PLUM OR M&M?

Everyone knows that plums are healthier than M&M's.  But when it comes to breast cancer screening, nothing is sweeter than an M&M-sized breast cancer.  

Why?  

Because cancers that are about 1 cm (or the size of an M&M) have a 97% chance or better of cure.  And although a breast cancer can be detected by physical exam when it is still small, the average size of a cancer found on palpation is about the size of a small plum.  

Size isn't the only thing that matters when it comes to breast cancer survival.  The other two most important factors are whether or not there has been spread to lymph nodes under the arm and the aggressiveness of the tumor (also known as the grade of the tumor).  All of these factors are minimized when a cancer is detected on a screening mammogram as opposed to found on physical exam.

As I have blogged in the past, the continued confusion over when to screen, who to screen and how often to screen is unnecessary.  To be clear:  there is no 'debate' about whether or not screening mammography saves lives.  Recent follow-up studies to the original trials proving the efficacy of mammographic screening not only show that regular screening can decrease the death rate from breast cancer by over 30%, most of the benefit of screening occurs after the first 10-15 years of screening. In other words, the more screens you receive, the bigger the benefit.

And speaking of benefits, remember:  A Colorado law which went into effect 1/1/2011 (HB 10-1252) requires all insurance companies doing business in the state of Colorado to provide for annual mammography for all women age 40 and older.  And the Affordable Care Act, now finally becoming fully implemented, requires the same nationwide, with no out-of-pocket expenses.  If you find yourself uncovered under commercial insurance, you can get a free mammogram through the state-sponsored Women's Wellness Connection (must be a legal resident) or Denver Komen for the Cure (covers even undocumented women) if you meet certain criteria.

So, when you're stealing M&M's from your kids Halloween candy later this month, remember that an M&M-sized breast cancer is curable, but the only way to find a cancer that small is on a screening mammogram.  So go ahead, have a handful of M&M's, then call us at The Breast Care Center  to make your annual screening mammogram appointment.  Then maybe go on a bike ride...

Angelina Jolie and Genetic Breast Cancer

I'm sure many of you heard about Angelina Jolie's editorial in the New York Times yesterday disclosing that she recently underwent prophylactic bilateral mastectomies due to her carrying the BRCA1 gene mutation.  I think what she did was an excellent medical decision and her choice to disclose this publicly, a brave one.  By doing so, hopefully more women will confront their own known high risk or find out more about their risk if they have a significant family history of breast and/or ovarian cancer. 

What exactly are BRCA gene mutations?  BRCA (which just stands for BReast CAncer) genes are two (BRCA 1 and BRCA 2) beneficial genes in our genetic code.  When functioning properly, they help to suppress tumors which may otherwise grow.  If you carry a genetic alteration in the BRCA 1 or 2 gene, then the suppression of tumors malfunctions, allowing cancers to develop.  BRCA genes primarily protect the breast and ovaries, so if you have one of these mutations, you are most susceptible to cancers in these two organs.  This is as high as an 80% chance of breast cancer and 50% chance of ovarian cancer. 

BRCA gene mutations are passed on generation by generation in a dominant fashion.  This means that any offspring of a carrier has a 50% chance of having the mutation, too.  Angelina's mother had the gene, as she died of ovarian cancer and any other siblings of hers would also have a 50% chance of having the mutation.  It's important to realize that the gene can be passed down from the father and that male offspring of carriers also have the risk of carrying the mutation.  Men who carry the mutation have up to a 6% chance of getting breast cancer (although this seems low, it is more than 6 times the 'average' risk for male breast cancer) and a 20% chance of developing prostate cancer.  And men and women carriers have additional risks of pancreatic cancer, melanoma and stomach cancers which are many times higher than those at general risk.  

As Angelina writes, knowing that you have the mutation empowers you to make proactive decisions about your health and medical care.  She chose bilateral mastectomies which is usually recommended prior to menopause (breast cancers in mutation carriers usually develop sooner than 'typical' breast cancers). And usually these women also undergo prophylactic removal of the ovaries and Fallopian tubes.  Until a woman is ready or prepared to make these decisions, however, mutation carriers are usually aggressively screened for breast cancer by annual screening mammography AND MRI from age 25 and ultrasound exams and blood tests to screen for ovarian cancer by age 30.  

It is important to remember that gene mutations only account for a small percentage (less than 10%) of breast cancers-so called 'genetic' breast cancers. Most breast cancers are 'sporatic,' meaning that there are no identifiable risk factors other than female sex and age.  Some breast cancers occur in multiple family members without the gene mutation.  These are called 'familial.'  It's likely that we'll eventually identify and be able to test for genetic alterations in these women.  

At my center, we screen all women for risk factors which may point towards a genetic mutation and/or an increased risk for breast cancer.  As a comprehensive screening and cancer treatment center, we have an on site genetic counselor to whom we refer patients at possible high risk.  If appropriate, we will test for the gene mutations (now just a 'swish and spit' test).  However, we strongly believe that all testing should be done in the presence of counseling in order to appropriately manage the results of the test, no matter what they are.

As we learn more and more about the biology of breast cancer and our own genetic makeup, I am optimistic that we will continue to identify more situations in which we can alter the natural course of genetic alterations.  It's exciting to work in a field which can offer hope and alternatives to patients who just a decade or so ago had to face cancer diagnoses at young ages which often led to devastating outcomes.  Knowing your genetic risks is an empowering and life-saving experience in many situations.  Angelina's disclosure of her own situation will raise awareness and save lives. 

The Uninsured

A.C. is a 60 year old uninsured white female who recently was seen in my clinic.  She was referred for assessment of a new palpable right breast mass which had initially been imaged at an outside institution.  When the institution wanted $2000 to perform a biopsy on this suspicious mass, A.C. was referred to us because we have programs to cover the cost of imaging and biopsies for uninsured women.

M.G. is a 35 year old woman whom I saw this week, one year after her surgery to remove a malignant right breast mass.  She was initially imaged in April, 2011 at an outside institution, but, because she was uninsured and not a legal resident, it took her six months to find us to have her mass biopsied and eventually removed.  By the time she had her surgery, her mass had more than doubled in size and multiple lymph nodes under her right arm had cancer in them.

When I worked at my previous position, a patient had to quit her job in the middle of treatment for her breast cancer because the chemotherapy made her too sick to work.  When she quit her job, she lost her insurance and she stopped her cancer treatment.  When she returned to my clinic a year later after re-gaining her job and her insurance, her cancer had spread.

I recently met a young, white female conservative at a social gathering and, while she said she agreed with my 'liberal' social views, she stated that she 'belonged to the other side.'  When I asked her what she meant, she said that she didn't believe that people should 'be given something for nothing.'  What flashed in my head was the phone call I had made earlier that day to A.C. to tell her that she had breast cancer.  I could only get ahold of her between 3pm and 4pm.  Why?  Because that is the only time she had between her two full-time waitressing jobs, neither of which provided benefits.  She was only able to get the biopsy done because of our assistance programs for uninsured women.

There is something seriously wrong when we, members of the richest country on the planet, allow fellow citizens (and, yes, noncitizens) to suffer the consequences of undiagnosed or untreated disease simply because their situation doesn't allow for the safety net of medical insurance.  The amount of unnecessary suffering is heartbreaking.  All three of the examples above were dedicated, hardworking women who wanted to take care of themselves, who wanted to make the right decisions.  They weren't 'takers' or 'moochers,' just in need.

Although far from perfect, The Affordable Care Act will have the effect of mandating medical insurance for millions of people who currently are uninsured and are at the mercy of an often heartless and inaccessible system.  Although most economists believe that a single payer system is the best (this is also my opinion with Medicare, Medicaid, the military, TRI-CARE, S-CHIP and the Federal Employees Health Benefits system as multiple examples), taking the first wobbly steps towards this with The Affordable Care Act is the right thing to do.  You can read some questions and answers about The ACA here.

Part of the reason I took my current job almost five years ago is that part of the mission of St. Joseph Hospital is to serve the underserved.  This usually means poorer, uninsured patients, many of whom are undocumented.  Every year, we compete for grants and work with state funds to provide these vital services to these patients who would otherwise have no other options.  Politics aside, we as a country must figure out how to ensure coverage for all patients regardless of their ability to pay.  If these means more taxes for those of us who can afford it, then that is the price we pay for a stable, healthy, educated and safe population.  This is the moral, ethical and right thing to do.

We all benefit from a healthy, educated and safe workforce.  Doing what I do at the Breast Care Center at Exempla St. Joseph Hospital helps me keep the Hippocratic Oath I made when I graduated medical school nearly 21 years ago and helps to ensure that I, First, Do No Harm.