Dr. Saundra Buys is the medical director of the High Risk Breast Cancer Clinic at the Huntsman Cancer Institute and a professor at the University of Utah School of Medicine. She’ll be speaking about breast-cancer treatment and research as part of the What Up, Doc? lecture series at the Salt Lake City Main Library (210 E. 400 South, 801-524-8200) on Tuesday, May 7, at 7 p.m.
Can you set the record straight on when women should get mammograms?
Well, not really. Equally ardent supporters of different views can strongly make a case. If you’ve got a cancer for which there is no good treatment, then there’s no point in screening—because the point of screening is to find it early when it could be more effectively treated. If there’s no good treatment, there’s no point in looking for the disease. And on the other hand, if there’s an extremely good treatment, then you don’t really need to look for early disease because you can treat it just as effectively later. Breast cancer is kind of in a middle ground—it’s a disease for which early detection is effective, but our treatments are getting better and better. The death rate from breast cancer has gone down. And some people say that’s because we’re doing more mammograms, and so we’re catching it earlier and treating it more effectively. And other people say that’s not the reason—the reason is that even if it’s more advanced, our treatments are more effective—our chemotherapy is better, we’ve got more targeted treatment against that particular cancer. And it’s probably a combination of both—our treatment is better even if the cancer is more advanced, and mammograms are catching cancer earlier. I think the answer is that there’s not one good recommendation.
One recommendation is to begin at age 40 and do it yearly. Another recommendation is to begin at age 50 and do it every other year. So if you’ve got someone who’s got a higher likelihood of having breast cancer—they’ve got a family history of breast cancer, for example—then I think starting earlier and doing it yearly makes a lot of sense. And if you don’t have a family history and don’t have other risk factors for breast cancer, then maybe starting at 50 and doing it every other year may be adequate. But when we talk about risk factors for breast cancer, it’s important to realize that the No. 1 risk factor is being a woman, and the No. 2 risk factor is being older.
Another thing that we’re doing in breast cancer and other cancers is to predict who’s most at risk. We can do that based on family history, we can do that based on the density of the breast tissue. If we think there’s a high risk, yeah, start early. If we think there’s a low risk, we can maybe delay.
When you talk about family history, does that mean of breast cancer specifically, or any cancer?
If you have a family history of colon cancer, that doesn’t particularly raise your risk of breast cancer. There are about 5 to 10 percent of cancers that are probably caused by a specific alteration that increases the risk of getting that kind of cancer. And what you see in those families is people getting cancer at earlier ages, getting multiple kinds of cancers, and then clusters of related cancers—for example, breast and ovarian cancer tend to be the same little cluster. So if you’ve got a family history of breast or ovarian cancer, your risk of breast cancer is higher. Colon cancer and endometrial cancer go together.
Do breast-cancer awareness campaigns work?
A lot of the grass-roots movement against specific diseases really started with AIDS awareness. The people with AIDS in the ’80s and into the ’90s really brought funding, public attention, legislation, clinical trials. And I think the same kind of thing is happening with the breast-cancer advocacy movement, much more so than a lot of other kinds of diseases. I think it’s helpful to a certain extent. I think what happens, though, is that when you’ve got it so much in the public awareness, women overestimate their likelihood of getting breast cancer. You hear that 1 in 8 women will get breast cancer. So you’re sitting around with your seven best friends and you say, “OK. Let’s make a pact. We’ll all go get a mammogram.” And what women think that means is that one of us after the mammogram will end up with breast cancer. But that’s a lifetime rate, of course, so chances are very low that one of the eight will end up with breast cancer in the next year or decade.
And because these campaigns focus so much on early detection and cure, women who get breast cancer sometimes have a false idea about how curable it is. You drive down the freeway and you see a billboard, “If caught early, breast cancer is 99 percent curable.” In a sense, that’s true, but in a much bigger sense, that’s not true. Women with breast cancer don’t have a 99 percent chance of being cured.
The other thing that happens is that sometimes women who end up with advanced breast cancer end up feeling like people are looking at them, saying, “What did you do wrong? You must not have done everything right or else you would’ve caught it early and it would’ve been cured.” But sometimes it’s just not.
It’s important to get the word out. It’s a good idea to get a colonoscopy, to get a mammogram, but most people are not going to benefit from that—if 1 in 8 women gets breast cancer in their lifetime, then 7 out of 8 women are never going to benefit from a mammogram—they can only be harmed by screening. So we have to think about what’s the downside.
What advances have there been in breast-cancer research and treatment?
One of the really important advances in breast cancer is our ability to predict how it’s likely to behave. We can look at breast cancer and see whether it’s in lymph nodes, we can see how big it is ... you can get a general sense of how this cancer is likely to behave and how this person is likely to do. But sometimes those good cancers are going to behave badly, and sometimes those worse-looking cancers are not going to behave badly. Some breast cancers don’t look like they’re going to be too bad, but maybe 20 percent of them actually become metastatic. You’d like to be able to predict which ones are going to become metastatic. And others, you think, “Gosh, this has a really high likelihood of becoming metastatic,” so you might treat it really aggressively, but in actuality, it’s one that was destined to not do too badly.
We have the ability now, with genetic profiling, to look at the specific genes that are turned on and turned off in the cells, which can tell us, “This shouldn’t behave too badly, it’s not in lymph nodes, it’s not bad-looking under the microscope.” We can look at genetic changes in the cells and try to figure out if this is a cancer that’s going to behave in a way that we should be treating it more aggressively right up front, or if it’s one that’s not going to be too bad so maybe we don’t even need to treat it too aggressively.
What impact has this had on your field?
Particularly in the past few years, both with breast cancers and with other cancers, we’re starting to fairly routinely look at genetic profiles, genetic signatures of cancers, to make a prediction about how they’re likely to behave, or which treatments might be most effective for this particular kind of cancer. Better predicting how that cancer’s going to behave will allow us then to treat people who need to be treated, and leave people alone who don’t need to be treated.
Another important thing is the more widespread use of adjuvant therapy. Most cancers, when they’re already spread, aren’t able to be cured, but cancers that are localized to the colon or to the lung or to the breast, the goal in treating them is to cure. With this information about which cancers are likely to behave badly, then we can intervene as soon as the cancer’s diagnosed, and give chemotherapy or whatever treatment needs to be given. We tend to treat more cancers early, which clearly treats some people that didn’t need to be treated, but it also clearly prevents some cancers from coming back that otherwise would have come back and been incurable when they came back.
Are there more cases of cancer these days?
I think there’s more cancer now. If you look historically, most people died of infections diseases, and a lot of people died in childhood. Not that many people lived until old age. So I think that cancer’s always existed, but it tends to be a disease of aging, and we no longer die of infectious disease.
How did you get into your field?
I started thinking about it in high school. I just really liked school, and I thought, “What can I do that will keep me in school for a long time?” I really liked blood disorders—hematology—and hematology and oncology are one field, one specialty, so I started doing oncology as well. I just really liked cancer—there are really interesting diseases, really wonderful people. When I started in oncology, everyone treated every kind of cancer. So I treated lung cancer and melanoma and everything. And as the treatments became more specialized, people started specializing in lymphoma, melanoma, lung cancer. So I just started doing breast cancer—nobody was really doing that, and it’s a really interesting area.