Hope at Last
Considering the strides made in breast cancer research just this year, Anderson's wish may be more than a dream. Results released last month from the National Cancer Institute's tamoxifen trial in the U.S. and Canada show that the drug can cut the risk of breast cancer in half for women especially susceptible to developing the disease. And a new gene-based treatment called Herceptin that has surprised scientists by shrinking advanced breast-cancer tumors is available now—years earlier than expected.
Meanwhile, researchers across the country are working on techniques as diverse as ultrasound and breast cloning in their efforts to prevent breast cancer, detect and treat it, and deal with its aftereffects. Everyone knows there is far more to be done, but the news is encouraging. "Breast cancer is becoming more curable," says Dr. Marc Lippman, director of the Lombardi Cancer Research Center at Georgetown University in Washington, D.C. "This is the dawning of a new era of therapy in which we're not simply x-raying and cutting things out."
The most promising breakthroughs involve anti-cancer drugs. For years studies have indicated the preventive powers of such natural products as soy-based foods and broccoli. But until recently medical science has been at a loss to avert breast cancer, even as women have become more prone to it by menstruating as early as age 11, delaying childbirth and going through menopause later in life. Over a lifetime these factors—products of a prosperous Western lifestyle—increase the body's level of estrogen, which is known to be one of the causes of breast cancer. "The bad joke is that we do know how to prevent most breast cancer: Delay puberty until a woman is 16," says Lippman. "But that would be social engineering."
So far tamoxifen, which works by blocking the estrogen that fuels breast-tumor growth, is the closest science has come to prevention in a pill. The Food and Drug Administration is expected to extend its approval of the drug—which was first passed in 1977 for patients with advanced breast cancer—for use in healthy but high-risk women later this month. But it is far from perfect. In the National Cancer Institute study postmenopausal women taking tamoxifen were twice as likely to develop uterine cancer during the five-year test as those on the placebo and were much more susceptible to developing blood clots in major veins and the lungs.
More promising is another estrogen-blocker called raloxifene, which is already prescribed to prevent osteoporosis in menopausal women and which might reduce the risk of breast cancer without tamoxifen's dire side effects. The NCI is launching a clinical trial with 22,000 women this fall. The drug "is one of the most exciting developments in breast-cancer prevention," says V. Craig Jordan, director of the breast-cancer research program at Northwestern University, who pioneered the development of tamoxifen in the early 1970s and will head the scientific team for the raloxifene study.
But if preventing breast cancer has captured the imagination of scientists, the prospect of curing it at the genetic level has blown them away. Herceptin, the first in a group of new gene-based drugs, represents a whole new approach to treatment. "Traditional chemotherapy and radiation are tantamount to throwing in a hand grenade and hoping it will kill more bad cells than good cells," says Dr. Dennis Slamon, director of the Revlon/UCLA Women's Cancer Research Program, who developed the drug. "New therapies like Herceptin specifically target what's broken in the cancer cell."
Combined with chemotherapy, Herceptin has been shown to shrink tumors in women with an aggressive type of breast cancer that accounts for 30 percent of all cases and involves a gene called HER2. The gene produces a protein which acts like an antenna on the membrane of a cancer cell, transmitting and receiving the signals that tell the cell to reproduce. Herceptin arrests the cancer by bonding to the protein that prevents the tumor from growing. And the side effects? A small fever at times, but nothing an over-the-counter painkiller can't fix.
Virginia Empey is living proof of the drug's potential. A nurse from Bakersfield, Calif., Empey, 54, discovered a lump in her right breast in 1993. Two different doctors told her there was nothing to worry about because the cancer didn't show up on her mammograms. A year later it had swelled to the size of a tennis ball. A mastectomy and chemotherapy failed to prevent the cancer from spreading to her liver, and by June 1995 her oncologist had lost hope, giving her less than six months to live. "Get your affairs in order," he told the thrice-married mother of two grown children. "Take a trip."
Unwilling to surrender, Empey pressed the doctor for more options until he mentioned the Herceptin trial. After establishing that her cancer involved the HER2 gene, researchers signed her up for the trial and for more than three years she has received weekly Herceptin infusions. Today the spots on her liver, once the size of silver dollars, are as small as peas. And although Empey is not considered cured, her hope is restored. "I was supposed to be dead, and I'm not," she says. "Now I treasure every day."
For most women a diagnosis of breast cancer still means surgery plus chemotherapy or radiation. Of course, early detection remains the best way to avoid severe treatment. And although mammograms, recommended annually for women 40 and over, miss about 15 percent of cancers, a new digital scanner approved by the FDA in July could increase the accuracy of detection. Traditional treatments have also been improved. New antiemetic drugs developed in recent years have relieved much of the nausea associated with chemo. And these days about 45 percent of breast-cancer patients undergo a lumpectomy, a procedure used rarely until about 10 years ago, which targets only the malignant area of the breast. While doctors once removed many of the lymph nodes under a woman's arm to learn whether a cancer had spread, they are now able to test just one or two key, or so-called sentinel, nodes. Unfortunately, experts say as many as 35 percent of women who are eligible for lesser surgery still undergo a full mastectomy. "What that suggests," says Dr. Monica Morrow, a surgeon married to tamoxifen researcher V. Craig Jordan, "is that women are not being informed of the choice."
At the experimental stage are anti-angiogens that cut off a tumor's blood supply and have cured cancer in mice; vaccines that could work by "turning off" the cancer gene; and nonsurgical treatments that use ultrasound waves to zap away tumors without breaking the skin. Says Dr. Eva Singletary, chief of the Surgical Breast Service at the M.D. Anderson Cancer Center in Houston: "We are within 10 years of not even needing surgery to treat most breast cancer."
Still, for many survivors treatment is just part of the trauma. "It's a real roller coaster for most women," says Dr. Julia Rowland, codirector of the psycho-oncology program at the Lombardi Center. "Once a woman has been diagnosed with breast cancer, she isn't ever going to be the same person again. It will always be part of her life."
Body image is a major concern for many women. Three years ago, Kristina Pavlou had survived Hodgkin's disease and advanced breast cancer, but was left with only one breast and forced to use a prosthesis at age 22. Dating, says the former TV reporter from Chicago, was a daunting ordeal. "I wanted to feel whole again," she says. "I wanted to feel confident about dating and being intimate." A new reconstruction technique helped restore her breasts—and her self-esteem. In February 1995, using a microsurgery technique refined in the 1980s, Dr. David Hidalgo, chief of plastic and reconstructive surgery at Memorial Sloan-Kettering Hospital in Manhattan, replaced Pavlou's missing right breast with a cosmetic one fashioned from skin and fat from her buttocks. A few months later he repeated the procedure after Pavlou had her left breast removed to prevent further spreading of the cancer, which had already appeared in her lymph nodes. "Everyone thought I was nuts to go through it again," she says. "But I was happy I was getting my life back."
The 12-hour operation is among a host of new options for more natural-looking breasts. Surgeons at M.D. Anderson have helped perfect a new mastectomy procedure that preserves the patient's breast skin, creating a pouch that can be immediately filled with a saline implant. Alternatively surgeons can take a section of fat and muscle from the lower abdomen and—keeping it attached to the blood vessels that feed it—tunnel the mass up between the skin and the rib cage and into the pouch.
At Anderson and elsewhere scientists are even experimenting with cloning breast cells and cultivating other body tissues to grow personalized, natural implants. "Some people are a little frightened that maybe we are learning too much," says Singletary. "But this could save a lot of suffering." Pavlou's new breasts certainly did. Now director of education for the national breast-cancer organization Why Me and dating Greg Chip, 30, a marketing consultant, she is no longer reluctant to show her naked breasts around women's locker rooms. "My breasts are a work of art," she says. "I'm proud of them."
Other aspects of breast cancer can't be surgically fixed, which is where the relatively new field of psycho-oncology—psychotherapy tailored specifically to cancer patients—comes in. "The vast majority of survivors have gotten on with their lives," says Rowland. "But a very small proportion of women find themselves drawn down through a spiral of despair." Some become obsessed with fear of a recurrence. Others over-compensate by running themselves into the ground at work. Mothers sometimes feel as if they've cursed daughters with a hereditary cancer. And single women may fear they'll never be able to date or have a child.
Some, like Angela O'Connell, a breast-cancer patient at Chicago's Rush Presbyterian St. Luke's Medical Center, simply needed a sympathetic ear. O'Connell, 51, began seeing the hospital's psycho-oncologist Suzanne B. Yellen almost three years ago after finding out that her cancer had spread. "She understands," O'Connell says. "She has assured me that this is not the end of the road." Most important, the experience is helping her toward the finish line that every woman with breast cancer hopes to reach—"to go back," she says, "to a normal life."
Reported by: Giovanna Breu and Sheree R. Curry in Chicago, Linda Kramer in Washington, D.C., Patricia B. Smith in Houston and Lyndon Stambler in Los Angeles