Tag breast cancer

How Did the Month of Halloween Become Breast Cancer Awareness Month?

abhollingsworth Leave a comment

(Originally posted October 31, 2019, then yearly in October)

Date for this post: Oct 31, 2025

Mammography schedules are jammed in October. It’s hard to work in the callbacks and biopsies. Everyone is pressured to get it done before the looming Holiday Season. And if we find cancer, it spoils that festive stretch from Thanksgiving to Christmas, Hanukkah, or whatever, through New Years…not to mention the fact that deductibles were met at the time of the mammographic screening, but then in January, it starts over again as cancer care continues. Ugh! How did we ever get here?

Prior to 1980, there were no pink ribbons, no races, no walks. There was very little awareness and breast cancer was not discussed in polite society. The fact that Shirley Temple Black (breast cancer in 1972), Betty Ford (1974) and Happy Rockefeller (diagnosed 2 weeks after Ford in 1974) made their diagnoses public was shocking (and trailblazing). And when the Susan Komen Foundation was established in 1982, newspapers resisted using the words “breast cancer.” As late as 1993 when we opened our doors at the University of Oklahoma Institute for Breast Health, there were complaints about our signage with its “irreverent” word BREAST plastered right there in public.

Let’s go back to the 1940s when Susan and Nancy Goodman were sisters growing up in a well-to-do Jewish family in Peoria, Illinois. Who could have conceived of the notion that both girls carried a mutation in BRCA-1 that would lead to breast cancer in the both of them? After all, it would be more than 50 years before the launch of commercial testing of BRCA-1 and BRCA-2.

susan komen and nancy brinker

(Susan Komen on the left; sister Nancy Brinker on the right)

Susan grew up to be the “darling of Peoria,” a beauty queen and local model. She would enter a disastrous first marriage (groom collapsed at the wedding for starters), followed by a second marriage to Stan Komen who would run a liquor store – Stan’s Wine and Spirits – in Peoria until his retirement in 2014.

At age 33, Susan felt a breast lump. Not a good thing in 1977, on the eve of a revolution about to occur in the management of breast cancer. 1977 was, however, the peak time of enthusiasm for “subcutaneous mastectomies” with the newfangled breast implants for reconstruction…sometimes patient-driven, sometimes surgeon-driven and sometimes both. Pain, cysts, “fibrocystic disease,” you name it, then cough up the money, and surgeons would perform the “scoop out” procedure with implant reconstruction. Some women were very happy with their result. Many were not. And for some, considerable amounts of breast tissue remained in place. Nevertheless, no one at the time conceived of using the procedure for treating cancer — except for Susan’s surgeon who had been recommended by her family physician in Peoria.

After performing subcutaneous mastectomy for Susan’s cancer, the surgeon pronounced her cancer-free, a tad premature since she developed positive nodes shortly thereafter and systemic metastases as well. After treatment at both the Mayo Clinic and M. D. Anderson, she was still left with chest wall recurrences and died 3 years later in 1980 at the age of 36. Given the aggressiveness of this tumor, it is hard to lay blame on the unusual subcutaneous approach used for local control, but it is noteworthy nonetheless.

Meanwhile, younger sister Nancy had moved to Dallas where she became a buyer for Neiman Marcus, and then, in 1981, she became the bride of Norman Brinker, the restaurant magnate who founded Steak and Ale, et al, (now Brinker International) and is credited with the development of that omnipresent dining staple – the salad bar. With her new financial stature and a deathbed promise to her sister Susan, Nancy Brinker founded the Susan G. Komen Breast Cancer Foundation in 1982, a mere 2 years after Susan’s death. The foundation became intimately linked to Dallas as a result of Nancy’s new home, not Susan’s home in Peoria (although Peoria did become a site for a “Komen Breast Center,” a nationwide network concept of screening centers that never happened.)

The first Race for the Cure took place in Dallas, Texas with 800 participants in 1983. The rest is history. I attended the first race in Oklahoma City (1989, as I recall) where participants raced around the track at Remington Park. Pink ribbons were not introduced until 1991, and though several groups lay claim to the pink revolution, I’m pretty sure it was a Komen innovation.

One year after that first Race for the Cure, Nancy Brinker was diagnosed with breast cancer. She underwent unilateral mastectomy and later contralateral prevention, even though her BRCA-1 mutation was not confirmed until 2006.

Initially, the sole agenda for Komen was to flood the country with high quality screening mammography. This drew some objections, including one prominent breast surgeon, the late Susan Love, who broke ranks with the movement by clarifying that mammography is not a “cure,” and that we needed to be thinking more about a true cure and a “post-mammographic era.” Eventually, Komen expanded its scope to all types of breast cancer research.

Nevertheless, the growth of the Race for the Cure was phenomenal, taking place in a parallel fashion to the breast cancer diagnosis and treatment revolution that was well underway. It is estimated that, today, over 1.5 million participants raise money through one of several outreach programs sponsored by Susan G. Komen (several name changes of the foundation have occurred over the years, but Susan’s name is always there). Politics, of course, wormed its way into the activities of Susan G. Komen and eventually Nancy Brinker resigned as CEO.

Back to Breast Cancer Awareness in the spooky month of October. Around 1985 or 1986, the American Cancer Society teamed up with a pharmaceutical company that later became Zeneca, then AstraZeneca, announcing October as National Breast Cancer Awareness month. Zeneca was criticized for self-serving interest since they manufactured pharmaceuticals used for breast cancer. But they had, in fact, done their own internal audit on employees, showing that it was cheaper to screen with mammograms for an early diagnosis than to do nothing and pay for treatment of more advanced disease.

At this same time, the famous (or infamous) Breast Cancer Detection Demonstration Project was reporting results indicating that massive screening of the general population in the U.S. was both feasible and effective. The BCDDP was sponsored by the American Cancer Society and the National Cancer Institute, both organizations riding the waves of the War on Cancer legislation signed by President Nixon in 1971. So, by the mid-80s, the policy makers were wildly enthusiastic about general population screening with mammography, and it was a case of “full steam ahead.”

Still…why October?

I’ve not been able to nail down the exact details surrounding October as Breast Cancer Awareness Month, but I have a theory — a link between the rapid rise of the Susan G. Komen Foundation and the proclamation about October made by the American Cancer Society. I think the answer might be found by looking at Susan Goodman Komen’s birthday – she was born on October 31, 1943. She would have been 82 this Halloween.

Will $2 million Revolutionize Breast Cancer Screening?

abhollingsworth Leave a comment

The breast cancer screening “industry” in the U.S. is sometimes pinned to a 6-8 billion dollar figure that is supposed to reflect high cost and low gain. That is, few lives saved for such an impressive price tag. And when compared to $6 billion, $2 million seems piddly. But it’s $2 million that has been awarded by the National Cancer Institute in a R-01 grant to my collaborators (“inventors”) and me to see if we can revolutionize how we screen for breast cancer.

First, some background. Here sits a breast MRI machine, less than 20 feet from my office. I have to consider, every day, that if we were able to screen the entire population with this device, very few women would ever die of breast cancer. So, while everyone waits for a “breakthrough” to radically alter the treatment of breast cancer, I’m looking at that breakthrough in the past tense. It’s already been done. Yet, many experts either ignore it or criticize it.

And for sure, it’s not the long term answer – the final answer will come when we are able to cure or control metastatic breast cancer 100% of the time. Or, alternatively, when we can immunize against cancer, so that the disease becomes an historical relic. Then, we won’t need to screen. Early diagnosis won’t be required. But that day is not yet on the horizon. For the next 50 years, at least, early diagnosis through screening will be important. And, we could do so much better than the status quo with the technology currently at our disposal. What a shame that it is nearly impossible to use. Strict guidelines and stricter insurance companies make it difficult to identify patients who qualify for MRI screening.

Currently, women qualify only when they are at very high risk for breast cancer. Sounds both obvious and justifiable, but in fact, it’s an inefficient approach piggy-backed onto inefficient baseline screening. First of all, it excludes the vast majority of women who are headed toward breast cancer, the 80% who do not have a family history. Then, under current guidelines, women qualify on the basis of “lifetime risk,” an unwieldy number that declines as you age, given that you are “passing through” your risk. So, young women with risks qualify more easily, but as time goes on, when individuals actually enter the danger zone where incidence peaks, their remaining lifetime risk may not allow them to be screened with MRI.

Risk-based screening is on the tip of everyone’s tongue, but for me, it leaves a bad taste even though my area of expertise is breast cancer risk assessment. Why? Because the difference in cancer yields between very high-risk women vs. normal-risk women is not great enough to warrant completely separate approaches. If you screen 100 women with MRI who have already had a normal mammogram, you will find 1 cancer in a population of “normal risk” women. If you screen 100 women at the very highest level of risk, e.g., BRCA-positive women, you will find 3 cancers. All that work to find 3 cancers instead of one.

My point is this: research should focus on how to identify women that have mammographically-occult breast cancer on the day of the negative mammogram, NOT using the surrogate of breast cancer risk spread out over a lifetime. For 20 years, my only idea to make this happen has been through a low cost screening blood test that would tell you to proceed with MRI if mammograms were negative. And, I am recently encouraged by new developments in this area, and will be writing about it more in the future.

But I’ve always been haunted by another fact, well-known to all breast radiologists, but seldom discussed. Often, when you diagnose breast cancer, you can look back one year earlier and see a subtle change in the density level in the area where cancer has recently been diagnosed. In fact, so many attorneys were taking advantage of this, and successfully swaying juries into rendering guilty verdicts against radiologists, that a group of experts wrote an article on the topic, admitting that 58% of the time, you can detect “something” happening in a zone where cancer will be diagnosed 1-2 years later. Yet, these changes are too minor to hold the radiologist accountable. If breast radiologists called back everyone with such subtle changes for diagnostic work-ups, then they would be calling back the majority of patients being screened.

The article was designed to address the absurd standard to which radiologists were being held by the courts, not simple perfection, but prescience beyond perfection. But when I first read the article, my “take home” message was entirely different. What if those women had undergone breast MRI? I suspect nearly 100% would have been positive for cancer. But again, you can’t do MRI on all those with such subtle changes. Or can you?

One year ago, a publication caught my eye in The Breast Journal, where an accomplished computer scientist (Bin Zheng, PhD) and his mentor (Hong Liu, PhD) had been working on image analysis through computers in the detection of subtle differences in the comparison of one breast to the other, and over time. Using their invention, they reported being able to find women at nearly 10-fold short-term risk for breast cancer based on mammographic density changes. This is not CAD (computer-assisted diagnosis), already in current use where specific lesions are identified by the computer. This is a “second line” computer analysis, an “ultra-CAD” if you must, identifying changes after routine CAD has “signed off” on normal mammograms.

It was a brilliant approach, and my mind raced back to the 58% who have subtle changes in the year(s) prior to diagnosis. This “ultraCAD” would serve the same purpose as a screening blood test, that is, in the efficient selection of patients for MRI, not based on future long-term risk, but based on the high probability of a current malignancy missed by mammography.

And to my surprise, these computer scientists were working out of an Advanced Cancer Imaging Lab located only 30 miles away at my alma mater, the University of Oklahoma, Norman campus, only a short walk to the basketball arena and a short jog to the football field. As always, basic scientists need clinical collaborators in order to lift their inventions from laboratory into actual practice. I contacted Dr. Zheng, and we ran a quick pilot study that included 30 patients with normal mammograms, but 5 of whom actually had cancer discovered on MRI. Dr. Zheng’s system identified 9 of 30 as “very high short-term risk,” and all 5 of the cancers were included in the 9. Had we used his system to select patients for MRI in the first place, we would have only performed 9 MRIs instead of 30 to find the cancers. This is efficiency. I won’t take up a lot of space here, describing what this means in terms of cancer yields on MRI, but in summary, if it works, 1) the cancer yields will dwarf anything ever accomplished through risk stratification, and 2) it will open up MRI screening to all women, not just the minority who have risk factors.

The National Cancer Institute seemed to agree that we may be onto to something. In July, 2015, the NCI awarded us over $2 million for a 5-year study that will involve approximately 10,000 breast images. In keeping with NIH policy, “Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number R-01CA197150. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.”

Our grant title is: “Increasing Cancer Detection Yield Using Breast MRI Screening Modality.” Breast MRI can detect more than 90% of breast cancers at an early stage, twice the number detected by mammography in head-to-head comparisons. While molecular biologists whittle away at the secrets locked inside the cancer cell, going for the eventual cure, it’s well past time to take full advantage of the miracle of multi-modality imaging, something invented in the past, yet presently offered only to a select few.