Breast cancer treatment options increasing: Disease remains challenging

TCU's Frogs for the Cure during the 2012 football season

• Since 1946, the American Cancer Society has invested more than $4.3 billion in cancer research.

• As of August 1, 2015, the American Cancer Society is supporting 198 grants with $83.5 million to find the answers that will help save lives from breast cancer.

• Breast cancer death rates decreased by 34 percent between 1990 and 2010.

Source: American Cancer Society

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Susan G. Komen

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American Cancer Society

Cancer Care Services

As CEO of her husband’s Fort Worth chiropractic and wellness clinic, Nancy Michlin thought she had a healthy lifestyle – until that fateful day in late 2011 when she was diagnosed with breast cancer.

In some ways, Michlin’s experience was similar to other breast cancer survivors. After her annual mammogram, doctors took additional views of the breast tissue, then scheduled a needle biopsy.

“They tried to downplay it,” she said. “There was some concern but I didn’t expect them to tell me I had breast cancer. But the doctor who did the biopsy said she knew it would come back positive by looking at the original X-rays.”

But Michlin’s experience once she was diagnosed with ductal carcinoma differed in many ways from that of many other breast cancer survivors.

During her first surgery in February 2012, doctors discovered that the cancer they hoped would be contained had spread 10 millimeters out of the ducts. They also found lobular cancer, which is known for hiding from X-ray view, inside one lymph node.

When three surgeons each recommended a mastectomy over a lumpectomy because of the size and area of the cancer, Michlin chose one surgeon who used a different technique to spare the nipple.

When doctors couldn’t assure her that cancer wouldn’t show up in her other breast, she had a second mastectomy. After six surgeries in six months, including breast reconstruction and removal of infected tissue, Michlin faced the next phase of her treatment.

With some doctors recommending chemotherapy and others saying the toxic chemicals would do more harm than good, she decided to forego one of two follow-up treatments most often recommended for people who undergo mastectomies.

“I felt like I was in a bad game of pin the tail on the donkey,” she said. “I was blindfolded and had to make the decision.”

Although Michlin’s breast surgeon helped her assess the options, the choice was hers.

“I made a jump of faith,” she said. “I decided not to do chemo. Either a net would appear or wings would form. I found my trust and belief in my decision after I made it. A month or two later I knew it was right.”

Michlin did follow her doctor’s recommendation to take hormone therapy to reduce the risk of cancer that feeds off estrogen and progesterone. She discontinued it after two and a half years because tests showed it did not substantially reduce her risks of cancer recurring. She now takes natural hormone-reducing supplements.

Although she has been cancer-free for almost four years, Michlin’s cancer journey goes far beyond her diagnosis and treatment. Her experience led her to research ways to reduce her risk of future cancer, including changing her diet, exercising more and taking vitamins and supplements.

It also led her to start BacktoHealth4Life! to teach others the four pillars of health and wellness she practices – BASE – Breathe to reduce Stress, Act to increase activity. Smile to focus on gratitude and Eat for nutrition.

“Everybody out there is saying that early detection is the best prevention,” Michlin said. “That’s great. I want to empower people to make healthy lifestyle choices so they can prevent cancer or flourish if they get it.

“I just knew I got breast cancer to teach other people what I learned. I had a certain health background but I increased everything I knew. My passion is for helping others make healthy lifestyle choices.”

Michlin’s story illustrates many aspects of breast cancer that medical professionals and nonprofit agencies emphasize year-round but especially during Breast Cancer Awareness Month in October.

Education and screening

This year, the Susan G. Komen Foundation is continuing to emphasize early detection, with a special outreach to minorities and others in whom the breast cancer rate is higher than the general population.

Komen executive director Mary Ann Means-Dufrene said early detection through screening has increased the odds of survival by 34 percent since 1990. Of the 4,633 women screened last year, 428 were diagnosed with breast cancer; however, more than half had third- or fourth-stage cancer, she said.

“For them, their chance of survival is not only less but the treatment they receive is more intensive and much more expensive,” Means-Dufrene said.

That also affects the community because Komen and other funders are able to pay for treatment of three or four women with Stage 1 breast cancer – who have a 99 percent chance of survival – for the cost of one patient with Stage 3 or 4 cancer, she said.

Means-Dufrene said many people now know that early detection is crucial but rural residents and urban minorities may have trouble accessing screening because of either limited transportation options or finances.

That’s why Komen and the Tarrant County Disparities Coalition are sending mobile mammogram units to seven locations throughout the county on Nov. 14 as well. Screening also will be available at several hospitals and clinics.

Means-Dufrene said Komen is also reaching out to the community through a new “Worship in Pink” educational program in churches and Blue Zone cooking demonstrations to clarify misconceptions and cover prevention as well as screening.

“Understand your normal is the focus this year,” she said. “For so long, it was about the tactile exam to see if you feel a lump. Now we need people to see there are signs – a rash or a nipple discharge or just pain.”

Diagnosis and treatment

Even with better education, oncologists and breast cancer surgeons often have difficulty helping their patients understand that there are many types of breast cancer that show up in different forms in each patient, requiring individually tailored treatments.

“In the early days, the thoughts were the more normal tissue we took out around the cancer, the more likely the patient would survive,” said surgeon Amy Gunter, who has devoted her practice to breast cancer surgery for nearly 20 years. She has offices in Fort Worth, Weatherford and Granbury.

That meant that more mastectomies were performed, many times along with removal of large numbers of lymph nodes, where breast cancer cells frequently travel, she said.

With ongoing research in genetic connections to cancer, Gunter said, doctors are able to determine how changes in each patient’s cells caused the cancer and how best to treat it.

“In general, surgery is now less invasive,” she said. “We’re able to take smaller amounts of tissue and achieve the same results. We can take a smaller number of lymph nodes under the arm and reduce the swelling after surgery.”

Oncologist Robyn Young, who is director of breast cancer with the Center for Cancer and Blood Disorders, said the newer tests on genes extracted from the cancer cells help tailor post-surgery treatment. She has offices in Fort Worth and Weatherford.

In the past, that treatment was usually a lumpectomy followed by radiation or a mastectomy followed by chemotherapy, hormone therapy or both, she said.

“To me, with the better drugs, it can truly go either direction,” Young said. “Some cancers are big enough, bad enough or worrisome enough that they need chemo and hormones. Some need one or the other.

“You very rarely get someone who needs nothing. How a tumor is behaving drives the decision. Saying it’s breast cancer is like saying it’s cancer. There are so many distinct breast cancers that go to different places at different rates of growth. They are biologically different cancers.”

Even with the scientific advances that have reduced the necessity for invasive surgery, both doctors say that many young women are still having mastectomies, sometimes double mastectomies, for a variety of reasons.

Young women with genetic histories of breast cancer – mothers, sisters and even fathers – may elect mastectomies over the less invasive lumpectomies, most likely to reduce their risk of breast cancer, Young said.

But many also elect to remove the breast without cancer, Gunter said.

That may make sense if those women have genetic mutations that increase their risk of breast cancer from the 12 percent in the general population, Young said. If their risk is only 20 percent, however, they may be removing a health breast unnecessarily, she said.

Gunter believes their reasoning may be at least partially cosmetic – to make the two breasts match through reconstruction.

“But there probably is just some anxiety,” she said.

Financial and emotional support

When Debra Rundles entered nursing 31 years ago, she was assigned to a unit at an Arlington hospital that included 10 beds for women undergoing treatment for cancer, mostly breast cancer.

“I was 19 and it was pretty sad,” Rundles said. “These patients came in with no family. They removed all the breast and lymph nodes. There was no reconstruction surgery unless you were wealthy enough to have someone pay for it.”

After treating breast cancer patients off and on for years, Rundles was named coordinator for breast cancer patients at Medical Center of Arlington, a new position that is often called a breast cancer navigator.

Five years later, she is convinced that she and others like her perform a vital role in helping breast cancer survivors do just that.

Her job essentially is guiding patients through their treatment, helping them understand their diagnosis, coordinating their appointments with different medical staff, making sure they know about community resources to help with financial and other needs, and just being a listening ear.

Rundles said she fills the gap between the patient and the doctor who may spend only 20 minutes with each patient.

“That’s where I come in – educating, decreasing anxiety and being supportive, filling in the missing pieces,” she said. “My patients have my office and cell numbers and email address. Sometimes they call me about a rash. I’m able to tell them it’s probably ok but ask if they want me to call the doctor.

“Having navigators gives the patient empowerment and better outcomes.”

Two area nonprofits have been providing similar support plus financial support for needy patients – one for 70 years.

Cancer Care Services was started in 1946 when local physicians and others noticed families struggling to pay the bills for cancer treatment, said spokeswoman Deanna Stuart.

Initially it served Tarrant County residents, but the nonprofit agency expanded to Parker and Hood counties in 1987 and now serves about 4,200 clients including 770 with breast cancer, she said.

With a $1.9 million budget, Stuart said, the nonprofit provides financial aid to clients – 50 percent with incomes below the poverty level and others devastated by medical expenses – plus counseling and other support for patients and their families.

Parker County breast cancer patients have been aided for 21 years with proceeds of an annual celebrity cutting horse event. Supporters of that event formed the Careity Foundation 14 years ago so they could use the funds locally as they saw fit instead of giving them to other cancer agencies, according to co-founder Lyn Walsh.

Walsh, who runs the foundation with co-founder Beverly Branch, said most of the cutting horse proceeds now go to Parker and Johnson county residents with some Hood County residents also served.

Careity now pays for mammograms and other screening tests, pays for treatment through participating doctors including Gunter and Young, and provides other types of emotional and social support, she said.