Thursday, April 10, 2014

Just A Salad

Last week I finished the first salad I've had in months. Of all things this is the last test you'd think of as a measurement for metastatic breast cancer. But it's just one of the many ways this disease can impact the lives and health of the women and men it strikes every year.  As with primary breast cancer, you can take two different women with exactly the same breast cancer and how it manifests itself will vary.
      The salad itself was simple. Measly even, compared with the vegetable-laden salad bombs I used to toss together. It was all spinach, with hard-boiled egg, some chunks of chicken, mushrooms and a smattering of some excellent French feta (don't ask me who did the labeling on that one) DH picked up at the market. DH had made the salad himself, in fact, after his internist not so gently suggested he make a concerted effort to work more "green stuff" into his diet. He was out cycling so I figured if things did not go well he would be spared knowing that his creation, like so much other food, was quickly spit out by my digestive system.
       That's been the problem. After my initial mets diagnosis and accelerating through the summer and fall I continued to lose weight from nausea and vomiting. Blergh. It took my energy and my strength. Suddenly I empathized with pregnant women suffering from morning sickness. I took ginger in every conceivable form, threw that up, carried saltines in my purse, and ate teeny little meals. My nutritionist at MD Anderson became my inner cheerleader. Yes! I could eat every two hours! I would eat nutritionally-dense foods! I would add peanut butter to everything! I could do this! But when DH returned from the grocery with a carton of Ensure I suddenly felt like we were in the middle of a senior citizen sitcom with a lousy script.
      During this time I learned another rite of passage of the metastatic underworld: familiarity with emergency rooms. Emergencies in metastatic illness can happen quickly. Ultimately I did not wrestle with this fact but learned what I needed to do. Dehydration from vomiting can send you down a bad path. When the nurse scolded me for waiting too long before coming in I was about to turn pissy on her until I realized that what she was telling me was that witnessing suffering is hard. It didn't have to get this bad, she was telling me. The next time it didn't.

* * *

Beginning in June my regular oncologist was taken up by meetings, conferences and vacation.  DS (darling sister) and I joked about this upset by calling the substituting oncologist Dr. Today.  Unlike my regular onc, Dr. Today did not come into the exam room prepared. She usually appeared sleepy.  Or bored. Or both. I was convinced my cancer bored the hell out of her. Since I was on the vomiting end it was not all that boring to me. Not surprisingly, when my regular oncologist returned we talked for less five minutes before we had a GI consult arranged. 
      That brings me back around to my salad. As you know, metastatic lobular cancer was found in the lining of my stomach at the end of October. My oncologist told me that the aromatase inhibitor I was on, the formerly $4-now-$22 letrozole, would work at eliminating the cancer but it would work more slowly than chemotherapy.
       He was right.  It has been worth the wait.
       It was a year ago today that I was lying in the ultrasound suite at MD Anderson waiting for the results of a lymph node biopsy from my neck. You know the rest of that story, but the one I just told you is new.  There will be many more. As of now all systems are go in a gentler, slower way. Yesterday I just returned from five days in San Diego as part of AACR's Scientist-Survivor Program. I managed to practice self-care AND fully participate in the program.  No, I didn't get to the 7 am "Meet the Expert" sessions I wanted to attend, I missed some lectures, and I put up my feet instead of putting on heels for a late evening reception. When the mental fatigue and fog set in I remembered to keep my eye on the prize: learning, educating and advocated for women with breast cancer.
       And believe me, did I ever enjoy my salad.  Dear God, few things have ever tasted so good.

***






Monday, January 13, 2014

Cue the Kellers

Lisa Adams is a stunningly articulate blogger and mother of three from New England who has suddenly found herself as the Rorschsach test for two prominent journalists who should have known better. The husband and wife team, Emma and Bill Keller, writing for the Guardian and The New York Times respectively, in the end tell us more about their own fears and experiences with cancer than they do about Lisa and her current difficult treatment for metastatic breast cancer.  She has currently been hospitalizaled at New York's Memorial Sloan Kettering Cancer Center (MSKCC) for almost two weeks now.

The two pieces of writing are disrespectful, inaccurate, and to return a word grenade lobbed by Emma Keller in her Guardian piece, "unethical."  Somehow both writers managed to conclude that Lisa is dying (metastatic and terminal are not synonyms), a huge assumption that isn't theirs to declare.  Most bloggers I follow, including Lisa Adams, pay more attention to accuracy than these journalists did. Keller, former executive editor of The New York Times, originally misstated the number of children Lisa has. Emma's piece has been removed from the Guardian "pending investigation."

There are many levels on which their "blame the patient" posts are so wrong but I'll stick with two: the gigantic misunderstandings surrounding metastatic breast cancer and a withering lack of savvy about social media and its role in fostering healthy epatient communities.  

Somehow, both writers have found the whole idea of patients writing about their experience, and how @adamslisa in particular does so, strangely offensive. Cue the Kellers with a big welcome sign to the 21st century!  Cue the Kellers: no one is forcing you to read anyone's tweets!  Cue the Kellers: ever since blogging platforms evolved we've heard from men and women about their disease experience and exchanging that knowledge with others. Cue the Kellers:  Peer to Peer Healthcare  published in 2011 by Pew Internet, a project of the Pew Research Foundation. 

For many of us, social media has been the only vehicle in which something approaching truth can be found about living with cancer, and I mean actually living with it, not understanding what cancer is or a definition of chemotherapy. We want hints on helping a phlebotomist find the sweet spot and ten ways of stopping nausea without Zofran. We want to find out more about genomic analysis and in when it's really helpful. No breast cancer patient is going to find these kind of essential details about treatment from the web sites of breast cancer organizations.  We find this info from other patients. The organizations may have been founded with the best intention to end disease but each is ultimately vested in its own survival. Patient communities, on the other hand, and patients within social media, exist to help educate and help each other. Patients share freely.  It is interactive, dynamic, and powerful, not a one-way street like a newspaper.

The understated nastiness of Bill Keller's "Heroic Measures" starts early. He refers to Lisa as  " ... a research subject and proselytizer for the institution" (MSKCC).  The subliminal shift to "research subject" shows where his perspective hovers about cancer. He constantly uses military language and metaphor, which isn't part of Lisa's style book. Bill Keller's perception of cancer is limited, naive and just plain stupid.  Women with metastatic breast cancer or anyone with metastatic cancer period can endure difficult periods of illness and pop back to tell us about it next month. Cancer treatment, even today with many advances, is grueling.  Earlier today I corresponded with a woman who has been in hospice three times. She isn't even 60. Yet Keller's point of view is based on this, "In October 2012 I wrote about my father-in-law's death from cancer in a British hospital. There, more routinely than in the Unites States,* patients are offered the option of being unplugged from everything except pain killer sand allowed to slip peacefully from life." If that's not enough, since Keller has already misread what Lisa has written about the palliative care she's receiving, "His death seemed to me a humane and honorable alternative to the frantic medical trench warfare that often makes an expensive misery of death in America."
       
Wow.  He writes on from there for about two more pages. That basis is where Bill Keller's understanding of Lisa's situation stopped, if he ever had any understanding of her situation to begin with.  He extrapolates the experience of one (elderly? it looks like Keller himself is middle aged) family member with cancer to everyone with cancer and especially to that woman whose tweets annoy him.  It is a failure on an unforgivable scale.
 
Cue the Kellers: next time you want to write about cancer, take a look at your own stories.  Better, yet, just talk between yourselves.

                                                                            #   #   # 

*Thousands of patients in the United States are offered palliative care on a daily basis.  The UK doesn't hold a patent on this.  There is a weekly tweet chat on Twitter every Wednesday evening on hospice and palliative care under the #hpm hashtag at 8 pm CT.

Tuesday, November 19, 2013

The Cone of Uncertainty

Anyone living along a coastal area knows about the cone of uncertainty.  These are widely ranging swaths of land that lie in the projected path of a hurricane or typhoon.  The cone starts small, at the point of landfall, then widens exponentially to include every blade of grass or bird that could possibly be impacted by the storm event. 

At one point prior to Hurricane Ike the weathermap showed IKE sucking up heat as it moved across the entire Gulf of Mexico, then striking the Houston Ship Channel and barreling up a narrow corridor until it landed directly on my house. I was sure of that. This was not a happy moment. I crawled into the bathtub with the dog and ate almonds and chocolate while the storm ripped all the leaves off the trees for miles around and anniliated large sections of beach and homes in Galeston, which suffered the most devastating damage.  

Hurricane Ike's Cone of Uncertainty 

This came back to me again because I've been living in a cone of uncertainty for the last month or so.  My thoughts darkened.  I felt like I was sheltering in place, treading water, as I waiting for results from tests and as importantly, learning what those tests meant in the context of my life, my health. This is especiallly important in cancer, where an errant fact might look bad yet fit in a cohesive narrative on an indivual level.  From what I knew? I could be in trouble. Or not.  And I wouldn't know the answer for a number of weeks.  
            At the end of October metastatic breast cancer was found in the lining of my stomach.  My oncologist had ordered an endoscopy to check out my gut's workings when I continued to lose weight and suffer from bouts of nausea and vomiting without rhyme or reason.  None of these episodes could be related say, to a batch of minor food poisoning or a 24-hour virus running through the community. 
            Metastatic lobular breast cancer,  this little darling of a breast cancer I have (only comprising from 10-15 percent of all breast cancers) can weasel its way anywhere, sneaking along through the lymph system and even wedging between the lining of the stomach and the muscle. When my oncologist explained this yesterday, drawing a decent stomach, esophagus and upper intestine, he penciled in how the cells line up between the two layers. From there it was a mental skip and a jump to grasp what is described medically as a "plastic-type" presentation. As the cells accumulate the stomach itself becomes more rigid and and lead to the symptoms I've been experiencing. 
           But the stomach mets did not represent progression.  No progression.  In cancer land there's no better music to one's ears.  The stomach mets were mostly likely present when I was diagnosed with metastatic disease in April.  These would not have become apparent on CT until they formed tumors and given the symptoms I've already had, I shiver to imagine how ill I would have been by then. 
           So the good news definitely is no progression.  The obvious news is learning to live with a stomach that's been damaged by cancer.  Some, but not all, of the damage will ease as Femara continues its work.  An aromastase inhibitor, which works by blocking the enyme that allows androgen to convert to estrogen, Femara has done remarkable work in my system in six months, nearly knocking out the extensive lymph node involvement I presented with.  This is like removing the tree trunk from all the limbs. The more we continue to shut down the feeding system, the fewer malignancies -- like these monsters creeping along in my stomach -- will be there to find.  
          In the meantime my disease falls back into the manageable, chronic category. If I continue to take the daily medicine I could be fine for many, many months.  I'll have scans again in eight weeks.  But no one is a fool, either.  There are some indescriminate lesions we want to remain boringly, indescriminate. We want them to stay as boring as they are now. 
          I'll watch, yes, I'll be mindful, but I certainly am not qoing to stick around and wait for trouble.  No one can say when the next inevitable progression or drug resistance will occur, when the cone of uncertainly will hover again.  All of us know that cancer can change its mind in a moment, fake out your immune system, and even recruit a few buddies to help its do its dirty work.  We do what we can. Stay rested, eat well, exercise.  Don't give the creeps an inch.
          I felt hope growing yesterday, small, but true, and deep. 


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Tuesday, October 1, 2013

October 2013

It's October 1, 2013. Our government? Lights out.  Our culture? Splashes of pink pop up like crabgrass, from the grocery store aisles to newspaper supplements.

But the truth is out. Those most affected by metastatic breast cancer are not fooled by the government's stonewalling nor are they taken in by a commercialized illusion of cancer. They are busy with other things. Things like living.  Things like dealing with neuropathy or nausea from yesterday afternoon's treatment. Things like tracking down a researcher while juggling a child's after-school schedule, or sharing news about Perjeta, the first neoadjuvant treatment for women whose breast cancer tumors express the surface protein HER2-neu (human epidermal growth factor 2), which account for perhaps 20 percent of the 160,000 new cases of breast cancer expected this year. Things like researching second generation sequencing and asking about the differences between genomic profiling and chemo-sensitivity testing. These are just some of the things people with metastatic disease do. Some are preparing for palliative radiation therapy, a new round of chemo, others are returning home with drains and pain medicine, another has just entered hospice care. Every year approximately 40,000 die of metastatic, not primary, breast cancer. That comes to 1,000 women every day.

Everyone is changed. Our shared humanity ties us together in a sacred space.

Two weeks ago I attended the Metatstatic Breast Cancer Network's annual conference that was held in conjunction with the MD Anderson Cancer Center in Houston. There Don S. Dizon, MD of Massachusetts General Hospital and frequent ASCO Connection contributor, presented a perspective  on living with metastatic breast cancer that didn't as much resonate as detonate. That's because the words typically associated with metastatic disease aren't of the back-slapping hey, make my day variety.  In oncology corridors the frequent phrases are incurable, progressive, chronic and relapsing to the frequently repeated "many live well a long time."  

With Don S. Dizon at MBCN's Annual
Conference in Houston 9/21/2013.

In the first weeks following my metastatic diagnosis I frequently deconstructed "many," "live well" and "long time." How was many was many? Greater than 70 percent of women live a long time? 60 percent? I gnawed on my own chances.  I had little blobs of cancer in a lot of places, a tad more difficult than one big blob that could be nixed out with a scalpel or a jolt of radation. Listen, someone else's cancer is always cooler than yours.  What about a long time? Was that ten years? How about 11? Twelve sounded magnificent but 13!  Greedy and perhaps unwise. At that point in my own experience acceptance and uncertainty had not yet laid down the essential, parallel tracks through my consciousness, like the smudge of a jet stream against a fall sky.

In fact statistics on metatstatic disease, which uses information gathered from the past to project how you may do in the future, now feel absurd to me. They feel inaccurate and out-dated. Social media amplifies the difficult at the expense of underplaying the rhythms of regular life. Many out here in mets country are visually unidentifiable. We don't look sick. Tumor biology and the array of available treatments now, plus the unknown interplay between each woman's individual health, her tumor and reaction to treatment are the final arbiters of health, of lived days. All these intangibles. There are no answers, only guidlelines and decisions formed by each woman's preferences, her perception of the facts, and an oncologist's wisdom and experience in helping to guide the patient and significant other (s) through the process.

"Breast cancer sucks. Metastatic breast cancer sucks even worse," Dizon said. He wasn't swearing for an easy conference chuckle (zesty cancer crowds swear a lot)  but because it led him to what was even more important, "Feel it. Own it. Embrace it. Then move on."

Dizon uses a three-prong approach to make some order out of a disease with so many uncertainties. When oncologists say, "everyone's different," that is the truth.  Give 100 different women Femara and the range  of reported side effects will stagger you.  To keep things simple Dizon recommended three words: pragmaticism, realism and optimism.

A pragmatic approach to metastatic disease, which has stages I'm only now understanding that are not linear but cyclical, simply means being practical. "No one else has to walk in your shoes," he said. "Do what matters.  With metastatic disease it's all about you and those you love."

It's about you and those you love.  It occured to me not to let cancer screw that up, that nothing was that powerful.  "Prepare for an uncertain present, and an even more uncertain future," he said.

For me, that is where both optimism and a realistic approach play. This week I have another set of staging scans. That's the reality. Numbers and digital images may or may change my current prescription. But what Don Dizon brought home was his emphasis that being realistic does not mean ceding your independence or sense of less.  Cancer won't make me less than.
MBCN Conference Shirt Says it all.

I listened, then walked around for a few moments after his address. When you step into a ballroom full of women amd men who have lived with this illness for many years -- its peaks and valleys, months of clear scans, a body's sudden betrayal, an errant tumor marker, a treatment failure -- your perspective once again expands. It can only be so. Your eyes fill with tears.  I know who these women are now. I see them.  Yes, finally, I get it. I know each and every one would divorce themselves from this disease in a heartbeat if it were at all possible  So far it isn't. But I can feel it, own that, and embrace my life.

I wish the same for you.

***

Some pertinent links for October:

1) The Advanced Breast Cancer Community, Who Are We? 
2) The power of grass roots advocacy & growth:  Metavivor, supporting metastatic breast cancer research 
3) Amazing work: Think Before You Pink
4) Takes no offense from the word no: Terry Arnold, survivor and advocate for Inflammatory Breast Cancer (IBC).  IBC is a rare (approximately 4 percent of all cases) and aggressive form of breast cancer that often appears as a rash and may not appear with a lump. It is frequently misdiagnosed. This is one case where early detection can make a profound difference.

To come:
1) ABC2 - Advanced Breast Cancer Second International Consensus - Novemeber 7 - 9, 2013
2) San Antonio Breast Cancer Symposium -  December 10 - 14, 2013

*   *    *

Friday, April 26, 2013

Cancer: Round Two


This is how things change.

On Tuesday, April 9 we celebrate DH's (darling husband's) birthday with an extravagant dinner with friends at our favorite restaurant. We make happy noises about the food and pass around bites so rich it is absurd to even contemplate their arterial impact. We simply go with the moment and taste everything.

The next day I'm at MD Anderson for my yearly visit to the survivorship clinic. This will mark - let's celebrate anyway - my 15th cancer-free year.  The mammogram shows an anomaly.  We take another view. The second shot is inconclusive.  My nurse practitioner meets me in the exam room and says, "I don't want to alarm you, but we need to get another an ultrasound to make sure it's benign."

I'm not alarmed. Lobular breast cancer, which affects approximately 10 percent of all breast cancer cases, does not image well.  Never has, never will.  It's sneaky. The cells line up in a single file instead of clustering to form a mass.

But by the time I'm in ultrasound, where a radiologist in heavily accented English says, "Do not talk when I have needle in your neck," I realize, this is how your life changes.  I see the oblong node above my collar bone, a plump little dude, and the needle moving up and down within it.  For a moment something pierces. "So sorry," the doctor says, "I didn't put novocaine in the muscle."

I know.

The ultrasound room is so dark and quiet it has become its own universe, sealed off from regular life. Yet I know that behind the door is a small waiting room where four or five women in bathrobes are waiting. They read old magazines, legs crossed, feet jiggling and twitching. Those gestures mark time. They are waiting while I'm lying still, insanely comfortable on a new gurney (brand new, $4,000 worth of new, the wonderful ultrasound tech informed me) and bundled up in heated blankets. Then I realize a third person is in the room; the pathology assistant for the second, then third biopsy. The tissue will be analyzed immediately. I will know what I need to know what I already know from seeing the enlarged lymph node on the screen. Between biopsies I actually fell asleep. Right now that is my operating definition of mercy, to understand that another diagnosis of cancer is imminent and to be all right with that knowledge.

With cancer it's not one simple moment but a series of steps, one leading to the next. By the time I arrive home, when DH asks how my visit went, I have to tell him, "not well." He is a three-time melanoma survivor. "Not well" tells him something he never wanted to hear.

*  *  *

Since April 10 I have been largely offline,  either at MD Anderson or trying to get the next appointment in place, and talking with gracious physicians who have been generous with their time, explanations and kindness.  

Plus after 15 years NED I now enter the changed world of cancer diagnostics.  I am no longer a CT or MRI virgin. I drank the fruit-flavored barium smoothie, I've had the contrast IV's.  I ran into the inevitable young phlebotomist who missed a vein the size of a worm; I looked at her pleasantly and said, "go get someone else." 

The scans showed a different, but not rare, metastatic trail. There is nothing in the lungs or liver; but lymph node involvement and small nodules in the peritoneum and along a lymph chain that travels behind the diaphragm. There are positive nodes in the left axilla and neck, which were discovered by ultrasound. There is NO second primary cancer. All of this stems from the first cancer, so neither surgery nor radiation are needed at this point.

Biologically? The cancer's make-up is the same: 100 percent estrogen positive, progesterone negative, HER 2-neu negative. It's time to take away this cancer's food source. I'm about to be so thoroughly estrogen deprived that what I used to complain about menopause will soon become "the good old days." There are many options for shrinking this cancer and I have every hope that this will happen. The fact that it has been 15 years since my original diagnosis helps considerably. 

Last night I started treatment via the local Kroger's, where I picked up a prescription for Femara (letrozole), an AI or aromotase inhibitor. Where tamoxifen blocks the estrogen receptors on cancerous cells themselves Letrozole blocks the enzyme that converts androgens into estrogen in postmenopausal women. In premenopausal women the ovaries are the primary estrogen source.  In two months we'll look at what the Femara has accomplished, then consider the double whammy of Aromosin (exemestane) and Affinitor (everomilus),  another AI combined with an oral chemotherapy agent. With both approaches I'll receive monthly injections of Xgeva (denosumab) to shore up my bone strength.  

This morning DH wonders if I've experienced any side effects.  "No," I told him, "all systems are go."

It has been difficult, and still is, to relate to this new information.  Yet my life is different.  How I prioritize will be different.  One thing is steadfast: my commitment to #BCSM and advocacy. This is as strong if not stronger than ever. So is my knowledge that I am not alone in living with metastatic breast cancer. When there are times of complete stillness, I know all of you will be with me.  That is how I feel about you.  And that we are all in this together, in this moment and those to come.


* * *

Monday, March 18, 2013

Survivorship Guidelines. For real.

Late last week the National Comprehensive Cancer Network (NCCN), a nonprofit alliance of 21 comprehensive cancer centers, announced its first ever set of clinical practice guidelines for survivorship care.
     There are some 13.7 million cancer survivors in the United States alone. Of those, 2.9 million are breast cancer survivors. All of us have found our way through those first difficult months and years following diagnosis. Treatment itself was one thing. Trying to adjust to life after cancer was another.
      But by any measure the guidelines are good news for any man or woman in treatment now. The 100-page report covers eight distinct areas:
  • anxiety and depression
  • cognitive function
  • exercise 
  • fatigue
  • immunizations and infections
  • pain
  • sexual function 
  • sleep disorders. 
           Standards for evidence-based survivorship care are only being developed now. The first conference on survivorship science as an entity in and of itself did not take place until 2003. In 2004, the CDC and Livestrong published "A National Cancer Action Plan for Cancer Survivorship," which included the simple, yet powerful recommendation to establish an infrastructure for a comprehensive database on cancer survivorship. I don't know if that has transpired.  While that sounds smart to me, making smart things happen is not one of the hallmarks of our framented health care system.  
           Then as most of you know, in 2005 the Institute of Medicine published its landmark consensus report Lost in Transition, which made the case for survivorship care. Six years later Livestrong held a collaborative symposium of stakeholders, health care professionals and advocates to begin a consenus building project to articulate the "essential" elements in surivorship care. 
            A later IOM report, "From Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs," recommended that psychosocial screening be part of quality cancer care.  This is well covered in NCCN guidlines but why other concepts from Lost in Transition and Elements didn't become part of NCCN's report aren't clear, even though both reports are mentioned. NCCN surivorship care guidlines, for example, don't even support the need for a survivorhip care plan or treatment summary. While we all understand that there's no economic incentive in place for this let's get serious. A one page print out is not rocket science. Both "Lost" and "Elements" stress the need for education - of providers and patients - and coordination of care. NCCN's guidelines don't venture that far.
            NCCN's guidelines are directed at professionals. How this material will make its way from the nation's 21 comprehensive cancer centers to the community setting, where the majority of women are seen, is not explained. Color me skeptical but I see a packet of information stacked on an oncologist's already stacked desk. Neither were there any outside patient advocates or organizations on the committees as listed in the report. This makes no sense to me. You'd think that patient advocacy networks would be tapped for their assistance and guidance in moving this material to where it needs to be. Let patients know and let them help. No one is more invested in assuring the provision of good survivorship care than we are
          A few other take-aways to the report:
  • at least 50% of (all) survivors suffer from some late effect of cancer treatment. The most common problems seen are pain, depression and fatigue.
  • anxiety and depression affect up to 29 percent of all survivors; and some 19% meet the diagnostic criteria for post-traumatic stress syndrome.
  • the increasing trend toward more treatment, combined chemo, radiation, hormone therapy and surgery can result in more late effects. One example was the study from last week on increased of heart disease for women receiving radiation therapy.
          Believe me, I am far from done with this topic. Sometimes It seems the more we do to treat - not cure - cancer - the more potential for problems there are down the road.  We can't go back and undo treatment we selected, decisions we made when faced with a difficult, confounding disease. I do believe we can do a better job with survivorship though, and these guidelines are one place to start.
          I hope you'll take a look at the report. You will need to establish an account but you can access the material by registering with your email address here:
       
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Interesting note:  I just saw a news release from NCCN announcing that two additional cancer centers have been added to their network.  They are UC San Diego Moores Cancer Ceneter and University of Colorado Cancer Center.

Wednesday, February 27, 2013

Is Metastatic Breast Cancer on the Rise in Young Women?

Update: 3/2/2013: Ann Partridge, MD, director of the breast medical oncology at the Dana Farber Cancer Institute, with excellent questions on the study data and findings: see below.

Update:  On Thursday, February 28, #BCSM co-moderator Deanna Attai, MD added more clarity in this appearance on @MyFoxLA


Something long noted in breast cancer circles was study coming out today in the Journal of the American Medical Association that found a very small, but statistically significant, increase in the number of young women between the ages of 25 to 39 who are diagnosed with metastatic breast cancer.  

The change noted comes down to an absolute increase of 1.37 women per 100,000 women over 34 years, or approximately 2 percent per year. The same increase was not noted in older women and was consistent across all ethnic and socioeconomic groups.  One surprise is that there was a more pronounced increased in women with hormone sensitive breast cancer, rather than ER- cancer. 

Why this is happening is yet to be determined and was not the purpose of the study. We are left with more questions than answers.  

Studies are often complicated, and this one, a retrospective, observational analysis of three different sets of incidence and survvial rates from the US Surveillance, Epidemiology and End Results (SEER) program at the National Cancer Institute from l976 through 2009 - even more so. The collection of SEER data began in l973, yet the study years ran from 1976 - 2009.  Even the largest data set used, SEER 18, only comprises 28 percent of the US population.  SEER 9, by comparison, only includes 9.5% of the population, and the third set, SEER 13, 15 percent.  

Study author Rebecca Johnson, MD, Seattle Children's Hospital and University of Washington, wrote in the study that, "Whatever the causes - and likely there are more than 1 - the evidence we observed for the increasing incidence of advanced breast cancer in young women will require corroboration and may be best confirmed by data from other countries.  If verified, the increase is particularly concerning, because young age itself is an independent prognostic factor for breast cancer."

Vast improvements in diagnostic imaging between 1976 and now, staging work-ups and other factors come into play.  "The changes noted may be multifactorial," said Jennifer Litton, MD, of The University of Texas MD Anderson Cancer Center, "with changes in rates of incidence and younger women having more aggressive underlying biologies  coupled with potentially other genetic factors. What is much more clinically important than this would be changes in overall survival."

Breast cancer advocates concur. "These numbers do not change it for anyone who dies of this disease today," said Joy Simha, co-founder of the Young Survival Coalition. "We need to focus on finding the cause of breast cancer so we can make change happen."

Another aspect confirms what was discussed in last night's #BCSM discussion. "What the study enforces to me is the need for all young women to be aware of changes and to be proactive about their health," said Deanna Attai, MD, breast surgeon and #BCSM comoderator.  "Doctors need to be educated that there's no such things as "too young for breast cancer." No such thing."

For women with breast cancer today?  Nothing changes.  If you're in treatment today? Nothing changes.  But if you're watching the larger picture of cancer incidence in the United States in a population that already suffers unduly from a breast cancer diagnosis?  Heads up.  This is a signal we need to heed. 
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3/3/2013:  Comments from Ann Partdridge, MD:  breast medical oncologist from the Dana Farber Cancer Institute in Boston and medical advisor to the Young Survival Coalition: 


It is not clear from the study "whether the overall rate of breast cancer in young women is actually increasing," said Ann Partridge, MD, a medical oncologist from the Dana-Farber Cancer Institute and Harvard Medical School in Boston, Massachusetts. In other words, the study does not indicate whether the increase in advanced disease means that there is an overall increase in disease in young women.
That is important because other studies using SEER data have indicated that the rate of overall disease is stable in young women, said Dr. Partridge.
She pointed out that Dr. Johnson and colleagues found that the rates of localized and regional disease held steady in young women. Therefore, because they found an increase in advanced disease, thereshould be an overall increase in young women, she said.
However, the researchers "did not show/discuss data on overall rates of breast cancer in young women," Dr. Partridge wrote in an email. This omission, combined with the fact that the study findings might be in conflict with findings from other studies using SEER data, "leads me to wonder about the article," she said.
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