Members of BCAM attended two events marking "Breast Cancer Awareness" during the month of October.
Dr. Gerald Batist, Director of Oncology, McGill U., and of the Translational Research Unit at the Lady Davis Institute of the Jewish General Hospital presented "Update: Progress in Cancer Research," an outline of where science is going in terms of novel therapies — not limited to breast cancer. Dr. Batist presented information on four wide-ranging approaches to the problem of cancer: new molecular targets, new targeting agents for cancer therapy, developments in cell and gene therapy, and cancer prevention. As an example of new molecular targets, we were told that genes and proteins critical for cancer cell growth have been identified and can now be targeted. For instance, hormonal therapy is used to target estrogen receptor positive tumours, and herceptin — a laboratory-produced antibody that blocks the HER2 receptor overexpressed by some tumour cells — can be targeted to deprive tumour cells of a crucial factor required for cell growth.
In addition, both the Jewish General Hospital and McMaster University are involved in programs comprising a form of therapeutic immunization using a vaccination to stimulate the patient's immune system to produce antibodies to the HER2 receptor. To do this, a HER2 rat gene is incorporated into a virus and the combination used to immunize individuals. So far, the vaccine trials are projected only for specific tumours and receptors.
Cell therapy involves a technique called 'apheresis' which removes stem cells (potential immune cells) from the blood. Growth stimulants are added to these cells to produce cancer-killing cells that are reinfused into the patient. The theory is that tumour antigens or antibodies could also be added to search for receptors.
These three approaches have yet to be tested in clinical trials which are, of course, critical in testing the viability of each approach.
The final approach, prevention, was presented in terms of self-care (nutrition and exercise), and medication (tamoxifen or similar products). Environmental issues were not mentioned.
According to Batist, cancer patients are doing better and living longer, even with metastases. Because they live longer, researchers now have the time to look at quality of life and to deal with complaints such as weight loss and fatigue. Recently, exercise has been found to help increase tolerance to chemotherapy — particularly on the day of administration.
Dr. Batist spoke for about 40 minutes and about half of that was in praise of the Oncology Unit at his hospital, i.e., the superb people on staff, and the plans for their new centre. [Note that although the JGH didn't have long wait times in October, a recent report on wait times at the MUHC (McGill University Health Centre) is bound to have repercussions at JGH.] Dr. Batist was especially helpful during the question-and-answer period but, unfortunately, the substantive part of his presentation was overly technical and not always understandable for a lay audience. Moreover, his perception of 'prevention' is a far cry from the environmental factors that concern us at BCAM. In closing, Dr. Batist stressed that good cancer care is available in Montreal and that we should not look to other centres for better treatment, because all the hard-won information is shared.
A second forum on "Breast Cancer, News You Can Use," sponsored by Cedars Cansupport, was moderated by Dr. Davis Fleiszer, Oncology Surgeon and Co-director of the Cedars Breast Clinic of the MUHC. Dr. Fleiszer claims that the Cedars Clinic can provide a mammogram, ultrasound and biopsy in the space of a single day.
Four speakers were featured: Dr. Benoit Mesurolle (Radiologist) who spoke on the role of ultrasound in the management of breast cancer; Dr. Antoine Loutfi (Oncology Surgeon, Co-director of Cedars Breast Clinic) who provided an update on the status of Hormone Replacement Therapy (HRT); Ms. Debbie Fitzmaurice (breast cancer survivor) who was there to speak on behalf of the patient: and Mme Maryse Carignan (R.N., Cansupport Co-ordinator) who discussed whom to turn to for help. Later, two more Oncology Surgeons, Drs. Sarkis Meterissian and Marius Wexler, joined the group as members of a panel.
According to Dr. Mesurolle, the Cedars Clinc performs approximately 12,000 mammograms each year, about 3,000 ultrasounds and orders fewer than 100 MRIs (Magnetic Resonance Imaging). Obviously mammography remains the principal imaging technique, although more ultrasound is being done. For younger women or for women on HRT with dense breast tissue, the sensitivity of mammography is limited (<70%) but, combined with ultrasound, this can be increased to 90%. Therefore, ultrasound is the diagnostic tool of choice for younger women or for women on HRT.
Ten years ago, ultrasound was used solely to determine whether a lesion was a cyst or solid nodule Today, with better resolution, smaller images can be seen. While only 7% of mammograms are problematic, ultrasound has proved useful in determining that ~6.5% of this 7% are benign while only ~0.5% are malignant. In effect, ultrasound has become invaluable in reducing the need for biopsy and the rate of false positives, as well as a guide for interventional procedures. Ultrasound is most effective in conjunction with mammography and clinical breast examination (CBE).
Dr. Antoine Loutfi commented that there has been a great deal of publicity about HRT since May of 2003, and discussed the role of HRT in relation to breast cancer, osteoporosis and cardiovascular disease (CVD).
Two recent studies — The Women's Health Initiative (WHI) in the U.S. and the Million Women Study (MWS) in the U.K — have demonstrated an increased risk of breast cancer with prolonged use. This risk disappears after five years NOT on HRT. While the WHI found that the rate of death was not affected, the MWS (which drew from a much larger pool of subjects) reported that women presented with larger tumours, more positive nodes, at more advanced stages and were more likely to die.
Although HRT has, for some years, been promoted to reduce the risks of CVD. two preliminary studies, HERS (Heart and Estrogen/Progestin Replacement Study) and ERA (Estrogen Replacement and Atherosclerosis) determined, respectively, that the risk of CVD increased by 52% for users of HRT or that there was no clinical benefit for users of HRT. More recently, the WHI has confirmed the increased risk of CVD (including stroke), pulmonary edema as well as invasive breast cancer.
At the same time, HRT was beneficial in terms of relief from menopause symptoms (i.e., hot flashes), and reduced the risk of hip fractures and colon cancer. There was no significant effect on general health, vitality, mental health, symptoms of depression or sexual satisfaction, but HRT did help sleep disturbances, physical functioning and pain tolerance. Cognitive benefits were uncertain, i.e., the risk of dementia increased but this may have been a side effect of the increased rate of stroke.
The WHI arm using estrogen and a progestin reveals a higher but not significant risk of ovarian cancer, as well as added protection against endometrial cancer and osteoporosis. Dr. Loutfi conceded that it might be permissible for some women to use HRT for short-term relief of menopausal symptoms, but said it was important to talk this over with one's doctor. The moderator, Dr. Fleiszer, interjected that a 50% increase in CVD could be relative or absolute, which might mean merely going from a risk of 2% to a risk of 3%. Dr. Fleiszer is apparently not so opposed to HRT as is Dr. Loutfi, who was adamant about the dangers of HRT.
The patient representative, Debbie Fitzmaurice, had just received her fourth diagnosis of cancer, but is hopeful because of new medications being made available. Ms. Fitzmaurice feels strongly that stress affects body chemistry and that this can induce cancer. In her own case, she said that she was going through a particularly stressful time just before each diagnosis. She added that anecdotal evidence from others supports her view. She looks to the day when chemical events in the body can be measured and emphasized that support — whatever helps one to cope — should be made available during treatment. She had found that her nurses were very important in providing support and underlined the need to understand what is going on, being poised to see a specialist if a problem is suspected.
The nurse, Maryse Carignan, commented that it is vital for the cancer patient to address emotions of distress, despair, anger, loss, etc. She described how Cansupport, an organization funded by the Cedars Breast Centre, works to improve the patient's quality of life by providing services, support and education to patients and families.
The panel convened to deal with questions from the audience. A question about lumpectomy yielded the response that segmental mastectomy plus radiation was as effective as a total mastectomy. One woman wanted to know if there was anything as effective as HRT but with fewer side effects. Research is continuing into various types of SERMs (Selective Estrogen Receptor Modulators) such as tamoxifen, raloxifene, droloxifene,etc. When asked why there appeared to be so much breast cancer today, the panel responded that cancer rates are probably unchanged over the last hundred years but that better and earlier detection was taking place because of increased health consciousness, more breast self-examination and earlier detection by other means. One panelist added that, since the 1990s, mortality from breast cancer has decreased 5%-6% in absolute (not relative) terms.Within ten years, women will be getting the treatment that will work with their particular cancer.
In general, this was an interesting program with knowledgeable speakers and presentations geared to the audience. The medical professionals gave the impression of caring for their work and for their patients. Debbie Fitzmaurice was incredibly courageous. "You carry on, she said, "you don't have a choice."
- Beral V, Banks E, Reeves G, Bull D. Breast cancer and hormone-replacement therapy: the Million Women Study. Lancet, 2003 Oct 18; 362(9392):1330-1331
- Grady D, Herrington D, Bittner V, et al, HERS Research Group. Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II). JAMA, 2002 Jul 3;288(1):49-57.
- Rossouw JE, Anderson GL, Prentice RL, et al; Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women's Health Initiative randomized controlled trial. JAMA, 2002 Jul 17;288(3):321-33
- Sherman AM, Shumaker SA, Kancler C, et al; ERA Trial Investigators. Baseline health-related quality of life in postmenopausal women with coronary heart disease: the Estrogen Replacement and Atherosclerosis (ERA) trial. Journal of Women's Health (Larchmt), 2003 May;12(4):351-62
- Shlipak MG, Chaput LA, Vittinghoff E et al, Estrogen/progestin Replacement Study. Lipid changes on hormone therapy and coronary heart disease events in the Heart and Estrogen/progestin Replacement Study (HERS). American Heart Journal, 2003 Nov; 1):870-875.