In honor of Breast Cancer Awareness Month, we checked in with Susan Love, M.D., a highly respected surgeon and prominent expert in the field of breast cancer prevention, detection and treatment. She shared the latest findings of her research foundation and weighed in on recent government guidelines...
Few people have the inside scoop on breast cancer prevention and research discoveries like Susan Love, M.D., author of the best-selling Dr. Susan Love’s Breast Book and clinical professor of surgery at the David Geffen School of Medicine at University of California, Los Angeles.
As president of the nonprofit Dr. Susan Love Research Foundation in Santa Monica, Calif., Love devotes herself to research aimed at breast cancer prevention, detection and treatment, and to improving the quality of women's health through science, education and advocacy.
In 2008, she partnered with the Avon Foundation for Women to create Army of Women, an ambitious effort to recruit 1 million women to participate in studies to help unlock the secrets of breast cancer.
A high-profile advocate for women’s health, Love doesn’t dodge controversy. Two years ago, she surprised and enraged much of the medical community, including the American Cancer Society and the American Medical Association, when she spoke out in support of new federal guidelines that recommend doing fewer routine mammograms, and starting them at a later age.
One angry commenter on her blog at the time wrote, “I’ve donated my last penny to Dr. Susan Love,” and another said, “Have you lost your freaking mind?”
In this exclusive, eye-opening interview, Love tells women what they need to know about the latest developments in breast cancer prevention, screening, treatments and more. And she talks about her latest initiative, which aims to involve the public in shaping the next steps in crucial research.
What are the biggest developments in breast cancer research over the last two years?
[We learned that] in treatment, more isn’t better. Taking out all the lymph nodes isn’t better than just [taking out] the sentinel nodes [the first lymph nodes to which cancer cells are most likely to spread from a primary tumor] in women with small cancers. Other findings:
Partial breast radiation may be as good as a full six weeks of treatment in many women. In “partial breast radiation,” a balloon is placed in the biopsy cavity and the radiation is put in the balloon. It takes five days (rather than six weeks [of traditional treatment], and is done as an outpatient. You can also deliver the radiation in the operating room.
Not all women with hormone-positive breast cancers respond to chemotherapy; some do better with hormone therapies. A test called Oncotype DX can be done on the tissue of a woman to determine whether she is either in the group with a high risk for recurrence that responds better to chemotherapy, or in the group with a low risk for recurrence that responds better to hormone therapy. The treatments have to match the biology of the tumor.
Not all ductal carcinoma in situ (DCIS) will go on to become invasive cancer. [DCIS, according to the Mayo Clinic, is “the presence of abnormal cells inside a milk duct in the breast” that haven’t spread out of the milk duct to invade other areas of the breast.]
What is the biggest stumbling block right now in making progress against breast cancer?
There’s not enough focus on finding the cause of the disease. It could be a virus, which would lead to a vaccine, for example, as in cancer of the cervix. But we won’t know until we look.
I get frustrated that we put so much into treatment. It’s all well and good to find the cure, but treatments have collateral damage, such as leukemia and other cancers. It would be much better not to develop cancer at all.
We need a vaccine for cancer of the breast. We’re not even close to that.
How hereditary is breast cancer?
The major genes for breast cancer we know about – BRCA1 and BRCA2 – explain about 5%-10% of all breast cancers.
Could there be other genes we don’t know about? We’ve looked hard but haven’t found them. So they’re not really common, but they’re possible.
But [most] breast cancer probably isn’t directly hereditary.
What are the most important things a woman can do for her own health and breast cancer prevention?
You can exercise, maintain a healthy weight, reduce stress and have an early first pregnancy, if you have a choice. [The American Cancer Society says “Women who have had not had children, or who had their first child after age 30, have a slightly higher risk of breast cancer.”]
Avoid unnecessary medical radiation, such as computerized tomography [CT] scans. Only have them if they are critical to your care.
Avoid hormone replacement therapy after menopause. [The National Cancer Institute says, “Women who take menopausal hormone therapy for many years have an increased risk of breast cancer.”]
How often should women get mammograms? The updated 2009 guidelines by the U.S. Preventive Services Task Force said healthy women should get routine mammograms every two years, not annually, and start at age 50, not 40. You took a lot of flak for supporting those guidelines. Do you regret your stance?
I don’t regret it because I believe we should go with the science.
On the one hand, the idea that every cancer can be found early if you just do screening has been sold so well that the public doesn’t realize that biology is more important than the screening itself.
You can have all the mammograms in the world, but if you have a very aggressive cancer, it’s going to grow in [the time between screenings]. Mammography can’t find every single cancer.
Also, the guidelines don’t say you can’t have a mammogram under a certain age.
The [task force was only] talking about public policy, and they said: As a country, should we pay for every woman starting at age 40 to get a mammogram every year? And they said: No, we shouldn’t. And I agree.
That’s very different from what an individual woman should do. That’s her decision, with her doctor, based on her risk factors and other things.
Why is it not worth it to do annual mammograms starting at age 40?
It doesn’t improve mortality enough, and it causes you to biopsy a lot of things that aren’t cancer.
But it also [establishes] a false sense of reassurance: If you feel something or you’re worried about something and the mammogram is normal, you think: I’m OK.
And then it also gives you radiation, which is cumulative, and if you start it at a younger age and have it every year, that can be a risk too.
Are there any women who would benefit from having breast cancer screening through mammography every year?
Certainly. Women who have the gene for breast cancer [or] a strong risk should think about it.
What’s your opinion of digital mammograms? Are they more accurate?
The difference between digital and nondigital mammograms is like the difference between a digital and regular camera. They both take good pictures, but the digital mammograms are much easier to store, email, enlarge and look at.
It’s not that the pictures are any better. They did a big study looking at whether [digital mammography] was better at detecting breast cancer. Except in a few subgroups, it really doesn’t seem to be better.
What’s more important than the machine is the person reading it. You want to make sure they [know what] they’re doing and are comfortable with the equipment.
Other than mammograms, how can women detect breast cancer early?
The notion of early detection is being reevaluated. It depends on the biology of the cancer.
About 30% of cancers can be found early, but others, especially in younger women, cannot, which is why we need to focus on breast cancer prevention.
Magnetic resonance imaging (MRI) is useful in women who carry the gene for breast cancer, but too sensitive for the average woman.
Most importantly, if a woman feels something that doesn’t seem right, she should get it checked out. And if a doctor doesn't agree with her, she should find another doctor.
What about women with dense breasts? You said in 2009 that breast density was a risk factor for getting breast cancer, but that it was just beginning to be studied.
There are two things that are getting confused.
One is that the denser the breast, the harder it is to see something in a mammogram because the cancer is white and dense breast tissue is white. It’s like looking for a polar bear in the snow.
In general, young women have dense breasts – another reason mammography doesn’t work as well in women under 50.
The second issue is they’ve found women with dense breasts tend to have a higher risk of breast cancer.
But you’ve got to be careful – because if you did mammograms of everybody in their 20s, they all will have dense breasts. But as you get older, particularly once past menopause, the density should go away. If it doesn’t, that’s a sign of higher risk.
If you take hormone replacement therapy, your breasts also may become denser. It should be a sign that maybe you shouldn’t be on hormone replacement therapy because your breasts are sensitive to that.
What would you advise a woman who came to you with dense breasts?
If she’s taking any hormones, she should probably stop. She also should do all of the usual things that we’ve shown help reduce risk: Exercise, watch your diet.
Then, if she’s at high risk for other reasons too, she might consider taking tamoxifen or raloxifene (if she’s post-menopausal), two drugs that have been shown to reduce breast cancer risk – at least in hormone-positive breast cancer risk [cancer that is sensitive to hormones].
A bill recently passed in California, awaiting the governor’s signature, would require mammogram providers to notify patients with dense breasts and suggest that they might benefit from additional breast cancer screening tests. What do you think of this bill?
I don’t think the bill is a good idea. It’s pretty subjective to say who has dense breasts and who doesn’t. It’s in the eye of the beholder.
I worry about the repercussions of magnetic resonance imaging (MRI) tests, which have a lot of false positives, lead to too many biopsies and have not been shown in any of my studies to make a difference in mortality.
The place for MRIs is with women who may carry the gene for breast cancer and are really at much higher risk. For the average woman, they’re too fine a screen.
Who would the proposed law benefit?
The law says you should be notified so that you can have other kinds of imaging. To me, that automatically benefits the manufacturers and providers of other types of imaging.
No other kinds of imaging have been shown to change the death rate of breast cancer.
What’s the latest news on the Love/Avon Army of Women initiative that your Susan Love Research Foundation and the Avon Foundation for Women launched in 2008 to recruit women to participate in research on breast cancer?
We have about 358,000 women; 51 studies have been done; and more than 55,000 women have been involved in studies. It’s doing quite well.
Your goal with Army of Women was to recruit 1 million women. How likely is that to happen?
The prospects are good. Initially, we had a lot of people sign up, and now it’s more of a steady stream.
What’s the next step in breast cancer prevention and research?
We’re about to launch our own study around the first of the year.
Our frustration has been that there are not enough studies for all the women who want to participate, and the studies are not always asking the questions women are interested in.
So we’re going to have our own online study, called the “Health of Women.” We’ll let everybody submit questions.
[It’s] the democratization of research. Let’s make research something we can all participate in. We all have good ideas on things that should be looked into. We’ve left it to scientists, [who] are not always the ones who think of what happens in the real world.
By getting the infrastructure, [I’m hoping] we can look at these different questions in a variety of people and also get from the public what they think are some of the issues that might be involved. We can test them and find out.
For more information, visit our Breast Cancer Health Center.
What's Your Breast Cancer Risk?
The biggest risk factor for developing breast cancer is simply being a woman, though a small percentage of men develop it, too. Fortunately, with better screening processes for early detection, breast cancer doesn't have to be fatal.
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