breast cancer

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Pathologist: What Women Need To Know About Breast Biopsy Accuracy

A breast biopsy which illustrates the grey zone of pre-cancer (Courtesy of Dr. Michael J. Misialek)

A breast biopsy which illustrates the grey zone of pre-cancer (Courtesy of Dr. Michael J. Misialek)

By Michael J. Misialek, MD

If you’re a woman who has ever had a breast biopsy, you may be asking yourself a few serious questions:

“How do I know if my breast biopsy is completely accurate?” And, “Who is the pathologist reading the biopsy, and what is their level of training?”

Many more patients are asking these and similar questions following widespread media coverage on a Journal of the American Medical Association (JAMA) study, which casts doubt about the accuracy of interpreting these biopsies.

Let’s break the study down and ease some anxiety. Perhaps most importantly, this provides a great opportunity to learn about one of the lesser know medical specialties, pathology…which is what I do.

The JAMA study, “Diagnostic Concordance Among Pathologists Interpreting Breast Biopsy Specimens,” revealed the following key finding:

• Overall agreement between individual pathologists’ interpretations and that of an expert consensus panel was 75 percent, with the highest agreement on invasive breast cancer and lower levels of agreement for ductal carcinoma in situ (DCIS) and atypical hyperplasia.

What this means is that the agreement between a general pathologist and an expert was excellent for breast cancer (those with the ability for metastasis), but varied significantly for early cancers and high-risk pre-cancers.

While the study’s findings may not be surprising to physicians who understand the challenges of diagnosing complex breast cases, news of the article could lead to unnecessarily heightened anxiety for patients and the public as breast cancer is a highly publicized and pervasive disease.

The study confirmed that the majority of breast pathology diagnoses, especially at either end of the spectrum (benign disease and invasive breast cancer) are accurately made by practicing pathologists regardless of practice setting. The overall rate of agreement for invasive breast cancer cases was 96 percent.

Issues with diagnostic disagreement mainly center on the borderline cases, between atypical hyperplasia, that is, pre-cancer, and DCIS, early cancer.

Why does this matter? Overdiagnosis can lead to unnecessary surgery, treatment and anxiety. Underdiagnois can lead to a delay in treatment. The bottom line is that experience matters.

Factors that contributed to greater disagreement included: a low case volume, small practice size, nonacademic practice and high breast density.

The study has many weaknesses. Chief among them was that only a single slide per case was given to each pathologist. As a practicing pathologist, this never happens. I will review multiple slides, often ordering several additional deeper sections and ancillary special stains, studying each carefully. This practice was prohibited in the study.

Additionally, the study cases were a mixture of core biopsy and excision specimens. A core biopsy is obtained using a needle, often by a radiologist, in which a small core of tissue is removed. An excision is a “lumpectomy” which is done in the operating room where a large section of breast tissue is removed. Diagnostic criteria vary between a needle core and excision. Often times it is not necessary to render an exact diagnosis on the core biopsy, but rather recognize an abnormality and recommend an excision for which additional tissue will clarify the diagnosis.

Even the experts disagreed in the study (75 percent initial agreement then 90 percent after discussion).

This illustrates the fact that pathology is both a science and art. Experts may stress slightly different criteria in their pathology training programs. The “eye of a pathologist” is a difficult measure to quantify and is dependent on multiple factors that best function in real time, not an artificial study.

Another weakness is that there is no evidence that the experts were more accurate in predicting outcomes than test subjects. Perhaps most importantly, a second opinion was not allowed in the study, even when study participants indicated uncertainty. These are in fact the very cases that would most likely have been shown around, sent out for consult and further worked up.

It is not realistic to introduce such a large caseload of breast biopsies that are heavily weighted towards atypical hyperplasia and DCIS. Since these borderline cases represent only a small fraction of breast biopsies in actual practice, diagnostic agreement in routine practice is higher than that reported in this study. No clinical information other than patient’s age was given to the study pathologists, and no imaging findings were included. In actual practice, integration of the clinical setting and imaging findings is routinely used in making a diagnosis.

The findings are not unique to pathology. All of medicine has grey zones, where controversy often exists. The study does have an important message for pathologists. As noted in the accompanying editorial, it should serve as a “call to action.” A better, more reproducible definition of atypical hyperplasia is needed.

The article highlights the need for an active quality management program in surgical pathology that includes targeted review of difficult or high risk cases. The College of American Pathologists (CAP) and the Association of Directors of Anatomic and Surgical Pathology have been developing an evidence-based guideline expected to be released in May to provide recommendations to reduce interpretive diagnostic errors in anatomic pathology.

The CAP is proactively addressing educational opportunities through advanced breast pathology training programs designed to provide a route for pathologists to demonstrate their expertise regardless of the setting in which they practice.

Patients can take steps to help ensure their breast biopsy is read accurately:

o Inquire about the pathology laboratory that will examine your tissue sample. Is the laboratory accredited? The CAP accredits more than 7,600 laboratories worldwide and provides an online directory for patients. Continue reading

Slashing The Pink Ribbon From Beyond The Grave

We’ve written about “Pink Fatigue,” “depinkification,” “pinkwashing,” “Taking on the Pink Juggernaut.” It’s getting to the point that every pink-tinged October also brings a backlash arguing that National Breast Cancer Awareness Month has perhaps jumped the shark.

But never have I read as powerful and furious an indictment of the current breast cancer scene as a piece by longtime Los Angeles Times reporter Laurie Becklund, As I Lay Dying. She died of metastatic breast cancer on Feb. 8, a postscript notes, but I suspect her writing will live virally on for a long time. An excerpt:

Promise me, I told my friends and family, that you’ll never say that I died after “fighting a courageous battle with breast cancer.” This tired, trite line dishonors the dead and the dying by suggesting that we, the victims, are responsible for our deaths or that the fight we were in was ever fair.

Promise me you’ll never wear a pink ribbon in my name or drop a dollar into a bucket that goes to breast cancer “awareness” for “early detection for a cure,” the mantra of fund-raising juggernaut Susan G. Komen, which has propagated a distorted message about breast cancer and how to “cure” it.

I’m proof that early detection doesn’t cure cancer. I had more than 20 mammograms, and none of them caught my disease. In fact, we now have significant studies showing that routine mammogram screening, which may result in misdiagnoses, unnecessary treatment and radiation overexposure, can harm more people than it helps.

Laurie Becklund tells her own story of unexpected cancer recurrence; she describes grappling with her new identity as someone who was surely dying, and her encounters with other women in the same situation; and she expresses her outrage at how the medical establishment and the breast cancer world have failed such patients. Part of her conclusion:

The most powerful organization in the breast cancer universe, Susan G. Komen , has raised $2.5 billion over the last 20 years, much more than many corporations will ever earn. Yet Komen channels only a fraction of those funds into research or systems to help those who are already seriously sick. Most of that money continues to go to a breast cancer “awareness” campaign that is now painfully out of date. Continue reading

So Much For The Killer Bra: Study Finds No Link With Breast Cancer

(canonsnapper via Compfight)

(canonsnapper via Compfight)

If you’re a bra-wearing woman, maybe you know this feeling: You exhale with relief as you unhook your band at the end of a long day. Looking over your shoulder into the mirror, you see the slight indentation the elastic has left on your torso, and think: “Constriction like this just can’t be good.”

That intuition resonates with popular theorizing that bras can lead to breast cancer by blocking the healthy drainage of waste products from the breast area. Hence the higher breast cancer rates in developed countries.

But give me good hard data over feelings and pop theories every time. A big new study, funded by the National Cancer Institute, finds no link at all between bras and breast cancer.

The study, published in the journal “Cancer Epidemiology, Biomarkers & Prevention,” found that whether women wear bras just a few hours a day or more than 16, whether they wear underwires or wireless, whether they have big cups or small cups, brassieres are guiltless: They just do not seem to be linked to the two most common forms of breast cancer.

The research involved hundreds of postmenopausal women: 454 with invasive ductal carcinoma, 590 with invasive lobular carcinoma, and 469 without breast cancer, who served as controls. Each woman answered questions about everything from her pregnancy history to the age at which she started wearing a bra, whether it had an underwire, cup size, band size and how many hours a day she wore it.

Bottom line: It looks like your bra won’t kill you unless someone strangles you with it. Which contradicts a 1995 book that added gallons of fuel to the theory that bras are harmful: “Dressed To Kill: The Link Between Breast Cancer and Bras.”

The new paper’s senior author, Dr. Christopher Li, head of the Translational Research Program at the Fred Hutchinson Cancer Research Center, says “Dressed To Kill” provided some of the impetus for the study. Our conversation, lightly edited:

Why did you think this study was worth doing?

The whole theory about bra-wearing and breast cancer came to my attention years ago, when there was this book published called “Dressed to Kill.” The whole premise of the book was that bra-wearing is the primary culprit for breast cancer in the world. Being a breast cancer researcher, I had never heard of this theory, and people, friends of mine who had seen it, were saying, ‘What’s going on with this?’ Continue reading

My Right Breast: One Man’s Tale Of Lump And Mammogram

Journalist B.D. Colen chronicles  his own mammogram experience both in prose and in photos he took during the procedure. ((c) B. D. Colen, 2014)

Journalist B.D. Colen photographed his own mammogram during the procedure. ((c) B. D. Colen, 2014)

By B. D. Colen

It began with an itch I just had to scratch. Doesn’t every adventure begin that way?

I was lying in bed reading on a Saturday evening, and without even looking I idly scratched a spot on the right side of my chest –- at that point I had a chest, not breasts. As I did, my fingers rode over a small something, a little like a speed bump about an inch below and two inches to the left of my right nipple.

I stopped reading and started poking. And prodding. And pushing. And feeling. And manipulating. And panicking.

“That’s a lump!” I thought, and suddenly I had a right breast. With a lump in it.

I spent Sunday attending to the usual chores and pleasures, with a good deal of poking and prodding added in. There was absolutely no question that something was dwelling there, beneath my AAAA right breast. But what was it? And what was I worried about? After all, I’m a man, and men don’t…Well, yes, men do get breast cancer. In fact about one in every thousand men will develop breast cancer during their lifetimes. Granted, that’s barely worth mentioning compared to a woman’s one-in-nine chances, but it still means that the possibility was indeed real that something ugly and malignant was barely hiding beneath my skin.

The following day, I already had an appointment with my primary care physician about something else, and when we were finished I said, “So, Sam, I seem to have this lump in my right breast.”

(Photo c. B.D. Colen, 2014)

(Photo (c.) B.D. Colen, 2014)

Suddenly, my normally garrulous physician grew serious. “Let’s take a look,” he said, asking me to lie down on the examining table. He had me show him where I thought the lump was and I instantly isolated it – I’d already felt the damned thing enough times to be able to go right to it.

He felt it, felt around it, poked and prodded, and in less than a minute said, “You’re right, there’s something there.” Then, without further kidding – which I’d expect from him – and without any “Well, it’s probably nothing, but let’s be sure,” he sat down at the computer and started typing. “I’m putting in an order for a ultrasound and a mammogram,” he said. “For tomorrow.”

Mammowhat?! Mammogram? Me? But I’m a man! And at 67? Is this some really, really weird dream I’m about to wake up from? How in God’s name were they going to do a mammogram when there’s practically no mam on my chest?

But into the rabbit hole, through the door marked “Women (almost) Only” I went. Though not before Googling “male breast cancer” and convincing myself that I was going to die: Family history? Check. Average age of 68? Check. Sometimes Google is not your friend.

The nice woman down in radiology scheduled me for 10 the next morning, and told me that I shouldn’t worry. “It’s probably nothing,” she assured me. I thought, “That’s probably what you tell all the guys.”

I don’t need to tell any of you who are women what a painful, essentially degrading experience having a mammogram is. I’ve since read the jokes advising women to prepare for the procedure by placing a breast on the edge of their freezer and slamming the door on it – and that is pretty close to the reality. Continue reading

More Concern Over BPA, Link To Breast Cancer

 

USA Today sounds the latest warning on BPA, or bisphenol A, in a report on growing concerns that the industrial chemical and synthetic estrogen (which is still used as a lining in many canned goods as well as in plastics and other common products) may be linked to breast cancer.

The news report cites a just-released study by advocates at the Breast Cancer Foundation that focuses on the potential dangers of prenatal exposure. According to the report:

Prenatal exposure to this toxic endocrine-disrupting chemical is of even greater concern than childhood exposure.

During the prenatal period, the foundation is set for how the body’s systems develop, and animal and human studies show us that fetal exposure to BPA can set the stage for later-life diseases, including breast cancer.

To understand the mechanism at work, reporter Liz Szabo quotes Tufts biologist Dr. Ana Soto, who published a paper last month that found BPA increased the risk of mammary cancers in rats:

In two studies of rhesus monkeys published last year, other researchers found that BPA disrupted egg development, damaged chromosomes and caused changes in the mammary gland that made animals more susceptible to cancer.

Soto says it’s possible that prenatal BPA exposure makes fetuses more sensitive to estrogen, a hormone that drives the growth of most breast cancers. In that way, BPA could indirectly increase the risk of breast cancer later in life. Continue reading

Are Young Women With Cancer In One Breast Needlessly Having The Other Removed?

Are young patients with cancer in one breast, driven by unfounded fears and anxiety, having the other breast removed unnecessarily?

That’s the troubling question implicit in this new survey of women 40 or younger who chose to undergo double mastectomies even though their cancer was only in one breast. The procedure, called contralateral prophylactic mastectomy (CPM), has increased “dramatically” in recent years, particularly among younger women, researchers report.

But evidence suggests that the removal of a healthy breast in a woman with cancer in only one breast does not improve survival rates.

TipsTimes/flickr

TipsTimes/flickr

Still, researchers from the Dana-Farber Cancer Institute and colleagues report that more and more young women with breast cancer are electing to remove their healthy breast to “avoid recurrence and improve survival.”

Specifically, the study found that among 123 women surveyed, 98 percent said they chose CPM to avoid getting cancer in the other breast and 94 percent said they did it to improve survival. (Also of note, 95 percent said they did it for a more nebulous but emotionally potent reason: “peace of mind.”)

If you’ve had breast cancer, or know anyone who has, it’s easy to see why such a subjective, non-data point like “peace of mind” might trump a more rational, just-the-facts approach to treatment. But this paper, published in the Annals of Internal Medicine, points to what it calls the “cognitive dissonance” between what women know to be the facts and what they actually do.

“Many women overestimate their risk for actual cancer in the unaffected breast,” the paper says, concluding that: “Interventions aimed at improving risk communication in an effort to promote evidence-based decision making is warranted.” Continue reading

Patients’ Joy Over Supreme Court Decision On Gene Patents

Catherine Corman (courtesy)

Catherine Corman (courtesy)

By Cathy Corman
Guest Contributor

My inbox and voicemail were filled with gleeful messages from colleagues, friends, and family Thursday afternoon. My beloved friend Martha put it just right when she called me from Connecticut: “I’m happy for you, and me, too, and everyone else!”

In what may be the single most popular opinion of his Supreme Court career, Justice Clarence Thomas wrote the unanimous decision, released Thursday, that liberates scientists to perform research on and design tests for BRCA 1 and 2. These are the genetic mutations linked to an elevated risk of developing breast and ovarian cancer.

Some of us belong to families where grandmothers, mothers, aunts, and sisters don’t survive into middle age because they develop breast and ovarian cancer. Up until today, the only way we could find out if we’d be likely to share the fate of our doomed relatives was to give our cells to one company — Myriad Genetics.

Myriad claimed its patent prevented any other entity from providing this service, and it set the cost for testing so high that low-income, uninsured, and underinsured women weren’t able to unlock the riddle of their fate.  In addition, it made research into effective cures impossible. Continue reading

Abercrombie: ‘No Uncool.’ Now Victoria’s Secret: No Mastectomy Bras

Abercrombie & Fitch models (Wikimedia Commons)

Abercrombie & Fitch models (Wikimedia Commons)

This is what we call an aggregating post, in which we pull together related news items, and the items I’m aggregating today concern companies that define their brands as “exclusive” — not as in “luxurious” but as in “We choose to exclude certain populations, such as disabled people or women who’ve lost breasts to cancer or are not sylphs.”

First, this just in from CBS News here: Victoria’s Secret Will Not Make Mastectomy Bras, despite the 128,000 signatures on a petition asking for them.

Despite immense public support, Victoria’s Secret will not manufacture a mastectomy bra, the company said Monday.

“Through our research, we have learned that fitting and selling mastectomy bras in the right way…a way that is beneficial to women is complicated and truly a science. As a result, we believe that the best way for us to make an impact for our customers is to continue funding cancer research,” Victoria’s Secret said in a statement.

Allana Maiden had started a petition on Change.org earlier this year, urging the company to create bras for women who had a mastectomy. Maiden’s mother Debbie Barriett underwent a mastectomy over two decades ago when she fought breast cancer.

The Victoria’s Secret decision, of course, says nothing like “We want our brand to be linked to sexy models, not mastectomy patients,” but it immediately made me think of the still-resonating impact of a 2006 Salon interview with Abercrombie and Fitch CEO Mike Jeffries. It was resurrected earlier this month by Business Insider, and includes this much-spread quote: Continue reading

My ‘Personal Fantasy’ For Angelina Jolie (Hint: It’s All About Genes)

By Cathy Corman
Guest contributor

Back in 1998, I tested positive for the same genetic mutations that led Angelina Jolie to have a double mastectomy. When I talked with my doctor about the surgery to remove my healthy breasts and ovaries, I asked her what would be left of my femininity.  “You still have your brain,” she told me.

I’ve thought about that exchange as I’ve read commentaries weighing in this week on the meaning of Angelina Jolie’s decision to undergo prophylactic mastectomies and to go public with the details. Most have focused on the impact of Jolie’s decisions on her film career and on women’s assessment of cancer risks.  They have missed an important point:  Jolie’s revelation is ultimately as much about her brain as her body.

Ivan Tortuga/flickr

Ivan Tortuga/flickr

There’s a reason Jolie has been the highest paid actress in Hollywood, earning up to $30 million a year.  Sure, she’s got bee-stung lips, big boobs, a tiny waist and comely hips. But she’s not just beautiful.  She’s brainy.  Jolie has cannily put her physical assets to work in roles that have allowed her to link sex and power: as video-game heroine Lara Croft, a super spy in Mr. and Mrs. Smith, and as a daring CIA agent in the film Salt. Jolie has taken her body to the bank by choosing to be seen as active and able.

Jolie consciously continues in her role as action/adventure hero in the way she shapes her decisions to undergo genetic testing and surgery.

Here’s how:

• She remains powerful because she controls the flow of information.  She managed to keep her mastectomies private until she was ready to share.  And when she chose to share, she “bared all” on the opinion page of what is arguably the most respected newspaper in the world. Continue reading

Angelina Jolie’s Double Mastectomy: How Times Have Changed

(Alastair Grant/AP)

(Alastair Grant/AP)

About five years ago a close friend of mine had a prophylactic double mastectomy to lower her extremely high genetic risk of developing breast cancer, which had killed her mother. She begged me to keep the operations a secret: she didn’t want to worry her two young daughters.

Today, in a New York Times opinion piece that is about as out-there and open as it gets, 37-year-old actress and activist Angelina Jolie, who carries the BRCA1 gene which greatly elevates her risk of breast and ovarian cancer, writes that she recently had her breasts surgically removed to lower that risk.

On April 27, I finished the three months of medical procedures that the mastectomies involved. During that time I have been able to keep this private and to carry on with my work.

But I am writing about it now because I hope that other women can benefit from my experience. Cancer is still a word that strikes fear into people’s hearts, producing a deep sense of powerlessness. But today it is possible to find out through a blood test whether you are highly susceptible to breast and ovarian cancer, and then take action.

My own process began on Feb. 2 with a procedure known as a “nipple delay,” which rules out disease in the breast ducts behind the nipple and draws extra blood flow to the area. This causes some pain and a lot of bruising, but it increases the chance of saving the nipple.

Two weeks later I had the major surgery, where the breast tissue is removed and temporary fillers are put in place. The operation can take eight hours. You wake up with drain tubes and expanders in your breasts. It does feel like a scene out of a science-fiction film. But days after surgery you can be back to a normal life.

Nine weeks later, the final surgery is completed with the reconstruction of the breasts with an implant. There have been many advances in this procedure in the last few years, and the results can be beautiful.

I wanted to write this to tell other women that the decision to have a mastectomy was not easy. But it is one I am very happy that I made. My chances of developing breast cancer have dropped from 87 percent to under 5 percent. I can tell my children that they don’t need to fear they will lose me to breast cancer.

Jolie’s mother died of cancer at age 56 and Jolie writes that she didn’t want to put her own kids through that kind of pain if possible. That this highly public figure offers such intimate details about her body and her breasts may be a sign that the taboos around cancer are dwindling. (“On a personal note,” Jolie writes, “I do not feel any less of a woman. I feel empowered that I made a strong choice that in no way diminishes my femininity.”)

Sharon Bober, a clinical psychologist and director of the Dana-Farber Cancer Institute’s Sexual Health Program, who counsels many women who have had similar surgeries, said in an email that Jolie’s honesty is truly refreshing:

Wow!

One thing that strikes me is how times have changed – not that many years ago BRCA carriers would be worried about insurance being dropped, stigma, judgement, (“you are removing healthy breasts?? What are you crazy??”) and now this too is out of the closet. Continue reading