Breast cancer fight has special significance for state

It's a No. 1 ranking that we could live without.

According to a Centers for Disease Control and Prevention announcement in 2004, Washington state had the highest incidence rate for female breast cancer in the nation, based on the years 1999-2000. Women here are still living and dying with that designation.

So why would women here contract breast cancer at a rate higher than in other states?

No one seems to know exactly, but researchers are looking for factors shared by high-incidence regions around the country.

Two reasons are that we have a largely white population. White women have a high breast cancer incidence rate. Also, women here are by and large well educated and financially successful. Such women, as a group, tend to delay having children, have fewer when they do or never have them. Women who have children later or don't have children face an elevated risk of developing breast cancer.

And these women tend to consume alcohol on a regular basis, another increased risk factor.

Another factor may be that such women are self-aware and savvy about health issues and access to health care, which may lead to earlier -- and more numerous -- cancer detections.

"There are increased breast cancer risks associated with parity (how many children and when) later in life," says Dr. Peggy Porter, a cancer researcher at the Fred Hutchinson Cancer Research Center. "We have more women who delay having children and have fewer children." There's an even higher risk, she says, for women who don't have children.

The American Cancer Society reports breast cancer incidence rates have increased annually since 1975. And while a growth spike between 1980 and 1987 is attributed to greater use of mammography scanning, "much of the long-term underlying increase in incidence is attributed to changes in reproductive patterns, such as delayed childbearing and having fewer children, which are recognized risk factors for breast cancer."

Breast cancer is the most frequently diagnosed cancer among women.

Juliet VanEenwyk, state epidemiologist for non-infectious conditions at the Washington Department of Health, agrees that researchers have "looked at delayed childbearing. ... Women in Washington state had children at ages older than in the rest of the county."

There may be other factors as well in Washington's high breast cancer rate, including patterns of taking hormone replacement therapy, another known breast cancer risk factor, lower rates of vitamin D absorption because of limited exposure to the sun and even Scandinavian heritage.

In Washington state, as elsewhere, other risk factors are being explored, including environmental pollutants and chemical toxins, but there seems to be no conclusive evidence to date.

Other risk factors include starting one's period at an early age (under 12) or entering menopause late (over 55), not breastfeeding, recent oral contraceptive use (within 10 years) and postmenopausal obesity. Women with two or more first-degree relatives (mother, sister or daughter) with the disease have a higher risk. A research consensus has ruled out a link between abortion and breast cancer.

Bluntly put, for most women the biggest risk factors for breast cancer are being female and getting older, especially older than 65.

Regular exercise, minimizing alcohol intake and keeping the weight off can counter those risk factors but, the American Cancer Society says, "at this time, there is no guaranteed way to prevent breast cancer."

In a small number of breast cancer cases (5percent to 10 percent), the cause is as clearly identifiable as the risks are terribly quantifiable. Mutations in the BRCA 1 and BRCA 2 genes can present an 80 percent or higher risk of getting breast cancer. A normal 30-year-old woman has a 1 in 2,500 chance of developing breast cancer at that age, but a 30-year-old carrying the mutation can face a risk as high as 1 in 3.

And the predictability comes with a daunting and controversial price, including the prospect of surgical removal of both breasts and both ovaries as a "preventive" measure.

About one in 40 Ashkenazi Jews, who comprise the vast majority of the U.S. Jewish population, carries one of the two genetic mutations. People from Norway and Iceland also have been found to have a higher incidence of the mutation.

But the vast majority of breast cancers have no identifiable cause. Something goes wrong at the genetic level and cancerous cells are produced in glands for milk production, called lobules, or the ducts that connect the lobules to the nipple.

When the cancer is discovered before it has broken through the gland or duct walls into the surrounding fatty tissue, the five-year survival rate is extremely high. The later the cancer is found, the lower the survival rates. Once the cancer has metastasized to other parts of the body, the survival rate drops dramatically.

Early detection, obviously, is key to prospects for surviving the disease.

"We know what to do about breast cancer," says Lynn Hagerman, executive director for the Puget Sound branch of the Susan G. Komen Breast Cancer Foundation. "If we get to it early, we can save lives." Headquartered in Dallas, the Komen Foundation was established in 1982 by Nancy Brinker to honor the memory of her sister, Susan G. Komen, who died of breast cancer at age 36.

And perhaps due in part to the importance of early detection, a woman's race can be key to her prospects for survival as well.

Overall, 88 percent of American women are alive at least five years after being diagnosed with breast cancer. For white women, the five-year survival rate is 90 percent or higher. For African American women, the survival rate is 76 percent.

Far more white women are diagnosed with the disease (about 151 per 100,000 population in Washington state) than African American women (about 110 per 100,000), but African American women die at a higher rate from the disease (about 32 per 100,000) than do white women (about 25 per 100,000).

Breast cancer is an equal-opportunity disease in who gets it, but not in who survives it.

Porter at the Hutch and VanEenwyk at the Department of Health agree that the higher mortality rates are a result of cancer being detected at a later stage in African American women, when it's more difficult to defeat. They agree too that socioeconomic factors may play a role, such as limited access to health care, lack of trust in a white-dominated health care system and lack of health insurance both for diagnosis and ongoing treatment. African American women are also more likely to contract breast cancer before age 45, when it's usually more aggressive.

African American women also have a higher incidence of non-hormonal breast cancer, which can't be battled with estrogen-blocking drug regimes.

"They have a subtype of breast cancer that's very difficult to treat," says Janet Daling, a researcher at the Hutch studying the origins and genetics of breast cancer. She pointed to a study published Wednesday in The Journal of the American Medical Association indicating that African American women younger than 50 have a dramatically higher rate of a particularly dangerous form of breast cancer called a "basal-like" subtype.

The New York Times reported that the study was the first to measure how common the different genetic subtypes of breast tumors are in American women and sort them by race.

Breast cancer in younger women is rare; less than 1.5 percent of all cases occur in women younger than 45, according to Daling.

"There may be something biological going on" in African Americans experiencing more aggressive types of breast cancer and at younger ages, VanEenwyk says.

It's clear more research is needed, both in determining if there are specific genetic differences in the development and appropriate treatment of breast cancer in African American women and in the economic, social, language and cultural barriers to early detection and effective treatment for all minorities.

Hagerman at the Komen Foundation said that language and cultural barriers keep minorities and recent immigrants from getting necessary breast cancer screening and treatment.

Any woman, she says, needs to be assertive as a patient and not accept a health professional's dismissal or downplaying of her concerns. "Push the issue or get a new doctor," Hagerman says. "And call us if the doctor isn't listening."

There is, of course, hope on the horizon for improved treatment of breast cancer for all women. But it will take increased research funding.

A major fundraiser, the Komen Foundation's "Race for the Cure," comes to Seattle this Saturday.

The event might be more accurately called the "Race for the Cures." As Porter at the Hutch says, breast cancer is a very diverse disease that will likely be best fought by "looking at ways to shut off entire molecular pathways" with treatment regimes targeted against cells that have cancerous characteristics.

There is, of course, a massive research effort going on at the Hutch. But on the other side of the state, too, a researcher in his lab is blowing on an ember of fresh hope in something called p53.

P53 ("p" for protein and "53" for its weight) is a tumor-suppressor gene. Simply put, its job is to keep abnormal cells from growing. When p53 is dysfunctional or mutated, this "brake" doesn't function and tumor cells are allowed to grow.

Professor Sayed Daoud, a breast cancer researcher at Washington State University, is a two-time recipient of the Komen Foundation's $250,000 two-year research grant, most recently in 2004, for his work on p53. The gene, once dubbed "Molecule of the Year" by the journal Science, is found to have mutated in roughly half of breast cancer cases, and in as many as 70 percent of colon cancer cases.

Daoud says he's been able to use specific small molecules to restore the function of mutated p53 and to kill tumor cells in the test tube and in animals.

"This is proof that the concept is real. What I need now is to go to the federal government for financial support I need to sustain my work," Daoud said in a phone interview.

Is this the cure? Is it a cure? It and other such targeted therapy prospects offer the hope of a far more sophisticated, less invasive and difficult treatment than the blunt instrument of chemotherapy, poisoning all the cells in hopes of killing the cancerous ones.

The mapping of the human genome, opening a pathway to fighting disease at the genetic level, promises to make chemotherapy, radiation treatment and the routine surgical removal of body parts seem as medically crude as 18th-century blood-letting techniques.

To see more of the Seattle Post-Intelligencer, for online features, or to subscribe, go to http://seattlep-I.com.

© 1998-2004 Seattle Post-Intelligencer. All Rights Reserved.