Austin American-Statesman NOV 10 2011

New Texas law informs women of a possible cancer risk from dense breasts By Mary Ann Roser

Women in Texas will soon get new in-formation about their breast scans. A law that becomes final in January requires mammography facilities to inform women that dense breast tissue could put them at risk for breast cancer.

The law, House Bill 2102 , is one of the newest affecting breast cancer detec-tion in Texas, the second state after Con-necticut to pass a breast density notifica-tion law. It's also an example of how breast cancer care — whether it's detec-tion or treatment — is moving into "per-sonalized medicine," or health care that examines a person's unique clinical, ge-netic and environmental information to help doctors predict an individual's risk for disease and response to treatment.

Doctors and scientists who work on breast cancer are making strides at tailor-ing treatments against specific kinds of tumors, and they are using new technolo-gies to aid in tumor diagnosis. But they are humbled in their efforts to treat triple-negative breast cancer, a more aggressive kind that does not respond to hormonal therapy or treatments that target receptors for the breast cancer gene HER2.

"The good news is we are understand-ing it more," said Dr. Jenny Chang, direc-tor of the cancer center at Methodist Hos-pital in Houston.

Whether the new law will catch more cancers or make women anxious and lead to overtreatment remains to be seen, doc-tors said.

An estimated 15,562 new cases of breast cancer will be diagnosed this year in Texas women, according to the Texas Department of State Health Services. More than 2,800 Texans are expected to die from breast cancer in 2011. The cases include 1,013 new breast cancer diagnos-es and 173 deaths estimated for Travis, Hays, Williamson, Bastrop and Caldwell counties, according to the Austin affiliate of Susan G. Komen for the Cure.

While mammograms remain the gold standard for breast cancer screening, they are not perfect.

Jury is still out A woman in Dallas who learned she

had dense breasts stressed that point, prompting the new Texas law.

Henda Salmeron, a Realtor, was diag-nosed with breast cancer in June 2009 af-ter having a mammogram that was deemed normal six months earlier, ac-cording to her blog, densebreasttissue.net.

Mammograms can hide tumors in dense breasts — ones with a high percen-tage of breast tissue versus fat — and Salmeron told lawmakers at hearings and in personal visits that while mammograms save lives, they fail more than 20 percent of the time to detect tumors in dense breast tissue.

Younger women have denser tissue than older women, but about 40 percent of women overall are believed to have dense breasts, said Dr. Sarah Avery, one of five women on a team of seven radiologists at

Austin Radiological Association who in-terpret mammograms.

Salmeron didn't know she did until her diagnosis.

"Information about my health was kept from me," she wrote on her website. "When I asked why doctors don't tell women about breast density, the answer is: 'It's not standard protocol.' Well, you know what? I had stage 2 breast cancer, and that is not a good enough response. Period."

After having two lumpectomies and radiation, Salmeron says she considers herself lucky to be cancer-free.

There is debate in the medical and scientific community on whether dense breasts by themselves are a risk factor for breast cancer. Dr. Beth Hellerstedt, an on-cologist who leads the research team at Texas Oncology in Central Texas, is among those who believe the jury is still out.

"There is concern that younger people tend to have denser breasts, and if your breasts are more like rubber cement than whipped cream, it may be harder to see" a tumor, Hellerstedt said.

She says more research is needed to determine whether density alone raises the risk of breast cancer.

Avery, the radiologist, says density by itself is a risk factor for cancer, although doctors are not sure why.

The law requires facilities that per-form mammograms, including hospitals, to let patients know they "might benefit from supplemental screening tests" if they have dense breasts and other breast cancer risk factors. The facilities are not required to tell patients whether they have dense breasts but will let them know that their prescribing doctor will have that informa-tion if they want to pursue it.

Avery said that Austin Radiological Association, the largest provider of mammograms in Central Texas, plans to give patients a letter that restates the lan-guage in the law. But whether the notifi-cation will be handled the same at every facility is uncertain, she said.

That's because "the notification is the responsibility of the technical facility per-forming the mammogram. In many cases that will be a hospital," said Avery, who reads mammograms for hospitals affi-liated with St. David's HealthCare and the Seton Healthcare Family. The final deci-sion will rest with each facility's adminis-trators.

State Rep. Ana Hernandez Luna, D-Houston, author of the legislation, wrote in an email that she was satisfied with how Austin Radiological was planning to follow the law.

"This allows one, for the patient to be-come aware of this issue and two, allows them to take steps to discuss with their physician just exactly what that means in each woman's case," Hernandez Luna wrote. "It serves as a way to open dialo-gue with their physician on whether or not they have dense breast tissue."

Avery said she thought the law would be informative and potentially helpful to women but said "it really needs to be put together with the women's other risk fac-tors."

Some doctors said they worry it will provoke anxiety and lead to more costly MRIs.

"I think it's going to make things very complicated for the breast center and the women," said Dr. Jane Nelson, an Austin breast surgeon. "We'll just have to see how it plays out."

A powerful new diagnostic tool A woman who discovers she has

dense breasts might seek an MRI, which uses radio waves and a powerful magnet. MRIs are more sensitive than mammo-grams or ultrasound at detecting tumors, but they are more expensive and give a higher number of "false positives," ac-cording to the National Cancer Institute.

For women already diagnosed as hav-ing a tumor, a relatively new diagnostic scanning tool can help a doctor examine the breast at the molecular level.

Nelson invested in a Positron Emis-sion Mammography, or PEM, scanner four years ago, spending "between $500,000 and $1 million" and has the only PEM scanner in Austin, according to Na-viscan, the manufacturer.

PEM scans show metabolic differenc-es in tissues, which indicate the extent of disease and helps inform the treatment.

It is another example of personalized medicine. It can also see tumors when a woman's hormone levels are high — a problem with MRIs, Nelson said.

To do the scan, a radioactive dye is in-jected to highlight the metabolic activity of the cells. Cancer cells absorb and ac-cumulate sugar faster than healthy tissue, enabling the doctor to see the size, shape and location of a mass.

Some see the radiation as a downside. PEM exposes women to much more

radiation than the relatively small amount they would get from a mammogram, but it's much less than they would get from a full body and head CT scan, Nelson said. Research is under way to cut the amount of PEM radiation in half, she said.

Nelson does not expect PEM scanning to become a "supplemental screening test" for women with dense breast tissue, at least not anytime soon.

Many doctors are more comfortable with MRIs, which don't expose patients to radiation, and there is more data support-ing the use of that long-standing technol-ogy.

But not all women can have an MRI, Nelson said, because of claustrophobia or body size.

Research key to detection, care Someday, scanning to detect and di-

agnose cancer might not be necessary. A vaccine to prevent breast cancer is

in early stage trials, said Hellerstedt, who added that she is not working on it. And someday a blood test might detect breast

cancer, but that's not on the horizon yet, she said.

"We need to continually look for bet-ter screening," she said. "There is a limit to what a mammogram can tell you."

In addition to the problem with breast density, it sometimes takes a few years for a mammogram to detect a tumor.

Oncologists in the Austin area said they are encouraged by the boost cancer research received when voters in 2007 created the Cancer Prevention and Re-search Institute of Texas through a $3 bil-lion state bond issue. Since then, the insti-tute has awarded 283 grants for cancer re-search totaling $455.2 million. Breast cancer research has received about $40 million, institute Executive Director Bill Gimson said at a Breast Cancer Aware-ness Month event in October at El Buen Samaritano Episcopal Mission in Austin.

Researchers hope not only to get bet-ter at detecting breast cancer but also to devise better treatments.

"We will look at all patients to figure out what makes their tumor grow abnor-mally and develop medications that can

specifically address that with the least amount of toxicity," Hellerstedt said. "We won't get rid of chemotherapy anytime in the near future \u2026 but we should be able to target it more effectively."

Various drugs in late-stage trials are showing promise for extending lives, in-cluding Trastuzumab-DM1 for HER2- positive breast cancer and Pertuzumab, which is combined with Herceptin and chemotherapy.

Advances also are being made in radi-ation therapy. Radiation regimens that typically lasted 6½ weeks can be short-ened to four, said Dr. Courtney Sheinbein, a radiation oncologist with Texas Oncolo-gy in Austin.

And some of his colleagues are using a targeted radiation therapy that is work-ing out well for certain patients with early stage breast cancer, he said.

They insert a tube with a small balloon into the lumpectomy cavity. A machine with a radioactive Iridium 192 pellet de-livers a short burst of radiation into the balloon twice a day for a week. A similar

procedure has been used to treat lung and prostate cancers, Sheinbein said.

"The goal of those treatments is to im-prove convenience without reducing the cure rate or worsening toxicity," he said.

Doctors have no tailor-made therapy for triple-negative breast cancer.

A promising drug that was being tested in Austin to treat that cancer, inipa-rib, did not meet patient survival goals and has not been approved by the Food and Drug Administration. Doctors said they have not given up hope.

In that same vein, women with breast cancer that has spread — metastatic can-cer — have seen advances and have a bet-ter chance of living longer, Chang, the Houston doctor, said.

"I think we are at a point where we understand a lot about cancer, and breast cancer is the furthest along," she said. "Even with metastatic disease, we can of-ten turn this into a chronic illness. \u2026 We have come a long way."

maroser@statesman.com; 445-3619