April 01, 2007
Breast Cancer Risk -- the Missing Element
In the wake of Elizabeth Edwards' breast cancer recurrence, the New York Times ran six op-eds and one op-art that all drew a similar conclusion: the answer lies in more research.
Susan Love, a prominent advocate, wants research aimed at more far-out approaches, including resuscitating the hunt for the elusive cancer viruses that dominated the research agenda in the 1970s. Harold Varmus, former head of NIH now running Sloan Kettering Memorial Cancer Center in New York, wants more genomics research. Ralph Moss, whose newsletter usually casts a critical eye at the anti-cancer establishment, laments that generic chemicals that might be good drugs rarely get tested for their efficacy on cancer because of the patent system. Even journalist Shannon Brownlee, who spent most of her op-ed lamenting the cost of cancer care, the profits generated by the system, and the limited efficacy of that care, winds up calling for, you guessed it, more research.
The op-art had some interesting tidbits about how much money is spent advertising cigarettes and on soda pop. That suggests public health measures, not more publicly-financed research, is the most cost effective way to bring down cancer rates. But even artist Marisa Acocella Marchetto (I just had to reprint that name, say it softly it's almost like praying) wound up with her final panel filled with white-coated researchers "desperate" for more funding.
I also did a little research this week on breast cancer among younger women because of the Edwards setback. It might have been nice if at least one of the op-eds was given over to discussing her risk of disease. She is only 57 years old. But she had children, probably by in vitro fertilization with its attendant hormone injections, when she was 48 and 50. That immediately puts her in a high risk category.
So, my next logical question was what overall impact on breast cancer risk has late childbearing, rising in vitro fertilization rates, and rising smoking and obesity rates had on among Baby Boomer women? The pink ribbon advocacy groups frequently point out that women's overall risk of contracting breast cancer in their lifetimes has risen to one in eight compared to one in eleven some years ago.
Yet it turns out that female Baby Boomers' overall risk of contracting invasive breast cancer is actually below previous generations, according to a recent study by former National Cancer Institute researcher Robert Tarone, who is now at the International Epidemiology Institute. Breast cancer incidence is falling among Baby Boomers despite greater risks posed by environmental and social factors.
In a brief e-mail exchange, he told me researchers are enmeshed in furious debates over the role of late childbearing, early detection through increased mammography and changing diets on overall cancer risk. But the bottom line is that women are experiencing less invasive cancer at younger ages, and the increasing long-term risk is attributable almost entirely to women living longer since older women (over 65) get breast (as well as other) cancer at much higher rates.
I'm not trying to make an argument against more research. Is the $11.5 billion mentioned in the Marchetto op-art too little? In the best of all possible worlds, it would be nice to have a larger pot of money to give to those white-coated researchers, who, she points out, only get 18 percent of their grant applications funded. If we compare it to the billions wasted in Iraq, then more money for breast cancer research seems like a no-brainer.
But even in a post-Iraq world, we're going to be dealing with limited resources. It's worth pointing out that today's level of public investment in cancer research is over twice the government's investment in ALL energy research (from oil and coal to solar and wind), and that sector has been steadily declining since the Carter era.
If people think we need more money for breast cancer research specifically and cancer research generally, perhaps we should levy dedicated taxes on cigarettes, soda pop, meat and milk products, air polluters, and the hormone pills and injections that are contributors to overall cancer risk. That way, we'll be killing two birds with one stone -- generating more money for research while cutting down on the behaviors and corporate actions that led to the need for the research in the first place.
One avenue of research in breast cancer that has not been fully explored is the effect that the age of the parents has a woman's risk for breast cancer. Some studies have shown a paternal age effect. Some a maternal and paternal age effect. With the recent news that there are more than
100 new genes that might be involved in breast cancer, it might be important to look for Copy Number Variations in the cells of woman with early breast cancer with the technology that Dr. Michael Wiggler used in Cold Spring Harbor. If copy number variations are found in breast cancer patient's non-cancerous cells maybe her parent's cells could be checked. This research might lead to something eventually.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1064078
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1291359
http://aje.oxfordjournals.org/cgi/content/full/152/12/1121
Posted by: Les at April 1, 2007 05:15 PMWhat happened to prevention as in researching & eliminating endocrine disrupters until they are proven "safe."
Posted by: david egilman at April 2, 2007 09:06 AMI didn't actually lament the cost of cancer care so much as the fact that a great deal of it is wasted effort, which is driven in part because doctors have nothing else to offer, but also because cancer is highly profitable. Spending $100 billion a year on detecting and treating cancer would make more sense if it were actually reducing suffering and mortality. But a great deal of cancer treatment is overtreatment -- we are treating cancers that either would not have caused a problem, or that could have been successfully detected and treated later, or that weren't going to respond to treatment no matter what we do.
More research is indeed what's needed, but as Susan Love points out in her op-ed, we need to change the direction of that research. We keep going down the well-worn paths of trying to find cancers that are smaller and smaller, and searching for drugs that will more effectively kill cells. It's time for new paradigms. But those are hard to come by when the system is so heavily invested in doing the same old thing.
A critical and neglected area of research is cancer prevention. Yes, we know that getting rid of tobacco will prevent many, many cancers. Beyond that, what do we really know?
Posted by: Shannon Brownlee at April 2, 2007 09:11 AMI recently attended the San Antonio Breast Cancer Symposium as an advocate for the 50 women I work with who are in treatment for breast cancer. I support more funding for molecular research based on what I learned from the research community:
1) we can cut, poison, and burn the cells, but never get rid of them entirely (cancer cells are immortal). Chemo never kills ALL the cells, and stem cells can survive radiation.
2) Breast Cancer results because of an autoimmune disease in the body. "Tumor suppressor" genes change and are no longer able to perform their normal functions of preventing excess cell division and, normal cell death. They acquire migrating traits from the environment around the cell (stroma)which enables the altered cell to invade another part of the body (which has already become receptive to this invasion by abnormal biological changes). We do not yet know what is going on here.
3)It would seem that our focus on killing the tumor cell as if that would "cure" the cancer is misplaced. We need to focus on the system by which the environment of the cell changes it to become malignant. This is a formidable opponant.
I was impressed at the Symposium by the 8000 dedicated people from all over the globe joined in the "war" to understand these mechanisms. The "cure" of any autoimmune dysfunction is still a long way off, but I experienced Hannah Arendt's "shared sense of purpose" that the allies in WWII experienced during wartime.
Environmental toxins are a popular culprit, but basic scientific research at the molecular level has already led to treatments targeted to the gene expression of several particular types of breast cancer. This will lead to screening tests to manage cancer for many years. Attempting to alter human behavior by regulating substances we "believe" are related to disease may be politically popular, but better we spend the money on "evidence-based" basic research.
Les and David raise important questions about social and environmental factors that may be contributing to increased cancer rates, and Shannon asks that more research get done in these areas because, as she asks, what do we really know. Ann, on the other hand, endorses the Varmus/Nathan approach. We can't change society, so let's get on with the hunt for ways to kill the cancer with targeted drugs or stimulate the immune system to do the job.
In my opinion, none of these approaches will have as fast an impact on bringing down the already declining breast cancer rate as public health measures aimed at already well characterized risk factors like smoking and obesity. That's not an argument against more research. It's an argument for applying cost-benefit considerations to our marginal investments in health.
Posted by: Merrill at April 2, 2007 10:50 PMAnn Crickmer brings up a factor that points, in my opinion to advancing paternal age and mutated sperm DNA which brings a greater risk of other "autoimmune" disorders such as diabetes 1, MS, etc.
I again say that we should fund using Dr. Michael Wiggler's micro array technology to look for copy number variations in women with early pre-menopausal breast cancer. These mutations could cause the tumor suppressor genes to change or be labile.
)" Breast Cancer results because of an autoimmune disease in the body. "Tumor suppressor" genes change and are no longer able to perform their normal functions of preventing excess cell division and, normal cell death. They acquire migrating traits from the environment around the cell (stroma)which enables the altered cell to invade another part of the body (which has already become receptive to this invasion by abnormal biological changes). We do not yet know what is going on here."
Merrill's right about redirectly money towards public health measures that we know will reduce cancer incidence. In fact, to be perfectly honest, I don't actually think that money saved from reducing overtreatment and overscreening should be directed towards research. A better use of that money would be smoking cessation programs, taxing the daylights out of cigarettes (which deters young smokers pretty effectively), building sidewalks and bike paths, getting businesses to put in gyms, blah blah blah.
It's all such simple stuff in theory, but very difficult in practice because it requires changing things like zoning laws. It also means a different mindset. We are set up to rescue people once they get sick, and all the money flows in that direction. We don't reward individuals or businesses or even health care providers for public health measures to prevent disease in the first place. In other words, prevention isn't profitable, treatment is.
Posted by: Shannon Brownlee at April 3, 2007 11:53 AM