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Toward optimal health: the experts discuss advances in breast cancer management.

25 JUST BECAUSE WOMEN HAVE a greater fear of breast cancer than other diseases does not mean that physicians should respond with equal concern. Because having breasts is inexorably linked with our identity as women, we may place breast cancer ahead of more common health concerns, such as heart disease and obesity, which pose a greater health risk to most women. The risk of dying from cardiovascular disease is 60% for women over age 75, and mortality from breast cancer is 4% in women over age 64. That does not affect the reality that breast cancer incidence increases with age, rising sharply after age 40, or that an estimated three quarters of invasive breast cancers occur in women over age 50, and the average age at diagnosis is 62. Clearly, there is reason for concern. One woman in eight either has or will develop breast cancer in her lifetime, and an estimated 43,300 will die annually. When detected early, the 5-year survival rate for breast cancer exceeds 95%. It is troublesome that although mammograms offer the best tool for early detection, 13 million women who are 40 years of age or older have never had a mammogram. Who is at risk? Although every woman is at risk for breast cancer, the majority of breast cancer cases occur in women with no identifiable risk factors who have reached menopause. Other than genetic predisposition, compelling factors include age (a woman over age 60 is at greatest risk), a family history or prior history of breast cancer, reproductive and menstrual history, race (more common in Caucasians than Latina, Asian, or African Americans), radiation therapy to the chest, having been exposed to diethylstilbestrol (DES) in utero, and excess body weight and inactivity. Research and technological advances promise improvement in screening and detection as well as better forms of treatment, but our hopes have gotten ahead of the scientific evidence. “Although advances in breast cancer are exciting, much of what has been picked up in the news comes straight from uncritiqued corporate press releases rather than clinical trial results,” according to Susan M. Love, M.D. “What gets lost in the clutter are the big shifts in thinking, such as the move away from chemotherapeutic agents—the slash-burn-and-poison approach—and toward a more targeted process that employs hormonal agents and identifies molecular markers and agents, such as monoclonal antibodies, to interrupt the cancer, giving better benefits and fewer complications and side effects.” What should women know about preventive agents and risk reduction efforts for breast cancer, heart disease, and osteoporosis? It is critical to look at the risk of each chronic condition for every woman but to consider the impact on the whole patient when planning a treatment strategy in addressing breast cancer concerns. Two breast cancer experts, Dr. Julie Gralow and Dr. Susan M. Love, graciously agreed to share their insights about the state of breast cancer research and advances in clinical management.