Dear Friends,

Welcome to the second annual Breast Cancer Symposium. It is exciting to see the new research on breast cancer treatment presented this year. To help inform people about progress in cancer, ASCO publishes Cancer Advances, a series of consumer information resources. Cancer Advances: News for Patients from the 2008 Breast Cancer Symposium provides the latest information about breast cancer research and treatment. The information in this issue was presented at the 2008 Breast Cancer Symposium held in Washington, DC from September 5-7, 2008. For additional information about breast cancer, please visit Cancer.Net (www.cancer.net), ASCO’s patient information website.

Sincerely,

Richard L. Schilsky, MD
ASCO President

The study: Researchers looked at differences in the use of radiation therapy after lumpectomy (removal of the tumor and a small, cancer-free area around the tumor) for white and black women. Using a national Medicare database, researchers analyzed the treatment for 34,024 white women and 2,305 black women age 66 or older who were treated with lumpectomy in 2003 for newly diagnosed early-stage breast cancer. Although earlier studies have shown racial disparities in breast cancer treatment, this study is the first to look at the use of radiation therapy after lumpectomy on a national scale and compare geographical regions. The standard treatment for most early-stage invasive breast cancer is lumpectomy followed by radiation therapy. However, a small number of women who may not be able to tolerate treatment may not have radiation therapy.

The results: Black women were less likely to receive radiation therapy after lumpectomy than white women. Overall, only 65% of black women received radiation therapy after lumpectomy compared with 74% of white women. Among women younger than 70, who are more likely to receive standard treatment, 71% of black women received radiation therapy after lumpectomy compared with 81% of white women.

The following regions showed the greatest difference in the use of radiation therapy after lumpectomy:

• East South Central region (AL, KY, MS, TN): 57% of black women compared with 72% of white women
  
  
• Pacific West (CA, OR, WA): 55% of black women compared with 72% of white women
  
  
• New England (CT, ME, MA, NH, NJ, NY, VT): 58% of black women compared with 70% of white women

The regions with the smallest difference in treatment were the Mountain West (AZ, CO, ID, MT, NV, NM, UT, WY), where 74% of black women received radiation therapy after lumpectomy compared with 76% of white women, and the West North Central Midwest (IA, KS, MN, MO, NE, ND, SD), where 72% of black women and 74% of white women received radiation therapy after lumpectomy.

What this means for patients

“The results of this study indicate that we need to identify and correct the obstacles that are causing these disparities, and work to increase awareness about the benefits of radiation therapy after lumpectomy among patients with breast cancer,” said lead author Grace Smith, MD, PhD, MPH, Postdoctoral Fellow in the Department of Radiation Oncology at the University of Texas M.D. Anderson Cancer Center. “We don’t know if fewer black women are receiving radiation therapy because it is not offered to them, because they decline the treatment, or because they are unable to complete treatment.” Before making a treatment decision, talk with your doctor about all the treatment options available to you, including the benefits, risks, and possible side effects.

The study: Researchers at Johns Hopkins University analyzed data from 80,000 patient records available in the 2006 U.S. Surveillance, Epidemiology, and End Results (SEER) database and the 2004 Area Resource File to determine whether there were differences in radiation therapy use between women who live in urban or rural areas. Previous studies have shown that women in rural areas are more likely to choose mastectomy (removal of the breast as a treatment for breast cancer) over lumpectomy than women in urban areas. This finding has often been attributed to lack of access to radiation therapy in rural areas. This study is the first to compare the use of radiation therapy after lumpectomy and mastectomy between women in rural or urban areas to determine if access to radiation therapy could be affecting a woman’s choice of treatment.

The results: The rates of radiation therapy after lumpectomy or mastectomy were not different based on whether a woman lives in a rural or urban area. Among the women who had a lumpectomy, 81% of urban women and 80% of rural women received radiation therapy after surgery. Among women who had a mastectomy, 39% of urban women and 38% of rural women received radiation therapy. Although the percentage of women receiving radiation therapy after surgery was similar, rural women were more likely to choose mastectomy instead of lumpectomy. About 60% of rural women chose a mastectomy compared with about 45% of urban women.

What this means for patients

“We thought access to radiation therapy was influencing rural women to choose mastectomy over lumpectomy with follow-up radiation, but our findings show this is not the case,” said lead author Lisa K. Jacobs, MD, Assistant Professor of Surgery at Johns Hopkins University in Baltimore, Maryland. “Since these findings show access to radiation therapy does not impact a woman’s decision about which type of surgery to have for breast cancer, we will need to look at other factors, such as quality of patient education about treatment options.” Talk with your doctor about all your treatment options. The best treatment for you may be different than the best treatment for another woman with breast cancer.

What to Ask Your Doctor About Lumpectomy and Radiation Therapy

• Would you explain my surgical treatment options to me?
  
  
• Am I a candidate for lumpectomy, or do I need a mastectomy?
  
  
• Will I receive radiation therapy after surgery?
  
  
• Will you describe what I will experience when I receive radiation therapy? Will it hurt or cause me discomfort during the treatment?
  
  
• What are the possible short term and long term side effects of each treatment?

The study: The study, conducted at the University of Texas M.D. Anderson Cancer Center, included 143 women with HER2(human epidermal growth factor receptor 2)-positive tumors (determined before treatment began) who received chemotherapy and trastuzumab (Herceptin) before surgery. About 25% of breast tumors produce too much HER2, called HER2-positive cancer. A tumor with low levels of HER2 is called HER2-negative. Trastuzumab is a specific treatment for a HER2-positive tumor

The results: Of the 143 women, 50% had no sign of invasive cancer at the time of surgery. In other words, treatment with chemotherapy and trastuzumab was able to eliminate all signs of invasive cancer before surgery.. Among women who had signs of invasive cancer (meaning that treatment was not completely successful), tumor samples from before and after surgery were available for 23 of the women. These samples were tested for HER2. For about 30% of these women, the HER2 status of the tumor changed from HER2-positive to HER2-negative during treatment.

After approximately 10 months, the women who had signs of invasive cancer during surgery were 3 times more likely to have a recurrence (cancer that comes back after treatment) than those who did not. Two women (3%) who had no signs of invasive cancer had a recurrence compared with eight women (11%) who had signs of invasive cancer.

What this means for patients

This study suggests that the HER2 levels in a tumor can change, which could either mean that tumor cells change over time, or that some tumors are composed of both HER2 positive and HER2 negative tumor cells. “This information is important for doctors to keep in mind so we can provide patients with the most appropriate treatment for their cancer,” said lead author Elizabeth A. Mittendorf, MD, Assistant Professor in the Department of Surgical Oncology at the University of Texas M.D. Anderson Cancer Center.

What to Ask Your Doctor

• What is my HER2 status? What does this mean?
  
  
• What are my treatment options? Am I a candidate for HER2-specific treatment?
  
  
• What are my other treatment options, if this treatment stops being effective?

The study: Researchers looked at whether screening with molecular breast imaging (MBI) could detect more breast cancers than screening with mammography for women with dense breasts and an increased risk of breast cancer. In an MBI, a radioactive tracer is injected into a patient’s body that is absorbed by breast tissue. A special camera is used to distinguish between healthy breast cells and cancerous breast cells. Although mammography is the standard screening option, it can be difficult to locate a tumor in women with dense breasts.

Researchers screened 940 women with both MBI and mammography. All women included in the study had dense breasts, determined by a previous mammogram, and they had an increased risk of breast cancer due to personal or family history, a genetic mutation related to breast cancer, a previous precancerous condition, or previous radiation therapy to the chest. Follow-up screening was performed for 375 women about 15 months or longer after the original screening to determine if they had been accurately diagnosed.

The results: MBI detected 3 times as many cancers in women who had dense breasts and increased breast cancer risk than mammography. Among the women in the study, 13 tumors in 12 women were found: eight with MBI only, one with mammography only, two with both screening methods, and two with neither screening method. About 8% of women who received MBI needed follow-up testing compared with approximately 9% of women who received mammography. Biopsies were performed on 36 of the tumors discovered by MBI and 17 of those discovered by mammography. About 28% of the tumors discovered by MBI were cancerous when biopsied compared with about 18% of tumors discovered by mammography.

Among the women who received follow-up screening, 75% who received MBI were accurately diagnosed with breast cancer compared with 25% of the women who received mammography. Approximately 93% of women who received MBI were accurately determined to not have cancer compared with 91% of women who received mammography.

What this means for patients

“These results suggest that MBI could become an important screening tool for women who have dense breasts and increased breast cancer risk,” said lead author Carrie B. Hruska, PhD, Research Fellow in the Department of Radiology at the Mayo Clinic in Rochester, MN. “More research is needed, but it is encouraging to find that MBI can detect cancers that are not easily visible on mammography.” MBI is only available at a limited number of cancer centers. For more information, talk with your doctor about your risk of breast cancer and the screening methods that are available in your area.

Cancer.Net Guide to Breast Cancer

Cancer.Net Feature: Breast Cancer: Questions to Ask Your Doctor

Cancer.Net Feature: Frequently Asked Questions About Radiation Therapy

ASCO Expert Corner: Race and Breast Cancer

ASCO Expert Corner: Health Disparities in Cancer

What to Know: ASCO's Guideline on HER2 Testing for Breast Cancer

Cancer.Net Feature: Understanding Targeted Treatments

Cancer.Net Feature: Mammography – What to Expect

Cancer.Net Feature: Breast MRI for Early Detection of Breast Cancer