By Mary Carpenter
OCTOBER is Breast Cancer Awareness Month (BCAM)—with each advocacy group proclaiming a different slogan, but with similar goals of women supporting each other and supporting research. From Breastcancer.org, the awareness month “aims to promote screening and prevention of the disease, which affects one in eight women in the United States every year and 2.3 million women worldwide.” Another group describes “this year’s theme [as] ‘No one should face breast cancer alone.’”
“For 2023, the slogan is “Pink Together, Stronger Forever,” from still another group. And one more: “Living Beyond Breast Cancer is sharing some of the ways people thrive with breast cancer and how your support today can help people impacted by breast cancer—all year long. This year’s Breast Cancer Awareness Month theme is Thrive365.”
BCAM began in 1985 with a week-long event and the participation of Betty Ford; the pink ribbon emerged as its official symbol in the early 1990s. Since then, according to a review by Irish researchers: “an international health campaign [has led to] “increased levels of online activity relating to breast cancer…consistently generated each October”—along with advances in detection and treatment.
Five-year survival rates for invasive breast cancer jumped from about 75% between 1975 and 1997, to above 90% between 2003 and 2009. “When caught in its earliest, localized stages, the 5-year relative survival rate is 99%,” according to the National Breast Cancer Foundation. “In 2023, an estimated 297,790 women and 2,800 men will be diagnosed with invasive breast cancer.”
“The most significant risk factors for breast cancer are being a woman and getting older,” according to the website of the National Breast Cancer Foundation. U.S. breast cancer rates began decreasing in 2000 but have increased by about .5% annually in recent years. After lung cancer, breast cancer is the leading cause of cancer-related deaths in U.S. women and is the leading cause for Black and Hispanic women. In addition, 85% of breast cancers occur in women with no family history — “due to genetic mutations that happen as a result of the aging process and life in general.”
For women in their 70s and older, there continues to be a “sometimes intense debate about whether it’s appropriate to screen these women for breast cancer,” according to the National Cancer Institute website. The “risk of overdiagnosis with routine screening mammography [is] substantial…and this overdiagnosis risk escalates with increasing age.” Overdiagnosis for these women refers to the discovery of a cancer that is expected to grow “very slowly or not at all—and would never cause problems during someone’s lifetime.”
For all ages, however, overdiagnosis additionally includes the risk of false-positive results—and “the anxiety that comes with follow-up tests or procedures,” according to Cancer.gov. As a result, the WISDOM (Women Informed to Screen Depending on Measures of Risk) trial is examining whether risk-based screening—at intervals based on individual risk from genes, family history and other factors—is as “safe, effective, and accepted as standard annual screening mammography.”
A woman’s risk of breast cancer nearly doubles if she has a first-degree relative (mother, sister, daughter) who has had this diagnosis. The risk of breast cancer rises from 13% of women in the general population to—for those with a BRCA gene variant—between 45 and 72% of women, who are expected to develop breast cancer by 70 to 80 years old. In screenings of unselected populations, 50% of those discovered to have BRCA variants reported no personal or family history to indicate increased cancer risk.
Screening populations with no family history is worthwhile for three conditions—Hereditary Breast and Ovarian Cancer Syndrome (cancers linked to the BRCA variants), Lynch Syndrome (the most common form of hereditary colorectal cancer) and Familial Hypercholesterolemia (very high cholesterol starting at an early age), according to the CDC. The reason: for these three, there is sufficient evidence that interventions can reduce morbidity and mortality.
In addition, at-home screening tests, such as the Color Extended test, can analyze genes related to eight types of cancer including breast—as well those related to cardiac disease and medication response. Such genetic screenings—also offered by 23andMe, Veritas and others—usually require an order from a physician, either one’s own or one provided by the company.
Also currently under study is 3-D mammography because, according to cancer.gov: “it isn’t known whether it is better than standard 2-D mammography for detecting cancer at a less advanced stage.” Also in question, whether 3-D screening is better for some kinds of breasts, such as those with very dense tissue.
Treatment for aggressive subtypes of breast cancer was the research focus of the 2019 Nobel Prize winners in Physiology or Medicine. Examining the role of decreased oxygen levels in cancer cells involved in metastasizing cancers, the researchers found that hypoxia can transform some cancer cells so that, much like embryonic stem cells, they can multiply indefinitely. Low oxygen levels also enable these cancer cells to hide and evade treatments with radiotherapy, chemotherapy and immunotherapy. At least two drugs now in clinical trials focus on reversing tumor hypoxia.
Recent advances also include the division of breast cancers into subtypes based on response to hormone treatment, including HR-positive cancers that contain estrogen and or progesterone receptors. Some women with one subtype of aggressive HR-positive cancer, for example, do not benefit when chemotherapy is added to hormone therapy. And treatment success with HR-positive cancer in a group of postmenopausal women has led to new hope for individualized, targeted therapies.
After 2000, cancer incidence rates in the United States that had increased for the previous two decades began to drop—by 7% from 2002 to 2003 alone. One theory traced the decrease to reduced use of hormone replacement therapy (HRT) after early results from a large 2002 study suggested a connection between HRT and increased breast cancer risk. Since then, however, critics have pointed to poor selection of study subjects and flawed results of the study.
Over time, raising public awareness has been essential to improving detection and treatment of breast cancer, along with decreasing the incidence and improving survival rates. One explanation is that inadequate attention has traditionally plagued medical issues related to women. But, too, directing focus onto critical health problems has often required public intervention—perhaps most for the AIDS crisis. Recently, the documentary film “All the Beauty and the Bloodshed” showed photographer Nan Goldin’s almost single-handed organization of public protests in art museums that galvanized an enormous public reaction, followed by increased legal and medical response, to the opioid crisis.
—Mary Carpenter regularly reports on topical subjects in health and medicine.