October 29, 2015

beyond pink

As we navigate an ever-enlarging sea of pink each October, Breast Cancer Awareness Month stands out as one of healthcare’s marketing success stories. But beyond awareness, how has breast cancer treatment changed? Three ways:

  1. Personalized Screening: Most of the data used to determine mammogram screening recommendations is 30-40 years old, according to Laura Esserman, MD, MBA, Director of the Breast Cancer Center at University of California, San Francisco. So recommendations vary. The American College of Obstetricians and Gynecologists still recommends screening at age 40. The American Cancer Society just raised its recommended starting age from age 40 to age 45. Meanwhile, the U.S. Preventive Task Force has recommended since 2009 that screening mammograms begin at age 50.  Faced with these conflicting guidelines, physicians are partnering with their patients to make more personalized decisions. If a woman has a strong family history of breast cancer, or influential personal experience with it, they may begin screening earlier. Conversely, if they want to avoid unnecessary follow-up biopsies and treatment following a false-positive reading, they may delay longer.
  2. Cancer: Big C or Little c? Not all cancers require the typical course of surgery + chemotherapy + radiation. Every woman has a unique biological risk and a unique tolerance for aggressive treatment. In breast cancer treatment, less may in fact be more. As a recent Time article explores, this is not an easy message to digest for many physicians. For example, a 2004 study of women over age 70 with early-stage breast cancer showed no additional benefit of radiation over surgery and chemotherapy alone. Regardless, 10 years later there was only a 7% decrease in the number of these women receiving radiation. Similarly, while the number of women dying from breast cancer has stayed relatively constant over the last 13 years, women’s perceived risk has increased due to effective awareness campaigns. But not all breast cancers require treatment. New research indicates that women with Stage 0 breast cancer have a 20-year mortality risk of 3.3%—whether or not they receive treatment. Thanks to routine screening, Stage 0 cancers now represent almost 25% of those diagnosed. Experts are calling for a policy of active surveillance for cancers like these. Ironically, as screening leads them to find more cancers, the evidence demands that doctors do less about them. As Dr. Esserman summarizes, “How wonderful if we can learn how to do less for women.” That means treating “little c” cancers more as early-stage chronic diseases than life-threatening emergencies.
  3. Putting Quality of Life First: Survival might not be an achievable outcome. But continued quality of life is. By treating the whole person, not just the disease, providers can make breast cancer treatment successful for every woman, regardless of the ultimate outcome. So they are leaving the celebration of breast cancer survivors to external organizations, and focusing on making every potential outcome an empowered and peaceful one. It starts with involving patients in choosing a doctor and hospital. A recent PriceWaterhouse Coopers survey indicates 77% and 83% of patients want to be involved in these respective decisions(PDF). Then it means clearly presenting all treatment options and recommendations, which 81% of patients feel is extremely important.

Breast cancer care is no longer one-size-fits-all. Screening, treatment, and quality of life have all become individualized decisions: one woman, one care plan.

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