“Early detection is the key,” we all say. But is it really that straightforward? In the late 1980s, one of the most influential surgeons in the history of breast cancer management (Bernie Fisher, MD) was at the podium defending his theory of breast cancer biology, in support of lumpectomy, when he said: “I don’t know what early breast cancer really is. There’s no satisfactory definition.” Mammography had hit the scene, prompting the term, “mammographically-detected cancers,” but Dr. Fisher was adamant that his theories that justified lumpectomy were not dependent on the method of tumor detection. Furthermore, just because a cancer was identified through screening mammography did not necessarily mean it was “early.”
(For those who believe that screening mammography was the primary reason behind breast conservation, or that pre-op mammography was part of the “package” tested in the landmark NSABP B-06 trial, you might be surprised to know that accrual to those studies started in the 1970s and did not require that mammograms be performed. Lumpectomy arose from a biologic theory that pre-dated mammography, and would have confirmed the safety of lumpectomy with or without mammography.) That said, if Dr. Fisher didn’t know the definition of “early breast cancer,” then who am I to attempt a definition? And, yes, I remember that it’s the umbrella name of this blog.
The problem with the term, Dr. Fisher explained, was that small tumors can still be deadly, and large tumors can be indolent, so using tumor size for the definition was not reliable. And if we try to use a measure of time to represent early vs. late, we are equally lost since we really don’t know how long the tumor has been present. He maintained that the outcome (cure vs. no cure) was based on the inherent biology of the tumor and how it interfaced with the “host’s” immune system. Both tumor and host were equally important. Since he came up with that theory from laboratory studies in the 1950s, it’s hard today to call this concept “new.” Yet, given the immense amount of research now being performed, not necessarily on the cancer cells, but on the immune cells that govern the host reaction, one can say that the late Dr. Fisher was a scientific prophet or, at least, remarkably prescient.
I bring this up because I was recently surprised by a “new” use of the term “early.” In fact, within the context I’m going to give you, “early” was used for what I’ve always called “late,” or even “locally advanced.”
Recently, I attended the 46th annual San Antonio Breast Cancer Symposium, a spectacle that every breast specialist should attend at least once (I think this was my 20th time). Over 10,000 attendees from 102 countries, with literally 1000s of posters and presentations over a 5-day period. The conference has always been skewed heavily toward medical oncology and its associated research, now in high speed with the development of countless drugs that alter the immune system to attack cancer cells. And all power to them. But if you’re looking for new developments in breast imaging, surgery, radiation, plastics, prevention, or basic pathology, this is not the conference for you. These topics are relegated to the poster sessions, rather than the podium. Even more than before, it has become a medical oncology event, along with related research. Admittedly, one reason I attend is to meet with international collaborators who have made the trip to San Antonio. In fact, the first 3-4 times I attended, I went to meetings “on the side” and didn’t even enroll in the course itself.
This time around, I had not attended for three years, so you’d think not much had changed. But it has. There is a shifting tide, a subtle sociologic phenomenon, that I can’t find the right words to describe. It’s easier to point out that we were told: “Given physician stress levels of today,” we attendees would have access to massages, yoga, etc. And, “if you need to up your brand,” there was a professional photographer stationed in the event center who would give you the “head shot” of your choice. The line of scientists and clinicians hoping to “up their brand” was long and was populated by attendees who appeared as teen-agers to me. A quiet voice whispered: “This is no country for old men.”
Back to the conference sessions. One by one, researchers and clinicians approached the podium and announced the title of their presentations, many of which contained the phrase “early breast cancer.” For a generic example, “Thank you for that wonderful introduction. I will be presenting today the final results of the XXX trial that administered YYY in combination with ZZZ versus YYY alone in the pre-surgical neoadjuvant therapy of early breast cancer. Over and over, it was early, early, early, while I’m seeing late, late, late. Through societal forces too complex for my blood, in the past 3 years, it had become a conventional norm to apply the word “early” to any patient with breast cancer who did NOT have known metastatic disease. That is, any patient with Stage I, Stage 2, or Stage 3. It seemed the only time “late” would have been used was if study patients had Stage 4 disease.
So, as the researchers would announce life expectancies extended by 3 months, or 5 months, or 8 months, through the use of the new ZZZ compound, I had to think what would have been the results if every participant in each particular trial had been on a long-term program of breast MRI screening at 1-2 year intervals? In fact, we’re only now seeing the “cure rates” for breast cancer when discovered by MRI, but it appears that very few patients would have qualified for the ZZZ trial because their disease would have been “too early.”
Debate and analysis about the relative benefit of systemic therapy (by medical oncology) vs. screening (by radiologists) has, in the past, called it a tie — that is, both approaches reduce breast cancer specific mortality by the same amount. But that’s mammography, where half the cancers are missed when breast tissue is dense. Screening with MRI is a whole different ballgame, yet it is held in check due to outdated guidelines (that don’t include breast density…yet), and the impracticality and cost of screening the entire population with MRI.
But I digress. My astonishment was in the new definition of “early.” And it speaks to the remarkable confusion imparted by different meanings for the same word or words. Brilliant scientists somehow get comfortable with the ambiguous lexicon used by their particular sub-specialty, while colleagues from different camps are using the same word for something else. Oddly enough, I’ve published an Editorial on this very thing.
In 2015, the Editor-in-Chief of The Breast Journal asked me to write a critique about the lead article, which was going to be published soon. Such an analysis of a lead article is a time-consuming honor, by the way, that counts very little for anything, other than knowing your opinion is respected by at least a few. But when I read the article about to be published (dealing with the implications for surgery and radiation when patients have more than one location of tumor in the breast), I asked if I could use a major deficiency as a springboard for another topic entirely — the power of language (a theme in my novels, too). The authors, all from a prestigious academic center, had used terminology that meant different things to different people. Specifically, no attempt was made to distinguish the varied definitions of “multifocal” vs. “multicentric,” in my view, imparting a great deal of confusion for any reader. Same thing for the term “local recurrence,” which drags around several different definitions as well.
The result was an Editorial titled, “The Beginning of Wisdom is the Definition of Terms,” a phrase I borrowed from Socrates.
Some of my colleagues around the country got a kick out of the tongue-in-cheek editorial and emailed their responses, and that was the end of that. But 2 years later, a notification came through the mystery of the internet, stating that I had been quoted in the Journal of Volcanology and Geothermal Research. Must be a different Alan Hollingsworth, I thought. Nevertheless, I looked it up, and sure enough — I’d made it into the world of volcanos. As it turned out, this article was an appeal for the different sub-specialists to sit down and agree upon the meaning of “overpressure” (a word that sounds pretty important to me). Apparently, reservoir engineers, volcanologists, and structural geologists, were all using the word “overpressure,” but each group used a different definition. The problem, apparently, is widespread. (Must have something to do with that nebulous concept — human nature.)
So, what is the definition of “early breast cancer?” As I noted above, if Bernie Fisher doesn’t know, then I can’t claim enlightenment. Yet, if all breast cancers were discovered at a size 1.0cm or smaller, deaths due to breast cancer would plummet. Mammography is not reliable enough to guarantee this small size, especially when density camouflages the tumor. Yes, some tiny cancers can still metastasize prior to early discovery, and yes, some small cancers might be so slow-growing that “early” detection is not required. But overall, MRI or MBI (molecular breast imaging) or CEM (contrast-enhanced mammography), can identify tumors reliably, with incredible life-saving potential, and we’re now on the brink of confirmation of this dramatic mortality reduction. Yet, due to cost and the cumbersome aspects of using a contrast agent, it has been impractical to screen the general population with these highly accurate tools.
But what if I were to tell you that screening MRI and contrast-enhanced mammography (CEM) can be performed at a cash rate that is only a fraction of the going rate? For my patients who weathered the $4,000 storm of a few years ago, screening MRI can be offered for one-tenth the price patients were asked to pay previously. That’s one-tenth.
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Premier Breast Health Institute of Oklahoma — http://www.pbhiok.com — Call 405-768-1970 for a risk assessment appointment to see if insurance will cover your screening MRI. Or, check the price of the various imaging studies if insurance does not offer coverage. Whole breast ultrasound adds a lot if you have dense breasts, but CEM or MRI can offer a higher detection rate than mammography and ultrasound combined.
Primary Staff: Dr. Anna Stidham (breast radiologist), Dr. Stephanie Taylor (breast surgeon), Courtney Carrier, MPH, MSN, APRN, NP-C (certified nurse practitioner genetic counselor)
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As for my personal research dealing with blood testing that would properly identify who should have MRI or CEM, perhaps the purpose makes more sense now. FYI — current blood tests being covered by the media often have low sensitivity for cancer detection, that is, EARLY CANCER (there it is again). These tests might boast an 80% detection rate, for example, but then you read the fine print — that number is applicable to advanced stages only, Stages 3 and 4. Developing a breast cancer blood test has turned out to be remarkably difficult because it has to work in “early” disease. The test that finds 80% of Stage I breast cancers will be something to write home about. But if that same 80% sensitivity holds up for even smaller tumors, and in the face of dense breasts….well, we’re talking about a revolution in screening that would impress even the likes of Dr. Bernie Fisher.
For more off-the-cuff, tongue-in-cheek, cliche-laden musings, get a copy of this collection of essays (blogatorials), available on Amazon.