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News from CaSfA's Director

Blog

Dealing with Breast Cancer

Posted on May 17, 2016 at 12:02 PM Comments comments (0)


A CaSfA member recently gave me The Silver Lining Companion Guide: A Supportive and Insightful Guide to Breast Cancer by Hollye Jacobs, RN, MS, MSW.  While this was written specifically for the breast cancer survivor, much is relevant to survivors of all cancers. (The companion guide is available free to all at:  https://www.directrelief.org/silverlining/).  This publication reminded me of a handout I developed a few years ago:

If you are Diagnosed:
Accept feelings-anger, guilt, denial, despair…
Try to stay in the moment-one day at a time
Network with survivors-will help you find doctors and the right treatment plan for 
      you
Try to find mentor-networking/ACS “Reach to Recovery”
Find the right doctor for YOU—Consider 2 opinions, change doctors if not happy
Be careful with internet-can make you crazy!
Get copies of all reports, x-rays, tests
Determine which friends and relatives you want to communicate with and how          
     (email, phone, blog)
Consider support groups/professional help for spouse/kids
 
Determining Treatment Plan:       
One of the toughest times-consider journaling
Write out questions before doctor appointments
Soul Search for your philosophy--what is most important to you (breast
     conservation/Aggressive therapy?)         
Ask to see before and after pictures of reconstruction procedures you are 
     considering
 
Surgery and Chemo:
Reconstruction is usually a process & rarely a single event
Get list from drs. what can/can’t do, can/can’t eat…
You will need help—ACCEPT IT!!—meals, errands, cleaning, kids
Get fresh air and exercise-helps even in small amounts
Take advantage of professional help available-PT, medications, psych counseling,              
     acupuncture,massage therapy, support groups, Healing Garden!!
Be patient—very hard to do, but recovery takes time-there will be a new “normal”  
     for you
Hair loss is very traumatic-You will need emotional support!!!
Keep a journal of medications—there will be many.  Log type, time taken and 
     reaction. Drs. can make adjustments for side effects
SAVOR THE GOOD TIMES—do something fun when you are feeling good
           
 
After Treatment:
Fear, anxiety can build-“What do I do now?”
Consider support groups, professional help
Check out Living Beyond Breast Cancer-lbbc.org

“Cancer may leave your body, but it never leaves your life”, Livestrong.org

Results from the TH3RESA trial

Posted on January 12, 2016 at 5:16 PM Comments comments (0)

Results from a study presented at the San Antonio Breast Cancer Symposium showed patients with metastatic, HER2-positive breast cancer who received a combination antibody/chemotherapy drug in a phase 3 clinical trial survived longer, on average, than patients receiving other treatments. (http://news.cancerconnect.com/conjugate-drug-extends-survival-in-patients-with-advanced-her2-positive-breast-cancer/ )“The TH3RESA trial, which enrolled more than 600 participants in the U.S. and overseas, compared survival times in patients randomized to treatment with the conjugate drug trastuzumab emtansine (T-DM1) to those randomized to treatment of their physician’s choice. All patients had metastatic breast cancer that tested positive for the human epidermal growth factor receptor 2 (HER2) protein – a feature in about 20 percent of all breast cancers – and had previously been treated with chemotherapy as well as the HER2-targeted drugs trastuzumab and lapatinib. The investigators found that those in the T-DM1 group lived a median of 22.7 months vs. 15.8 months for those in the treatment of physician’s choice group – a 44 percent improvement.”  In addition, serious side effects were lower in the TDM-1 group.

The Updated ACS Guidelines for Breast Cancer Screening

Posted on November 4, 2015 at 7:14 PM Comments comments (0)
The American Cancer Society (ACS) released its new breast cancer screening guidelines, raising the recommended age for beginning annual screening from 40 to 45, and endorsing biennial screenings beginning at age 55. In addition, the new guidelines suggest physicians should forgo clinical breast exams for women of any age. 

I have an admittedly biased opinion about these recommendations.  My breast cancer was found by a routine annual screening mammogram.  I had a very low risk of developing breast cancer.  I am thankful that the mammogram uncovered the tumor early, allowing me the best chance for a cure.  I was upset when the US Preventative Task Force recommended biennial screening mammography for women starting at the age of 50.  And I was disappointed when the ACS recently released their updated recommendations. 

Mammograms and breast exams are not the perfect screening tests.  They can diagnose tumors that are not cancer, and they can miss tumors that are cancer.  But they are all we have for screening now.  Until a better screening test is determined, the best we can do is to take these recommendations as mere guidelines.  Each individual woman should discuss with her personal physician her risk factors for breast cancer and try to determine when it would be best for her to start screening mammograms. 

The DCIS Controversy

Posted on October 20, 2015 at 3:07 PM Comments comments (0)
Ductal Carcinoma in Situ is diagnosed by examination of the biopsy of breast tumor.  The cancer cells are within the milk ducts and have not invaded the underlying tissue.  It is classified as Stage 0 breast cancer.  The incidence of DCIS has increased with the widespread use of screening mammography and it now accounts for 20-30% of all newly diagnosed breast cancers.
 
The treatment of DCIS has become controversial.  Even the name is a source of controversy.  Some believe it should not be called cancer at all, since it doesn’t involve tissue invasion.  The problem with DCIS is that somewhere between 25-50% of cases will progress to invasive disease. 
 
Because of this progression, most patients with DCIS are undergoing surgery—either mastectomy or lumpectomy with radiation.  A recent study in JAMA Surgery looked at the outcomes of women who did not have surgery, but instead were followed by active surveillance.  (JAMA article: http://archsurg.jamanetwork.com/article.aspx?articleID=2300045&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=ArchivesofSurgery%3AOnlineFirst06%2F03%2F2015)
 
Articles in The New York Times (http://www.nytimes.com/2015/09/29/health/a-breast-cancer-surgeon-who-keeps-challenging-the-status-quo.html ) and Time magazine (http://time.com/4057310/breast-cancer-overtreatment/ ) both quote practitioners who advocate renaming DCIS as well as changing to non-operative management of the disease. 
 
The surgeons followed in these articles, Dr. Laura Esserman of UCSF and Dr. E. Shelley Hwang of Duke, propose DCIS should be renamed “IDLE, indolent lesions of epithelial origin”.  They believe many women are erroneously deciding on aggressive treatments just because they are frightened and reacting to the word “carcinoma.”  Dr, Esserman follows many DCIS patients with active surveillance.  They receive yearly mammograms alternating with MRI’s.  Depending on receptor status of their tumors, some undergo ovarian suppression and hormonal therapy.
 
But many cancer specialists believe the aggressive treatments are warranted since DCIS can progress to invasive cancer.  They believe we don’t know enough to determine which cases of DCIS will progress and because of this we should continue to treat all cases of DCIS.
 
The JAMA study has again sparked the debate on how DCIS should be treated.  It was
a retrospective study of 57,222 American women with DCIS that showed no survival benefit from surgery in women with low-grade disease. (Tumor grade is the description of a tumor based on how abnormal the tumor cells and the tumor tissue look under a microscope. It is an indicator of how quickly a tumor is likely to grow and spread.)  1169 patients with DCIS in 10 health districts were managed without surgery from 1988 to 2011 and entered into the logs of Surveillance, Epidemiology and End Results (SEER) database. These exceptional cases were compared with the 56,053 patients who were treated with surgery.
 
They found that 10-year breast-cancer-specific survival was significantly better in patients with intermediate- and high-grade disease who had undergone surgery than in those who had not. For intermediate grade DCIS, there was an absolute difference in weighted 10-year breast-cancer-specific survival of 4.0% between the surgery and nonsurgery groups (98.6% vs 94.6%); for high-grade DCIS, there was an absolute difference of 7.9% (98.4% vs 90.5%).
 
But for women with low-grade DCIS, surgery appeared to be superfluous. Ten-year breast-cancer-specific survival was the same for patients who underwent surgery and for those who did not (98.8% vs 98.6%; P = .95).

Most clinicians are not convinced. Some do not feel tumor grade alone is a good enough predictor of which cases of DCIS will progress.  They also point out limitations in the JAMA study.  For example, it is not known how many women were diagnosed with low grade DCIS on biopsy, but after surgical excision were found to have invasive cancer.

So what if you are diagnosed with DCIS?  If your biopsy shows intermediate or high grade disease, surgical excision (+/-radiation and hormonal therapy) provides a higher percentage 10 year-breast-cancer-specific survival.  If it’s low grade DCIS, the decision is a bit more difficult.  There is a test available called the Oncotype DX DCIS test.  This test is a genomic test that analyzes the activity of a group of genes that can affect how DCIS is likely to behave and respond to treatment. The test is performed on a sample of DCIS tissue. The Oncotype DX DCIS test offers results as a recurrence score. Depending on the recurrence score number, the DCIS has a low, intermediate, or high risk of recurrence.   Other factors that should be considered are family history of breast cancer and genetic testing results.

Studies are constantly being conducted and sometimes the results change medical practice.   But we can’t see into the future.  The best any of us can do is to gather all the information available at the present time and choose what is best for ourselves.
 

New Finding in Triple Negative Breast Cancer

Posted on January 19, 2015 at 3:47 PM Comments comments (0)

Researchers in the UK have found an overactive gene, BCL11A, in 8 out of 10 patients with triple-negative breast cancer.  This type of cancer is especially aggressive. Without estrogen, progesterone and HER2 receptors targeted therapy using tamoxifen, aromatase inhibitors, and Herceptin do not work.  Finding this gene is the first step in developing targeted therapy for this type of breast cancer.  (http://www.telegraph.co.uk/news/science/science-news/11336050/Breast-cancer-breakthrough-as-Cambridge-University-finds-gene-behind-killer-disease.html )

Evidence for Screening Mammography before the age of 50

Posted on September 18, 2013 at 10:09 AM Comments comments (0)
My invasive ductal carcinoma was diagnosed by routine mammography.  I know other women whose breast cancer was diagnosed after feeling a lump on self-exam.  So I did not agree with the U.S. Preventive Services Task Force (USPSTF) when it recommended the following changes in its breast cancer screening guidelines in 2009: 
 •   Routine screening of average-risk women should begin at age 50, instead of age 40. 
 •   Routine screening should end at age 74. 
 •   Women should get screening mammograms every two years instead of every year. 
 •   Breast self-exams have little value, based on findings from several large studies. 

Research out of MGH just published online September 9, 2013 from the journal Cancer, supports initiation of annual mammographic screening before age 50.
This study hypothesized that breast cancer deaths predominantly occurred in unscreened women.

To determine the survival benefit of women who have been screened, Cady and colleagues analyzed data on 7,301 patients who had newly diagnosed breast cancer during 1990 to 1999. Follow-up continued to 2007.

The authors also examined duration of screening interval, defining biennial screening as intervals of no more than 2 years. Women whose most recent screen occurred more than 2 years in the past were included in the unscreened group.

During the study there were 609 confirmed breast cancer deaths, 29% were among women who had been screened, whereas 71% were among unscreened women, including > 2 years since last mammogram (6%), or never screened (65%). Median age at diagnosis of fatal cancers was 49 years.

So the conclusion states:
“Most deaths from breast cancer occur in unscreened women. To maximize mortality reduction and life-years gained, initiation of regular screening before age 50 years should be encouraged.”

Kudos to the American Cancer Society, American College of Radiology and other organizations that have continued to recommend annual mammograms for women starting at age 40 despite the USPSTF policy.
 

Moderate Alcohol Intake Does Not Increase Risk of Breast Cancer Recurrence

Posted on August 2, 2013 at 8:35 PM Comments comments (0)
I enjoy the occasional cocktail or glass of wine.  So I was happy to hear about a  recent study published in the Journal of Clinical Oncology.  (http://jco.ascopubs.org/content/31/16/1939.abstract?sid=3da965f1-03df-486b-a310-19982aa74d65). This was a large population study and it showed that modest alcohol consumption (up to one drink per day in women) is not a risk factor for breast cancer recurrence.  It also showed alcohol consumption is not related to an increase in death from breast cancer and may, in fact, be associated with reduction in deaths due to cardiovascular disease as well as overall mortality.  (Unfortunately, alcohol is still thought to raise the risk of developing breast cancer in the first place.) This study is sure to stir up some controversy.  It will be interesting to hear if oncologists will be changing their recommendations to limit or discontinue alcohol consumption.

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