Save the Date!
Ellen P. Hermanson Memorial Symposium
This Year’s Topic:
“The DCIS Controversy Through the Lens of Better Science:
Will President Obama’s Precision Medicine Initiative Save Lives?”
Monday, October 26, 2015
6:15 PM – 8:30 PM
New York City Bar Association
42 West 44th Street, 2nd Floor Meeting Hall
The very latest developments in the fight against breast cancer will be presented by renowned breast oncologist Larry Norton, MD, followed by this year’s program.
The Precision Medicine Initiative (PMI), announced by President Obama to advance the field of precision oncology, will be explored against the backdrop of established approaches to care.
The panel will discuss the new studies regarding treatment of DCIS, whether it impacts the standard of care to be employed by physicians treating DCIS, informed consent, and the benefits and availability of personalized “precision” medicine.
Moderator: Hon. Judith S. Kaye, Former Chief Judge, New York State
Open to the public without charge.
Refreshments will be served.
CLE-Professional Practice- 2.0 credits, qualification pending
Link coming soon for more information and to RSVP.
What You Need to Know from JALBCA’S Spring Program, “Breast Cancer: Upworthy Ideas”
Earlier this year, on March 10, JALBCA and the New York County Lawyers Association (NYCLA) co-sponsored the program, “Breast Cancer: Upworthy Ideas.” The program was moderated by our own past Co-President Hon. Jennifer Schecter and opening remarks were provided by Jamie Sinclair, Co-Chair, NYCLA Committee on Women in the Law. JALBCA members Hon. Barbara Jaffe and Karen Blaustein, Esq served as co-chairs. Hon. Richard Lee Price of NYCLA introduced the speakers. The program featured two well-known speakers – Dr. Mary Jane Massie, MD (Attending Psychiatrist, Memorial Sloan Kettering Cancer Center), who spoke about psychosocial issues around breast cancer, and Devra Lee Davis, PhD MPH (Founder and President, Environmental Health Trust), who spoke about breast cancer and the environment in the 21st Century.
Dr. Massie started by identifying broad areas of psychosocial impact of breast cancer such as psychological discomfort, behavioral changes due to physical discomfort, marital or sexual disruption and altered activity level and fears and concerns related to body image and recurrence of cancer or death. She described why psychiatric consultation may be helpful when facing difficult decisions about whether to undergo genetic testing, whether to inform family members of results of genetic testing and whether to have risk reducing surgery (e.g., prophylactic mastectomy and/or prophylactic oophoroectomy) after a cancer diagnosis or if the person is a BRCA1 or 2 mutation carrier. She went on to describe the two types of genetic mutations which include (1) germline mutations which are inherited and (2) acquired mutations which are not inherited but may develop during our lifetime as a result of exposure to radiation, chemicals and viruses. Most cancers are caused by the latter.
Issues Surrounding Genetic Counseling
Those who should consider genetic testing were described by Dr. Massie. These include multiple close family members affected with breast or ovarian cancer (particularly if the relative was diagnosed at less than age 50), a close family member with more than one cancer (breast cancer involving both breasts or breast and ovarian cancer), where there are multiple generations of close family members with cancer (paternal or maternal) and where there are other cancers in addition to breast and ovarian cancer in women as these can be suggestive of hereditary cancer. Dr. Massie described examples of patients who fell into these categories.
Pretest genetic counseling was also discussed by Dr. Massie. A counselor would help consider medical, emotional, practical and financial effects of testing on a patient and her family. Testing can be expensive and most health insurance companies cover most of the cost. Of course, genetic testing is not perfect and not all people who have inherited an abnormal gene will develop cancer. If one does test positive for a BRCA mutation, Dr. Massie provided these statistics: the lifetime risk of breast cancer is between 55 and 85% for BRCA1 and between 50 and 85% for BRCA2; the lifetime risk of ovarian cancer is 35 to 46% for BRCA1 and 13 to 23% for BRCA 2.
Finally, Dr. Massie referenced the Genetic Information Nondiscrimination Act (GINA). Under GINA, employers cannot deny a person a job or fire a person because of the results of genetic testing. Health insurers cannot use genetic testing to deny coverage or set insurance rates. Employers and insurers cannot require a person to have genetic testing. The law, however, does not have provisions for disability, life insurance or long-term care insurance.
Personal Risk Factors
Dr. Davis, an epidemiologist, focused on the environment and the reasons why the environment can be a cause of cancer. This is borne out statistically given that fewer than one in 10 cases of breast cancer arises in women born with genetic defects and even identical twins do not have identical chromosomal banding patterns (and, as they age, their chromosomes look less similar). She also noted that the cancer risk of adopted children mirrors that of their adopted (not their biologic) parents, fewer than half of identical twins get the same cancer, migrants develop risks of their new countries and workers have higher cancer rates. Jobs which indicate an increased risk of breast cancer include solvent workers, chemists, nurses/dentists and physicians, painters and hair dressers.
The personal risk factors for breast cancer for women include use of hormone replacement therapy/late menopause, early life radiation, lack of exercise/obesity, alcohol, family history, late or no pregnancy and early menses. But the common link between most known risk factors is the higher total lifetime exposure to unbound steroid hormones binding globulin.
As for the environmental risks for breast cancer, Dr. Davis listed the following: pesticides, metals, paints, solvents and plastics. Statistics from 14 studies, she said, show that second-hand smoke increases the risk of breast cancer in younger people, not in older people. Mention was also made of the potential risk of cell phone radiation. She explained, by way of background, that fat and fluid cook in the face of radiation from microwave ovens and that the breast is chiefly composed of adipose and fluid. This was noted in connection with some cases where women developed multi-focal tumors located in the area where cell phones were stored in their bras. She made several recommendations, as shown in the box at right.
The program was followed by a question-and-answer period. In the context of a question about sugar, both speakers asked the audience to “(p)lease do not drink your fruits.”
Report from the NBCC’s
2015 Project LEAD Institute
This report was written for JALBCA by Virginia Trunkes (shown at right), a commercial and real-estate litigation attorney in Manhattan who has developed a fascination with the science of breast cancer and a true appreciation for the women – and men – who have been afflicted with the disease.
In July, on behalf of JALBCA I attended the Project LEAD Institute (“LEAD” meaning Leadership, Education, Advocacy and Development), sponsored by the National Breast Cancer Coalition (NBCC). Held in San Diego, this was Project LEAD’s twentieth anniversary in training breast cancer advocates, each affiliated with a breast cancer organization – nationally and internationally – to learn the science of breast cancer, understand breast cancer research and become empowered to better set public policy and obtain the best research and clinical studies to end breast cancer. NBCC has set a deadline of 2020 to know how to end breast cancer, by finding either the correct vaccine or medicine to either prevent its onset or prevent it from metastasizing to the point of death. From what I learned at Project LEAD, if we accelerate forward in the right direction and more aggressively leverage what scientific advances we have achieved, that goal could actually be attainable.
During the five full-day intensive training, the format was in keeping with the tradition: several expert faculty members presented on topics including cellular biology, genetics, epidemiology, research design and advocacy. Students were given the tools to learn the language of breast cancer, including the roles of DNA, RNA and proteins, media, advocacy, current legislative efforts, how to critically evaluate research studies as well as how the media reports on the results of same, how to interpret scientific literature, what advocacy opportunities are available and how breast cancer research decisions are made.
We learned about the successes of NBCC’s previous advocacy efforts, including NBCC’s historically notorious persuasion of the Department of Defense to fund a Breast Cancer Research Program (DOD BCRP). Since its creation, this program has funded $3.1 billion for innovative breast cancer research and has ensured consumer activist participation at the peer-review research table. We learned that recently Senator John McCain, who is now Chair of the Senate’s Armed Services Committee, threatened to eliminate the program from the DOD’s budget on the ground that its funds should be limited to providing the nation’s defense. One of the more dynamic students at the conference, an army veteran who developed breast cancer and found that our nation’s Military Health Care was not entirely adequate, vowed to “take on” Senator McCain by explaining that investing in the DOD BCRP program is investing in our nation’s defense, inasmuch as our service people are afflicted by the disease as well. (Since July, efforts continued in working with other Senators to discourage Sen. McCain from pursuing his threat, and ultimately Sen. McCain did not seek to alter or eliminate the program.)
Also discussed was a NBCC’s conception of and successful lobbying for the passage of the Breast and Cervical Cancer Prevention and Treatment Act of 2000, which provided access to treatment funding for uninsured women who were screened for and found to have breast or cervical cancer, including precancerous conditions. Currently, NBCC is advocating for the passage of a bill in Congress, the Accelerating the End of Breast Cancer Act (S. 746 and H.R. 1197), which would create a commission comprised of representatives of biomedical research, business, breast cancer advocacy, and other related and unrelated disciplines who have demonstrated an ability to be innovative.
The commission would identify promising opportunities, tools, technology and ideas not currently being prioritized for breast cancer by the public and private sectors, but which hold true promise in ending breast cancer. It would implement strategies to leverage these opportunities and maximize prior investments in these areas.
At Project LEAD, periodically we broke-up into six pre-determined study groups which each contained a Faculty Member and a Mentor. Within our study groups we had the opportunity to identify which concepts were still unclear so as to best ensure that we were absorbing the important themes. “Group dynamics” were triggered as we worked through problem-solving among brand-new colleagues from heterogeneous demographic backgrounds.
Among the extremely-detailed and complex information presented, we focused on the “Hallmarks of Cancer” – distinctive and complementary capabilities that enable tumor growth and metastatic dissemination. Continuing to provide a solid foundation for understanding cancer, over time these Hallmarks are: (1) sustain proliferative signaling; (2) evade growth suppressors; (3) resist cell death; (4) enable replicative immortality; (5) induce angiogenesis; and (6) activate invasion and metastasis. Over time scientists have added four more “enabling characteristics:” (1) destabilize genomes/permit mutations; (2) promote tumor inflammation; (3) deregulate cellular energetics; and, of much interest to scientists recently, (4) avoid immune destruction.
In fact, two scientists presented on “immune-oncology,” or “immunotherapy”: Stephanie Goff, MD, PhD of the National Cancer Institute at the National Institute of Health and Sasha Stanton, MD, PhD, of the University of Washington. While scientists and physicians have always appreciated the role that the body’s immune system plays during treatment, within the past several years many have been focusing their efforts on “harnessing” the immune system to fight off cancer in advanced stages. Unlike targeted therapies, which use medicine to interfere with specific molecules involved in tumor growth and progression, immunotherapy does not target cancer cells directly. Rather, it restores or increases the activities of specific immune-system components or counteracts immunosuppressive signals produced by cancer cells.
Note that the immune system, a complex network of organs, tissues, and specialized cells, recognizes and destroys foreign invaders, such as bacteria or viruses, as well as some damaged, diseased, or abnormal cells in the body. An immune response is triggered when the immune system encounters a substance perceived as foreign or dangerous, called an antigen. As discussed above, certain “Hallmarks of Cancer” enable cancer cells to evade detection by using one or more strategies. For example, cancer cells can undergo genetic changes that lead to the loss of cancer-associated antigens, making them less “visible” to the immune system. They may also use several different mechanisms to suppress immune responses or to avoid being destroyed by “cytotoxic T cells.”
Doctors Goff and Stanton discussed current experimental anticancer immunotherapies including “adoptive T cell transfer,” which attempts to enhance the natural cancer-fighting ability of a patient’s T cells. Cytotoxic T cells release chemicals that can directly destroy microbes or abnormal cells. In one form of adoptive T cell transfer therapy, researchers first “harvest” cytotoxic T cells that have invaded a patient’s tumor (i.e., they surgically remove one of a patient’s many metastasized tumors along with the accompanying T-cells). They then identify the cells with the greatest antitumor activity and grow large populations of those cells in a laboratory (akin to a “petri-dish”). The patients are then treated to “deplete” their immune cells (i.e., massive, one-time aggressive chemotherapy), after which the laboratory-grown T cells are infused into the patients. Dr. Goff analogized this process to a “software update.”
We also learned about the continuing knowledge which scientists have acquired at the cellular level. For instance, in molecular biology, the central theme is that the flow of genetic information moves from DNA to RNA to protein, i.e., instructions for making proteins. This process occurs in only 1.5 percent of the genome, however. In recent years scientists have determined that other parts of the genome – the non-coding majority – appear to have “functional elements” as well. Specifically, what scientists once termed “junk DNA,” i.e., the gaps in between the groups of three of the four “bases” (nucleotides) which are termed “codons” in the DNA “translation” process, have now revealed the presence of portions of the genome which, although they do not code for proteins, still play a role in signaling.
Consequently, many scientists are focusing on single nucleotide polymorphisms, a/k/a SNPs. A SNP represents a difference in a single nucleotide (a “DNA building block”). Stated another way, SNPs are substitutions in individual bases along a chromosome. They are the most common type of genetic variation among people. SNPs are often found in non-coding regions of DNA (so that the DNA is not altered in the traditional sense of a genetic mutation), and yet can still influence phenotype traits such as susceptibility to disease. In other words, the theory is that epigenetic (non-coding) events which result in changes in gene expression capacity are important in tumor progression, and variation in genes involved in epigenetic mechanisms might therefore be important in cancer susceptibility. As such, SNPs may hold some answers in preventing or fighting cancer.
This year’s Project LEAD included two male students: one who runs a non-profit organization “Theresa’s Research Foundation,” which had been created by his mother before she died at a young age from breast cancer, and the other a fellow New York City (Bronx!) native who is a breast cancer survivor himself. Michael Singer was diagnosed in 2010, a time not long ago and yet a time when there was minimal information available about men’s breast cancer. (Males reflect one percent (1%) of breast cancer victims and comprise a population extremely reluctant to reveal their diagnoses.) Thereafter, Michael contacted the Bret Miller 1T Foundation (named after a survivor who was diagnosed with male breast cancer at age 24), and has continued to advocate for awareness and compassion for men inflicted with the disease. Recently, the organization, which merged with the Male Breast Cancer Coalition, persuaded more than thirty state governments to recognize the third week of October as Men’s Breast Cancer Awareness Week, and Michael was responsible for obtaining New York State’s recognition.
By mid-week, when Michael became so comfortable with (or perhaps tired of) all of us women inquiring about his experience, he showed us his mastectomy (and no, reconstructive surgery had not been offered to him)!
The issue of the overall value of mammograms for younger women without a known, higher risk of breast cancer continued to generate extended/heated discussion. The U.S. Preventive Services Task Force (USPSTF) currently recommends that routine screening of average-risk women should begin at age 50, instead of age 40, and that women should get screening mammograms every two years instead of every year. (The American Cancer Society, in contrast, continues to recommend yearly mammograms starting at age 40, albeit this year it is reviewing its guidelines.) There has been a shift in thinking among some based on concerns about (1) the significant percentage of “false positives” and the emotional and physical toll on those women who subsequently undergo further testing and biopsies; (2) overtreatment; and (3) cost. The message conveyed by many advocates, and the USPSTF, is that each individual is different, and that the results of genetic testing, family histories and an understanding of all that is involved with mammograms, as well as its potential limitations, should inform a woman’s decision of when and how frequently she should receive the test, versus an arbitrarily-chosen age.
The highlight of the week occurred on the last day, right before our “graduation” ceremony. Each study group was responsible for creating and presenting, through a selected group member, a five-minute presentation on a topic which we learned during the conference. It forced us to fully grasp and translate some of the extremely complex information taught to us in such a short period of time.
The experience was illuminating and extremely enriching. If the occasion arises where other JALBCA members can attend Project LEAD, I highly recommend that they avail themselves of such a wonderful and important opportunity.
JALBCA Holds a Fundraiser at Felidia
On September 16, JALBCA sponsored cocktails and conversation at the four star restaurant Felidia in Manhattan. This wonderful event featured a presentation by Tanya Bastianich Manuali, PhD, co-author of the book Reflections of the Breast: Breast Cancer in Art Through the Centuries. Manuali is an art historian who teamed up with oncologist Francis Arena, MD, FACP to trace a fascinating visual path through our knowledge of breast cancer from ancient Egypt to Michaelangelo to where we are today.
Once Again JALBCA Races for the Cure!
JALBCA Team co-leaders for the 25th Annual Greater NYC 5K Walk/Run Race for the Cure in Central Park, NYC, Hon. Shirley Werner Kornreich and Sandy Lespinasse, successfully organized another group of JALBCA participants for the September 13, 2015 event.
Contacts & Resources:
Adelphi NY Statewide Breast Cancer Hotline & Support Program
Adelphi University School of Social Work
Garden City, NY 11530
275 Seventh Avenue
New York, NY 10001
200 West End Avenue, Suite 12 G
New York, NY 10023
Gilda’s Club New York City
195 West Houston Street
New York, NY 10014
Memorial Sloan Kettering Cancer Center
Post-Treatment Resource Programs:
SHARE (Self-Help for Women with Breast or Ovarian Cancer)
1501 Broadway, Ste. 704A
New York, NY
Speak to a survivor toll-free: 1.866.891.2392
410 Kenwood Avenue
Delmar, NY 12054
110 Spring Street
Saratoga Springs, NY 12866