Medicine: Attacking Breast Cancer on All Fronts
Hadassah Hospital tops the world’s best breast-imaging centers: It has a patient population that carries important clues to causes and possible cures.
A modified and infinitely complex sweat gland that once nourished the entire human race, in today’s industrial world a woman’s breast is more susceptible to cancer than any other part of the female body.
Although more and more women in developed countries are falling victim to breast cancer, far greater numbers of them are surviving its onslaught. In Israel during the past two decades, while incidence has doubled to a frightening one in eight, mortality has dropped by 30 percent—down from 1,200 a year to about 800.
Much of the credit for this rests with early detection through high- technology screening. At the forefront of breast imaging in Israel stands a tall, slender woman named Miri Sklair-Levy, who moved to Israel from Russia in 1971, at the age of 9. A graduate of the Hebrew University–Hadassah Medical School, she specialized in women’s imaging in Toronto and returned to Israel four years ago to set up the country’s leading breast-imaging unit at the Hadassah–Hebrew University Medical Center at Ein Kerem.
Although our unit is housed in a utilitarian collection of rooms rather than a tranquil facility, stressed women can find equipment equal to that anywhere,” says Dr. Sklair-Levy.
“As well as standard tools, such as a mammogram and a sonogram, we have a prone stereotactic biopsy table that allows us to perform minimally invasive biopsies, and we’re the first hospital in Israel to have a digital mammogram and an MRI-guided breast biopsy coil. We also have the backup of the advanced medical center of which we’re part.”
If its technology is the match of the best North American and European centers, Hadassah’s breast-imaging unit may have something they do not: a patient population that could carry important clues to the causes and thus to possible cures of breast cancer.
“Cancer’s ravages are far from indiscriminate, and we believe this can help us uncover important information,” says Dr. Tamar Peretz, head of Hadassah’s Sharett Institute of Oncology and a key member of the medical center’s comprehensive breast-health team.
“One clearly important statistic is that the disease attacks 95 Jewish Israelis compared with 46 Arab Israelis in every 100,000 women,” she explains. “Its incidence is significantly higher among Ashkenazic immigrants to Israel than among newly arrived Sefardim. Jewish newcomers from Russia have the highest rate of all. The disease is virtually unknown in the Ethiopian Jewish community, and Jewish women of all ethnic backgrounds who are born in Israel have breast cancer levels approaching those found among Ashkenazic newcomers.”
These statistics have generated intense interest inside Israel and around the world. Hadassah’s breast-imaging researchers are among those studying the disease in Ethiopian woman.
“Our research has a dual aim,” says Dr. Sklair-Levy. “We’re working both to find ways to establish regular screening among what is a stubbornly noncomplicit population as well as to learn why breast cancer is virtually unknown among them.”
The team has already found definite differences between the far fattier breast composition of Ethiopian women and that of Israel’s general population. But with breast cancer now appearing among Ethiopian women who have lived in Israel for more than 20 years, lifestyle, diet, environment and hormones are likely to be involved as well.
Nature and nurture also vie to account for the strikingly different incidence of breast cancer in Arab and Jewish women in Israel. Here, however, another factor must be considered: Although rates of breast cancer among Arab women are less than half those in Jewish women, the Arab population presents with much more advanced disease and experiences far poorer treatment outcomes.
“We haven’t yet established why this is,” Dr. Sklair-Levy states, “but perhaps Jewish women make better use of early detection services, or perhaps these services are insufficiently accessible to Arab women. Or maybe their community carries a more aggressive form of the disease. It could be any of these, all of these, or something else entirely.”
The ultra-Orthodox community is another research focus. “This is a largely Ashkenazic community in which the cancer susceptibility genes BRCA1 and BRCA2 occur significantly more often,” says Dr. Sklair-Levy. “Combine this with their high birth rate and their reluctance for screening, and the result is a community at risk.”
Programs are being developed with the community’s rabbis to encourage ultra-Orthodox women to come forward for screening. In a recent case, the rabbi played a key role. “The patient was a 33-year-old woman who had given birth to her sixth child three months earlier,” relates Dr. Sklair-Levy. “She’d noticed changes around her nipple. When nothing showed up on ultrasound examination, she consulted her rabbi, who referred her to us. Our sonogram identified a vague mass in her breast. Biopsy revealed extensive carcinoma. A total mastectomy was performed immediately, and she is now doing well.”
With statistics plainly showing that 77 percent of breast cancer diagnoses and 84 percent of related deaths are in women older than 50, most of Israel’s health insurance funds cover the cost of triennial mammograms for their members. Not all members, however, take advantage of this.
“One afternoon last week, a 58-year-old woman came into the clinic, referred by a breast surgeon,” recalls Dr. Sklair-Levy. “She’d never had a mammogram in her life, and the tumor was over an inch in diameter. She’d been aware of it for months, but in her fear denied it. By the end of the day, we’d followed the mammogram with ultrasound and biopsy. Unfortunately, it was among the 40 percent we find positive.”
Hadassah’s breast-health team is extensive, including breast, plastic and reconstructive surgeons, diagnostic and medical oncologists, pathologists, radiation oncologists, gynecologists, psychiatrists, physiotherapists, nutritionists and clinical nurse specialists. In consultations, they mapped out a challenging six months of treatment for this patient, starting with aggressive adjuvant chemotherapy to shrink her tumor, surgery to excise it, radiology and more chemotherapy.
“This unfortunate woman is in stage three of the disease,” says Dr. Sklair-Levy. “Had she sought medical help even a year ago, the entire picture would be different. When tumors are detected in their beginning stages, the cure rate is over 90 percent.”
The woman is one of some 600 breast cancer patients newly diagnosed at Hadassah, a fifth of all annually diagnosed in Israel. Dr. Sklair-Levy and her staff test all these women. They also test several hundred more whose tumors are benign or come simply for screening.
“On an average day, we perform 30 to 40 mammograms, five to ten sonographies and two to four biopsies,” says Dr. Sklair-Levy. “We also do about five MRI examinations a week.”
With the sensitivity of the mammogram limited by breast density (dense tissue can hide results), many modalities can be necessary in a single patient.
“We’ll follow mammography with sonograms and breast examination, as well as one of various types of biopsy, surgical or nonsurgical, and sometimes MRI imaging,” explains Dr. Sklair-Levy. “MRI has an accuracy rate of up to 98 percent in detecting even very tiny breast lesions, in contrast to ultrasonography and mammography, which pick up only 70 to 90 percent of tumors and don’t show their extent.”
While super-accurate, MRI has a disadvantage: Its magnetism affects the steel biopsy needle, making biopsy impossible during scanning. But after scanning, it is not always possible to find the tiny clusters of cancerous cells picked up by MRI.
Until recently, the best we could tell patients in whom MRI found very small tumors was ‘Come back in three months,’” says Dr. Sklair-Levy. “By then the tumor would probably grow sufficiently to show up on ultrasound, allowing a biopsy that told us whether it was malignant, benign or hormone reactive. This consigned women to months of anxiety and delayed treatment in a disease in which time can make the difference.”
In late 2003, Dr. Sklair-Levy introduced into Israel a new diagnostic technology that enables breast tumors as tiny as two-tenths of an inch in diameter to not only be located by MRI but also biopsied during scanning. The technology is known as an MRI-guided breast biopsy coil.
“With early diagnosis so closely related to outcome in breast cancer, this biopsy capability has changed the whole field,” says Dr. Sklair-Levy. “Used primarily in women with dense breast tissue, with palpable breast masses and for those at high risk for breast cancer, we perform over 200 such examinations a year.“
The newness and rapid development of technology is part of what attracted Dr. Sklair-Levy to breast imaging. “There’s always something different, something to learn, something to contribute,” she says. “But at the same time, it’s an area in which you have a close relationship with your patients and where your intervention can be critical—which is why I chose medicine in the first place.”