She is an actor/singer/entertainer who entered the national limelight as Miss America of 1959. He is a surgical oncologist whose research has changed the way breast cancer is treated worldwide. What Mary Ann Mobley and Armando E. Giuliano, MD, share—besides the close bond they have developed since she became his patient nearly a decade ago—is the tenacity they bring to the battle against breast cancer. “I can do it” is the mantra that keeps Mary Ann going even in her darkest moments. Dr. Giuliano confronts obstacles in his trailblazing work as a surgeon and scientist with the same resolve.
Undeterred by Gunfire, Sharks–Or Breast Cancer
* Mary Ann Mobley
On September 6, 1958, 21-year-old Mary Ann Mobley was crowned Miss America in front of 60 million television viewers and a live audience in Atlantic City, New Jersey—a long way from her hometown of Brandon, Mississippi, and its population of 2,500.
Since that crowning moment, Mary Ann’s life has taken many twists and turns as her talent, adventurous spirit, compassionate heart, and personal health challenges have led her in unexpected directions. Her humanitarian work led her to Third World countries—Cambodia, Ethiopia, Somalia, Zimbabwe—where she traveled in dangerous territory to film documentaries on the plight of starving children and the devastating impact of war on young lives.
She filmed amid guerrilla gunfire in Mozambique, but even that did not deter her. She also has performed trapeze acts, flown in an F/A-18 Hornet with the Blue Angels, and gone on diving expeditions that brought her face-to-face with sharks. “All my life, I didn’t want fear to stop me,” she says. “I will rush out to face the unknown rather than have it hang over me.”
For the past eight years, this has meant facing breast cancer with the help of her surgical oncologist, Armando E. Giuliano, MD. She is one of many patients who followed him when he was recruited from Saint John’s Health Center in Santa Monica in 2011 to serve as Cedars-Sinai’s vice chair of Surgical Oncology.
Sitting on the patio at a favorite Beverly Hills restaurant on a balmy evening, Mary Ann talks about life and her cancer battle with humor and frankness—pausing periodically to offer waiters generous doses of her gracious Southern charm. She reflects on everything from her surprise at winning the Miss America pageant (“I was short with a Darth Vader haircut”) to the way she keeps her problems in perspective by reminding herself of others who are less fortunate. “I’m always aware of how lucky I am,” she says.
After a year of nonstop Miss America travel, she continued her entertainment career in Broadway musicals. A diagnosis of debilitating Crohn’s disease slowed her down for a bit, but once her symptoms were under control, she garnered starring roles on film, stage, and television, including romantic leads in Elvis Presley movies (Harum Scarum and Girl Happy), recurring parts on television’s Diff’rent Strokes and Fantasy Island, and guest roles on many other popular series.
In 2004, following a mammogram, Mary Ann was told she had a precancerous lesion in her left breast. After Dr. Giuliano performed a lumpectomy, she was soon able to return to her busy life, but she continued to see him every six months.
Then in March 2009, when she was between appointments, something strange happened. Her normally lethargic rescue dog—a cross between a Corgi and a Jack Russell Terrier, named Benjamin Brewster Collins—“went crazy,” Mary Ann recalls. “He was jumping up and down, following me around, and putting his paw on my right breast like he was trying to tell me something.”
“All my life, I didn’t want fear to stop me. I will rush out to face the unknown rather than have it hang over me.”
She called Dr. Giuliano and asked to come in for a checkup. The oncologist took the part about her dog’s mysterious behavior in stride but performed a physical exam and ordered a mammogram. Nothing. At this point, Mary Ann thought her doctor might send her home. Instead, he made a decision that may have saved her life. “He told me, ‘I can’t feel anything, and the mammogram doesn’t show anything, but you know your body and I will always listen to you. Let’s get an MRI.’” As soon as the results were in, he called her. “You and Brewster were right,” he said.
This time, Mary Ann required more extensive treatment—another lumpectomy and lymph node removal, radiation, chemotherapy, and five years of estrogen-blocking hormone therapy to reduce her risk of recurrence.
“When they told me it was Stage III cancer and I’d have to go through all this treatment, I thought: ‘Others have done this. I can do it, too. It’s not going to help to cry,’” she says.
Dr. Giuliano says Mary Ann has faced cancer with “courage, determination, and grace. She is always looking at the positive side of life—and her sense of humor is never far from the surface. This makes her a joy to be around, and an inspiration to other patients.”
She acknowledges there are times when fear of another recurrence arises, but adds, “I don’t dwell on ‘what ifs.’” She says she will always be grateful to Dr. Giuliano. “Every time I go in for a checkup, I know he is doing everything he can to keep me alive. And now he is looking out for a second generation of my family as my daughter faces a higher risk because of what I’ve been through.”
Mary Ann says she and cancer have “come to terms with each other.” This frees her to get back to performing and also do something she considers her duty as a breast cancer survivor: to speak out about the importance of being proactive about regular screenings to ensure early detection.
Mary Ann places no limits on what she might do in the future. She may even return to scuba diving. This idea brings up a broad smile—and a memory. Her father gave her a pony when she was about 9 years old. She fell off eight times, and each time he urged her to get back on. Finally, she was able to ride, and she vividly remembers the sense of pride she felt in her accomplishment. “What a wonderful feeling that was,” she says. “There’s got to be another pony out there.”
A Mission to Prove Less is More
* Armando E. Giuliano, MD
After decades knocking down pillars of conventional thinking, Armando E. Giuliano, MD, could not have been more pleased with the 2011 New York Times article about his game-changing research. A framed copy of the article is displayed in his office. Its headline reads: “Lymph Node Study Shakes Pillar of Breast Cancer Care.”
“It’s very dramatic,” he says with a glint of hard-earned satisfaction in his eyes.
So is the arc of his career as a surgeon, scientist, and educator dedicated to increasing survival rates while improving patient quality of life. Dr. Giuliano has been at the forefront of historic changes in breast cancer treatment for more than three decades. Yet he has sometimes felt like a voice in the wilderness, challenging the prevailing idea in breast cancer surgery that “more had to be better.”
Dr. Giuliano was among the researchers who participated in a landmark 1980 study that showed a breast-sparing lumpectomy could be as effective as a mastectomy for some patients. He has pursued scientific proof that “less is more” in breast cancer surgery ever since. He is also focused on identifying target genes to more effectively fight the most aggressive and difficult-to-treat breast cancers.
With high-voltage energy contained in a lean frame with an aura of quiet intensity, Dr. Giuliano addresses questions with the efficiency of someone perpetually on call. “As we did more and more mammograms and found earlier tumors that are less likely to spread to the lymph nodes,” he explains, “it became clear that removing one sentinel node could be as effective as removing 30 lymph nodes.”
Based on a collaborative, nationwide clinical trial led by Dr. Giuliano through the American College of Surgeons Oncology Group, this finding challenged the commonly held belief that removing all lymph nodes was the key to improving breast cancer survival rates. The February 9, 2011, New York Times article noted: “The discovery turns standard medical practice on its head. Surgeons have been removing lymph nodes from under the arms of breast cancer patients for 100 years, believing it would prolong women’s lives by keeping cancer from spreading or coming back.”
Dr. Giuliano found further evidence to support his minimally invasive approach with his next discovery, published just five months later. The study found that removing lymph nodes because of microscopic cancer cells in the sentinel lymph node did not impact survival outcomes for women with early-stage breast cancer. This means potential freedom from the side effects of lymph node removal—such as arm swelling, pain, and loss of mobility.
Mary Ann Mobley, actor, singer, and former Miss America, is among Dr. Giuliano’s many longtime patients. She calls him “committed, sensitive, and brilliant.” As she says: “He is incredibly caring. He is a true partner—you never feel alone.”
Dr. Giuliano’s research has always been inspired by his patients, but the ideas he brought from the clinic were initially viewed with skepticism. His first grant proposal to a major government agency was turned down with words seared in his memory: “a technical tour de force of no clinical relevance.” He smiles as he slowly repeats this phrase with a sense of wonder at how far from the truth it turned out to be.
Undeterred, he turned to donors who helped him continue research that was ahead of its time. Today, major cancer centers such as Memorial Sloan-Kettering, MD Anderson, and Harvard are practicing his less-is-more approach.
Still, he adds, many surgeons hold on to the idea that it is better to “get everything out” even when cancer is detected early. Dr. Giuliano is confident the majority will eventually come around. “Bringing about a major shift in how cancer is treated is like turning a big ship. It doesn’t change direction right away.”
While others catch up, Dr. Giuliano is proceeding full speed ahead. He came to Cedars-Sinai in July 2011 (after 20 years at the John Wayne Cancer Institute at Saint John’s Health Center in Santa Monica) as vice chair of Surgical Oncology and co-director of the Saul and Joyce Brandman Breast Center—A Project of Women’s Guild at the Samuel Oschin Comprehensive Cancer Institute. That year, the program provided medical and surgical care to more patients from California than any other hospital in the state. What’s next on his agenda?
“I would like to further minimize surgery and improve survival without diminishing quality of life,” he says. “If you look at breast cancer over the last 120 years, every time we have compared a radical procedure to a more thoughtful, less radical procedure, the less radical procedure has turned out to be as good or better.”
Looking forward, he says breast cancer management—including surgery, radiation, and drug therapy—will become increasingly targeted to attack tumors with fewer side effects. He believes the greatest hope lies in the growing understanding of the genetic basis of cancer. “As researchers find more gene mutations and more drugs that are appropriate to counteract the effect of these mutations, the need for surgery will likely decline,” Dr. Giuliano predicts.
He has no problem with the ramifications. “I would like nothing more than to work my way out of a job,” he quips.
Even in the event that Dr. Giuliano the surgeon manages to work himself out of a job, Dr. Giuliano the researcher will have plenty to do. He is leading innovative research in genetic studies and the development of targeted therapies in collaboration with the Samuel Oschin Comprehensive Cancer Institute’s Women’s Cancer Program and Xiaojiang Cui, PhD, associate professor in the Department of Surgery and the Department of Obstetrics and Gynecology.
Two years ago, their team reported a major discovery: They found a certain gene is overexpressed (i.e. produces excess proteins) in aggressive, invasive, difficult-to-treat triple-negative breast cancer (so named because it lacks three biomarkers that control cell growth or death). This subtype is less common, tends to affect younger women, and is more likely to grow faster and spread earlier than other forms of the disease. “This is the foundation for detecting this type of cancer earlier and for developing effective targeted treatments,” Dr. Cui explains. “It will also help us predict whether the patient has a higher risk of recurrence, brain metastasis, and resistance to chemotherapy.”
The next step is to validate this genetic finding in clinical studies and to apply it in the clinical management of breast cancer. The team is also investigating Dr. Giuliano’s hunch that using a targeted therapy such as Herceptin® earlier than commonly practiced could improve outcomes for women with certain types of breast cancer.
Dr. Giuliano does not rule out the possibility of another breakthrough that will shake the foundations of breast cancer care. “Changing the way disease is treated is pretty hard,” he says, “but I am sure there is another blockbuster out there.”