When Dr. Love says she is optimistic that a cure for breast cancer will be found in her lifetime, I hope that it will be within my lifetime as well. Dr. Love was born in 1948. I was born in 1949. Two years ago I had a breast biopsy that revealed non-invasive cancer, a diagnosis that carried an increased risk that my life span might not equal that of my friends.
Research into my options and a look down the "what-if" path led me to nod in agreement when I heard Dr. Love say, "We're still using the same old slash, burn, and poison approach." Closer inspection of the diagnostic tools currently available to our physicians, left me with the disturbing sense that they are neither precise nor always accurate. Notably outspoken on the issue of early detection, Dr. Love says, "It's wishful thinking on our part. I wish it always worked, but it doesn't."
Hearing that in spite of this evaluation Dr. Love remains optimistic about the future, I welcomed an opportunity to interview her. Dr. Love has agreed to continue the research of Dr. Otto Sartorius, founder of the Santa Barbara Breast Cancer Institute and my former surgeon. I was curious how his research fit into her perspective.
"There's a lot of stuff in the pipeline that over the next four or five years we're going to see come to fruition," she told me. "Molecular biology," she said, "I think that's where we're heading. All cancer is genetic. It's all screwed-up genes." Some people inherit BRC1 or BRC2 genes from their mother or father. Most inherit normal genes but she believes that something comes along that alters the genes, something that affects the cell environment.
"We've used the bacterial infection model for cancer. While bacterial infection is a foreign invader, cancer is not." Dr. Love prefers the mental health model where efforts are made to rebuild the cells or change the environment in a way that will restore normal cell behavior. "This makes more sense" she says, "than trying to blast it away, trying to kill every last cancer cell."
Dr. Love points to tumor dormancy. "You treat somebody for breast cancer and then ten years later it comes back. What were those cells doing for ten years? Why were they asleep and what woke them up? If they can be asleep for ten years, why not thirty years? Why does Tamoxifen work? Why does taking out the ovaries work? It works because it changes the cell environment."
Asked about outside environmental sources like pesticides, she said, "The solution is not going to be as straight-forward as smoking causes lung cancer." She suspects a more complex gene environment interaction. As an example, she describes individual response to cholesterol. "Some people can eat all the fat they want and their cholesterol stays normal. Other people look at a cheesecake across a crowded room and their cholesterol goes up. Likewise, there may be some people who cannot metabolize pesticides as well as others. Maybe there's something genetic that makes you more susceptible."
Another example, one she is watching closely, involves the Ataxia-Telangiectasia or A-T gene. Children with two copies of this gene develop a degenerative neurological disease ---few live to adulthood. People born with one copy of this gene do not develop the disease, but they have four times the normal risk of breast cancer. This gene is involved in the DNA repair of mutations caused by radiation. People with that gene may be more susceptible to low-dose radiation.
Dr. Love's particular research interest is breast anatomy. She says, "One of the problems in both prevention research, and treatment of breast cancer is that we don't have good access to the breast. With cervical cancer. you can do a pap smear. With colon cancer, you can do a colonoscopy." The solution is to find a non-surgical way to get inside the breast. "If you could get into the lining of the milk duct, then you could potentially biopsy the lining, see what the cells are doing, and see early changes." In researching this idea, she came across the work that Dr. Sartorius was doing here in Santa Barbara. She flew here from Boston several times to talk with him about it.
Dr. Sartorius theorized that fluid drawn from nipple ducts might be the key to early detection, since nipple secretion contains cells from the tissue inside the breast. He was also experimenting with a dye-enhanced mammogram. Using a microscope that he developed for the procedure, he injected dye into the nipple ducts. The resulting mammogram provided a vivid map of the breast. Prior to his retirement, Dr. Sartorius had performed about 800 of these ductograms.
After his death in 1994, Dr. Love inherited his microscope and his collection of ductograms. While Dr. Love still has hope for breast fluid analysis as a predictor, she says, "Most breast cancer starts in just one ductal system." Not all breasts secrete enough fluid to analyze and it's not always clear exactly which ductal system the fluid has been expressed from.
Dr. Love foresees her current work to comprehensively map the ductal system as a primary contribution to this line of research. She recently received a $762,000 grant from the Dept. of Defense to continue her work. Her first challenge is to map the location of the holes in the nipple. "When you look at your nipple you don't see six to nine ducts looking back at you. I have an assistant going to La Leche League meetings to find volunteers." Her assistant diagrams the nipples of breast-feeding women. "It is easier to find the holes when there is milk coming out of them," Dr. Love says.
Analyzing the ductograms she inherited, is helping her to document the network of ductal systems within the breast. She also has been experimenting with a fiber optic scope about a the size of a hair and doing some of her own ductograms as well as devising new techniques for doing washings to remove cells. "One of the great revelations I had this year, I remembered from breast-feeding," she said. She discovered that if the fluid is in introduced slowly, the ducts will expand to carry more fluid, as they do when a baby sleeps past its normal feeding time and the breasts become engorged.
"The hope is that eventually we will be able to get into any duct that we want, whenever we want." Achieving this, doctors would be able to monitor high-risk women more closely. She further suggests that, "for pre-cancers like DCIS, you could squirt something into the duct and just clean it out."
Regarding gene therapy, she says, the problem is getting the new gene right into the area where the malfunctioning cells are. With a ductoscope, you could conceivably transport the gene directly into the target area. "I think it looks pretty promising," she said as we finished up the interview.
And if Dr. Love is right, I will join breast cancer survivors around the world in drinking a toast to her on her 85th birthday. "To Susan Love, for helping to find a cure for breast cancer in our lifetimes."
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