Breast cancer has become more common, but less lethal. Judy Siegel-Itzkovich reports on a new Israeli guide to the disease.
By JUDY SIEGEL-ITZKOVICHbreast cancer ribbon 88(photo credit: )
A lot has changed in the quarter-century since Israel's then-first lady Ofira Navon aroused the wrath of doctors by refusing to have a radical mastectomy for her breast cancer and instead chose radioactive "seeding" for the tumor in the US. Physicians didn't like to present various treatment options and ask patients which they preferred; they expected them to "follow orders."
Only in her 40s, the beautiful wife of the fifth president of Israel Yitzhak Navon had a family history of the disease and contracted it on the other side. Though she fought it valiantly, she succumbed to leukemia in 1993 at the age of 57.
YES, A LOT has changed. Unfortunately, the prevalence of breast cancer has increased, and instead of one in 10 women (and a very small number of men) being struck by it during their lifetimes, breast cancer now hits one in nine, eight or even seven (depending on country). But the development of new chemotherapy drugs, hormonal treatment and immunotherapy, as well as less-radical surgery and lower-dose radiation have raised the survival rate, and significantly improved quality of life. Breast cancer, which accounts for 30 percent of all tumors in women, is being diagnosed earlier than before. And now most physicians - encouraged by the Patients' Rights Law passed nearly a decade ago - ask people in their care about their preferences rather than dictating courses of action.
A new Hebrew-language book on the medical, personal and social perspectives of breast cancer in Israel was recently released by Carta Publishing in Jerusalem (ww.carta.co.il). Called Be'emtza Ha'derech (Along the Path), the 205-page softcover was written by Dr. Ilana Kadmon, a nurse specializing in breast cancer at Hadassah University Medical Center in Jerusalem's Ein Kerem and a faculty member at the Hadassah-Hebrew University School of Nursing. It will be very helpful to Hebrew readers with a personal or academic interest in the disease, especially during October, which is World Breast Cancer Awareness Month (marked by the Israel Cancer Association lighting up one of Tel Aviv's Azrieli Towers in symbolic pink).
Kadmon - who wrote the book with advice from Dr. Noa Ben-Baruch of Kaplan Medical Center's oncology department - writes with great sensitivity about her patients, and clearly has a mission. For the past decade, she has promoted the role of nurses and social workers as "breast cancer specialists," starting with Hadassah and then in other hospitals around the country. In Jerusalem, she accompanies hundreds of women and family members in their struggle from diagnosis and treatment through rehabilitation, giving special stress to the emotional repercussions along with the Hadassah's psycho-oncologist team headed by Prof. Lea Baider. Kadmon was recently added to the board of the European Oncological Nursing society and is chairman of the Israel Coalition Against Breast Cancer.
Israel Cancer Association (ICA) director-general Miri Ziv writes in the introduction that after obtaining research by Bar-Ilan University Prof. Susan Sered on the need for breast cancer patients to get caring support and comprehensible information from the minute of diagnosis rather than only after surgery, the association made Kadmon the first "breast cancer counsellor specialist" at Hadassah. She had just returned from her Ph.D. studies at the University of Edinburgh in Scotland and did her thesis on the psycho-social aspects of breast cancer. Her Chinese-born life partner, whom she met in Scotland, has collaborated on research with Kadmon, and the book contains a comparison between Israeli and Chinese breast cancer patients and their partners.
IN ISRAEL, some 4,000 people are diagnosed and 900 die of it in an average year. Since Kadmon launched the specialty here, 35 breast cancer coordinators have been hired in hospitals around the country with ICA assistance and Health Ministry encouragement. "It's difficult to conceive of how things functioned without this vital function of counselling and coordination among the many interdisciplinary professionals involved in treatment," Ziv writes.
The excellent book (marred slightly by the lack of an index) provides the latest information, understandable to the layman, about diagnosis by mammography, ultrasound and MRI, to treatment, side effects, emotional stress, breast reconstruction and treatments expected in the future. She devotes many pages to BRCA-1 and BRCA-2 - the mutated genes more prevalent in Ashkenazi Jewish families that increase the risk of early breast and ovarian cancer.
Kadmon works hard to enlighten readers so they will abandon misconceptions that cause unnecessary anxiety and fear.
THESE ARE the main myths:
• A woman can get breast cancer only if she has a family history; otherwise, she doesn't really have to worry about it.
In fact, more than 80% of breast cancer patients have no close blood relative with the disease. Every woman over 50 (or from 40 or younger, if there is a family history) should have a biennial mammogram.
• In their 20s or 30s, women are too young to worry about breast cancer.
In fact, although it is much more common among post-menopausal women, the tumor can hit at any age, and one in four victims is below 50.
• Breast cancer is a death sentence.
In fact, five-, 10- and 20-year survival rates are 86%, 73% and 65% respectively, and when caught early, up to 98% survive at least five years. Even many women with metastatic breast cancer (which has spread to other organs) often live for years, thanks to improved treatments.
• If a woman has survived for five years, breast cancer will not recur.
Unfortunately, breast cancer can return at any time, although it's more likely within the first five to 10 years: 75% of women who will get a recurrence see it within six years, and 25% in the 10 years after that. New hormonal therapies, including tamoxifen and aromatase inhibitors, can delay recurrence, so the cancer is more likely to return after the woman stops taking those drugs.
• Chemotherapy causes constant vomiting.
In fact, drugs introduced in the past decade almost completely control nausea, and very few people have persistent nausea and vomiting from chemotherapy.
• Breast lumps mean cancer.
Most lumps are benign cysts or fibrocystic changes. Lumps could also be pre-cancerous conditions, or they could be malignant. All abnormal tissue should be examined by a specialist.
• Herbal remedies and dietary supplements can help treat breast cancer.
But no complementary therapy has been shown scientifically to treat breast cancer. Anyone who takes herbs or other food supplements should know that these can interact with prescription drugs and either trigger side effects or counter the effectiveness of medications. If you consult a complementary medicine practitioner, make sure he or she is a physician as well.
• If you eat a healthy diet and exercise, you don't have to worry about breast cancer.
These may lower the risk, but no one food or vitamin will make women immune. Lifelong exercise has been shown to reduce the risk, however. Soya and other sources of phytoestrogens in the diet can help protect against breast cancer. Animal fat and processed-food consumption should be minimal, and try to avoid exposure to environmental pollution. Having a baby in one's 20s and 30s is protective, as is breastfeeding.
• If a mammogram result is normal, you don't have to worry about breast cancer until the next one.
While a breast scan does detect the vast majority of cancers, it is only one screening tool; one in five breast lumps is invisible on a mammogram. Clinical breast exams by a specialist are recommended once a year. But self-examination every month is no longer recommended by the ICA or other experts; it has not been shown to save lives, and can lead to unbearable anxiety and needless biopsies.
• Mammograms are excruciatingly painful.
They're not like going to the hairdressers, but they are not horrible and are over in a few minutes. Pre-menopausal women should schedule their exam for the first two weeks of their menstrual cycle, when their breasts are less tender.
• If a woman has to get a breast biopsy, the surgeon might continue and remove the entire breast without consulting her.
While years ago surgeons would remove a suspicious mass, biopsy it on the spot and proceed to mastectomy if it showed signs of cancer, women today have many more treatment options and the surgeon must discuss them after a biopsy.
• If a breast lump is painful, it's not cancer since malignant lumps are supposed to be painless.
In fact, breast cancers are usually painless, but pain alone cannot rule out cancer.
• Radiation therapy is dangerous and will burn the heart, lungs and ribs.
Radiation techniques today are safe and effective, with few complications and minimal exposure to other organs. Any reddening of the skin will clear up after treatment.
• Men whose wives or partners are diagnosed are likely to leave them.
In fact, relationships are often strengthened by coping with cancer, but women whose marriages were failing before diagnosis may be emboldened to end them as a result.
Kadmon gives special attention to three groups who tend to avoid mammograms - Arab women, haredi women (due to issues of modesty and reduced media access) and Russian-speaking former immigrants (because of cultural or language problems that reduce access to medical care). These sectors, she notes, require special attention, and the ICA seeks them out with mobile mammography vans.
On the last page, Kadmon urges women struck by breast cancer to get emotional and practical support from their loved ones; seek out information; consult an interdisciplinary team of professionals and a variety of voluntary organizations; be ready to participate in decisionmaking; and preserve one's hope and optimism.
This is good advice for any woman.
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