Source: Chicago Tribune
Author: Bonnie Miller Rubin
Published: October 15, 2013
Oncologist shares expertise about causes, delay, haste
While breast cancer continues to be one of the most terrifying diagnoses a woman can get, Dr. Dennis Citrin sees cause for optimism. Citrin, an medical oncologist with Cancer Treatment Centers of America at Midwestern Regional Medical Center in Zion, specializes in treating advanced and complex breast cancer. When he started his career more than three decades ago, women had few options. Today, treatment is more effective and less invasive, he said.
Before joining Cancer Treatment Centers of America in 2004, Citrin was on staff at Northwestern Memorial HospitaL His research has been published extensively in medical journals and he is the author of the forthcoming book, "Knowledge Is Power: What Every Woman Should Know About Breast Cancer." Here's an edited transcript of our interview.
Q: Despite major gains, this is a truly frightening diagnosis. "What would you want women to know?
A: Fact No.1: Early-stage breast cancer is highly curable in most patients. Fact No.2: Delay can be tragic ... if you feel a lump see your doctor right away. And Fact No. 3: Modern breast cancer treatment is highly effective, but women have to complete the entire treatment program.
Q: What factors prevent women from benefiting from advances in treatment?
A: Fear of cancer, fear of side effects. Also some doctors rush patients into treatment before (the patients) obtain all the facts that they need to make an informed choice... No woman should start treatment without seeing a breast cancer surgeon and a medical oncologist.
Q: Why would anyone delay getting a diagnosis?
A: Fear clouds patient's judgment ... and denial-"Maybe it'll go away."
Q: How big a role do you think stress plays in getting breast cancer?
A: There's no good evidence that stress plays a role in causing breast cancer, but it certainly can result in poor outcomes if it prevents a woman from making appropriate treatment choices. We all recognize that cancer involves great stress and our role as providers is to help our patients cope with and deal with that stress.
Q: If a woman who had a mammogram is cancer free for five years post-surgery, what is the likelihood of a cancer of any kind recurring?
A: Five-year survival without recurrence is often used as the yardstick of cure for cancer. That doesn't apply to breast cancer (especially node negative or ER positive disease) where recurrences after five years are quite common.
Q: Do you think HRT (hormone replacement therapies) are a breast cancer trigger?
A: HRT with combination estrogen and progesterone is recognized to increase risk of developing breast cancer. HRT with estrogen alone does not apparently increase breast cancer risk.
Q: What should our daughters be doing to reduce their chances of getting breast cancer?
A: Know your family history, check your breasts monthly, limit alcohol intake, exercise regularly, minimize use of estrogens (the modern "pill" does not increase breast cancer risk).
Q: Given the increased incidence of breast cancer in the general population, do you think environmental factors trigger the disease and, if so, which factors?
A: There are no clearly recognized environmental factors like lung cancer with smoking and asbestos. As far as diet is concerned, regular use of alcohol (which contains phyto-estrogens) is to be discouraged. We also know that obesity is associated with inflammation and increased breast cancer risk.
Q: Since Angelina Jolie's surgery and announcement, have you seen an increase in women seeking prophylactic breast removals? How do you feel about this?
A: I haven't seen an increase. My opinion is that the vast majority of women don't need a bilateral mastectomy. Only 15 percent of breast cancers are associated with the BRCA gene or other gene mutation. Put another way, most breast cancers are sporadic. In BRCA-positive women the risk of developing one breast cancer can be as high as 80 percent, and the risk of a second cancer in the opposite side is approximately 50 percent. So in patients with a gene mutation, prophylactic mastectomy makes sense.
But for a typical 50-year-old woman with newly diagnosed breast cancer and no gene mutation, the life-time risk of developing a second cancer in the opposite breast is no more than 10 percent. So to remove the opposite breast would mean removing the remaining breast from 90 women who will never develop cancer.
I don't accept the patient-anxiety argument as being a valid reason to do prophylactic mastectomy. Remember, breast-conserving surgery is every bit as effective at curing women as more radical surgery. In my experience, if the doctor takes the time to carefully explain all this to the patient, her fears can be allayed, and excessive surgery avoided.
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