Note: Written by NBCF Chief Program Officer, Douglas Feil
It’s been over a decade since Malcolm Gladwell published his bestselling book, Outliers: The Story of Success. The book debuted at #1 on The New York Times Bestseller List in December 2008, just a couple months after I started working at the National Breast Cancer Foundation. At the time, Outliers was often referenced in business meetings, strategy sessions, and conferences.
In Outliers, Gladwell introduced “The 10,000 Hour Rule”—the idea that it takes a person 10,000 hours of practice, dedication, or attention to a thing in order to master it. According to Gladwell, “To become a chess grandmaster also seems to take about ten years. (Only the legendary Bobby Fisher got to that elite level in less than that amount of time: it took him nine years.) And what’s ten years? Well, it’s roughly how long it takes to put in ten thousand hours of hard practice. Ten thousand hours is the magic number of greatness.”
So here I am, over a decade later. I’ve done this thing, put in my hard practice for well over 10,000 hours. I’ve given the topic of breast cancer this magic number of greatness, and yet the idea of mastery over breast cancer seems as foreign to me as the day I started. In fact, as I’ve looked over the mysteries of breast cancer, one thing I’ve learned is that when one layer of insight or knowledge is peeled back, another thousand layers unfold.
I don’t know that I’ll ever master breast cancer, but I am not alone in my uncertainty. After all, there is still no cure for this disease and breakthroughs are often not as impactful as the myriad of headlines suggest. However, to say that I have not gained some level of expertise would be untrue.
I am now an expert in many of the things that matter most—things like uncertainty. I am an expert in what it’s like to lose control, to not be able to fix a problem right in front of you, an expert in feeling helpless.
I am an expert in the pain of loss. I know and understand that little ripple of fear and dread that seems to clamber from an unknown, secreted space within our consciousness. I know it so well that I know it doesn’t take 10,000 hours of practice, but just a single moment. Perhaps the moment a mother, my own even, depleted of platelets, slips on the bathroom floor. It only takes a second, really. And it’s important that I’m an expert in these things because I can’t help what I don’t know.
I am also an expert in hope. The kind of hope that doesn’t make sense, the kind that seems almost miraculous in its ability to strengthen and repair the most heartbroken. I am an expert in finding the silver lining in the darkest cloud—a dying patient that found a mother to adopt her child after her death, an early stage breast cancer patient afraid of bankrupting her family, then finding financial support, undergoing treatment and surviving, a husband who simply wanted to know the safest way to cuddle with his dying wife.
The future of breast cancer is uncertain, mysterious, and will require mastery that exceeds all the rules, and I do have an expert-level amount of hope. According to the American Cancer Society, the mortality rate for breast cancer has declined by more than 40% since 1991. The progress is attributed to improvements in early detection. Mortality rates of breast cancer continue to decrease, and I think the progress made will continue to compound in the years to come.
In the future, medicine and our understanding of how to treat and diagnose breast cancer will probably flow through a pool of artificial intelligence (AI). Cancer is one of the most complex problems of mankind, and what makes it so complex is its ability to trick and deceive our own cells to turn on us and disrupt the very blueprint of our existence. With AI, cancer’s algorithm may have met its match.
In the U.S., each state is responsible for collecting cancer data through a cancer registry. The amount of data collected is so vast it would be impossible to be thoroughly utilized by researchers and experts to improve outcomes without AI. With AI, this data can be analyzed in a fraction of the amount of time and key learnings can be interpreted to allow more timely and precise treatment recommendations for cancers.
Scientists are also combining behavioral science with AI technology to overcome screening hesitancy and more precisely target populations that may not understand or have access to early detection education. Using AI to target specific groups has already increased screenings rates in areas of low intake.
I’m cautiously optimistic about the future of immunotherapy—a cancer treatment that boosts the immune system to help fight tumors. I’m optimistic because of stories like former President Jimmy Carter, whose metastatic melanoma went into remission after receiving a breakthrough immunotherapy treatment. However, immunotherapy breakthroughs for breast cancer patients have progressed slower.
In recent years, new immunotherapy drugs were approved for patients with late stage triple negative breast cancer. These drugs block the PD-L1 protein on some tumor cells, which triggers the immune system to attack and shrink the tumor. Triple negative breast cancer patients desperately need more targeted therapies, as they have historically had few options outside of the traditional array of surgery, radiation, and chemotherapy.
Breast density has been a hotbed issue for many years. Women with dense breasts are slightly more likely to develop breast cancer, and it’s harder to spot tumors because the tissue is the same color—white—on traditional mammograms. New and improved 3D mammography is helping find tumors earlier, and breast MRIs and ultrasounds have shown to help find cancers masked by dense breast tissue.
New technology, however, requires improved awareness and regulation. Some states enacted laws, such as Henda’s Law in my state of Texas, that require mammography providers to notify all women with dense breast tissue that the accuracy of their mammograms is less than that of women with lower breast density and that they may benefit from “supplemental screening” in addition to their annual mammogram. However, these kinds of regulations are not standardized across the U.S.
The FDA recently proposed an amendment to the Mammography Quality Standards Act of 1992, a law that ensures that mammography facilities across the U.S. are providing quality services. One of the proposals will help improve communications between doctors and patients regarding breast density and increase access to higher quality screening options for these patients.
According to the FDA Principal Deputy Commissioner Amy Abernethy, M.D., Ph.D., “Given that more than half of women over the age of 40 in the U.S. have dense breasts, helping to ensure patient access to information about the impact that breast density and other factors can have on the risk for developing breast cancer is an important part of a comprehensive breast health strategy.”
The future will be improved screening results for patients with dense breast tissues and more cancers found in the earliest, most treatable stage. I believe future lives will be saved by these measures.
The future of breast cancer is research. We need more well-funded research and more targeted therapies for breast cancer. We especially need breakthroughs in metastatic disease, but also in screening and early detection. Researchers in California recently launched the Women Informed to Screen Depending On Measures of Risk Trial (WISDOM). This trial will introduce precision medicine to the screening process. We know that each breast cancer patient is unique, so undergoing genetic testing could guide when and how often a patient utilizes screening services to ensure the best chances of early detection.
According to the National Cancer Institute, “The goal of the WISDOM trial is to determine whether risk-based screening is as safe as annual screening (that is, no advanced-stage breast cancers compared with the annual screening group) and less morbid (that is, involves fewer mammograms and biopsies).”
Genomic analysis research is also being used to determine which patients will benefit from invasive treatments like chemotherapy and which patients will not.
A diagnosis of triple negative breast cancer means that the three most common types of receptors known to fuel most breast cancer growth–estrogen, progesterone, and the HER-2/neu gene–are not present in the cancer tumor. Breast cancers that are positive for hormone epidermal growth factor receptor 2 (HER-2), estrogen receptors (ER), and progesterone receptors (PR) all have targeted therapies that can dramatically extend survival, but triple negative does not. We desperately need targeted therapies for triple negative breast cancer and researchers are working around the clock to develop new drugs for this breast cancer subtype.
We live in a don’t-look-back world, but with breast cancer, we have to look at it all—the past, present, and future. And we are surrounded by disparity in healthcare. Women across America are dying of often treatable breast cancers because they lack access to early detection services and quality and timely care. For example, African American women have a 40% higher mortality rate of breast cancer than white women in the U.S. The future of breast cancer will be dim if we improve technology, research, and regulation, but do nothing to increase access or address biological differences that may increase the risk and mortality of breast cancer.
We have to find a solution to rising healthcare costs and the need for quality care. We have to ensure that all women in America have access to quality screening regardless of their ability to pay. Also, this must extend to treatment. We have many examples of patients that present a suspicious finding on a mammogram, but choose not to follow-up because of work-up costs, which often exceed thousands of dollars. We can’t offer free screening and expect patients to be able to afford follow-up biopsies or treatment.
We must increase patient navigation services. Every facility that screens, diagnoses, or treats patients for breast cancer should have a patient navigator or have access to one. Patient navigators work to decrease the wait times between screening, diagnostic, and treatment and eliminate barriers to timely care—language, cost, fear, and transportation. Without patient navigators working within the complex cancer care systems across America, patients that face these barriers are less likely to overcome and less likely to survive a breast cancer diagnosis.
Whatever the future holds, I know it is going to get better for women facing breast cancer. Improvements in research and technology, greater access to better screening methods, and an overall decrease in the mortality rate—these are the building blocks of what I see as a horizon of hope.
NBCF helps break down the barriers to health access & equality for all regardless of race, sexual orientation, disability, or age so that no one navigates breast cancer alone. No matter where you are in your journey, NBCF can help. Click here to learn more about NBCF’s programs.
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