kids and adults.

Acute leukemia cells cannot function as normal WBCs, leading to a rapid decline in health for those with these types of cancer.

CLL is the most prevalent type of leukemia (accounting for approximately 15,000 new cases of leukemia per year). AML accounts for approximately 13,000 new cases of leukemia per year, while CML and ALL each account for about 5,000 new cases of leukemia per year. Other minor subtypes of leukemia also exist, and together they account for approximately 6000 new cases of cancer per year. Ultimately, it is predicted that 47,150 new cases of leukemia will be diagnosed in 2012 and 23,540 people will die from the disease. One in 74 people will be diagnosed with leukemia in their lifetimes. It is also worth noting that while leukemia affects 10x more adults than children, it is still the most common cancer diagnosed in children. In the US, we spend approximately $4.5 billion treating leukemia every year.

The National Cancer Institute (who was my source for all of this information) allocates approximately 4.7% of it’s annual budget (or $239.7 million) for leukemia research in 2010, the last year for which that information was available.

The information in this section was provided to the public courtesy of the NCI. You can find more information about leukemia in their “What You Need to Know About Leukemia” booklet, here and in their “Leukemia Snap Shot” report, here. All of the stats came from the Surveillance Epidemiology and End Results (or SEER) fact sheet on leukemia, here.

Lymphoma

Whereas leukemias originate from stem cells located in the bone marrow, lymphomas are cancers that arise from lymphoid stem cells that are found in the lymphatic system. The lymphatic system (which is part of the body’s large immune system) includes lymphocytes (a specialized subtype of WBC), the lymph vessels (found throughout the body), the lymph fluid, and the lymph nodes, which connect the various lymph vessels and act as something of a filtration system to keep the lymph fluid clear of bacteria and other infectious agents.

There are two major types of lymphomas, and further subtypes of each of those:

1. Hodgkin’s lymphoma, which is distinguished by the presence of a specific type of cancer cells called Reed-Sternberg cells. Hodgkin’s lymphoma can be further classified as either the more common classical subtype of Hodgkin’s lymphoma or the comparatively more rare nodular lymphocyte-predominant Hodgkin’s subtype.

2. Non-Hodgkin’s lymphoma, which is defined as any lymphoma that lacks Reed-Sternberg cells. There are many subtypes of Non-Hodgkins lymphoma based on the rate of progression of the disease (generally defined as either aggressive or indolent/slow), the original lymphocyte subtype that the cancer developed from, and other cellular characteristics.

Lymphomas account for 5% of all cancers in the United States, with Non-Hodgkins lymphoma being far more prevalent than Hodgkins lymphoma. It is estimated that in 2012, 70,130 will be diagnosed with Non-Hodgkins lymphoma and 9,060 will be diagnosed with Hodgkin’s lymphoma. Further, it is estimated that 18,940 people will die from Non-Hodgkins lymphoma and 1,190 people will die from Hodgkins lymphoma this year. One out of every 47 people will be diagnosed with Non-Hodgkins lymphoma and one out of every 436 people will be diagnosed with Hodgkins lymphoma in their lifetimes. In the US, we spend approximately $10.2 billion annually treating lymphoma.

NCI allocated 2.7% of its annual budget (or $137.0 million) in 2010 for lymphoma research.

The information in this section was also provided to the public courtesy of the NCI. You can find more information about lymphoma in their “What You Need to Know About Hodgkins Lymphoma” and “What You Need to Know About Non-Hodgkins Lymphoma” booklets, here and here, respectively. Additional information can also be found in their “Lymphoma Snap Shot” report, here. All of the stats came from the SEER fact sheets on Hodgkins and Non-Hodgkins leukemia, here and here, respectively.

Myeloma

Myeloma (or plasma cell myeloma as it is also known) is a type of blood cancer that originates specifically in the plasma cells. Plasma cells are a highly specialized type of white blood cell that produces antibodies. When the disease first develops, myeloma cancer cells accumulate specifically within the bone marrow, much like with leukemia. As the disease progresses, myeloma cells accumulate in multiple bones simultaneously, at which stage the disease is described as Multiple Myeloma.

Myeloma is the second most common blood cancer and accounts for 1% of all cancers in the United States. It is estimated that 21,700 people will be diagnosed with myeloma in 2012 and that 10,710 people will die from the disease in this same time frame. One in 150 people will be diagnosed with myeloma in their lifetime. NCI did not report an estimate for aggregated annual treatment costs to the country for myeloma.

NCI allocated approximately 1% of it’s annual budget (or $48.5 million) in 2010 for myeloma research.

The information in this section was also provided to the public courtesy of the NCI. You can find more information about myeloma in their “What You Need to Know About Multiple Myeloma” booklet, here. Additional information can also be found in their “Myelnoma Snap Shot” report, here. All of the stats herein came from the SEER fact sheet on myeloma, here.

Recommend Resources

If you would like to learn more about blood cancer in general, or one of these types of cancers in particular, I highly recommend reading through the NCI’s web pages dedicated to leukemia, Non-Hodgkins lymphoma, Hodgkin’s lymphoma, and Multiple Myeloma. The “snap shot” reports linked to in each subsection are particularly informative, especially the sections discussing recent research investments and findings.

 The American Cancer Society also has the following subsections of their “Learn About Cancer” webpage dedicated to blood cancers:

 The American Association for Cancer Research also recommends the following blood cancer advocacy and patient support organizations:

Finally, to learn more about the origins of World Lymphoma Awareness Day, please visit The Lymphoma Coalition.

Image source – Thanks for letting me borrow it!

 

Note: While I am a biomedical scientist, I am not considered an expert (medical or otherwise) on any of these types of cancer. This post, as with future planned “awareness month” posts, is not meant to be an in depth review of these types of cancer. Rather, I only wanted to provide a brief overview of each type of cancer in the blood cancer family in order to help further the larger cancer community’s awareness of each of these cancers. Moreover, while I provided links to a number of blood cancer organizations at the end of this post, I have not researched these organizations to the extent that I do for my “Spotlight On” series of posts. Until I can research them further, I am not explicitly advocating financial donations to these organizations (although I certainly won’t advise you against it either should you find them worthy!). Instead, I am recommending them here because each organization is a well respected leader in these specific areas and is considered a reputable source for further information on blood cancers.

In the News: The new mammogram recommendations

Friday, December 11th, 2009

Welcome to the first installment of what will hopefully be a regular installment spotlighting stories relating to breast cancer research. While I claim no expert knowledge regarding breast cancer or oncology, I am a trained biomedical scientist with a passion for research advocacy. As such, I wanted to use my unique point of view to highlight some advancements (or set backs) in breast cancer research over the coming months.

To start, I wanted to focus on the newly released guidelines for mammogram screenings. This story has been playing out in the national media over the last few weeks, and while much of the hype around it has quieted down, I think it is critically important that everyone understands the what the study itself  was designed to address and what the actual findings of the study are.

About the United States Preventative Services Task Force

From the USPSTF webpage:
The U.S. Preventive Services Task Force (USPSTF), first convened by the U.S. Public Health Service in 1984, and since 1998 sponsored by the Agency for Healthcare Research and Quality (AHRQ), is the leading independent panel of private-sector experts in prevention and primary care. The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the “gold standard” for clinical preventive services.  The mission of the USPSTF is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care.
It is also important to recognize that (again from the USPSTF website):
“Recommendations issued by the USPSTF are intended for use in the primary care setting. The USPSTF recommendation statements present health care providers with information about the evidence behind each recommendation, allowing clinicians to make informed decisions about implementation.”
That is, the recommendations of the USPSTF are not intended to direct individuals in making decisions about their personal treatments nor are they intended to direct what services should be covered by health insurance plans.  These recommendations are solely to help primary care physicians make more informed decisions when recommending treatments to their patients.

This USPSTF is made up of 17 individuals that are appointed by the head of the Agency of Healthcare Research and Quality (AHRQ) and vetted by Health and Human Services (HHS).  These individuals come from various areas of health care, including doctors, nurses and public health policy.  About half of the members are women and the majority of them come from an academic background.  Of these members, I think it is important to note that there are no oncologists, oncological surgeons, radiologists or Ob/Gyns.  There is one member, Dr. Kimberly Gregory, who is the Director of Maternal-Fetal Medicine and Women’s Health Services Research at Cedars Sinai Medical Center, but otherwise, there are no other experts in women’s health.  In addition to the members of the panel, there are also a number of partners that “contribute their expertise in the peer review of draft USPSTF documents and help disseminate the work of the USPSTF to their members.” (USPSTF website).  While these groups represent a wide swath of the health services industry, it is again worth noting that there are no women’s health, oncology or radiology groups represented.  Because of the potential implications of the findings of the USPSTF on health insurance policies, I also wanted to point out that both the Centers for Medicare and Medicaid as well as AHIP, the association of health insurers ARE USPSTF partners.  That is not to say that insurance companies are behind these findings, but I do think it is important to recognize who is actually involved in this process when thinking about the findings of the Task Force.

More about the USPSTF, including a list of all members and partners can be found at http://www.ahrq.gov/clinic/uspstfab.htm.

About the Screening for Breast Cancer Recommendations and Study

This particular study and the resulting Recommendation Statement were designed to update the original recommendations on breast cancer screening for women of “normal risk” that were released by the USPSTF in 2002.  The USPSTF identified a series of specific areas from the 2002 report that they felt warranted more detailed investigation.  Specifically, the USPSTF felt that the 2002 findings regarding film mammography for women between the ages of 50 and 70 were strongly supported, but that questions still remained for women ages 40-49 and 70+.  In addition, the USPSTF wanted to reexamine the evidence surrounding the efficacy of breast self exams (BSEs) and clinical breast exams (CBEs).  Finally, the USPSTF wanted to begin to examine digital mammography and MRI in lieu of film mammography for women of all ages.   For each screening method that was reviewed, the USPSTF was solely interested in examining the effect of that screening method on the breast cancer mortality rate.  This is an important point that I will be returning to later, so I wanted to make sure to emphasize it here.

After defining these questions, a study was commissioned to address these particular questions.  This study was performed by a group from the Oregon Health & Science University; Veterans Affairs Medical Center; and the Women and Children’s Health Research Center, Providence Health & Services in Portland, Oregon.  For this study, all of the relevant published literature was reviewed and the data from independent studies that met the inclusion criteria of the researchers were pooled together.  A meta-analysis of this data was then performed to best identify the trends across multiple, independent studies.  The results of this study were published in the November 17th edition of Annals of Internal Medicine (vol 151, issue 10).

The members of USPSTF reviewed the findings of the study linked to above  in order to make their recommendations.  After weighing the benefits of the various screening methods for the age groups of interest against the identified harms that are associated with those same methods, the final  recommendations of the USPSTF were released in a Recommendation Statement on the HHS website.  Each recommendation was also graded using this classification system.  Their recommendations, copied from the above linked Recommendation Statement, are as follows:
  • The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
    Grade: B recommendation.
  • The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.
    Grade: C recommendation.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
    Grade: I Statement.
  • The USPSTF recommends against teaching breast self-examination (BSE).
    Grade: D recommendation.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
    Grade: I Statement.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.
    Grade: I Statement.
A detailed explanation for each recommendation can be found in the Recommendation Statement here: http://www.ahrq.gov/clinic/uspstf09/breastcancer/brcanrs.htm I highly recommend that anyone that is interested in this issue (and if you’re still reading this, I assume that you are) read the Recommendation Statement.  While the study on which these findings were based is fairly dense and written in “science-ese,” I found the Recommendation Statement very straight forward and easy to follow.

Specific Points of Discussion

1. The Cost/Benefit Question

The type of study on which the USPSTF based their recommendations is what is known as “comparative effectiveness research” or CER.  This type of research is focused on evaluating whether the benefits of a specific type of disease screening or treatment justify the costs of doing that screening or treatment in the first place.  CER has been pretty controversial over the years, in part because the relative values of both the benefits and the harms are highly subjective to the reviewer.  Personally, after reading this study, I found myself in strong disagreement with USPSTF almost entirely because I feel that they undervalued the advantages to breast cancer screening while simultaneously overvaluing the “harms” of screening.

So what are the advantages to breast cancer screening?  According to the USPSTF, the only advantage of breast cancer screening worth considering is a decrease in breast cancer mortality.  That is, saving lives that would otherwise be lost to breast cancer.  And the screening study did find that screening saves lives, stating that

“Our meta-analysis of mammography screening trials indicates breast cancer mortality benefit for all age groups from 39-69 years, with insufficient data for older women.”    (my own emphasis added)

It is not under debate that breast cancer screening, and specifically mammography saves lives.  The question then is at what age does number of lives saved outweigh the risks associated with screening.  But before we get into the specifics of that, I wanted to take a minute to talk about the additional advantages to mammography and breast cancer screening in general that the USPSTF failed to consider.  Mammograms have been shown to extend one’s life span when battling breast cancer, something that I personally value very highly.  In addition, when cancers are caught at earlier stages, the treatments required are much less invasive, take less time and are more affordable than treating a later stage cancer.  Without considering any of these very tangible advantages to mammography, I think this study falls incredibly short.

Now, what about those negatives?  In this study, the authors conclude that there are five major “harms” to be considered when evaluating the effectiveness of mammography and other screening methods, which I’m going to address one at a time.

1.  Radiation exposure during screening:  This is a very valid concern for many women and a legitimate potential harm of screening, to my mind.   In this study, the authors found that the radiation exposure during mammography is very low.  They felt that the ultimate harm of exposure was unclear but that some women may be at increased risk of developing breast cancer in response to these levels of radiation. The USPSTF noted that “radiation exposure, although a minor concern, is also a consideration.”

2.  Pain during procedures:  A major concern for CER is the level of discomfort and pain caused by the test being evaluated.  If a test is overly painful to the patient, I think that would constitute a legitimate  argument against the widespread use of that test.  The screening study here found that “many women consider mammography painful but don’t consider it a deterrent to further screening.”  Moreover, the USPSTF only mentioned pain as a deterrent to mammography once and concluded that “it had little effect on mammography use.”  As such, for the purposes of this study, the pain of mammograms was not considered a significant harm of mammography.

3.  Anxiety, distress and other psychological responses:  This is the issue where I really begin to disagree with both the authors of the study and especially the USPSTF.  One of the major “harms” that was considered in evaluating mammography effectiveness was that in the event that something was detected on a mammogram that warranted some form of follow-up, the women suffered from anxiety and breast cancer worry.  Personally, I would gladly endure a bought of nerves in order to know for sure what my questionable lump or lesion was.  This is doubly true for BSEs.  If I find something abnormal in my breast, I want to know what it is.  Trying to protect me from being concerned for my own health is a futile exercise.  If I have a bad headache, a strange freckle or a sore leg, I’m worried about what it might be and I highly doubt I’m the only one.  This idea that women are too fragile psychologically to potentially get bad news is ludicrous.  That this was even a concern of the effectiveness study really bothers me.  Interestingly, the actual conclusion of the authors of the study was that “patient adverse experiences like anxiety are common but seem to be transient and do not adversely influence future screening practices.” The USPSTF, on the other hand, seems to consider anxiety and distress to be a much more serious concern and reference it repeatedly.  My personal feeling is that this harm is seriously over-valued by the USPSTF.

4.  False positives/negatives:  The main “harm” here is that too many mammograms produce unclear results, leading to excessive follow up imaging and/or unnecessary biopsies to determine the true nature of the breast abnormality.  While mammograms may result in higher than ideal rates of false positives, the lack of a better test makes this “harm” less of a concern, at least to me.  An imperfect test is better than no test at all.  False negatives, while still more common than would be ideal, are less of a concern in regards to breast cancer screening.  Based on all of this, I consider this harm to be over-valued by the USPSTF as well.

5.  Overtreatment:  Overtreatment is defined as the treatment of a disease that would not become a risk to one’s life during their life expectancy.  This is a major concern of both the study authors and the USPSTF.  Given what is currently known about breast cancer progression, I disagree with the authors and the task force about the current magnitude of this problem, as I will discuss in detail below.  As a result, I consider this harm to also be over-valued by the USPSTF.

In conclusion, I feel the incredibly narrow focus on the effects of breast cancer on mortality rate  to the exclusion of other additional benefits coupled with at least three significantly overvalued risks has seriously distorted the findings of the authors of the study and especially the USPSTF.  Many other individuals may disagree with me.  Unfortunately, that is the nature of CER – it is based on subjective values.

2. High False Positives?

As I mentioned in the previous section, one of the significant limitations of breast cancer screening is the high false positive rate.  This is often the case with tests used to routinely screen otherwise healthy people.  This is especially true for tests that are self-administered, like BSEs.  In the specific case of breast cancer, there are a number of lesions or masses that frequently occur in breast tissue, most of which will turn out to be benign and/or non-cancerous.  However, when you are checking yourself or even on a mammogram, it is impossible to know what those abnormal lumps and bumps really are.  I think there is a common misconception that a mammogram is a diagnostic test.  It is not.  Breast cancer is should never be diagnosed from a screening mammogram.  Instead, a doctor will order additional screening using more specific and/or more advanced techniques or a biopsy in order to properly identify the mass.  Only after the actual cells of the mass are examined can a true diagnosis of breast cancer be given.

In the USPSTF-commissioned study, any time a mass was detected either in BSE or in routine mammography, the screening test was classified as “positive”.  However, as I described above, the masses detected in a large number of “positive mammograms” are found to be benign, non-cancerous  lesions with follow-up imaging or biopsy.  In this study, all of those tests, then, fall under the category of “false positives”.  So you can see now why mammograms and especially BSEs have such a high false positive rate.  In the opinion of the USPSTF, any follow-up test that is administered that doesn’t detect cancer is considered a “wasted” test.  That would be like considering an x-ray that reveals a sprain instead of a fracture a waste, as Nancy Brinker wrote in this wonderful USA Today column.  Why then, does the USPSTF consider any follow up test that doesn’t detect cancer as wasteful??

In an ideal world, the screening test that we use not just for breast cancer, but for any disease, would also be a diagnostic tool, telling us exactly which lumps and bumps are cancer and which aren’t.  But right now, that just isn’t the case.  To my mind, the only time a recommendation against a certain screening test based on a high false positive rate is warranted is if there’s a better test out there.  Right now, that isn’t the case for breast cancer.  Rather than recommending that women forgo the flawed but effective test that we currently have, we should be advocating for better screening methods.  But until we get those tests, having to perform too many “wasteful” follow-up procedures is a small price to pay for saving someone’s life.

3. Overdiagnosis and overtreatment?

Another area of concern for the USPSTF and the authors of the study on which the Task Force’s recommendations are based is overdiagnosis and overtreatment.  Overdiagnosis is defined in the Task Force’s Recommendation Statement as “detection of cancer that would never have become clinically apparent… and it is usually followed by overtreatment.”  In other words, overtreatment is unnecessarily treating a cancer that would not have killed the woman during the normal span of her life.  This is particularly an issue for women ages 75 and up because of their relatively shortened remaining life span.

To better understand why this is an issue, we must think for a moment about the actual biology of cancer.  Oftentimes, the words tumor and cancer are used interchangeably to refer to an abnormal mass of cells that can leave the site of the mass and spread to other parts of the body.  However, they are not exactly the same thing.  A tumor is a mass of cells that may or may not be malignant (multiplying and/or migrating to other parts of the body).  Cancer, on the other hand, refers only to malignant tumors, not benign masses.  While most people believe that all tumors will become cancerous if given enough time, that isn’t usually the case.  In actuality, the nature of a tumor (benign or malignant) is often determined when the cells first become abnormal.  Not all cells undergoing what we commonly think of as “cancerous growth” have the ability to migrate to other parts of the body and establish new tumors.  Many “cancerous cells” are dividing very slowly and are limited to the immediate surrounding tissue.  Now, if one of these slow growing, non-migrating tumors happens to be in or on a critically important organ, they can also wreak havoc on your health without ever becoming “malignant cancer”.  But more often than not, if the cells stay where they are and reproduce relatively slowly, then you could live with that tumor for a very long time without any impact on your day to day life.

The most commonly diagnosed form of breast cancer is what is known as ductal carcinoma in situ or DCIS.  This type of breast tumor is confined to the milk duct within the breast.  By it’s very nature, DCIS is not considered malignant because it is still confined to it’s site of origin.  A diagnosis of DCIS is often at a very early stage and is rarely a precursor for more advanced, invasive breast cancer.  Because of this, some oncologists and breast cancer specialists consider DCIS to be “pre-cancer”, not breast cancer.  Because DCIS is often has a long asymptomatic phase, it is almost always initially detected on a routine screening mammogram.  As a result, with the increase in routine screening, there has been a concomitant increase in the incidence of DCIS without a clear understanding of the long term nature of this type of tumor.  The other primary type of breast cancer is lobular carcinoma in situ or LCIS.  Unlike DCIS, LCIS often leads to an increased risk of developing later, invasive breast cancer.  Whether those tumors themselves become malignant or whether they just signal that other, more aggressive cancer cells may be present in the breast is still up for debate.

As I hope you are starting realize, the sticky point to all of this is that in the end, we do not know what causes a breast tumor or cancerous breast tissue cells to become invasive and malignant.  Let me say that again – we do not know yet what causes a breast tumor or cancerous breast tissue cells to become malignant.  We don’t know whether cells are destined to be malignant from the moment they become abnormal or if a benign tumor can evolve into a malignant tumor with time.  This is an important point for me because it represents a serious diversion between myself and the USPSTF.  As the USPSTF said in it’s Recommendation Statement:

“Because the likelihood that DCIS will progress to invasive cancer is unknown, surgical removal—with or without adjuvant treatment—may represent overdiagnosis or overtreatment.”

In essence, what the USPSTF is saying is that because we don’t know for sure that DCIS will become a malignant cancer that could kill you, we shouldn’t worry about treating it because we don’t want to expose women to unnecessary surgery or treatments.  While I recognize that only treating the tumors that we know for sure will become life threatening is the ideal, the fact of the matter is that we have no idea of know which tumors those are.  I know that for me, if I had a tumor that even had the slightest chance of becoming life threatening, I would want to treat it as soon as possible, when only a lumpectomy would be required rather than wait and see and ultimately end up having to go through a much more radical mastectomy and intense rounds of chemotherapy and/or radiation.  I suspect that the most women would agree with me, putting us at odds with USPSTF.  Again, while their recommendations are sound based on their values, they are out of line with the values of regular women.

4. So how did they decide to start recommending screening at age 50?

I mentioned at the beginning of this article that one of the primary questions that the USPSTF wanted to address was the effectiveness of breast cancer screening for women ages 40-49.  They felt confident in their previous recommendations for women ages 50-69, but felt that the evidence thus far for women in their 40s was less clear.  To address this question, the authors of the study commissioned by the USPSTF stratified the results of the studies they reviewed in order to compare the effectiveness of breast cancer screening for each group.  The primary results that they reported in the Annals of Internal Medicine were:

That is, for women aged 39-49 years old, mammography screening resulted in a 15% reduction in breast cancer mortality, with screening of 1904 women needed in order to save one life.  Interestingly, for women aged 50-59, mammography screening resulted in a comparable 14% reduction in breast cancer mortality compared to a control group.  Because death from breast cancer is more frequent in this age group, that means that 1339 women need to be screened in order to save one life.  Finally, for women aged 60-69, mammography screening resulted in a 32% reduction in breast cancer mortality and only 377 women needed to be screened in order to save one life.

Based on these results, it is clear that a large jump in the effectiveness of regular mammograms in reducing breast cancer mortality actually occurs at age 60, not at age 50.  In fact, mammograms are just as effective for women in their 40s as for women in their 50s at reducing breast cancer mortality, even though breast cancer in those women occurs less frequently.  Herein is what I consider to be one of the major design flaws of this study.  Just looking at this data, one might logically conclude that the most important age to start mammograms is actually at age 60, not age 40 or 50.  Without a lower age group to compare these results to, I don’t think you can properly assess the effectiveness of mammography for women in their 40s.  Let’s say that for women ages 30-39, regular mammography also results in a 15% reduction in breast cancer mortality and that the number of women that need to be screened to save one life is about 2500.  Those findings probably wouldn’t change your conclusions much: there is a moderate benefit that increases with each decade of life and that the big jump in effectiveness occurs around age 60.  But what if the results for women in their 30s were a little different?  What if for women in their 30s, regular mammography only results in a 5% reduction in breast cancer mortality and that a whopping 5000 women needed to be screened to save one life?  If that were the case, it would be incredibly clear that there is a boost in the effectiveness of mammography at reducing breast cancer mortality around age 40 and again at age 60.  I doubt anyone would look at that data and conclude that it was okay to wait to start screening when a significant effect at age 40 is so obvious.

Now, I don’t know what the numbers look like for women in 30s.  I wish that I did.  But more than that, I wish that the observers knew those numbers.  In order to properly assess the effectiveness of routine mammography for women in their 40s, you can’t just look at the next older group and determine that screening is slightly less effective.  You have to compare to the younger group as well.  As a scientist, I think this is a serious flaw in this study.

We know from the recommendation statement that the USPSTF looked at these results and (I feel, somewhat arbitrarily) decided that the benefits of routine mammography began to outweigh the risks starting at age 50 for most healthy women.  But is that really the right answer?  Personally, I disagree.  In fact, I think the authors of the commissioned study summed up their results the best:

“Our meta-analysis of mammography screening trials indicates breast cancer mortality benefit for all age groups from 39 to 69 years, with insufficient data for older women. …  Mammography screening at any age is a trade off of a continuum of benefits and harms.  The ages at which the trade off becomes acceptable to individuals and society are not clearly resolved by the available evidence.”

To conclude, I think that this was an important study to perform and I hope we continue to assess the effectiveness of our screening techniques well into the future, especially as newer, hopefully better techniques emerge.  But I found that my personal values were out of line with the USPSTF and as such, I do not agree with their ultimate conclusions.  I think the one thing highlighted by this study that we can all agree on is that we need better and more accurate tests, less invasive treatments and a better basic understanding of the nature of breast cancer.  If we can use this report as a call to action to increase breast cancer research, I think we will all be better off.

The Counter Argument

What I have written here is solely my opinions that I formed after reading extensively about breast cancer screening, the USPSTF and the study that was published in the Annals of Internal Medicine.  There are certainly people out there who disagree with me and in the interest of fairness, I wanted to provide links to two articles discussing the argument in support of the findings of the USPSTF.  The first article that I recommend was written by Devra Davis, PhD and can be found here (click for article), at the Huffington Post. Dr. Davis writes very passionately about her own experience with breast cancer screening in the context of the history of mammography.  It is a very interesting article, even if I don’t necessarily agree with her.  The second article that I would recommend was written by Kevin Sack and was published here (click for article), in the Health section of the New York Times.  Mr. Sack focuses on the emerging idea that early detection isn’t always the best and the harsh opposition that that point of view has faced.

Useful Links and Resources

In writing this piece, I used a number of resources and I tried to directly credit those sources where I could.  I repeatedly referenced both the USPSTF Recommendation Statement and the Annals of Internal Medicine study.  The links for those documents are:

The USPSTF Recommendation Statement on Breast Cancer Screening
Screening for Breast Cancer: An Update for the USPSTF, published in the Annals of Internal Medicine

I gathered much of my information on the USPSTF from their personal webpage (click for link) and from this highly informative article in the New York Times.

Following the release of the USPSTF recommendations, almost all of the major cancer groups released formal statements, which I have collected here (click the names for the links):

American Cancer Society
Komen for the Cure
Nancy Brinker, Founder and CEO of Komen for the Cure
National Breast Cancer Foundation
Breast Cancer Network of Strength (formerly Y-Me)
National Cancer Institute
National Breast Cancer Coalition
Stand Up 2 Cancer Coalition

I also want to call attention to the official statement of the Secretary of Health and Human Services, Kathleen Sebelius, which can be found in this article (click for link) on CNN.

While I was preparing this article, Nancy Brinker published an Op Ed in USA Today that I found very interesting.  It can be found here (click for article) if you’d like to read it.

Finally, in learning about breast cancer, I have found Dr. Susan Love’s Breast Book to be a great resource.  I highly recommend it to anyone who wants to learn more about the science of breast cancer and the history of breast cancer screening and treatments.  Dr. Love updates her book every five years, and the fifth edition is due in 2010.

Thank you to anyone who actually made it to the end of this piece! It was really important to me to use this platform to share my thoughts and insights with all of you.  I encourage everyone and anyone to leave me comments letting me know your thoughts as well!