Wellness

Illustration by Elly Maddock

New Cancer Tests That Could Save Your Life

Two little-known screening options—one specific to breast cancer—have the potential to help catch the disease much sooner than current norms. This in turn could have a massively positive impact on our treatment options, survival rates, and long-term health. While there is so much still unknown about cancer, it’s clear that outcomes shift dramatically when a cancer diagnosis comes early enough that the cancer is still localized, as opposed to later stages when it has metastasized. For example, the five-year relative survival rate of breast cancer is estimated to be near 100 percent for localized cases. This plummets to below 30 percent for metastasized breast cancer. So, how can we all be more proactive?

LA plastic surgeon Barbara Hayden, M.D. has specialized in reconstructive breast surgery for three decades; during which she’s become an important advocate for better breast cancer screening options, particularly for at-risk patients. As Hayden explains, she has both a professional and personal investment in furthering the science and availability of good, safe early detection methods: She found that some of her patients with breast implants were avoiding regular mammograms because they feared they would break their implants. (Not to mention that mammograms can hurt like hell in general, and especially if you have implants.) Personally, Hayden had breast cancer herself, as did her mom, which means her children are at an increased risk.

We asked Hayden to explain the current options available for breast cancer screening—the limitations of mammograms surprised us—and why she’s become a supporter of one method in particular, an automated ultrasound called SonoCiné (keep reading for more on its availability). Hayden is also a major proponent of breast self-exams, which she credits with saving her own life. “Every woman should know her body very well—every nook and cranny, not just the breast—what’s normal and not normal for her,” she says. Hayden’s simple self-exam tips are helpful for all of us who still worry we don’t know what we’re doing, and her advice on cancer screenings is something we can all feel good about following. Plus, she shares news of what seems to be a promising technology in early cancer detection, a blood test called ISET, which is being used to identify many different kinds of cancer cells (not just breast) in the blood, long before tumors are large enough to be spotted by imaging devices. The potential implications for both survival rates and the possibility of identifying early interventions that could be vastly preferable to chemo and radiation later in the game are extremely exciting.

A Q&A with Barbara Hayden, M.D.

Q

Do you find self-exams to be effective?

A

Self-examination saved my life. But more on that later.

Historically, women have been discouraged from touching their bodies, and also disempowered by the idea that they don’t know what they’re doing, and that when they do a breast self-exam, they’re prone to overreact and get hysterical. I just don’t see women that way—that doesn’t describe the women in my family nor the women I know—and I protest that profiling. I see women as inquisitive. Asking a question about cancer does not make you hysterical or mean that you think you have cancer; you’re searching for more data to be more informed about your health.

When we talk about breast self-examination, I often feel like we are going right back to the 1950’s, when women were told not to touch themselves: Don’t lookIt’s only going to scare youYou don’t know what you’re doing…. We are failing women by not empowering them to touch, explore, and know what’s normal about their bodies—and therefore develop a sense of if/when something isn’t normal.

The topic is made more controversial by a couple of studies that showed that doing breast self-examinations does not increase survival. The problem is, two studies don’t make a complete science. One could also hypothesize that the training around self-exams was, and is, imperfect, and could be greatly improved.

“Historically, women have been discouraged from touching their bodies, and also disempowered by the idea that they don’t know what they’re doing, and that when they do a breast self-exam, they’re prone to overreact and get hysterical.”

Even more factors are at play when it comes to outcomes, particularly how physicians respond to women’s questions. Let’s say I examine my breasts, I feel a lump, and I go to the doctor. The doctor says, “If you’re really going to worry about it, we will do a biopsy.” Another doctor, though, could have done an ultrasound, demonstrated that what I was feeling had benign features, and double-checked it in four months, and been done with it. Negative biopsies are sometimes falsely attributed to self-exam inefficacy when they may have more do with how women are treated, a physician’s fear of missing a cancer, or a physician covering him/herself from a malpractice standpoint.

Q

What’s the best way to do a self-exam, and how regularly?

A

Do it once a month. The best time is right after your menstrual period when your breast isn’t tender.

Find a system that works for you (there are many on the internet), but the key that many women aren’t taught is to get to know the entire breast tissue. Many women have breast tissue that goes up behind the pectoral muscle. When you examine your breast, don’t solely focus on the area around the nipple and the round part of your breast. The exam should include all tissue—beginning above your collarbone and going down to the lower edge of the rib cage, from the sternum (chest bone) to the latissimus dorsi muscle in your back. Extend up into your armpit to check out the lymph nodes that sit in this area. The point is simply to know what your own body feels like, so you’re able to notice changes.

What’s normal—what can you expect to feel? Every woman’s body is different, but here are the basics: Your breast is a modified sweat gland. Just like under your arm, there are lots of little nodules—pimple-like structures. They generally feel round and smooth. If you push them really hard, they usually feel tender. They may go up or down in size with your period, which is a sign of benign cystic structures. The more fat a woman has in the breast, the less likely you are to feel these nodules. For women with little fat in the breast, they may feel like little sacks of rocks. This is all normal.

“The point is simply to know what your own body feels like, so you’re able to notice changes.”

Breasts are filled with what usually feels like smooth and lumpy material—like lima or garbanzo beans, or petite pois (peas). But if you feel something really hard, especially if it’s not tender and it’s getting larger, you should call your doctor and get an exam. An ultrasound is always a reasonable option as it’s non-toxic.

It helps to draw a picture each month of your breast and what you feel. Put the pictures in a jewelry box or desk drawer so you can compare every new picture to your prior exam. Always map out the lumps, even if soft, so that you know what is normal for you. If you feel some kind of nodule, force yourself to put a measurement to it. Feel it with your fingers and then hold your fingers up to a ruler—is what you feel about ¼-inch in size, or ⅛-inch? Make a note and draw the nodule as a dot where it appears on your breast. Is it growing from month to month? If a lump is smaller than a centimeter, smooth, soft, and not changing, it is likely to be benign. If it’s changing, talk to your gynecologist. This doesn’t mean you necessarily need a biopsy. There are many things in the body that go up and down; now you have a way to follow it and track potential changes.

Q

How did you know something was off in your own-self exam? What did you do next?

A

One day, I felt something in my armpit that was larger than the tip of my finger, more than a centimeter in size. It wasn’t there before, and it wasn’t tender, and didn’t go away.

It made me a little nervous that the node didn’t hurt at all. If lymph nodes swell up because of an infection or cold or your period, they normally hurt a little. Things that hurt are almost always normal sweat glands with nerves attached to them that warn you that the glands are getting inflamed. Early on, cancer doesn’t hurt at all.

I had an ultrasound and was told it was a large lymph node but it looked normal. I repeated the ultrasound in a few months. (I tell my patients to get a second opinion if they have a lump that lasts 3 to 6 months. If a lump lasts longer than 6 months, it may, in the end, be worth removing.) My doctors found that I had metastatic breast cancer without a known primary tumor. They couldn’t find the original tumor in my breast (it was likely killed by the body in the breast) but it was already in the lymph node and thriving there.

“Self-examination saved my life.”

If I had ignored what I felt, my cancer likely would not have been curable. Even with the early diagnosis, I still had a significant chance of dying, but I was able to go ahead with chemo and radiation. (Getting a mastectomy didn’t make sense in my case because the breast didn’t have any cancer in it. This is unusual; it happens to around 1 in 300 breast cancer patients.) I’m now seventeen years out and still cancer-free.

But the point is: If you are touching and examining yourself regularly, every month after your period, when something really different pops up, you’re aware of it. If it’s not acting like a pimple (tender and sore, coming up and going away), if it’s staying and getting larger, there is every reason to have someone look at it and get an ultrasound at the very least.

Q

Is it generally okay to wait from one period to the next?

A

For the most part, cancer is slow-going. If you have a cancer and you delay treating it for six weeks, you don’t change the prognosis. People used to think that if you waited a day or a week, something horrible would happen, but that’s not true.

If you’ve been doing routine exams, and you feel a very small node, it’s okay to watch it from one period to the next. If you never do self-exams and/or you suddenly feel something big, talk to your gynecologist. Not every breast cancer forms as a tumor or mass. Some cancers grow in a lace-like pattern and then fill in. You might not feel it at first (while in the lace stage, a cancer can feel “stuck down,” like bubble gum in hair), and then suddenly you feel something like a walnut. Most of the time, though, when you suddenly feel something big, it’s likely a cyst that just blew up.

Q

At what age should women start getting breast exams and how often?

A

There is no magic number and opinions vary. Girls should get to know their bodies very young, and starting at age twenty-five, you should become more knowledgeable about how to screen yourself for breast cancer.

Women of all ages get breast cancer, but the percentage is small under forty years old. The Susan G. Komen absolute risk of breast cancer chart—which shows the chance of developing cancer in the next ten years—goes like this: If you’re twenty years old, the absolute risk is 1 in 1,674 (0.06%). If you’re thirty years old, the risk is 1 in 225 (.4%). If you’re forty, the risk goes up to 1 in 68 (1.5%). At fifty, the risk is 1 in 44 (2.3%).

The majority of women with breast cancer don’t have a family history, but if you have a first-degree relative with breast cancer, your risk is almost doubled. If you have multiple first-degree relatives with breast cancer, the risk is about 3-4 times higher. In general, the younger the relative at time of diagnosis, the greater the risk of breast cancer. All women are at risk of breast cancer if we live long enough.

As always, talk to your doctor about your screening schedule.

Q

What are the current options available for breast cancer screening?

A

Technology is always changing. I’m hoping that every year we will get better at screening for breast cancer.

The standard options regularly available are:

Self-Examination

(Described above.)

Gynecologist Exam

A professional exam at your annual gynecological appointment. Or, schedule an appointment with a breast surgeon or at a breast center if you have a question or concern from your self-exams.

Mammogram

Historically, we’ve relied heavily on mammograms. One positive aspect of mammograms is that they are reproducible every year. The pictures are shot in the same way so that the breast, and any changes, can be compared year to year.

Mammograms work better on fatty breast tissue (or, non-dense breast tissue) because the breast tissue appears dark and tiny cancers appear as white spots.

They are not as effective with dense breast tissue because both the breast and cancer appear white, so it’s harder to see what you’re looking at. A dense breast doesn’t mean that it’s firm to the touch; it just refers to the way the X-ray passes through the breast and gets obstructed by the tissue. Young women tend to have more dense breasts, but you can have dense breast tissue at any age. Women with dense breasts have a greater risk for breast cancer in their lifetime.

Mammograms are not ideal for women with implants. Silicone gel implants appear very dense in mammograms and can potentially hide small cancers. Also, while mammograms in general are uncomfortable—you feel like you are being hung up by your breast—women with implants may experience more discomfort. Some worry about damage to their implants (the pocket can tear or break). The risk of damage or pain, and cost of potential re-operation sometimes prevents women from getting adequate screening.

“Men are at an increased risk if they (like my son) have first-degree relatives with premenopausal breast cancer. Many men at risk are unaware that they also need to be screened.”

Mammograms are not ideal for women whose breasts are not a standard shape or who have abnormalities in their chest wall.

Mammography can also be less than ideal for screening small-breasted women and men at risk—it’s difficult to get the breast tissue into the scanner. Breast cancer is rare in men (the lifetime risk is about 1 in 1,000) but men can get breast cancer. Men are at an increased risk if they (like my son) have first-degree relatives with premenopausal breast cancer. Many men at risk are unaware that they also need to be screened.

The other issue with mammograms is the potential toxicity concern. Mammograms today use a 3D technology, which gives off more radiation than previous mammograms. We tend to tell our most at-risk patients to get regular mammograms starting at age twenty-five, but data shows mammograms before age thirty is associated with an increased risk of cancer. These patients are also encouraged to get annual MRI’s with gadolinium-based contrast agents to screen for cancer. Which means that by the time they are fifty, they have had significant doses of ionizing radiation. Gadolinium deposits have been found in the brain of patients who have had just four MRIs, so the FDA is investigating what the risk and any potential effect may be.

Handheld Ultrasound

A handheld ultrasound of the breast is done the same way we look at growing babies in the uterus.

One advantage of ultrasound over mammogram is that the ultrasound can view a larger area of breast tissue. With an ultrasound wand, you can view breast tissue up in the armpit, which a mammogram cannot do as thoroughly.

A disadvantage is that handheld ultrasounds are not done in regimented, reproducible ways. A human technician is twisting and turning the tool. If you’re looking at the resulting pictures, you wouldn’t necessarily know exactly what angle you’re looking at, so it’s not made for comparing results year to year.

For that reason, handheld ultrasound is typically used to hone in on and amplify data. If a lesion is spotted on another test, or you feel something, you might get a handheld ultrasound to see if there are cancerous features.

NOTE: Ultrasounds and X-Rays see things differently and create different pictures of the breast; both can potentially be informative. Some women may get both mammogram and ultrasound screenings. Some physicians recommend alternating every six months, year, etc. between mammogram and ultrasound depending on the patient. Decisions around the right screening method and cadence should be made on a case-by-case basis with physicians who can determine how useful or not a mammogram is for a given patient depending on the density of the breast (and other factors mentioned above), and who can also consider any potential risks, particularly for patients who are already at an increased risk for developing breast cancer.

Q

Can you explain the SonoCiné option and why you see it as the gold standard of breast cancer screening?

A

SonoCiné is an automated ultrasound tool that uses a computerized arm to look at the whole breast, from the midline to the back, including the armpit. It was developed by a radiologist named Kevin Kelly, M.D. (Please note that I have no financial stake in SonoCiné.) Like handheld ultrasound, it can be used in conjunction with mammograms, too (as noted above). Here’s why I like it:

  • It’s effective at finding very small lesions—tumors between 3 and 5 millimeters. The smaller the tumor when it’s discovered, the better the cure. The five-year relative survival rate for women with stage 0 or stage I breast cancer (compared to women who don’t have breast cancer) is nearly 100 percent. For stage II, this drops to 93 percent, then 72 percent for stage III. The five-year relative survival rate for metastatic (stage IV breast cancers that have spread to other parts of the body) is about 25 percent.

  • The test doesn’t hurt, so women aren’t afraid of it. For women with tender, cystic breasts, or small breasts, it’s more comfortable than a mammogram. You put on a vest, and the gel and automated arm go over the vest, so the patient feels much less exposed and vulnerable. It takes about 15 to 30 minutes.

  • SonoCiné works for all shapes of breasts. It can be done on a man. It can be done on someone with a chest wall deformity.

  • It covers more area than a mammogram, and it covers every square millimeter of the breast, which the handheld ultrasound does not. If you have a really wide breast, it will cover all the tissue.

  • There is a technician who makes sure that the transducer is making contact through jelly to skin, but he/she isn’t choosing where the transducer goes; the arm is automated. The test can be replicated from year to year.

  • Pictures of the breast are put together like a film (hence the name SonoCiné). When you touch your breast, sometimes things move around and away from your fingers. The SonoCiné can pick up on this kind of movement. The end result is like a movie reel, moving back and forth across breast.

  • It’s ultrasound, so there’s no radiation, and it’s safe.

Q

Why isn’t SonoCiné widely available?

A

It’s frustrating. SonoCiné should be in every gynecologist’s office but in reality it is in very few today. [You can look up SonoCiné locations here.] It’s available in my Santa Monica office because I’m including it in a research project and because I wanted to make it available specifically for my patients with implants who weren’t getting cancer screenings for fear of breaking their implants.

“I don’t think SonoCiné will become more available until the general public says, ‘Listen, we want this. Why isn’t this available?’”

My hunch is that SonoCiné is not generally available because it is not a money-making machine. It’s more costly than mammograms (but not expensive compared to MRIs or CT scans). SonoCiné is not covered by all insurance policies. It requires technicians and radiologists who know how to read the test. There are teleradiologists available to read remotely. (I don’t read SonoCine results; I send them to Dr. Kelly.)

Also, many patients aren’t aware that it’s an option. I don’t think SonoCiné will become more available until the general public says, “Listen, we want this. Why isn’t this available?” It won’t be brought to market until it is driven by demand.

When asking about what’s currently available in your own community, be aware that two other companies make automatic ultrasound screening tools, Siemens and General Electric, which use a cage-like structure that sits on the breast. I think they work, particularly if you have a very typical chest wall, but I’m not confident they’re best for women and men with different body types or implants. I chose SonoCiné for my office for this reason, and because it’s more sensitive. (Unfortunately, major hospitals often choose their tools based on what company they have a contract with, as opposed to what is the best option for their patients. So the burden falls to the consumer to find out which device is best for them.)

Q

Are there any drawbacks to SonoCiné?

A

Some radiologists say that ultrasound is too sensitive for cancer screenings, and often picks up lumps which leads to unnecessary biopsies. But you don’t have to immediately act and order a biopsy if you see something via ultrasound; doctors can note it and bring the patient back in a few months to do a repeat ultrasound of the area of concern.

When it comes to early detection, some people think along the lines of: We’re seeing too much, what can we do about it? That’s not a bad thing. That’s a good thing. We can see a lot. We should be able to pick up on tumors much earlier than we do with our current approach. Earlier detection saves lives and decreases morbidity associated with chemotherapy and radiation.

“Some people think along the lines of: We’re seeing too much, what can we do about it? That’s not a bad thing. That’s a good thing.”

Q

Do you recommend women get genetic testing to look for BRCA1 and BRCA2 mutations?

A

I think it makes sense if you have a first-degree relative who had premenopausal breast cancer or if you are of Ashkenazi Jewish descent (as there is a gene-increased risk in this population).

People tend to focus on BRCA, but it’s important for anyone with a family history of premenopausal breast cancer to be proactive about their health, even if they don’t have the gene mutation. (For instance, my mother had premenopausal breast cancer and so did I, but I don’t have the BRCA gene.) There is still a lot we don’t know about genes and there could be something at play that geneticists haven’t identified yet.

“But at least you’re more informed and better armed now, and you have the ability to catch cancer at much earlier stages, which improves survival, decreases treatment needs, and is the vastly preferable option.”

What we don’t want to do is fear-monger. I met a young woman the other day whose mother had bilateral mastectomies. The young woman was really frightened, and thinking about getting a mastectomy. It turns out her mother had postmenopausal breast cancer (as opposed to premenopausal)—which means the young woman’s risk isn’t really all that heightened. Here’s the bottom line: When there is breast cancer in the family, you need to know more, but just because you gather helpful information doesn’t mean you need to immediately take major action. So: Find out who else in your family had it, at what age, and if they have other relatives who had breast cancer whom you might not know about. (It’s never been easier to follow up on family members than it is now.) Talk to your doctor. You might just start doing SonoCiné or routine ultrasounds earlier if you’re at an increased risk. But at least you’re more informed and better armed now, and you have the ability to catch cancer at much earlier stages, which improves survival, decreases treatment needs, and is the vastly preferable option.

Q

You also offer the ISET blood test in your office—can you tell us a little bit about the test?

A

I’m specifically interested in looking at non-toxic methods for breast cancer screening for patients who are at high risk. The two that seem most promising are SonoCine and ISET—which has broader reach than breast cancer. (Please note that I do not have a financial stake in ISET either.)

ISET stands for the Isolation by SizE of Tumor cells. It’s a blood test that looks for early signs of cancer—circulating cancer cells (CCCs). The technology was developed by Patrizia Paterlini Brechot, M.D., Ph.D., a professor of cell biology and oncology at University Paris Descartes. CCCs get into the bloodstream when tumors are in very early stages, tiny, and before they are detectable by imaging screening.

“ISET can help detect invasive tumors at very early stages when we have a much better chance at a cure.”

By definition, once a tumor spills cells into your bloodstream, it’s invasive. It doesn’t mean that they necessarily take hold—these cells usually die in the bloodstream eventually. As invasive tumors grow, the cells need to keep evolving until they can fool the body into ignoring them. To become a metastasis, cancer cells in the bloodstream need to invade the immune system and get a better blood supply from the body. It takes time for the cancer cells to be able to grow elsewhere in the body. CCCs can circulate in the blood for years before metastasis. The ISET test is very sensitive: It can detect one tumor cell in 10 mL of blood.

So, ISET can help detect invasive tumors at very early stages when we have a much better chance at a cure.

ISET can identify CCCs from all types of solid cancers, except for lymphoma. (It cannot be used for leukemia, which is a cancer of the blood.) Right now, the source of the cancer can only be identified in research labs; these identifying tests are not yet available to the general public. But a positive test result does tell us that we need to monitor the patient more closely with other screening methods (like SonoCiné for patients at higher risk of breast cancer).

Q

Are there other potential implications of ISET?

A

In addition to early detection for at-risk patients, it can be used to monitor the efficacy of treatments in patients who have already been diagnosed. It’s also a good potential non-toxic screen option for people who are in remission and require regular screenings.

Importantly, ISET can allow us to look at the efficacy of potential early intervention therapies (like immunotherapy or dietary and environmental changes) that could help prevent cancer from spreading.

Additional potential ways of using ISET to identify other diseases and improve our health are being studied.

Q

What type of research has been done on ISET?

A

Studies are ongoing. There have been around fifty independent publications.

One peer-reviewed, independent study of ISET looked at lung cancer. The American Cancer Society reports that lung cancer is the leading cause of cancer death for both men and women—about a quarter of all cancer deaths. The survival rates for lung cancer are not good; the current estimated five-year survival rates fall between 45 and 1 percent depending on the stage of the cancer.

The study looked at 168 people with chronic obstructive pulmonary disease (COPD), which is a risk factor for lung cancer. ISET detected circulating tumor cells (CTCs) in 5 of the 168 COPD patients. These five patients were then monitored and received annual CT scans, which detected lung nodules one to four years after the ISET test. The nodules were removed promptly when the lung cancer was still at a very early stage. A year later, these five patients showed no cancer recurrence via CT scan and ISET. (No CTCs were detected in the control group who received the initial ISET test: 77 people without COPD, which included 42 control smokers and 35 non-smoking healthy individuals).

For the five people who had positive ISET tests, having that piece of data that told them it was important to get regular screenings and that signaled to the radiologists that they should be looking for something—significantly increased their five-year survival rate.

(As an aside, here’s a very little-known fact: When radiologists see something on a scan and the patient gets a biopsy, the radiologist can actually get a demerit if no cancer is found. They’re graded on the number of false positive results, or “unnecessary surgeries.” That bothers me. It costs the healthcare system a lot of money to do biopsies and there shouldn’t be too many unnecessary biopsies done, but radiologists should not be pressured in this way. A positive ISET test can provide a valuable piece of information for radiologists when reading an inconclusive scan.)

Q

What type of funding is needed for more research and to make the test more available?

A

Something like ISET should really be a multi-institutional program that doesn’t rely on one researcher or one person. We are looking to raise about $2 million for the Academy of Innovative Cancer Strategies (AICS), which is a nonprofit helmed by Dr. Patrizia Paterlini Brechot to support research around better early cancer detection and approaches to treatment and prevention. (You can donate here, and learn more about the BRCA and ISET study I’m working on here.)

Right now, the test is available in some places in Europe. I do offer ISET in my office; we usually do the test twice a month, and anyone can call and set up an appointment. Unfortunately, the test currently costs $2,500. My hope is that as the test becomes more mainstream, there will be more (local) pathologists to read the results, and the cost will come down significantly. The goal is to have ISET available for everyone during their annual exam.

Plastic surgeon Barbara Hayden, M.D. has thirty years of experience as a reconstructive breast surgeon. She graduated from UCLA with a degree in molecular biology, and after graduating from UCLA Medical School, she completed her general surgery residency and plastic surgery residency at UCLA as well. She was a full-time member of the faculty in the UCLA Department of Surgery from 1987 through 1991. She continued as UCLA clinical faculty, was Director of Outpatient Surgery, SVA Hospital and Director of Reconstructive Surgery at the Salick Cancer Center, Westlake Hospital. She has had a private practice in Santa Monica since 1990.

The views expressed in this article intend to highlight alternative studies and induce conversation. They are the views of the author and do not necessarily represent the views of goop, and are for informational purposes only, even if and to the extent that this article features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment, and should never be relied upon for specific medical advice.

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