October 2010

Body of Knowledge Full-Frontal Assault

An attack on BREAST CANCER has brought about greatly improved treatments—but are we on course to stop it entirely?
by SAMANTHA DUNN /illustration by DAN WINTERS

Twenty-six years ago, in the wake of Tamoxifen—the first major drug used to treat breast cancer—October was deemed National Breast Cancer Awareness Month. But I’m probably like millions of women who don’t need a special month to make me think of the disease. Let’s just say I learned this anatomy connection the hard way: If your hand feels a lump in your breast, your knees will go weak.

The year was 1994, and I was in my twenties. Back then, as today, the Centers for Disease Control and Prevention listed breast cancer as the most common form of cancer in American women, along with skin cancer, and the second leading cause of cancer-related deaths in women. If you got the diagnosis, on your treatment menu was a mastectomy or lumpectomy, some radiation...and a few Hail Marys.

Statistically speaking, as a twentysomething white woman, the odds were on my side that it wasn’t malignant. According to the U.S. National Cancer Institute, 1.9 percent of women aged 20–34 will be diagnosed with breast cancer, and mortality rates for that age group are .9 percent. Still, when the doctor told me it was merely an easily removable cyst, I felt lucky. When it’s your breast and your life, statistics offer small comfort.

Today I’m in my mid forties, and once again a lump has been found, this time through a routine mammogram. The American Cancer Society heads the long list of institutions that recommend the yearly test for women 40 and over, despite last year’s much ballyhooed report of the U.S. Preventive Services Task Force that advised delaying mammograms until 50, because false positives are more common in women 40–49, and reducing routine mammograms to every two years.

Once again, the tumor in my breast turned out to be benign, a fibroid my doctor says is better left where it is for now. But this time around, I’m slightly less lucky—first because the formation of these fibroids signals my increased risk for developing breast cancer and, second, because the older you get, the more your risk goes up.

Unlike when I was younger, the disease now has a real face for me: Breast cancer looks like the brown-eyed woman I was chatting with at a concert, who had a double mastectomy at 38; like my beautiful British friend Kate, who is in her second round of chemo at 51; like Melissa Etheridge, Christina Applegate, Edie Falco, Suzanne Somers and two of the original Charlie’s Angels, Kate Jackson and Jaclyn Smith. I can’t help wondering when my luck will run out and the face of breast cancer will include the one staring back at me in the mirror.

If in the future I’m among the faces of breast cancer, the good news is that the vast majority of women who are diagnosed with the disease today don’t die from it. The bad news is it’s still a gamble, because no one can predict which ones will die. (Mortality statistics are a convoluted mass of percentages on which even the experts are fuzzy).

“The hope for women has dramatically improved in the last decade. Improvement data keeps moving at almost light speed compared with other cancers,” says Dennis J. Slamon, director of UCLA’s Clinical/Translational Research and the Revlon/UCLA Women’s Cancer Research Program at UCLA’s Jonsson Comprehensive Cancer Center.

“It’s a bold statement,” says Slamon, “but I think it’s true—breast-cancer research has led the field of oncology.”

Slamon is a pioneer in this field, much laureled for heading the team that turned the tide for one in four women—between 40,000 and 45,000 each year—with breast cancer who test positive for Human Epidermal Growth Factor Receptor 2, otherwise known as HER-2, a gene that produces too much of a growth-promoting protein.

A HER-2 diagnosis had been, before Slamon came along, the genetic lottery ticket no one wanted. Death was the likely prognosis within two to three years. Now, Herceptin, developed in conjunction with work being done in Slamon’s lab, targets the genetic mutation that causes the protein to go wild and blocks the cancer’s power supply.

As a result, those women with a HER-2 form of cancer have gone from some of the worst prognoses to the best. “Too many women a year still die,” says Slamon, but he and his research team believe the numbers of those who do will continue to go down. And to that end, Los Angeles itself has been a major-league player in changing the odds.

Researchers nationally and through the world—at the Cleveland Clinic, the Mayo Clinic and Sloan-Kettering in New York, among many others—have substantially advanced the understanding of both the nature of the disease and treatments for it. But L.A. is unique for having powerful research institutions like UCLA, USC/Norris Comprehensive Cancer Center and NCI’s City of Hope and for being the very public stage of the world’s entertainment nexus. The combination provides a megaphone for world-renowned voices such as Susan Love, MD, MBA, clinical professor of surgery at UCLA’s David Geffen School of Medicine, president of the Dr. Susan Love Research Foundation and author of the seminal work for any woman facing the disease, Dr. Susan Love’s Breast Book.

Competition for funding can be fierce here, but Love says L.A.—and California as a whole—is “more open to new ideas and approaches. The expansive landscape does lead one to big ideas.”

No one knows that better than Slamon. In the late ’80s and early ’90s, he found nothing but dead ends for funding, and colleagues doubted his theories about HER-2. “We owe a huge debt to the greater Los Angeles community for the success we’ve had in combating breast cancer and other cancers,” he says.

Lilly Tartikoff Karatz—then wife of the late Brandon Tartikoff, former head of NBC, who was suffering a form of Hodgkin’s disease—came to know Slamon’s work when he helped in her husband’s treatment. Impressed, she brought her entertainment connections to bear, raising millions far quicker than any government grant could. It led to the creation of the Revlon/UCLA Women’s Cancer Research Program with Revlon CEO Ronald Perelman and brought public awareness to unprecedented levels.

“A lot of money comes into the laboratory and moves back into the community very quickly,” says Slamon, who doesn’t much resemble Harry Connick Jr., the actor who portrayed him in a 2008 Lifetime Original Movie, Living Proof, which dramatized his efforts to develop Herceptin.

What has been learned in the study of HER-2 and the development of Herceptin has widened the understanding of cancer as a whole. Cancer is not one thing. There are different types of tumors and different causes for them. “It’s a bold statement, but I think it’s true—breast-cancer research has led the field of oncology,” says Slamon.

Slamon believes we’ll see a day when breast cancer will be, if not cured, only chronic. And because of earlier detection and advances in radiation and chemotherapy, plus targeted treatments like Herceptin, endocrine therapy and gene therapy, it won’t cast a lethal shadow. “There are people alive today who barely remember there was such a thing as polio,” he notes. “We can’t wait for the day when we won’t need a Breast Cancer Awareness Month.”

“Competition for funding can be fierce here, but Susan Love says L.A. is ‘more open to new approaches. The expansive landscape does lead one to big ideas.’ ”

Joanne Mortimer—director of the Women’s Cancers Program and vice chair of medical oncology and therapeutics research at City of Hope, one of 44 National Cancer Institute centers around the country—agrees the landscape for breast cancer is different now than it was a generation ago. Understanding has evolved; researchers are now aware of at least seven types of tumors, with another 10 possible subtypes.

“The more we understand, the more we know that treatment is not a one-size-fits-all proposition,” Mortimer says. “Personalized medicine is somewhat of a kitsch phrase, but the fact is, how my body responds to a disease and treatment is different from how your body responds. We’re working for the time when treatments will be better tailored to the specific types of the disease and the people who have them.”

Mortimer says women’s fear of breast cancer outsizes the actual numbers of those who succumb to it. While the Centers for Disease Control and Prevention lists heart disease as the number one killer of women 65 and older and lung cancer as women’s most lethal cancer, she notes a recent survey found 30 percent of women think they will die from breast cancer.

Truth is, roughly 200,000 are diagnosed with this cancer every year, and estimates are that about 40,000 actually die from it. In a population of 307 million, that doesn’t seem high in the abstract, but when you think of it in terms of a population the size of Culver City filled with moms and daughters and sisters, the number feels more pressing.

Breasts are the symbol of our femininity. “Everyone knows of a young woman who was taken by the disease or a mom who died and had to leave her children,” Mortimer says. “Those stories rip your heart out.”

Despite the advances yielded by the more than $4 billion spent on breast-cancer research, there are still gaping holes. For one, says Mortimer, “We still can’t kill the cancer cells that kill the patient—women with metastatic cancer don’t get cured.”

Susan Love is among the most vocal calling for a shift in the way research is focused. Because 80 percent of breast cancers originate in the ducts, the Dr. Susan Love Research Foundation concentrates its efforts there.

“We still have no idea what causes the disease or how to prevent it,” says Love, who has become a major women’s health advocate by not being shy. “For a variety of reasons, all the emphasis in research has been on treatment, which, while it has saved many lives, has caused significant side effects in many women.

“It is time to put as much effort as we have into treatment toward prevention and finding the cause. A good example is cancer of the cervix. Thirty years ago, we were doing total hysterectomies, with a resulting loss of fertility, to treat abnormal Pap smears. Now we have a vaccine. In breast cancer, we are still removing normal body parts (breasts and ovaries) to prevent the disease, because we don’t know what else to do! We need to go beyond risk factors, which explain only about 30 percent, to finding the cause. Could it be a virus? Wouldn’t surprise me.”

Love notes that another big paradigm shift is the new understanding from basic research showing that cancer requires not just a mutated cell “but also an environment that is egging it on.”

As she explains, “Around 30 percent of women are walking around with dormant cancer cells that are causing them no harm. If, however, the local tissue or systemic environment changes—think obesity, hormones, stress—they can become activated. This new thinking of what’s called cell stromal interaction starts to explain how things like exercise might prevent disease and recurrence.”

Meanwhile, some days I swear I can feel that fibroid getting bigger, and I start to wonder...and worry. The exploding possibilities with new treatments, the investigations into the cause of the disease—how does this all translate to my everyday life? It seems today’s woman needs to become her own health advocate to sort through all the options. Will another quarter century go by before we know the answers that will make this type of cancer an artifact?

“I do think we will have the cause and how to prevent it figured out before 25 years,” Love says. “There is no reason we can’t be the generation that stops this disease once and for all.”