Breast cancer risk after supradiaphragmatic radiotherapy persists beyond 40 years

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Everything...and I mean EVERYTHING comes with a price tag.

I came upon this, and my breath caught. This has nothing to do with my personal health journey. It has everything, however, to do with dear sweet 16 year old Hannah...just another potential battle you may have to face down the road. Hannah was diagnosed with Hodgkin's Lymphoma this past spring when she was 15, and has been undergoing very aggressive treatment since. Her last round is scheduled for erev Rosh Hashanah. Her mother (Andrea), whom I got to shared a hug with this past Thursday, was looking at the poetic and positive portend associated with this timing.  Andrea has always been a 1/2 glass full lady.

I, on the other hand, have been trained to be the consummate cynic (4.5 years of law school and nearly two decades practicing law). I listen to the treatment regimen Hannah's young body has had to endure these past six months; I recall my own fears of cumulative radiation exposure;  I stumble across the following abstract; and I viscerally cringe.

And, again, I ask the question constantly on my lips - why must anyone sacrifice their long term health as the cost of being "cured" today?  ####

1:35 | Jun 29, 2012 | Oncology, Reuters Health • The Doctor's Channel Daily Newscast, Women’s Health

NEW YORK (Reuters Health) – The increased risk of breast cancer in women who received radiotherapy above the diaphragm for treatment of Hodgkin’s lymphoma (HL) persists for at least 40 years after treatment, according to a national cohort study from the United Kingdom.

These women need to be followed for at least 40 years, perhaps with more-intensive screening regimens, say the investigators from the England and Wales Hodgkin Lymphoma Follow-Up Group in a report online June 25 in the Journal of Clinical Oncology.

“Supradiaphragmatic radiotherapy is still widely used although techniques and doses keep changing,” first author Dr. Anthony J. Swerdlow, from the Institute of Cancer Research, Sutton, Surrey, England, commented in an email to Reuters Health.

He and his colleagues documented the clinical characteristics, treatment, and subsequent outcomes of 5,002 women with HL treated with supradiaphragmatic radiation (mantle-field in two thirds of the population) in England and Wales from 1956 to 2003. The women were younger than 36 at the time of treatment and were followed through the end of 2008.

The researchers used modeling to describe specific, cumulative breast cancer risk at given time points during follow-up according to age at diagnosis, treatment type (inclusion of alkylating agents or pelvic radiation), radiation dose, and time from first treatment.

A total of 373 women developed breast cancer or ductal carcinoma in situ during follow up, yielding a standardized incidence ratio (SIR) of 5.0.

SIRs were greatest for those treated at age 14 years (47.2) and “continued to remain high for at least 40 years. The maximum absolute excess risk was at attained ages 50 to 59 years,” the investigators report. Alkylating chemotherapy or pelvic radiotherapy diminished the risk, but only for women treated at age 20 or older, not for those treated when younger.

The authors tabulated “in detail” cumulative risks of breast cancer based on various factors. For example, the cumulative risk of breast cancer in a woman 20 to 24 years old at the time of treatment with supradiaphragmatic radiation is 3.5% at 20 years and 29.2% at 40 years. For those treated with supradiaphragmatic radiation plus alkylating chemo and/or pelvic radiotherapy, the corresponding risks are 3.6% and 11.5%.

“I think the clinical implications (of the article) are in the provision of risk statistics to use to advise patients,” Dr. Swerdlow said.

In an accompanying commentary, Dr. Michael Crump, from Princess Margaret Hospital and University of Toronto in Canada says, “The legacy of curative extended-field radiation for HL is a large survivor population that is at an increased lifetime risk of second cancer, in particular breast, lung and GI cancer. The article by Swerdlow et al … offers additional information to address the challenge of individual risk assessment.”

This is largest cohort of survivors of HL yet evaluated for breast cancer risk, Dr. Crump notes, and the results confirm those of others. Namely, that breast cancer risk is “highest in women treated with mantle radiotherapy around puberty, decreases with increasing age at treatment (although still elevated for women treated in their thirties, the median age at diagnosis of HL in most countries), and decreases with smaller radiation field sizes and lower radiation doses. Gonadotoxic therapy (alkylating agents or radiation) reduced subsequent breast cancer risk but only for women treated after age 20 years.”

Dr. Swerdlow and colleagues say the “large cumulative risks of breast cancer we found 20 to 39 years after supradiaphragmatic radiotherapy, especially in patients treated at age 20 years, are similar to or higher than the risks by the same ages in BRCA1 and BRCA2 carriers. They suggest that intensive breast screening programs for such women may need to continue for 40 years and longer after initial radiotherapy.”

They also say their data showing maximum absolute excess risk at ages 50 to 59 years suggest that “more-intensive screening (eg, annual screening with magnetic resonance imaging) may be needed.”

In his editorial, Dr. Crump points out that “Both the American Cancer Society and the United Kingdom Notification Risk Assessment and Screening Programme recommend magnetic resonance imaging (MRI) as an adjunct to annual mammography for women who have received thoracic irradiation younger than age 36 years, starting 8 years after treatment. Available data suggest that efforts to enroll high-risk women onto screening programs are falling short, and less than half of women treated during adolescence or as young adults currently receive annual mammography.”

Continuing, Dr. Crump says, “The United Kingdom guideline recommends commencing screening at age 25 years but returns women to standard mammography once every three years once they have reached age 50 years. The report by Swerdlow et al suggests that this upper age limit should be reconsidered in light of the very high cumulative risk faced by women even beyond 30 years of follow-up,” he concludes.

SOURCE:

Toward Risk-Based Breast Cancer Screening and
Prevention Strategies for Survivors of Hodgkin’s
Lymphoma: One Step Closer?

Breast Cancer Risk After Supradiaphragmatic Radiotherapy for Hodgkin’s Lymphoma in England and Wales: A National Cohort Study

J Clin Oncol. 2012.

 

Random Musings...

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In a society and culture myopically focused; stunted by an insatiable need for immediate gratification; and inexplicably driven to sacrifice reason for dogma.... "How [then] can we all get over ourselves long enough to really, truly notice other people? ~ Jeff Giles"

Overselling and Promoting Over Diagnosis...and the Winner is ?

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Breast Cancer: Komen Oversells Mammograms, Doctors Say By SYDNEY LUPKIN August 2, 2012—

abcnews.go.com

Medical Journal Column Calls Pink Charity Out for Bad Math

Two Dartmouth Medical School professors have called out Susan G. Komen for the Cure, accusing the pink-ribbon organization of overstating the benefits of mammograms in its advertisements.

The accusation comes about six months after the breast cancer charity came under fire for cutting Planned Parenthood funding, which it claimed was not a politically motivated decision. According to the foundation's most recent Form 990, it netted about $114 million in 2010.

The ad in question ran last October in several major magazines, and said, "The five-year survival rate for breast cancer when caught early is 98 percent." Its not. It's 23 percent."

"It sounds like you'd have to be crazy not to get screened. It sounds like a huge benefit," said Dr. Steven Woloshin, co-author of the article in BMJ, the British medical journal. "The statistic is totally distorted."

The problem is that a five-year survival rate is easy to manipulate, he said. The ad compares five-year survival rates for early-stage cancers and late-stage cancers, which Woloshin said is not a meaningful way to measure the benefits of screening. Here's why:

Suppose three women are diagnosed with breast cancer at age 67 when a doctor finds a small lump, and they die of the disease three years later, when they're 70. That five-year survival rate is a miserable zero percent because no one lived five years past their diagnosis dates.

Now, suppose the same women were diagnosed when they were 64 because the cancer showed up on mammograms, but they still die of breast cancer at age 70, he said. The new five-year survival rate is a triumphant 100 percent, even though the women actually survived cancer the same length of time. They just didn't know how long they had it.

"If there were an Oscar for misleading statistics, using survival statistics to judge the benefit of screening would win a lifetime achievement award hands down," Woloshin and his co-author Lisa Schwartz wrote.

More useful numbers, he said, are derived from randomized trials. They show that 0.53 percent of women in unscreened trial groups died over 10 years -- compared with 0.46 percent of the women who were screened. That's not much of a difference, the authors said.

This problem is further exacerbated by overdiagnosis, which happens when mammograms detect cancers that never grow or cause symptoms, he said.

For every woman saved by an early screening, two to 10 are falsely diagnosed, the authors wrote. This means patients endure biopsies, chemotherapy and radiation even though they don't have a threatening cancer.

"There's no way for an individual to know they've been overdiagnosed," Wolostin said, explaining that the only way to tell whether this has happened to a specific person is if that person is diagnosed, does not seek treatment and eventually dies of something else.

Doctors have seen evidence of overdiagnoses in long-term follow-ups to randomized trials and analyses of population data, he said.

In response to the article, Komen's Vice President of Research, Chandini Portteus, stood by the foundation's stance on mammograms, calling the screenings "the best widely available detection tool that we have today."

She said Komen has contributed funds toward even earlier detection.

"We think it's simply irresponsible to effectively discourage women from taking steps to know what's going on with their health," Portteus said, adding that the foundation is also funding research to determine which tumors will spread.

Woloshin said his article is not saying mammograms are bad.

"Some people benefit while other people are harmed," he said. "If you don't know, you can't make an informed decision."

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What this article, as well as Komen do not express, is that mammograms can also be ineffective as a diagnostic tool. My form of b.c., invasive lobular - which started as a nearly imperceptible node, was consistently misdiagnosed as "fibrous breast tissue" for years before it grew to 6.2 cm and a biopsy followed by a MRI confirmed its true nature. My history of mammograms gave both my doctor and myself a false sense of health. Until the tumor insisted on recognition.

Additionally, this article and Komen do not address the cumulative nature of radiation - which is the energy behind mammograms; and our bodies inability to naturally purge this and all of the other daily exposures to radiation we encounter. All of which create a toxic environment within our bodies where cancer can happily proliferate.

I personally know many women who have been "diagnosed," via mammograms, with stage -0- / in-situ carcinoma (a pre-breast cancer state). With this diagnosis they have gone on, with full encouragement of their medical teams, to undergo the slash/burn/poison protocol. Their outcome: "cured." Yet, they all seem to be experiencing some after"gift" of their treatments -- no one should leave a party empty-handed. It begs the question: what were they actually cured of?

And, if they and their medical team had not relied so heavily on mammograms, would they have made a different choice?
                                                                                                    ~ TC