Breast Cancer: The Insidious Enemy

Dr. David J. Holcombe
Dr. David J. Holcombe

Despite billions of dollars of research and treatment, breast cancer remains a leading killer of women.  By the end of 2015, it is estimated that there will have been 200,000 new cases of breast cancer and 40,000 women will have died from the disease during the year.  Even though awareness, screening and treatment have undergone tremendous improvements over the last decade, almost everyone still knows a friend, family member or acquaintance that has died from breast cancer.  Why does breast cancer refuse to go away?  And why do women continue to die from this terrible killer?


First, breast cancer is not one entity, but many.  There is considerable diversity among breast cancers, with respect to their own histological forms, genetic makeup, hormonal sensitivities, responsiveness to treatment and outcomes.  Second, women (and many men) who suffer from breast cancer are as different as the many variations of the disease itself.  Genetic susceptibility varies greatly, as do the propensity to develop breast cancer based on risk factors such as obesity and a history of no breastfeeding.  There are also individual variations in response to standardized treatment based on genetics, other familial characteristics and pre-existing medical conditions.


Third, while breast cancer survival depends on the stage at diagnosis (the earlier the better) that remains an oversimplification.  Sadly, at all stages of diagnosis, with all women, survival from breast cancer also depends on your insurance status.  Privately insured women (and men) do better and survive longer than those with no insurance or those with Medicaid (the two latter being almost identical). This finding also holds true for colon cancer survival, for which your survival also depends, to some extent, on your insurance status.  Although that may seem intuitive, the fact remains that patients with no insurance or Medicaid are predominately poor minorities and suffer the worst outcomes.  The American Cancer Society publicized this disturbing finding several years ago.  The implications of these revelations are that achieving equivalency between those treated with private insurance and those with Medicaid or without insurance would help improve breast cancer survival significantly in these latter groups.


Last, but not least, breast cancer is truly an insidious enemy with an almost unique profile.  While many cancer victims (such as those with early resectable colon cancer) are considered “cured” if they reach the 5-year disease free survival point, breast cancer has no such guarantees.  As local surgeon Dr. David McCoy pointed out, breast cancer is not an organ-specific disease, but rather a systemic disease.  Many women, correctly and aggressively treated for their breast cancer, will sail past their 5-year mark only to be diagnosed with widespread disease at 10 or even 15 years post treatment.  This disheartening reality devastates the victims and their family, friends and medical providers.


Given the variability of the disease, the diversity of the hosts, the vagaries of insurance and the insidious nature of breast cancer itself, what can be done?  Research certainly has improved diagnosis and treatment, with more customized approaches to each patient, and will likely continue to do so.  Universal screening with mammograms at the appropriate ages must still occur.  The controversies surrounding the optimal time to initiate mammograms (whether it be 40, 45 or 50) still confuses the public and professionals alike.  That being said, any woman, at any age, who detects a breast mass should seek professional help.  No one should wait beyond 50 years of age for her first screening mammogram.


Exploding costs for cancer treatments also complicate the situation, and realistic approaches with cost/benefit rations must guide those involved with individual treatment options.   It does little good to add a few weeks or months to a patient’s life when the process may bankrupt the patient and their family.  As painful as it is, demand will remain unlimited and resources will always be limited.   Policy makers, insurers, providers and the general public must work together to achieve realistic goals while tempering unrealistic expectations.  Our common insidious enemy, breast cancer, still remains to be defeated.