Friday, March 28, 2014

How Being Ignored Helped A Woman Discover The Breast Cancer Gene

How Being Ignored Helped A Woman Discover The Breast Cancer Gene

Mary-Claire King says obscurity gave her the freedom to spend years looking for breast cancer genes.
Mary-Claire King says obscurity gave her the freedom to spend years looking for breast cancer genes.
Mary Levin/University of Washington
Back in the 1970s, a geneticist named Mary-Claire King decided she needed to figure out why women in some families were much more likely to get breast cancer.
It took 17 years for King and her colleague to identify the single gene that could cause both breast and ovarian cancer. During that time, many people discounted her work, saying that genes couldn't cause complex diseases like cancer. She proved them wrong by mapping the location of the gene she named BRCA1. In 1994, after an international "race" of four years among competing laboratories, the BRCA1 gene was successfully cloned. (King describes her experience in Thursday's issue of the journal Science.)
The discovery revolutionized genetics and cancer treatment. Simple genetic tests now let women know if they have mutations in their BRCA genes that increase cancer risk. They then can act on that knowledge, as actress Angelina Jolie did.
King, now a professor of genome science at the University of Washington, talked with NPR's Audie Cornish on Thursday about how she slowly but surely built evidence to prove that BRCA did indeed cause cancer. The conversation has been edited for length and clarity.
What triggered you to think that there would be this genetic link to cancer?
For breast cancer, there was very good evidence that some families were at high risk of the disease, but without an explanation why that could be true. In the absence of any other explanation I was driven to consider genetics.
How did you come up with the answer?
Our strategy was to use the idea of mapping a gene as an epistemological tool. We felt that we could prove the existence of a gene by showing where it was. And that's what we did. It took 17 years, from 1974 to 1990, but by 1990 we really had incontrovertible proof that there was a gene that lived on chromosome 17 in a particular physical locale.
Now this was all before the Human Genome Project, right? Now we take it for granted that there's this kind of easy mapping technology — if you want to find a gene in a chromosome just go look it up.
You're right — anyone can loop up a gene for free! It costs nothing and it takes 10 seconds on the Genome Browser. You're also absolutely right that the Human Genome Project had not yet begun when we began working on this project. The Human Genome Project and the effort to find BRCA1 were essentially born at the same time.
It seems like we're at a point now where we can do all kinds of mapping, we know about all these genes, but that doesn't necessarily make the decision any easier in terms of what kind of treatment you should do or what kind of risk prevention you should take. The science has outpaced the treatment.
A challenge we face as scientists, and a challenge our physician colleagues face, is how to interpret this very rapidly growing amount of information in a way that can best empower our patients. Our goal is to be able to inform women of genetic information that will lead them to make the best choices for themselves. We need to provide data that is complete and accurate. And we need to be able to do that inexpensively and effectively.
Over time, do you see that there has been too much emphasis on genes and genetic links and that that has that been to the detriment of other factors like environmental factors?
We now are in a position to say genetics only goes this far; beyond this we need to think about environmental causes. Now the understanding of environmental causes and genetic causes are moving hand in hand rather than in conflict.
You've said in the past that as a woman doing this work there was a certain freedom in your research back in the 1970s when you were starting out; freedom in being ignored. In what way?
As a young scientist it can be liberating to not have expectations placed on you; if you can work quietly and if you can obtain funds for your work. And I could obtain modest funds for my work in the 1970s, and I could work in a way that allowed me the time and space to develop evidence until I was convinced of it. That's of course the highest bar — that you convince yourself that your evidence is good. Once you present your evidence then of course you're no longer being ignored. You're being attacked from all sides. Then you need to defend your evidence. But if you've had 17 years to develop your evidence then you're in a much better position to defend it well.
You've said you were a child of affirmative action. At that time did it really feel like not just that people were ignoring you, but they were dismissive of your work?
When one is a child of affirmative action one needs to anticipate that people, particularly those who didn't benefit from affirmative action, won't take you seriously for a while. But there's a wonderful phrase from Simone de Beauvoir: For a woman to be taken as seriously as a man she must be three times as effective. Happily this is not difficult.
Photo
I.B.M.’s supercomputer Watson is famous for besting human contestants on the TV game show "Jeopardy!" Now it's turning its digital attention to brain cancer.CreditIBM, via Agence France-Presse — Getty Images
Continue reading the main storyShare This Page
Continue reading the main story






When Robert B. Darnell was a graduate student in the early 1980s, he spent a year sequencing a tiny fragment of DNA. Now Dr. Darnell is an oncologist and the president of the New York Genome Center, where the DNA-sequencing machines can decode his grad-school fragment in less than a ten-thousandth of a second.
As an oncologist, Dr. Darnell is firmly convinced that this technological advance will change how cancer is treated. “It’s inspiring for me, and it’s inspiring for lots of doctors,” he said in an interview.
The idea is simple. Oncologists will get a tumor biopsy and have its genome sequenced. They will identify the mutations in the cancer cells, and they will draw up a list of drugs to treat each patient’s particular mix of mutations.
This isn’t pure science fiction. Oncologists have already created such drug cocktails for a handful of cancer patients. But that doesn’t mean people with cancer should expect personalized treatments any time soon. Unfortunately, the path from a genome to a treatment is blocked by a colossal bottleneck.
“We know that the devil’s in the details, and a lot of the mystery is still there,” said Dr. Darnell.
The problem is that many mutations in a cancer cell may be harmless, and targeting them will be a waste of time. And once oncologists narrow down their list to the mutations that actually drive cancer, they have to understand how they do so. Some mutations cause cells to ignore signals to stop growing, for example, while others promote the growth of blood vessels nearby.
Scientists have already found out a fair amount about those effects. But it’s hard to assemble this existing knowledge. “There isn’t any single magic database,” said Toby Bloom, the deputy scientific director at the New York Genome Center.
Rather than just typing in a mutation into a search box, doctors have to comb the scientific literature. Not only do they have to read many papers, but they have to evaluate the strength of their conclusions.
“You can do it, but it’s not scalable,” said Dr. Bloom.
Some cancer scientists are trying to open the bottleneck with the help of computers. They’re writing software that can read scientific reports and glean their insights.
The New York Genome Center has now joined this movement. It’s enlisting Watson, a computer developed by IBM that first came to fame in 2011 when it defeated human contestants on the game show “Jeopardy.”
Since its television victory, Watson has turned its attention to medicine. Its reading list include the study abstracts stored in Medline, a federal government index. “I believe at this point it’s up to 23 million or so now,” said Ajay K. Royyuru of IBM’s Thomas J. Watson Research Center in Yorktown Heights, N.Y. “We’re taking all of it.”
For a pilot study, Dr. Darnell and his colleagues will use Watson to help them come up with personalized treatments for a type of brain cancer known as glioblastoma. They chose the disease because forms of it are so devastating.
For the worst types, Dr, Darnell said, “It’s as close to a death sentence as you can get,” with patients typically surviving a year after diagnosis. In those cases, surgery, radiation and chemotherapy sometimes help, but they’re hardly a panacea. “It works for about a third of the patients, and it gives them about two extra months,” said Dr. Bloom.
In the new study, the scientists will initially recruit 20 patients. They will sequence genomes from tumor biopsies and feed that data (along with the sequences of healthy cells from the patients) to Watson.
Watson will identify the mutations in the tumor and draw on its medical knowledge to develop a hypothesis for how they cause cancer. It will then put together a list of drugs that could potentially treat the cancer.
“All of this is being done in seconds to minutes,” said Dr. Royyuru.
Those drugs may directly target the mutant proteins in cancer cells, or they may target other proteins they work with. Some of the drugs may have been studied for other types of cancer before, but not for glioblastomas. Some of the drugs may have never been tried out on any cancer before.
A group of experts including neurologists and pharmacologists will look over Watson’s suggestions and make the final decision about whether to give any of the drugs to a patient. Rather than patients being given a single drug, as happens in conventional treatment, Dr. Darnell hopes that in the new study, they will get as many as five drugs at once.
Because glioblastoma is such a deadly disease, Dr. Darnell also hopes he won’t have to wait long to see if Watson helps prolong people’s lives. And Dr. Royyuru will feed the results of the trials back to Watson, so that it can generate new hypotheses about glioblastoma and improve its suggestions.
Other scientists want to see those results before passing judgment on the new project. But they generally agree that powerful computers of some kind will be essential for making sense of cancer genomes.
“This is the course of how things will move forward,” said Kelly A. Frazer of the University of California, San Diego.
Still, Heidi L. Rehm, a molecular geneticist at Brigham and Women’s Hospital, said that computers alone would not deliver personalized cancer treatment. “It’s necessary — but it’s not sufficient,” she said. “It’s only as good as the data going in.”
Watson, for example, is reading only abstracts of papers for now, rather than the entire papers. And the quality of the information in those papers varies tremendously.
Dr. Rehm believes that medical research has to move beyond the tradition of scientific papers. Scientists need to organize their data so that it can go into easily searched databases, such as the Clinical Genome Resource, which she is helping to develop.
No matter how good computers get at understanding medicine, though, cancer researchers don’t think machines will have the last word on how to treat patients. “At some point a doctor has to look at the data and see if makes sense,” said Sameek Roychowdhury of Ohio State University. “That part is never scalable.”
http://www.nytimes.com/2014/03/27/science/enlisting-a-computer-to-battle-cancers-one-by-one.html?emc=edit_tnt_20140328&nlid=52389906&tntemail0=y&_r=0

I certainly wasn't expecting a breast cancer diagnosis.

Spring cleaning started early for me in 2014. In fact, it started in 2013.

How My Breast Cancer Diagnosis was the Gateway to the Ultimate Spring Cleaning

On Dec. 18, 2013, I went in for my first-ever mammogram. I turned 40 last year, and it was among the boxes I needed to check on my pro-active health list. I was not expecting anything other than a pat on the back when they squished my breasts on the cold metal plate of the mammography machine. With no lump or sick feeling, I certainly wasn't expecting a breast cancer diagnosis. It came anyway - on Jan. 6, 2014.
I didn't collapse to the ground when the phone call came with the news. I didn't vomit. I did cry, however. A lot. But mostly I was overwhelmed. I live 2,000 miles from my family and 200 miles from major hospitals in a city where I know very few people. I allowed myself to feel sorry for myself for about 48 hours. I drank a lot of red wine. I mewled to my husband about how I've spent my entire life causing my parents distress.
But then I got down to business. When you have a 2-year-old, a 5-year-old, and freelance work that doesn't give you paid sick days, I didn't have time to fall apart. Breast cancer became my job. With the help of many friends - but one in particular who is currently battling Stage 4 of the disease - I called up my health insurance company and grilled them on how the process is covered, what is actually covered and what the approvals process would look like. I researched doctors in New York (where my family lives) and Denver (which is much closer to where I live). I studiously avoided the Internet - I knew that I didn't need to go down the dark hole of other people's horror stories about cancer. I didn't need to; I know plenty of them. I didn't need to know more. I needed useful information. Not melodramatic data that would only take me away from my task, which was my own recovery.
I was quickly promoted to the CEO, COO, and CFO of my breast cancer, and I didn't need anyone to tell me that I earned a raise very quickly. My friends nearby and my family from afar all signed on to become my board members - helping organize care for my kids so my husband, a friend, and my mom could take me on frequent 600-mile roundtrips to Denver to consult with breast and plastic surgeons. I mobilized my home in preparation for my parents and mother-in-law to arrive and stay during the post-surgery time. I bought clothes that would be most convenient and comfortable for after my bilateral mastectomy. I took daily walks with a beloved friend who allowed me to laugh about saying goodbye to the breasts I never really liked anyway. I had endless conversations with one of my best friends about the horrors of some the plastic surgeons with whom we consulted and who were shocked - shocked - that when presented with the opportunity for bigger boobs during the reconstruction process, I was adamant about going small.
My breast cancer education from Jan. 6 to Feb. 14, which was the day of my surgery, was the difference between a kindergartner learning her ABCs to a Ph.D. candidate successfully defending her dissertation. I walked into the pre-op room frightened and full of dread, but not because I was uninformed. But because major surgery is just plain scary.
I'm grateful that I have never been one to avoid doctors. I look forward to my twice-yearly teeth cleanings. To my annual Pap smear. To visiting the dermatologist to determine the existence of any suspicious moles. I'd rather know than not know. Of course I'd rather there's nothing to know. But I loathe those stories of people who find out too late that they have something that could have been treated if detected earlier.
I grew up in a home where doctors were commonplace. Not because my parents are doctors (because they're not, although I have a Jewish mom, which is kind of the same thing). Not because many of my parents' friends are doctors (although many of them are). But because it's just how my family is - we go to doctors. There's nothing too small to investigate. We are not embarrassed to ask questions and have minor somethings investigated to ensure they are not major anythings. My insurance has always been good, or at least good enough. And I have just always loved my family from a place so deeply embedded in my bones to know that taking care of myself means being around for them for as long as possible.
I'm not asking anyone for a medal or a monument in my honor. My cancer was caught and treated early and for that, I am among a fabulously lucky group of women who won't have to die of breast cancer. I assume most women would have attacked this same job with the zest and zeal that I did. I wanted, no needed, the spring cleaning to be behind me in order to reap the rewards of summer. And I plan to do just that.
Photo source: Meredith Carroll
-By Meredith Carroll

Thursday, March 27, 2014

A struggle against cancer becomes a financial worry

“I walked in a person, and out a cancer patient,” my dad said as we filed home. Crossing this threshold, we found ourselves on the other side of medicine – the side on the exam table or gurney, as opposed to the one standing over it. As a physician I was used to the latter. This is my family’s story in our new position, and how the cost of medical care has impacted us.
My father — an engineer — worked furiously. His “free time” was consumed with jogging, fixing household items, doing yard work — essentially anything to keep busy. As an American employed overseas at diagnosis, he did not have US medical insurance, but rather an annual cap of $500,000 for healthcare. While this amount is generous in Europe, we accepted the exorbitant cost of care in the US so my dad may be near family during his battle with non-Hodgkin lymphoma.
My dad’s care was transferred to the academic institution where I trained. As his advocate, my first task was to schedule a PET-CT. After bouncing between central scheduling and radiology, I was instructed to speak to billing. Exasperated, I explained our situation and inquired how much this test may cost: “$12,000,” I was informed, “is the price for patients without US insurance.” (This was my first encounter with the “chargemaster,” a list of services and prices conjured by hospital administration. Hospitals set the price then expect payment to be negotiated down by insurance companies. Uninsured patients, however, are quoted prices and charged according to this list.)
My body tightened as my eyes watered. This test cost a few hundred dollars in Europe and I knew not “worth” the price quoted: How could we get through the year in need of multiple tests, medications and chemotherapy according to this list?
I negotiated: “My dad really needs this test and we only have a limited about of money.”
Silence.
“I went to medical school and residency here,” I pleaded, “is there anything you can do?”
After discussing with superiors, I reduced our charge by several thousand dollars. I paused, as I couldn’t believe I had to resort to such assertions. My small sense of triumph was clouded in an overwhelming sense of unfairness and anxiety.
That was the beginning. My dad went on to need a stem cell transplant, necessitating several weeks in the hospital as well as rehospitalization for graft-versus-host disease, a complication of his transplant. This disease has been the only thing to keep my dad from constantly moving; it has been hard for us to see him become weak, lethargic and sallow. We were not in control of his disease or its corresponding medical bills.
We asked about cost frequently and kept an informal and approximate record when available: filgrastim, $14,000; echocardiography, $7000; office visits, $300 and so on. Providers often expressed polite concern, replied with something to the extent of “I don’t deal with that” then referred us to billing. Billing representatives never met my dad, or understood his medical condition or need. Providers continued with treatment plans without regard for cost; my family controlled what we could, namely using warehouse pharmacies and doing as much self-care as possible. We found little compassion for our concern.
In time, it became clear we were running out of money. My parents contemplated selling their home or having my mom return to work (something she had not done in 20 years); my siblings and I made plans to subsidize healthcare costs. As my dad fought physically, we all faced this enormous financial worry.
This worry has been intertwined with my dad’s struggle with cancer. Providers cannot separate financial aspects from the esteemed patient-centered care of medical conditions.
Fortunately, my family recently learned of our successful bargain for my dad’s insurance cap to be increased through 2013, after which we are embracing Obamacare to access health services without financial fear. My dad continues to battle on.
We feel lucky for this. We are grateful that all Americans — despite resources, expertise or knowledge of our healthcare system — now have the opportunity to receive equitable and affordable healthcare. As my family is experiencing, the vulnerable position of illness is stressful enough.
Laura Sander is an internal medicine physician.
A struggle against cancer becomes a financial worry
This post originally appeared on the Costs of Care BlogCosts of Care is a 501c3 nonprofit that is transforming American health care delivery by empowering patients and their caregivers to deflate medical bills. Follow us on Twitter @costsofcare.

Lymphedema Lingers Long After Sentinel Lymph Node Dissection for Early Breast Cancer

By Shalmali Pal
Posted: 3/25/2014 2:03:28 PM
Last Updated: 3/25/2014 2:03:28 PM

Key Points:
  • Lymphedema occurred more frequently that clinically suspected, and with increasing incidence over time, in women with early-stage breast cancer who undergo sentinel lymph node dissection.
  • Increasing age and obesity were predictors of lymphedema after sentinel lymph node dissection.
  • Women who underwent sentinel lymph node dissection and axillary lymph node dissection had a greater cumulative incidence of decreased range of motion and axillary paresthesia at 5 years postprocedure.
Patients with early-stage breast cancer who underwent sentinel lymph node dissection experienced lymphedema more frequently than clinically suspected and with increasing incidence over time, according to a presentation at the 2014 Society of Surgical Oncology (SSO) Cancer Symposium in Phoenix (Abstract 3).
In women who took part in the American College of Surgeons Oncology Group (ACOSOG) Z0010 trial, the cumulative incidence of lymphedema after sentinel lymph node dissection was 10.5% at 1 year, 17.4% at 2 years, and 24.1% at 5 years based on objective measurements, reported Mediget Teshome, MD, of The University of Texas MD Anderson Cancer Center in Houston, and colleagues. Based on subjective assessments, the cumulative incidence of lymphedema was 3.7% at 1 year, 8.9% at 3 years, and 11.9% at 5 years.
Sentinel lymph node dissection is a minimally invasive approach to axillary staging in early-stage breast cancer, and many studies have demonstrated decreased morbidity with this approach compared to traditional axillary lymph node dissection, Dr. Teshome said during her presentation at an SSO Plenary Session.
However, lymphedema is a common complication of sentinel lymph node dissection, and long-term studies on this outcome have been lacking, she explained.
The results of ACOSOG Z0010, which was conducted from 1999 to 2003, showed no differences between sentinel lymph node dissection and axillary lymph node dissection for overall survival, locoregional recurrence, or distant metastasis in patients with occult sentinel lymph node micometastases.
Current Study
For the current follow-up study, eligible patients were women from ACOSOG Z0010 with clinical T1-2 N0 M0 disease. Sentinel lymph node dissection was performed in 3,966 women; of those, 899 patients went on to completion axillary lymph node dissection. The vast majority of women underwent whole-breast irradiation (89.7%), more than half received chemotherapy (56.5%), and about two-thirds had hormonal therapy (66.9%).
Lymphedema was evaluated objectively as an increase of 2 cm from the preoperative arm measurement vs the contralateral arm, corresponding with a 10% increase in arm volume, Dr. Teshome said. Subjective measurement consisted of ipsilateral arm swelling as reported by the patient.
Assessments were performed before sentinel lymph node dissection and then again at 30 days, 6 months, and annually for 5 years. The median number of assessments was four, and the median follow-up time was 9.9 years, although arm measurements were only done to 5 years.
Outcomes
In the sentinel lymph node dissection–only group who experienced lymphedema, the authors found that patients were older (age 58 vs 56, < .0001), had a body mass index of 30 kg/m2 and higher (< .0001), and had a lower percentage of medially located tumors (17.2% vs 21.2%, P = .016).
Although the authors wrote that lymphedema after sentinel lymph node dissection “occurs more frequently than clinically suspected and with increasing incidence over time,” they also noted that women who had only sentinel lymph node dissection fared better than those who required axillary lymph node dissection.
When comparing the two techniques, the 5-year incidence rate by subjective assessment was 41.2% for axillary lymph node dissection compared with 11.9% for sentinel lymph node dissection, while the 5-year incidence rate by objective assessment was 40.3% vs 24.1%.
Both increasing age (hazard ratio [HR] = 1.01, 95% confidence interval [CI] = 1.01–l.02, < .003) and obesity (HR = 1.89, 95% CI = 1.61–2.22, P < .0001) were predictors of lymphedema after sentinel lymph node dissection. However, increasing age and African American race were predictors of decreased range of motion and axillary paresthesia following axillary lymph node dissection.
Study Discrepancies and Limitations
Dr. Teshome called attention to some “notable and interesting points” in the study results.
“First, as expected, there is an increased incidence of lymphedema after axillary lymph node dissection  as compared to sentinel lymph node dissection,” she said. “Second, looking specifically at women undergoing sentinel lymph node dissection, there appears to be a plateau effect over time in regards to the subjective determination of lymph, while the cumulative incidence by objective arm measurements seems to slowly increase over time. Lastly, there is discrepancy between the subjective and objective reports of lymphedema, with approximately twice as many cases by objective measures.”
But the latter was not true in the axillary lymph node dissection group, where cumulative subjective and objective data were essentially the same, she said, adding that the discrepancy in patients undergoing sentinel lymph node dissection may be explained by improvement in lymphedema symptoms over time secondary to interventions.
However, there was limited follow-up on lymphedema treatment or symptom improvement, Dr. Teshome said. Other limitations were the lack of randomization, and attrition in arm measurements during the study period, which meant that every patient did not have a complete assessment profile.
“Lastly, the majority of our patients receive radiation therapy, and although there were no association in our analysis, this may have impacted the findings,” she said. 
Dr. Teshome said future areas of research would include the evaluation of severity of lymphedema after sentinel lymph node dissection, assessment of patient education on post–sentinel lymph node dissection symptoms, and lymphedema prevention efforts.
This study was funded by the National Cancer Institute. Dr. Teshome reported no conflicts of interest.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.