Genomics: The Next Big Thing in Mining the Genome Women's Health: Communicating Breast Cancer Risk and Means of Prevention Oral Biology: The Mouth's Microbes Could Hold Clues to Early Cancer Detection Genetics: Rearrangement of DNA Shown to Cause Certain Lymphomas Structural Biology: Molecular Jumping Jack Shows Off Moves Minority Health: Drug Abuse and Bioterrorism Among Issues Raised by Minority Fellows The Summer Bookshelf: Recent Books by Faculty of HMS, HSDM, and HSPH Cloning Study Creates Tissues for Transplantation Heart Protection by Corticosteroids Bypasses Gene Regulation Anti-aging Mechanism Shown in Yeast, May Be Similar in People Proceedings of the HMS Faculty Council Actor Ford Named Global Environmental Citizen Portraits of HMS Women Faculty Leaders Unveiled Human Genome Chief Forecasts Blue Skies for Medical Genomics HOLLIS Gets New Look, Features Alpert Prize Winners Reveal Secrets of the Heart HMS Junior Faculty Receive Armenise Awards Biosecurity Conference Addresses Bioterrorism Threat Barger Speaker Urges Advocacy New Howard Hughes Investigators Chosen for Patient-oriented Research HMS Presents Faculty Awards Honors and Advances Where Have All the Surgeons Gone? Front Page

WOMEN'S HEALTH Communicating Breast Cancer Risk and Means of Prevention Helping Women Make Better Decisions Thirty or more years ago, it was common for women suspected of having breast cancer to receive a one-step procedure in which a biopsy was taken, and if cancer was found, a radical mastectomy immediately followed. A patient would undergo this procedure not knowing if she even had cancer, much less if she would wake up with her breasts intact. These days, not only are there better treatment options, but patients have become much more involved in decisions regarding screening, diagnosis, and treatment of breast cancer. But this increased patient involvement creates new challenges for clinicians. No longer the sole decision-makers, they must now guide patients through different options and help them weigh risks without clear answers. Glorian Sorensen (left) believes that recent controversies about breast cancer warrant better communication about risk. Suzanne Fletcher (right) says that breast cancer risk can be misleading if the numbers are not put in perspective. (Sorensen photo by Richard Chase; Fletcher photo courtesy of Dana-Farber/Harvard Cancer Center) To address some of these issues, the Harvard Center for Cancer Prevention at HSPH and the Dana-Farber/Harvard Cancer Center's Risk Reduction Program held a workshop May 10 titled "Communicating Breast Cancer Risk: Challenges and Future Directions." Glorian Sorensen, HSPH professor of health and social behavior and an organizer of the workshop, said that its goal was to bring some of the latest concerns about breast cancer risk to the table and "to highlight that this is a communication issue." The speakers represented a variety of perspectives on risk--academic, epidemiological, clinical--as well as voices from the media and patient advocates. Sorensen and her collaborating organizers are seeking ways of communicating information about breast cancer risk and prevention to help women make better decisions. A Personal Choice Suzanne Fletcher, HSPH professor of epidemiology and HMS professor of ambulatory care and prevention at Brigham and Women's Hospital, commented on some of the controversies over screening mammography that have come to the public's attention. The benefits of mammography have been contested, especially for younger women, ever since it came into widespread use in the 1970s. A 1997 NIH consensus panel on breast cancer screening found inconclusive evidence either way on recommending screening for women in their 40s. The panel concluded that women should be provided the necessary information to decide for themselves whether to get screened. But groups such as the National Cancer Institute and the American Cancer Society continue to recommend regular screening for women in this age group. Now, Fletcher said, the idea that screening should be a woman's choice is spreading for all age groups; for instance, the National Breast Cancer Coalition, an advocacy group, suggests that women and their physicians make individual decisions about screening. Another aspect of the issue erupted into the popular press last year when a Danish meta-analysis questioned the validity of past studies that found benefits of mammography. After years of being advised by the medical community and the media to have regular mammograms, many patients are left wondering why anyone would argue against them. But the recent study helped reawaken public attention to an ongoing debate. Doubt still lingers about when early detection works, and it carries its own risks, including false positives and overdiagnosis. Mammography allows for the detection of very small tumors; according to the logic of early detection, these tumors can be treated or removed before they progress. The hitch is that it is still unclear when and if these small cancers will become malignant, so finding them early may subject patients to needless treatments. At the workshop, Gina Kolata, a reporter for the New York Times, talked about covering breast cancer over the past few years. She found that even when she reported on the NIH consensus and subsequently the latest controversy over screening, "patients still think it's better to get mammograms." These observations are supported by initial studies led by Larissa Nekhlyudov, HMS research fellow in ambulatory care and prevention, a workshop participant. Nekhlyudov is interested in the doctor-patient relationship and how women make choices about breast cancer screening. In conducting interviews with women about their views on mammograms, she found that most women had a fear of breast cancer and thought that early detection might help extend their lives. They "were really not aware of any major risks related to screening," Nekhlyudov said. Most of these women were getting information from personal contacts and the media, not their doctors. A recent study by a group from Oxford University found that newspaper coverage tends to overrepresent the benefits of screening. Misunderstanding the Risks Fletcher pointed out that the risks of screening that have been mentioned in the press are only a small part of the risk information that women should be given. Women need to know their risk of developing breast cancer, their risk of dying from it, the benefits of screening, and its risk of harm. For instance, many women are unaware that "at least half of women who get invasive breast cancer will survive regardless of screening," Fletcher said. Furthermore, the overwhelming risk factor for breast cancer is age, which is why it has been so difficult to determine whether younger women should be screened. In Fletcher's experience, young women tend to overestimate their risk of developing breast cancer, while older women are not always aware that they are at a greater risk. Jennifer Dacey Allen, instructor in health and social behavior at HSPH and a workshop participant, has helped design interventions to increase the use of mammography screening and has recently begun studying why some women do not get follow-up care after an abnormal mammogram. Allen believes that the medical community often focuses on the science of risk rather than trying to understand how women interpret risk and make choices about their health. "What do women understand when they're told they have an abnormal mammogram?" she asked. "We need to understand how women are perceiving this information." In addition to the risks of screening, the workshop discussed the risks patients must weigh when undergoing testing for genetic susceptibilities to breast cancer, as well as treatment choices for the disease. A recent study of women with breast cancer found that the vast majority of them preferred to take an active or shared role in their treatment decision-making rather than leave the decision to a doctor. However, this increased autonomy can create problems if patients are misinformed or have a skewed sense of risk. --Courtney Humphries