Dr. Susan Love has a ready answer when asked whether breast cancer gets too much media attention or government funding compared to lung cancer, which kills more American women each year.
“We sort of know what causes lung cancer,” says Love, a former UCLA breast cancer surgeon who now advocates for women’s health. (Tobacco use is a primary risk factor for lung cancer but doesn’t explain all cases.) “We don’t know what causes breast cancer and the treatments are really not great. We need to keep looking.”
Love is a voice of authority on breast cancer. She has just released an updated third edition of “Dr. Susan Love’s Breast Book” (Perseus, $20), which was first published in 1990 and last updated five years ago. It has been called the “bible for women with breast cancer” by more than one major media outlet, and the Journal of the American Medical Association judged the book highly useful for the layperson and equally valuable to doctors.
So when Love points to what she considers the future of breast care, it is worth paying attention.
“We’ve gone about as far with mammograms and imaging as we can go for women,” says Love, who has also started a new Internet site, www.susanlovemd.com. “If you see something on a mammogram, it has got to be a certain size. That means the cancer is already there.”
Instead, Love says the future is catching breast cancer earlier, sometime during or maybe even before the 1,000 or so days it requires for an abnormal breast cell to become cancerous. In all, it might be 8 to 10 years from the time a normal breast develops a palpable lump.
Other physicians agree with Love, though they have different ideas on how early detection is accomplished – or whether some of the technology, namely mammograms, is already in place. Everyone agrees treatments will be increasingly customized and targeted for individual patients as researchers learn more about cancer cells in the breast.
Love’s potential breakthrough idea is to examine a woman’s breast fluids from the lining of milk ducts, which is where nearly all breast cancer begins. She and colleagues have devised a “ductal lavage” technique that flushes out cells with a small amount of saltwater that travels through a thread-thin catheter placed in the microscopic open hole in a woman’s nipple. A local numbing medicine is used, and in preliminary trials patients have overwhelmingly reported they would much rather go through a ductal lavage exam than a mammogram.
“The doctors explained the procedure is done through an open duct [or hole], it’s not like they are sticking a needle into you,” says Kay Wissman, a Chicago woman who recently underwent ductal lavage. The screening showed no abnormal cells in Wissman, who was diagnosed with breast cancer in 1995 and had a recurrence in 1998. Both times mammograms found the cancer in the early stage. She is the ideal candidate for increased monitoring among high-risk women.
“You feel a little fullness [in the breast] with the saline solution, but it’s not uncomfortable,” says Wissman, 59, who works on the hotline staff at the Y-ME breast cancer awareness organization. “It doesn’t replace what a mammogram can find, but I prefer ductal lavage in terms of comfort. Mammograms can hurt when your breasts are squeezed between the plates; sometimes mine hurt for days afterward.”
The technique is approved by the U.S. Food and Drug Administration. Love and partners have started a company that sells the catheter for the technique.
“Ductal lavage gives us access to where breast cancer starts,” says Love, who received significant funding for the research from the Department of Defense.
The hypothesis, Love says, is breast cancer develops in a series of steps. It starts in the milk ducts. Hyperplasia is the first phase, during which extra cells develop on the duct lining. Then some of the cells become “funny-looking” or atypical. That’s called atypical hyperplasia. The next step is for the cells to develop into a lesion known as ductal carcinoma in situ or DCIS. The lesion itself rarely forms a lump, but instead indicates there are cancer cells in a woman’s breast that could break out of the milk ducts.
Ductal lavage is aimed at finding atypical hyperplasia, which would be a step earlier than the detection of DCIS in a mammogram. But it could take years of clinical trials for the technique to be confirmed as useful. And no one is talking about ductal lavage–or same-minded methods currently under study, including a modified breast pump or microscopic needles to withdraw a small amount of breast fluid–replacing mammograms any time, say, for the next decade or two.
“The technique is exciting for what it can do to eliminate deaths from breast cancer and provide another tool for a women’s risk assessment,” says Dr. Sheryl Gabram, a breast surgeon and director of the Breast Care Center at Loyola University’s Cardinal Bernadin Cancer Center in Maywood. “But it needs rigorous testing and years of data.”
For her part, Love says ductal lavage is “like any experimental technique–we know some things but not everything.”
Savvy health consumers may notice similarities between ductal lavage and Pap smears, especially the talk about hyperplasia and atypical cells. Dr. George Papanicolauou, who invented the Pap smear method some 60 years ago, explored the possibility of what he called a “breast Pap smear” beginning in 1958. Love says there are records of a physician in Uruguay named LeBourgne who first mentioned the concept of “ductal rinse” in 1946.
Papanicolauou’s research was largely ignored until some researchers re-evaluated the idea in the 1970s. In the 1980s, Love says she started investigating the concept of analyzing a woman’s breast fluid for early cancer markers.
Loyola is one of 20 centers throughout the country that are participating in a pilot testing project for ductal lavage. Eligible patients are women at high risk, whether by family history (mother or sister) or cancer in the other breast. Other women will continue with the recommended combination of self-exam, doctor’s exams and mammograms.
“I still feel many women would benefit from monthly self-exams, plus getting annual mammograms and clinical visits,” says Gabram. “We still have a tremendous opportunity to save lives if women undergo regular screening.”
Although mammograms are still the focus of a great deal of debate–about false-positive results, cost effectiveness, whether women 50 and under need to do it annually and potential radiation exposure–the technology behind them is better.
“No doubt, detection is greatly improved,” says Dr. Monica Morrow, director of the Lynn Sage Breast Care Center at Northwestern Memorial Hospital. “We can find cancer masses much smaller than 10 years ago.”
For example, Morrow says that only about 2 percent of breast cancer cases in the mid-1980s were detected at the ductal carcinoma in situ, which can be successfully treated in about 99 percent of cases (treatments range from minor procedures to mastectomy). Back then, most women knew they had breast cancer only when a lump was discovered. These days, about 30 to 40 percent of breast cancer cases are linked to DCIS. The reason is because mammogram imaging can now pick up the “microcalcifications” that result when rapidly growing cancer cells outstrip their supply of nutrients. Some cells die off and become a tiny heap of calcium. In her book, Love estimates only about half of DCIS will show up on a mammogram.
Mammogram imaging also has helped doctors more accurately target lump removal or radiation. In the mid-’80s, Morrow explains, researchers found 20 percent of all women who went into breast surgery thinking they were having only a lumpectomy woke up to find (with permission) that doctors decided a mastectomy was necessary because the cancer had spread more than the mammogram indicated. A decade later, only about 5 percent of women experienced a similar outcome, and the number is anticipated to go even lower.
More accurate mammograms also means less tissue must be removed. This can result in a more normal appearance for the breast. For women with dense breast tissue, magnetic resonance imaging (MRI) can help provide a better “map” for surgery.
Doctors are similarly enthused about digital mammography. One advantage is this computerized form of imaging allows a woman’s mammogram results to be sent by modem to another doctor for a second opinion. This figures to be a boon for women in smaller communities.
Yet Morrow says an even bigger advantage of digital mammography is saving women the anxiety of anticipating a second mammogram if the first one looks suspicious.
“Now we can manipulate the digital mammogram on the computer rather than manipulate the women,” she says. “We can zoom in on an area, lighten it or darken it. Before, the only way to zoom in was to bring the woman back.”
The Lynn Sage Breast Center hosted a symposium last month at which Love presented interim results of a clinical trial involving more than 500 women who underwent ductal lavage at 19 U.S. medical centers. All of the women had normal mammograms and clinical exams within 12 months of the lavage. Fifteen percent were found to have atypical precancerous cells (which don’t necessarily lead to cancer) and another five percent showed suspected or unequivocally cancerous cells, Morrow said.
Morrow says she sees ductal lavage as “an adjunct test” for high-risk patients but not replacing mammograms. Nonetheless, she agrees the future of breast care is discovering the abnormal cells sooner.
“The whole idea of changes in the cells is the wave of the future,” says Morrow. “A concept called `gene chip technology’ is likely to play a big role. We already have the technology for looking at thousands of genes on a cancer cell, we just have to figure out which ones cause cancer to spread.”
Morrow and Love both express concerns about unnecessarily alerting women to precancerous cells that may in fact never develop into tumors. Knowledge is good–to a point.
“We still have to sift through the data [of ductal lavage],” says Love. “For now, ductal lavage is like high cholesterol or low bone-density readings. You can have high cholesterol but never have a heart attack. You can have low bone density but not develop osteoporosis. Pap smears and PSA [prostate-specific antigen] screening for men are other examples.”
Even so, Love says ductal lavage could become a “wonderful research tool” because it will provide scientists with a way to measure if a drug or lifestyle change (exercise, diet) is helping cells to stay or return to normal.
“We won’t have to wait five years or risk some women’s lives to find out,” she says.
