ONS Responds to Update on Breast Cancer Screening
Evidence regarding the benefits of mammography screening and breast self-examination has been conflicting, and recently announced guidelines from the U.S. Preventive Services Task Force further add to the dialogue about this important issue. The task force?s update recommends against routine screening mammography in women aged 40?49 and teaching breast self-examinations. This is a change from the previous recommendation developed in 2002 that recommended routine screening mammography in women aged 40?49 every one to two years and stated that insufficient evidence existed at that time to recommend or not recommend breast self-examination instruction.

ONS strongly supports the use of evidence-based research in clinical decision making. The ONS Position on Breast Cancer Screening was developed in 2006 and reflected the most up-to-date research at that time. In light of the new evidence, the ONS Board of Directors will review its position and consider the possibility of a revision of its statement. In the meantime, ONS stands by its position that "the benefits, risks, and potential limitations of breast self-exam, clinical breast exam, and mammography need to be discussed with each woman and tailored to her risk factor assessment."

Sharsheret, a national organization "Linking Young Jewish Women in Their Fight Against Breast Cancer", will provide a free teleconference on Tuesday, November 24th at 8:30 PM (EST), entitled, "New Breast Cancer Screening Guidelines: What Do They Mean For Me?". To register for the teleconference, e-mail events@sharsheret.org. Dial 888-479-6525 at the time of the conference to be connected. This may be a way to understand what your patients are hearing and give you tools to answer the many questions asked. We will continue to post helpful messages regarding the new screening guidelines as a way to support you in the care of your patients.

Read these statements about the screening recommendations by USPSTF to help form your opinion about breast health care recommendations.
www.cancer.gov (See NCI Bulletin sidebar);
www.breastcancer.org (See Research news: Panel puts off mammography...)
www.acr.org (See ACR News center)www.stopbreastcancer.org (National Breast Cancer Coalition: see "Screening")

This is a Breast Care SIG announcement regarding the recent USPSTF recommendations concerning screening measures for breast cancer:
The new recommendations of the United States Preventative Services Task Force (USPSTF) regarding screening mammography and early detection of breast cancer were released November 17, 2009. As breast care professionals, we know that screening modalities have been and will probably always be under scrutiny. Historically, examination of existing care is often the way we make positive changes for our patients and reassessment of patient care is always productive. At this time, we feel that more evidence supporting these new recommendations needs to be found and we want you to be aware of the newest information available at this time.
It is important to keep patient centered, individualized care at the forefront of our concerns in this time of change. It is also important to remember that these recommendations are based on health care statistics, not individual patient situations.
Please take a moment to review the articles below to familiarize yourself with these suggestions for change in health care. The VC will be updated as new information becomes available.
www.annals.org (Position Statements of USPSTF: Effects of Mammography Screening Under Different Screening Schedules: Model Estimates of Potential Benefits and Harms;SCreening for Breast Cancer: An Update for the US Preventative Services Task Force)
www.hemonctoday.com
www.cancer.org (American Cancer Society Responds to Changes to USPSTF Mammography Guidelines)
Also check sites such as www.Komen.org; www.youngsurvival.org; www.LBBC.org.

Have you ever considered using your writing skills to share information with your fellow SIG members? The Breast Care SIG newsletter is looking to share fresh ideas and information with our membership. It's a great way to get published. Contact Alisa at alisaesp@consolidated.net for more information and guidellines for articles.

Nurses who are ONCC-certified can display their credentials with an OCN, CBCN, AOCNP, or AOCNS pin. Each pin is available in sterling silver or gold filled, with your choice of a black enamel and burgundy enamel finish. Each pin costs $34.00 plus shipping and handling. To order, call ONCC at 877-769-6622. To see examples of some of the pins access www.oncc.org "awards and credentials".

This is a great study to read! Access it at http://www.nature.com/nature/journal/v461/n7265/full/nature08489.html
Shah, SP et al.(2009) Mutational evolution in a lobular breast tumour profiled at single nucleotide resolutionNature 461, 809-813.
I am attaching the TAKE HOME message and Commentary from Axel Grothey, MD

Supplementary editorial provided by OncologySTAT

TAKE-HOME MESSAGE
In this study, Shah et al revealed the evolutionary nature of the tumor genome during progression of a low-intermediate grade, estrogen-receptor?positive lobular breast cancer. Sequencing of tumor genomes and transcriptomes from the same patient was used to compare genomic changes that occurred over a 9-year period during which the tumor had metastasized.

Of the 32 nonsynonymous coding mutations found in metastatic cells, 19 were not present in the primary tumor DNA at diagnosis. In contrast, 11 of the 32 mutations were present in the primary tumor, signifying that the primary tumor itself exhibited genetic heterogeneity. Validation of 75 RNA editing events yielded 2 high-frequency nonsynonymous mutations located within the COG3 and SRP9 genes.

The results revealed that, not only was the primary tumor genetically heterogeneous, but also that a significant amount of genetic evolution had occurred during progression. Tumor protein translation was altered, as evidenced by changes in the DNA sequence and by modifications of RNA transcripts. It is unclear whether these changes were a consequence of radiotherapy or of tumor progression.


EXPERT COMMENTARY
Axel Grothey, MD, Associate Editor

Genetic instability, one of the hallmarks of cancer, not only leads to tumor cell heterogeneity, but it also contributes to various aspects of the malignant phenotype of cancer cells, as well as to the resistance of cancer cells to tumor-directed therapy. Differences in genetic markers and gene expression between primary tumors and metastases have previously been confirmed for specific genes and proteins, but genetic differences have not been determined on a genome-wide level due to technical limitations. As exemplified by the study conducted by Shah et al, the ability to sequence whole genomes of tumors within a short time frame allows us to obtain a better understanding of genetic factors that drive tumor biology in individual patients. Success in this area of research ultimately promises to open the door for the utmost individualization of therapeutic approaches in cancer.

Ductal carcinoma in situ (DCIS), the most common non-invasive lesion of the breast, presents unique challenges for patients and providers largely because the natural course of the untreated disease is not well understood. Because most women diagnosed with DCIS are treated, it is difficult to determine the comparative benefits of different treatment strategies versus active surveillance, meaning systematic follow-up. An independent panel convened by the NIH urged the scientific community to identify appropriate biomarkers and other prognostic factors to better predict the risk of developing breast cancer.

"Instead of treating all women diagnosed with DCIS, we need to determine which individuals are likely to develop invasive breast cancer and which will not," said Dr. Carmen Allegra, panel chair and Chief of Hematology and Oncology at the University of Florida. "If we could accurately predict this, we might save some women from undergoing unnecessary invasive treatments while achieving the same positive outcomes."

DCIS is a condition in which a spectrum of abnormal cells are found in the breast duct and have not spread outside the duct to other tissues in the breast. Since the advent of widespread screening mammography in the early to mid 1980's, rates of DCIS have increased sharply. It is estimated that more than one million U.S. women will be living with a prior diagnosis of DCIS by 2020.

Despite the connotations associated with the term carcinoma, DCIS is associated with ten-year survival rates close to 100% when treated with currently available therapies. These include breast-conserving surgery (local excision, with or without radiation), removal of the breast (mastectomy), and/or tamoxifen. It is important to stress that each of these treatment options has physical and emotional impacts to patients and should be weighed accordingly. The panel recognized that there are relatively few reliable data on the comparative effectiveness of both diagnostic and therapeutic options in DCIS.

To improve our understanding of this complex disease, the panel recommended efforts to ensure detailed collection of clinical, pathological, imaging, and molecular data about DCIS using standardized reporting measures, annotated specimen repositories, and multicenter databases.

The panel emphasized the importance of patient preferences and recommended improved communication between patients and providers, and serious consideration of new nomenclature that more closely reflects the excellent survival rates for this condition.

Efforts to improve communication would also include further development of formal decision aids. Such tools would reduce misinformation and improve understanding of a DCIS diagnosis and the risks and benefits of various treatment options. Individuals who have DCIS should have access to the best possible information and guidance to aid them in making care decisions that reflect their unique circumstances, perspectives, and preferences.

The panel's updated draft state-of-the-science statement will be available later today at http://consensus.nih.gov. The conference was sponsored by the NIH Office of Medical Applications of Research and the National Cancer Institute along with other NIH and Department of Health and Human Services components. This conference was conducted under the NIH Consensus Development Program, which convenes conferences to assess the available scientific evidence and develop objective statements on controversial medical is sues.

The 14-member conference panel included experts in the fields of oncology, radiology, surgery (general and reconstructive), pathology, radiation oncology, internal medicine, epidemiology, biostatistics, nursing, obstetrics and gynecology, preventative medicine and population health, and social work. A complete listing of the panel members and their institutional affiliations is included in the draft conference statement. Additional materials, including panel bios, photos, and other related resources, are available at http://consensus.nih.gov/2009/dcismedia.htm.

In addition to the material presented at the conference by speakers and the comments of conference participants presented during discussion periods, the panel considered pertinent research from the published literature and the results of a systematic review of the literature. The systematic review was prepared through the Agency for Healthcare Research and Quality Evidence-based Practice Centers (EPC) program, by the Minnesota Evidence-based Practice Center. The EPCs develop evidence reports and technology assessments based on rigorous, comprehensive syntheses and analyses of the scientific literature, emphasizing explicit and detailed documentation of methods, rationale, and assumptions. The evidence report on diagnosis and management of DCIS is available at http://www.ahrq.gov/clinic/tp/dcistp.htm.

The panel's statement is an independent report and is not a policy statement of the NIH or the federal government. The NIH Consensus Development Program was established in 1977 as a mechanism to judge controversial topics in medicine and public health in an unbiased, impartial manner. NIH has conducted 119 consensus development conferences, and 32 state-of-the-science (formerly "technology assessment") conferences, addressing a wide range of issues. A backgrounder on the NIH Consensus Development Program process is available at http://consensus.nih.gov/backgrounder.htm.

The Office of the Director, the central office at NIH, is responsible for setting policy for NIH, which includes 27 Institutes and Centers. This involves planning, managing, and coordinating the programs and activities of all NIH components. The Office of the Director also includes program offices which are responsible for stimulating specific areas of research throughout NIH. Additional information is available at http://www.nih.gov/icd/od.

The National Institutes of Health (NIH) ? The Nation's Medical Research Agency ? includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

The National Institutes of Health (NIH) ? The Nation's Medical Research Agency ? includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

Interesting research news regarding Metformin:

Please connect to the National Cancer Institute Cancer Bulletin

http://www.cancer.gov/ncicancerbulletin/092209/page3

Connect directly to the research article:

Cancer Res. 2009 Sep 14. Metformin Selectively Targets Cancer Stem Cells, and Acts Together with Chemotherapy to Block Tumor Growth and Prolong Remission.

Hirsch HA, Iliopoulos D, Tsichlis PN, Struhl K.