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Vol. 12, No. 1 · January 2008 · Editor: Martha L. Golar, Esq.
The Secrets of the Secret History of the War on Cancer DATE: Wednesday, January 23, 2008 TIME: 6:30 - 7:30 P.M. PLACE: Skadden Arps Slate Meagher & Flom Four Times Square (between 6th Ave. & Broadway) SPEAKER: Devra L. Davis, PhD, MPH Director, Center for Environmental Oncology, University of Pittsburgh Cancer Institute · Male Breast Cancer Presentation by NYU Cancer Center Experts · JALBCA’S Annual Symposium · Health Care Financing and Breast Cancer · Calendar / Contacts Male Breast Cancer Presentation by NYU Cancer Center Experts
Who should be more vigilant? Men who have: male relatives with breast cancer and female relatives with a history of breast and ovarian cancer -- particularly a mother with pre-menopausal breast or ovarian cancer. Men in this category should be followed more closely with breast examinations and mammograms, as noted above. Dr. Axelrod also indicated that there are support groups for men: SHARE and the Susan G. Komen Breast Cancer Foundation offer such services. Dr. Singh also cautioned that men who have received radiation therapy during childhood (such as those receiving treatment for Hodgkin’s Disease) are at greater risk for breast cancer. Dr. Singh stated that papillary cancer of the breast is more prevalent in men, as is Paget’s Disease, which involves tissue breakdown of the nipple. Dr. Singh spoke about the tissue diagnosis of breast cancer and indicated that, although there are no meaningful research trials concerning male breast cancer, biological insights can be drawn from the female breast cancer experience. Early detection can impact greatly on the prognosis. For males, one of the disadvantages is that the diagnosis is often made late when there is a pronounced lump or ulceration, particularly in the central breast around the nipple. Men do not get lobular cancer of the breast (which accounts for only 10% of the breast cancers in women) because male breast tissue lacks the actual lobules, which serve the purpose of producing breast milk. Male breast cancer is for the most part, ductal; and papillary cancer is also known to occur in men, perhaps more commonly than in women. Dr. Singh stated that gynecomastia is the most common disease of the breast in men, not to be confused with lipomastia, which is simply a condition of being overweight with an increase in fatty tissue around the breast. True gynecomastia occurs when there is a proliferation of breast cells within the lumen of the breast ductal tissue, often associated with an endocrine disorder. It can also be a side effect of certain medications. Essentially, gynecomastia is the “male equivalent” of fibrocystic disease in women. Of all breast cancers, less than 1% occurs in males and less than 1% of all cancers in men occurs in the breast. Similar to the female experience with breast cancer, an excess of estrogen can put men at increased risk for breast cancer. A chromosomal abnormality which manifests as Klinefelter’s Syndrome (a genetic anomaly of the X chromosome) poses a 20 fold increase in the risk of male breast cancer. With respect to the BRCA gene mutation in males, Dr. Singh reiterated Dr. Axelrod’s remark that the BRCA II mutation is the more common culprit in men; however, this type of mutation poses only a 6% lifetime risk for breast cancer in men. Dr. Singh spoke about the lessons to be learned from hereditary syndromes observed with colon cancer, which have greatly enlightened genetic science in the battle against cancer. The study of molecular pathogenesis (when molecules go ”haywire”) has also led to the development of targeted therapies such as Herceptin. Overall, breast cancer is to be regarded as rare in men, but carries significant risk because of the typical delay in diagnosis -- when the disease is quite apparent. Also, the cancers in the male breast tend to be closer to the chest wall, which could put men at increased risk for metastases. In the year 2003, there were 1300 cases of male breast cancer in the U.S., with 400 deaths. Dr. Singh indicated that there is a concentration of male breast cancer on Long Island, San Francisco and certain western states of the U.S. We know from the female breast cancer experience that, over the past several decades, the number of cases have increased by 400% to 500%. With male breast cancer, Dr. Singh stated that the incidence is up 26% in men as compared to 52% in women, over the same general time frame (several decades). Interestingly, Dr. Singh also stated that while only 76% of female breast cancer is estrogen receptor positive, 90.6% of male breast cancers are estrogen receptor positive, which affords an important avenue of treatment -- blocking estrogen. Dr. Singh stated that the traditional stages assigned to breast cancer do not have tremendous prognostic value, as the molecular characteristics are far more important. The knowledge in this area has grown exponentially over the past several years and there is a combination of factors that affects one’s prognosis. Oncologists will look at staging, grading, hormone status and lymph node involvement in considering prognosis. Male breast cancers tend to be more poorly differentiated, as compared to breast cancers in women -- which is one factor in assessing the virulence of the disease. Race can also affect the behavior of certain cancers, as both black men and women are known to get more virulent forms of breast cancer. In Africa, Dr. Singh indicated that there is a particularly aggressive form of breast cancer. He also emphasized that there was no “lightning rod gene” as a pattern of genes is most likely responsible for cancers with a genetic origin. Treatment for male breast cancer includes surgery, typically a mastectomy with tissue resected down to the chest wall. If there are three or more positive lymph nodes or if a tumor is more than 5 cm, typical treatment includes radiation. There are also systemic therapies, including hormonal treatments, chemotherapy and targeted treatment such as Avastin (to block blood vessel production), Herceptin (to block cell protein in Her-2 positive cancers) and Lapitnib (a form of Herceptin that will cross the blood brain barrier). Both Dr. Axelrod and Dr. Singh indicated that genetic science is improving exponentially in identifying cancer risk. Similar to the finding of the BRCA I and II mutations in the Ashkenazi Jewish population, there has been a similar genetic discovery concerning breast cancer risk in Nordic populations, affecting Scotland, Northern Ireland, Iceland and other countries visited by “Viking” migration. JALBCA is grateful to the NYU Cancer Center, Dr. Axelrod and Dr. Singh for generously giving of their time to provide this informative program. JALBCA’S Annual Symposium JALBCA and the Post-Treatment Resource Program of Memorial Sloan Kettering Cancer Center sponsored the twelfth annual symposium on November 7, 2007. The panel discussed whether we have lost ground in the battle for improved breast cancer screening and whether we will gain ground with national health legislation. The Association of the Bar of the City of New York generously offered the Great Hall as the meeting location. Judges Judith S. Kaye, Helen E. Freedman, Shirley Werner Kornreich and William C. Thompson (Retired) served as the judicial panel and Larry Norton, MD, Julie Mitnick, MD, Danielle Halohan, MPH and Minna Elias, Esq. served as the expert panel. Ms. Elias, unable to attend, provided a written overview of issues facing Americans, set forth below.  Introduction Dr. Norton commenced with the provocative statement that “There is no such thing as breast cancer; there are breast cancers -- five types, two with a strong hormone link and three without this link.” He indicated that different drugs work against the different types of breast cancer, and that the means of diagnosis for each type also varies. Dr. Norton also explained that genes that are associated with the inflammatory process are also associated with the cancer process, leading researchers to conclude that breast cancer is a disease associated with the DNA. He emphasized the critical importance of early diagnosis because, in this way, physicians are able to get to the disease before the cells attain the ability to move throughout the body (which does not occur right away). This cell mobility, he said, is as important as the cell division of cancer cells. Dr Norton made the case for why it is important to fund fundamental or basic science and the need for the US citizenry to advocate for this as a national priority. Program Newly released reports suggest that female breast cancer rates have been decreasing in recent years. While expert opinions vary on what is responsible for the apparent decline, two explanations have remained in the forefront: evidence of a decrease in the use of screening mammography and discontinuation of hormone replacement therapy (HRT). Since there is evidence that breast cancer incidence rates began decreasing as early as 1999, well before the adverse effects of HRT were known, the discontinuation of HRT would not account for the entire decrease. Dr. Mitnick, a prominent radiologist in New York City, affirmed the need to encourage women to schedule earlier breast cancer screening. She described some of the difficulties presently facing patients and radiologists in the City: the quality of mammography centers is not uniform; 10% of centers in the City have closed; many physicians, concerned about malpractice claims, no longer want to practice mammography; women who go for breast imaging are very anxious so that it is harder for a physician to practice in this area, in addition to the substantial time needed to spend with patients; and reimbursement rates to providers have been decreasing. She noted a California tort reform statute which imposes a $250,000 cap on pain and suffering cases, which she suggested, while not popular with attorneys, would reduce the number of “failure to diagnose” lawsuits. Dr. Mitnick also explained another impediment for radiologists, i.e., that breast imaging is the most regulated area of medicine -- NYS investigations are annual and Federal investigations are bi-annual, and the investigations can continue for a week, leaving the provider with the inability to practice for days, while the investigators are present in the office. Dr. Norton added that people fear breast cancer less than they did in the past, which is a cause for concern.  The panel also discussed aspects of different models for health care reform, including a single payor system. Judge Freedman questioned why physicians oppose such a system. Dr. Norton disagreed that all physicians oppose a single payor system and indicated it could work well if it was adequately funded, included patient participation, and had standards of care that are applied by panels of qualified people and not government officials. Judge Kornreich questioned whether Congressman Conyers’ universal health insurance bill was likely to become law. Ms. Halohan questioned its likelihood of passing, indicating that many politicians do not discuss a single payor system but, rather, refer instead to state proposals and mandates on employers. Ms. Halohan noted that many state plans would have pay-or-play features so that all employers are taxed a certain amount and receive a credit if they offer coverage. The employer backlash is what has derailed a lot of state plans, she explained, and the state proposals that are successfully being signed into law are ones that involve modest assessments on employers. This led to a discussion about the interface of state plans with ERISA, and the effect of ERISA pre-emption. In New York, the Governor recently directed the Health Commissioner and Insurance Superintendent to develop a comprehensive strategy for universal health insurance in the State. The Governor called for a final proposal, after public hearings, to be submitted by May 31, 2008. In 2006, the United Hospital Fund and The Commonwealth Fund authored a report -- “A Blueprint for Universal Health Insurance coverage in New York” -- which provides approaches to address the specific characteristics of New York’s 2.8 million uninsured. Health Care Financing and Breast Cancer The growth in the number of uninsured could have a significant impact on breast cancer treatment in the United States. With nearly 47 million Americans uninsured [1], it is becoming increasingly clear that we need to make significant changes in how health care is financed. The United States spends more on health care than any other nation on earth, but our health care outcomes often are significantly worse. The United States is ranked 22nd in life expectancy at birth, 24th in people dying of respiratory disease, third highest in deaths from medical errors and third highest in infant mortality rates [2]. There are undoubtedly many reasons our costs are so high, but one reason is that we have an incredibly inefficient system with huge administrative costs and large numbers of people who lack adequate coverage. In 2004, the United States spent $6,102 per capita on health care [3], more than double the average for Organization for Economic Cooperation and Development (OECD) member countries [4]. When you look at where the money is going, it is clear that a lot of it is going to entities other than health care providers. US health care consumers are less likely to be hospitalized and less likely to visit physicians [5]. Americans spend roughly twice as much on prescription drugs, putting a lot more of our health care dollars into the hands of the pharmaceutical companies [6]. Administrative costs account for a large portion of US health care spending. An August 2003 article in the New England Journal of Medicine reported that roughly 27.3% of the US health care labor force are administrative workers [7]. The report stated, “After exclusions, administration accounted for 31.0 percent of health care expenditures in the United States and only 16.7 percent of health care expenditures in Canada.” The report also noted that American physicians are forced to spend much more of their time dealing with multiple insurers and different rules regarding co-payments, referral networks and approval requirements. One of the most critical problems for the US health care system is the high number of uninsured. A new report issued December 20, 2007 by the American Cancer Society makes clear that your chance of surviving all cancers depends heavily on whether or not you happen to have health insurance [8]. For breast cancer and other cancers for which screening tests are available, the connection is particularly striking. Among white women diagnosed with all stages of breast cancer, roughly 3/4 of the uninsured survived five years, compared with 9 out of 10 of those with private insurance. Among African Americans, the difference was even more significant, with a five-year survival rate of 65 percent for women who lacked insurance and 81 percent for privately insured women. At every level of education, individuals with health insurance were about twice as likely as those without health insurance to have had mammography or colorectal cancer screening. Not surprisingly, uninsured women were much more likely to discover their cancer at a later stage. The report found that women without insurance were significantly more likely to be diagnosed with late stage (stage III/IV) breast cancer than privately insured patients. Similarly, uninsured women were less likely to be diagnosed with Stage I breast cancer. Unfortunately, reimbursement rates are so low, that it is becoming harder and harder for women to find a place where they can get a mammogram. From 1999-2006, 12% of mammography facilities closed nationwide [9]. Rising overhead costs and a decline in the number of doctors willing to do the procedure have resulted in the high number of closures. In New York City, the number of locations offering mammography dropped from 261 to 194 [10]. Waiting periods citywide have spiked 171% over the past decade. That’s a drop of 26%, more than twice the national average [11]. Only 66% of women age 40 and over get yearly mammograms -- a drop of 4% or three million women over the last 5 years [12]. The highest drop was in women aged 50-65. Experts suggest there are three reasons for the drop -- the cost, the pain or hassle involved in having a mammogram and the inability to get an appointment [13]. The bottom line is that too many women are dying of breast cancer because they do not have health insurance or they do not have access to screening mammography. We have made great progress in developing treatments for breast cancer, but a treatment only works if women know they need it. If they are not being screened, or if they delay treatment because they do not have health care, all the medical breakthroughs in the world are not going to help. We need to find ways to ensure that every American has health care coverage. ——————————— [1] CRS Report for Congress, Health Insurance: A Primer, Updated September 5, 2007, Bernadette Fernandez, p CRS-9 [2] CRS Report for Congress, US Health Care Spending: Comparison with Other OECD Countries, Chris L. Peterson and Rachel Burton, dated September 17, 2007, pp. CRS-48 - CRS-52. [3] Congressional Research Service Report to Congress, US Health Care Spending: Comparison with Other OECD Countries, Chris L. Peterson and Rachel Burton, dated September 17, 2007, p. CRS-1 [4] The OECD consists of 30 democracies, considered the most economically advanced in the world. The average per capita spending by OECD countries was $2,560 in 2004. [5] CRS Report for Congress, US Health Care Spending: Comparison with Other OECD Countries, Chris L. Peterson and Rachel Burton, dated September 17, 2007, p. CRS-5 [6] CRS Report for Congress, US Health Care Spending: Comparison with Other OECD Countries, Chris L. Peterson and Rachel Burton, dated September 17, 2007, p. CRS-5 [7] New England Journal of Medicine, Costs of Health Care Administration in the United States and Canada, by Steffie Woolhandler, M.D., M.P.H., Terry Campbell, M.H.A., and David U. Himmelstein, M.D., (August 21, 2003) [8] Association on Insurance with Cancer Care Utilization and Outcomes, E Ward, M Halpern, N Schrag, V Cokkinides, C DeSantis, P Bandi, R Siegel, A Stewart, A Jemal, CA Cancer J Clin 2008;58:9-31, DOI: 10.3322/CA.2007.0011. [9] Dozens of City Clinics Halt Mammogram Screenings, by Celeste Katz, Daily News, July 22, 2007 [10] Access to Mammography At Risk: Fewer Test Sites, Longer Waits, Prepared by the Office of Congressman Anthony Weiner, July 18, 2007 [11] Access to Mammography At Risk: Fewer Test Sites, Longer Waits, Prepared by the Office of Congressman Anthony Weiner, July 18, 2007 [12] Your Health; Fewer American Women Are Having Routine Mammograms, ABC News Now, May 15, 2007 [13] Cancer Screening; Drop in Mammography Rate Worries Cancer Experts, World News with Charles Gibson, May 14, 2007 -- Minna Elias, Esq. Calendar / Contacts ADELPHI NY STATEWIDE BREAST CANCER Hotline & Support Program Adelphi University School of Social Work Garden City, NY 11530 www.adelphi.edu/nysbreastcancer/index.html CancerCare 275 Seventh Avenue NY NY 10001 www.cancercare.org 1-800-813-HOPE MEMORIAL SLOAN-KETTERING CANCER CENTER Memorial Sloan-Kettering Cancer Center Post-Treatment Resource Program 1275 York Avenue - Room-M107 New York, NY 10021 212-717-3527 www.mskcc.org/mskcc/html/19409.cfm Bendheim Medicine Center 1429 First Avenue (at 74th St.) SHARE Self-Help for Women with Breast or Ovarian Cancer) 1501 Broadway, 704A New York, NY 11530 www.sharecancersupport.org 212-719-0364
JALBCA does not endorse the content or efficacy of any workshops or programs listed in the Calendar of Events; listings are for informational purposes only, so that our readership is aware of current offerings. |
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