Breast Cancer Is Not One Disease Experts Say

Breast cancer isn't the same for every woman, even at the cellular level, according to a new statement from four major medical groups focused on the disease.

The report was issued Monday by the American Cancer Society, the U.S. Centers for Disease Control and Prevention, the U.S. National Cancer Institute, and the North American Association of Central Cancer Registries. They say that classifying breast cancers according to tumor subtypes could help improve treatment of the disease.

The report "assesses breast cancer as four molecularly defined subtypes, not as a single disease," National Cancer Institute director Dr. Harold Varmus said in an institute news release. "This is a welcome step, [resulting from] medically important information that already guides therapeutic strategies for these subtypes," he said.

The four major molecular subtypes are categorized according to their hormone receptor (HR) status, meaning a chemical receptor lying on breast cancer cells that reacts to hormones such as estrogen.

Categorization is also dependent on a tumor cell's activity around the HER2 gene. Both factors can affect how a tumor acts and might be treated, experts say.

The four tumor types are: Luminal A (HR+/HER2-), Luminal B (HR+/HER2+), HER2-enriched (HR-/HER2+), and triple negative (HR-/HER2-).

Experts have long known that the four subtypes respond differently to treatment and have different survival rates, according to the report published March 30 in the Journal of the National Cancer Institute.

Cancer registries across the United States are now recording these breast cancer subtypes, the groups noted, and this new data will help researchers more accurately rank breast cancer by risk. It should also help patients better understand each subtype's impact on their health, the authors said.

Some differences in breast cancer rates and deaths between racial and ethnic groups are also tied to differences in the rates of different breast cancer subtypes emerging in those groups, the report suggests.

It said there were unique racial/ethnic group patterns by age, poverty level, geography and specific tumor characteristics. For example, rates of HR+/HER2- breast cancer -- the least aggressive subtype -- were highest among white women.

Blacks had higher rates of the most aggressive breast cancer subtype -- triple negative -- than other racial/ethnic groups, and also had the highest rates of late-stage disease. Blacks have the highest rates of breast cancer deaths, the report noted.

Varmus called the move towards more categorization, "a harbinger of the more rigorous classification of cancers based on their molecular features that is now being aggressively pursued under the President's Precision Medicine Initiative. The new diagnostic categories now being defined will increasingly support our ability to prevent and treat breast and many other kinds of cancer, as well as monitor their incidence and outcomes more rigorously over time."

Two breast cancer experts applauded the move.

"The breaking apart of breast cancer into subgroups highlights the fact that not all breast cancers are equal," said Dr. Stephanie Bernik, chief of surgical oncology at Lenox Hill Hospital in New York City. "These cancers are treated differently by medical oncologists already, but the new classification will help patients have a better understanding of survival rates that are more specific to a particular subtype of breast cancer."

Dr. Charles Shapiro is director of Translational Breast Cancer Research at the Tisch Cancer Institute at Mount Sinai in New York City. He agreed that "the biology of these subtypes is of critical importance to selecting the most effective treatments for breast cancer.

"What was less clear was the apparent influence of race and ethnicity across these subtypes," he added. "That is of great importance to understand why these differences do exist and the biology that underlies them."

The bottom line, according to Bernik, is that "when investigating possible breast cancer treatments, one size does not fit all. Treatments need to be tailored to a patient's particular subtype, and in doing so, we will be optimizing outcomes."

SOURCES: Stephanie Bernik, M.D., chief, surgical oncology, Lenox Hill Hospital, New York City; Charles L. Shapiro, M.D., director, Translational Breast Cancer Research, Tisch Cancer Institute at Mount Sinai, and co-director, Dubin Breast Center, New York City; U.S. National Cancer Institute, news release, March 30, 2015

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Life is Not a Problem Rerun

by Nina

In the Kusama Room by Brad Gibson

When I was in Holland and Denmark, the last couple of weeks, I was dealing long-distance with a family situation. It was hard to be so far away and be unable to help in person, and I even considered cutting the trip short and going back home in the hopes that my physical presence could help solve some of my family member’s problems (I’m being purposefully vague here, to protect someone’s privacy). Brad thought I should wait because the situation was still unfolding and he felt I could be of more use at a later date. So for a while, I just monitored the situation from afar, mostly texting back and forth because my family member was afraid a phone conversation would be too emotional. 

After a few days of that, I started getting more and more anxious myself. One night in Copenhagen, I started to recognize the physical and emotional symptoms that I experience when in high stress mode (which can lead to an anxiety attack). So I asked Brad to step in for me temporarily and I took some time to calm myself down by practicing—if you know me at all by now you can probably guess—Legs Up the Wall pose (see Featured Pose: Legs Up the Wall Pose). As always, that helped me quiet my nervous system. (Thank you, supported inverted poses!)

But even after that I was still worrying in general about my family member, and what I should or should not do about the situation. So I was up very early the next morning, unable to sleep in even though I was on vacation. What I did with my time was to spend some time researching Copenhagen to see which more offbeat things I could come up with to do (most people just tell you to visit the castles, which is kind of like saying when in New York, visit the Statue of Liberty). And I remembered then that Kierkegaard, a philosopher who Brad and I both studied about in college, was from Copenhagen. So I started reading up on him. And when I found a list of some of his most famous quotes, one jumped out at me:

“Life is not a problem to be solved, but a reality to be experienced.” —Soren Kierkegaard

I instantly felt a sense of relief. Somehow just reading this statement allowed me to step back a bit from the family situation and let go of my attachment to the outcomes of my actions. I was still going to be helping as much as I could, of course, but anxiety started to lessen. Kierkegaard’s thought (he was considered to the first Existentialist) seemed very yogic to me and seemed related to the concept of detachment (see Acceptance, Active Engagement and the Bhagavad Gita). Today I’m trying to find a quote that reflects that same concept, and for now, the best I can do is this quote from the Bhagavad Gita, in which Krishna explains to Arjuna that a yogi is one:

“Who unperturbed by changing conditions sits apart and watches and says “the powers of nature go round”, and remains firm and shakes not.” —translation by Juan Mascaro

When Brad woke up, I excitedly told him what I had discovered. He loved the quote, too, and we started to wonder if we might visit Kierkegaard’s grave. A little research told us that he was buried in a graveyard quite far from where we were staying, and we decided that we didn’t want to give up a whole day in the city just to go there. But we did keep talking about Kierkegaard as we walked about his city, and almost took on that quote of his as a mantra.

One way Brad and I are compatible is in the way we like to explore a new city. We go everywhere on foot without a big agenda and spontaneously explore the things we stumble upon. For example, one day our agenda was simply to check out the oldest bakery in the city and try the snegles (cinnamon rolls!), and we ended up passing by the Round Tower on our way there so we went on in (it turned out to be one of the most beautiful interior spaces I’ve ever been in). On our last afternoon, we decided to walk back to our apartment a different way just to see what we might see, and ended up walking past the Royal Library, which was not a destination we would ever have picked. And, lo and behold, there it was, in the library garden, a beautiful statute of Kierkegaard.

Kierkegaard Statue by Brad Gibson

P.S. If you look closely at the photo of the Kusama room, you can see our reflections.

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