OncoLink Talks with President and CEO Susan Braun and Director of Grants Anice Thigpen, PhD
Two years ago this month, the Dallas, Texas-based Susan G. Komen Breast Cancer Foundation – known as the nation's largest private funder of breast cancer research – announced the addition of a new category to its National Grants Program: breast cancer imaging technology. Since its founding in 1982, the Foundation has funded basic, clinical, and translational research and many projects in the areas of breast health education and breast cancer screening and treatment. Thanks to a matching grant from the Joseph Drown Foundation, Komen was able to start awarding two-year, $250,000 grants to researchers seeking better alternatives to conventional mammography, such as digital mammography, positron emission tomography scanning (PET), magnetic resonance imaging (MRI), and ultrasound. Eleven such grants were awarded in 1999 and eight more for 2000.
In fact, so far this year, the Komen Foundation has awarded more than $2 million for projects in this new category of imaging technology. In addition, more than $3 million has been awarded this year to grant recipients studying novel approaches to identifying early breast cancer and pre-cancerous abnormalities. President and CEO Susan Braun notes that the new grant category, combined with an increased emphasis on projects devoted to improved screening and early detection in the grants program as a whole, provides a way for the Foundation to fulfill its mission more completely.
"We looked at our mission statement, which defines our focus on the four areas of breast cancer research, education, screening, and treatment," says Susan Braun. "Since we'd always been involved in promoting screening and funding for screening at the grassroots level, we felt we needed to make sure that we're looking at and investing in the right modalities. So it's fitting that we would invest more in this type of research."
The Foundation's reasoning appeared to receive a boost from the results of the Canadian National Breast Screening Study, published in the September 20th issue of the Journal of the National Cancer Institute. Canadian researchers reported that the addition of mammography to clinical breast exam did not decrease mortality among a group of 50- to 59-year-old women screened in the 1980s. Many U.S. researchers have challenged the study's validity, raising questions about how the women were selected, the quality of mammography screenings in the 1980s, and the training of the doctors who read them. Susan Braun says that she and her colleagues understand and even share some of these concerns, but they also feel that the results emphasize an important reality: mammography is an imperfect technology.
"We don't ever want to send out the message that when there is a randomized clinical trial like this, you can just ignore it," Braun stresses. "As rational people, you can't just blow it off. There are interesting questions that it raises."
"At the same time, we don't feel that what's there is strong enough on its own," she adds. "There's probably not going to be one study of any kind that is going to provide the definitive statement on mammography." Thus, the Komen Foundation stresses that it is still essential that women receive annual screening mammograms, starting at age 40, even as researchers search for better methods of detecting and diagnosing breast cancer.
"Digital mammography, ultrasound, MRI, PET – there are likely benefits to each and situations in which each would be appropriate," says Braun. More information from research is needed to make these determinations, and the Komen Foundation hopes that its funding will help to further this work.
Many of the Komen-funded researchers working in these areas were in Washington, DC, last month for the Foundation's Fourth Annual Mission Conference. The Conference is designed to provide researchers with an opportunity to "come out of the lab" and communicate with patients, survivors, and doctors who are dealing with breast cancer. Information about the Conference, as well as a list of 1999 grantees in the imaging technology category, can be found on the Komen Foundation's Web site at www.komen.org. (A list of 2000 grantees will be added shortly.)
Anice Thigpen, Ph.D., Director of Grants at The Susan G. Komen Breast Cancer Foundation, sees the addition of the imaging technology category as a way to work more efficiently towards the development of "unambiguous technologies."
"There's a real need for unambiguous technologies – technologies that will allow us to see something and know that its real, so we can get rid of unnecessary biopsies," Thigpen says. She adds that the Komen-funded research projects that are working toward this goal can be divided into two categories: short-term and long-term.
Short-term projects have the more immediate goal of actually improving mammography itself, which is basically just an x-ray of the breast. Digital mammography is one way to do this: it improves the read-out by producing digital images that can be manipulated, unlike the standard fixed images on film. Researchers are looking at ways that computer technology can be used to enhance the image, thereby increasing accuracy. Dr. Thigpen cites the example of a project that received funding in 1999, entitled "Gray Scale Image Processing for Digital Mammography," which is in progress at the University of North Carolina-Chapel Hill. These and other grants, says Thigpen, are looking for a "quick return" – that is, ways to improve on the existing technology as soon as possible.
Longer-term projects are looking at other kinds of breast imaging technologies besides x-ray mammography, such magnetic resonance imaging (MRI) and positron emission tomography (PET). Like x-rays, MRI creates images of the body's structures. These images are the result of radio signals emitted by specific atoms in a person who is lying in a strong magnetic field. PET scanning is different because it does not just create images of interior structures; rather, it can actually provide information about the processes taking place at the cellular level. Researchers are developing radioactive "tracers" that are processed differently by cancer cells and normal cells and therefore can highlight cancer cells on a scan. This holds forth the promise of getting better information about a suspected breast cancer sooner.
"Within at least the next ten years," says Dr. Thigpen, "I think we will get away from x-ray and towards these more sophisticated imaging technologies."
Komen's imaging grants for 2000 are designed to help move us closer to that goal. For example, researchers at Massachusetts General Hospital in Boston and the University of Pennsylvania in Philadelphia are investigating MRI as a breast imaging tool. Another researcher at the University of Illinois at Chicago is investigating the possible use of radiolabeled Herceptin to improve breast cancer imaging. Herceptin is a monoclonal antibody that specifically targets breast cancer cells that produce a protein called HER2 (or HER2/neu). Making the antibody visible on an imaging test could help distinguish cancer cells from normal cells much more accurately. Another Komen-funded researcher at the University of South Florida is evaluating PET scanning as an alternative to biopsy for staging breast cancer. Being able to diagnose lymph node involvement without surgery would represent a major advance. Still other researchers are seeking new "radiotracers" that will be taken up by breast cancer cells and make them easily visible on a scan.
"Basically, this technology has the potential to light these tumors up like a lightbulb," Dr. Thigpen explains.
Outside the imaging technology category, she adds, still other projects are trying to push the point of diagnosis back even earlier, before a tumor even has the chance to form. Many researchers are looking for early cell markers for breast cancer that could be picked up by a serum blood test. Basically, this would parallel the PSA (prostate-specific antigen) blood test now used detect the likely presence of prostate cancer, often at a very early stage. Other researchers are looking at mammary fluid and cell samples as potential sources for improving early detection. For example, a Komen-funded researcher at The Johns Hopkins University is researching molecular assessment of ductal lavage fluid as a detection tool. "Lavage" involves washing the ducts to obtain a cell sample that can then be analyzed for abnormal changes, before a tumor even develops.
"You know, we would like to see the day when giving 10 cc's of blood and having a ductal lavage would become the screening process for breast cancer," Dr. Thigpen notes. "We know that the earlier the detection, the better the prognosis. At some point you push back detection so far that it becomes a tool for prevention."
In the short-term, the Komen Foundation hopes that the research it funds will lead to a better prognosis for women who develop breast cancer. But over the long term, it hopes to move closer to prevention, which Dr. Thigpen aptly describes as the "holy grail" of breast cancer research.
Despite the incredible promise of such research, mammography is still the best screening tool now available. Its imperfections should not be seen as a justification for not taking advantage of it, says Komen President and CEO Susan Braun. She says that she sees financial and informational obstacles keeping women from getting annual screening mammograms.
"There are access issues," says Braun, "and more women need information about low-cost mammography." Komen's 1-800-IMAWARE toll-free information line and its affiliate programs throughout the nation are working to match women with lower-cost options. She admits that cost is likely to remain a pressing issue as newer and more expensive technologies are introduced. The Foundation is currently supporting a bill in Congress that would raise the reimbursement rate for digital mammograms.
"We realize we have to be fiscally responsible, but like most advocacy groups, we will push toward having coverage for any technology that seeks to improve outcomes," says Braun. "We will always be on that side of the equation."
She also believes that lack of information still keeps some women from having regular screening mammograms. "Some women don't want to be screened, and that is their decision," says Braun. "But we have to make sure that they have the right information about what screening is and what is does."
She adds that physician education plays a role in this, too. "We know that one persistent reason why women don't get mammograms is because their physicians don't tell them to!"
Braun says that the Foundation's high-profile awareness-promoting events, such as "Race for the Cure," "Shop for the Cure," and Lee Denim Day, provide a way for large numbers of the lay public to learn more about the disease and ways they can take action.
"We try to provide an array of means for people to get active," Braun notes. "And a lot of the money we've raised has come from organizations that would not normally fund breast cancer research" – such as Ford, Gillette, Yoplait, and Pier 1. In turn, these companies can get the message out to a larger number of people that would otherwise be possible.
"One of our central messages is that although each woman is at risk, we are better able to know what that means," Braun adds. "And we're better able to rule out lumps that are not breast cancer and find cancer earlier. We need to push the accelerator down, rather than let up. We need to keep the pressure high. And not just during October, but year-round."