Monthly Archives: August 2015

Compelling Case For Changing the Management of DCIS-Not So Fast

The New, Big Study

In a study of over 100,000 women published in the August issue of the Journal of the American Medical Association Oncology, Dr. Stephen Narod, the lead researcher, suggested that a change in the management of DCIS or ductal carcinoma in situ from lumpectomy and radiation to

Ask Questions about Your Best Treatment Options. Speak to your surgeon, medical oncologist and a radiation oncologist.

Ask Questions about Your Best Treatment Options. Speak to your surgeon, medical oncologist and a radiation oncologist.

endocrine therapy in some patients with low risk or even observation in others. The results were “confirmatory and surprising” according to Medscape Medical Oncology News.  Dr. Narod went on to say:

“If the goal is to prevent in-breast recurrence, then radiotherapy and mastectomy are good treatment options,” he said.

“If the goal is to prevent death from breast cancer, the best option might be watchful waiting followed by chemotherapy at the time of an invasive breast recurrence,” he explained.

So What Are the Problems with This Study?

Dr. Narod’s results fly in the face of level I evidence-the so-called gold standard prospective, randomized trials with long-term follow-up.  So as a physician scientist, I always want to look at the raw data myself, not just accept the authors’ conclusion.

The “blockbuster conclusion” in this study was that the risk of dying from breast cancer was exactly the same when Dr. Narod and co-workers compared women with DCIS to women in the general population.  So determining whether a person dies of breast cancer or from other causes seems to be simple, doesn’t it?  But nothing could be further from the truth.  It’s actually difficult in a “rearview mirror” or retrospective review of a patient database, like the SEER data base used in the study.

Let me give you a real-life example.  We all know that famous American, President Ronald Reagan, passed away from Alzheimer’s disease.  Yet nowhere on his death certificate was Alzheimer’s disease ever mentioned as the cause of death.  So looking at the SEER database and just accepting that a woman’s death was not from breast cancer is likely a gross underestimate.  Secondly, the follow-up in Dr. Narod’s the study was relatively short, only 7 1/2 years.  But it has been known for decades that the risk of recurrence from DCIS is much longer, as much as 8 years on average.  So a 7 ½ year follow-up is just not good enough.  So I’ll caution the authors of this study not to draw too many “blockbuster conclusions” based on these data.

So What Is a Woman with DCIS to Do?

For now, I think it’s best for a woman with DCIS to sit down with her surgeon, medical oncologist, and radiation oncologist to discuss her own particular clinical situation.  We’ve known for years about the high risk features of women with DCIS: younger age, high nuclear grade, size of the DCIS, comedo necrosis, estrogen receptor status, and even race.  So talk to your breast cancer specialists and decide how you’re going to choose wisely.

If you have any questions about your DCIS, please feel free to call me, Dr. Ed Hughes, at 855-Dayton 1.

 

NO CANCER RISK FROM YO-YO DIETING

The Food Pyramid has changed since you first learned it in Kindergarten.

The Food Pyramid has changed since you first learned it in Kindergarten. Click on image to learn more.

 

Nearly half of all adult Americans can breathe a sigh of relief. Weight cycling or so-called yo-yo dieting-does not appear to increase their risk for getting cancer.

In a 10 year study of over 96,000 men and women, who lost more than 10 pounds only to regain that weight, Dr. Victoria Stevens and co-researchers from the American Cancer Society found that yo-yo dieting did not increase the risk of getting cancer.  The yo-yo dieting study was reported in the July issue of the American Journal of Epidemiology.

The study looked at the following 12 cancers:

BREAST                COLON                 ESOPHAGUS        KIDNEY

LIVER                    LUNG                    MELANOMA      NON-HODGKIN’S LUMPHOMA

PANCREAS           PROSTATE            RECTUM            STOMACH

Of note, the effect of yo-yo dieting on the risk of breast cancer was not reported. Dr. Stevens noted that BMI or body mass index may have clouded a study reported in 2005 that found a link between the risk of breast cancer and yo-yo dieting.

SO WHAT DO I RECOMMEND? 

The whole lifestyle approach is key-smart food choices and daily exercise.  I like the hybrid approach between the Mediterranean diet and the DASH diet-Dietary Approaches to Stop Hypertension.  And one glass of wine is allowed each day!

The key points of the diet is eating at least 3 servings of whole grains, a green leafy vegetable and one other vegetable each day.  Snack on nuts most days, have a serving of beans every other day, and eat poultry and berries at least 2 times per week, with fish once per week.

The hard part is avoiding the 5 unhealthy groups-red meat, butter and stick margarine, cheese, pastries and sweets, along with fried and fast foods.

Stay healthy Dayton!  If you have any questions, call me Dr. Hughes at 855 DAYTON1.

 

Shorter Really Is Better

Woman with early stage breast cancer can now rest assured that short course radiation over 3-4 weeks is the same or even better than radiation treatments over 6 weeks.

Researchers at the MD Anderson Cancer Center, led by Dr. Simona Shaitelman, studied over 300 women age 39-years or older with early stage breast cancer, specifically stages 0-II.  All women had a lumpectomy and were then randomly assigned to either short course radiation or standard long course radiation treatments.

The majority of women with short course radiation had fewer side effects and were able to get back to their lives quicker.  The study was published in the August 6 issue of the Journal of the AMA Oncology. “Those patients who received a shorter course reported less difficulty in caring for their families’ needs, “ said Dr. Shaitelman.

Lessons from the Past

The study builds on major advances made in Canada, Great Britain, and Europe over the past 10-20 years.  Those studies were the so-called “gold standard” and compared thousands of women treated with short course versus long course breast radiation after lumpectomy.

In each and every study cancer survival, cancer control in the breast itself, and the cosmetic results were exactly the same whether short course or long course radiation was given after surgery.  Newer studies are now ongoing, based on the biology of breast cancer, that will compare only 5 treatments to 15 treatments.

The Choosing Wisely Campaign

The American Society of Therapeutic Radiology and Oncology or ASTRO has launched a national initiative to encourage women with breast cancer and their doctors to carefully consider using short course radiation after lumpectomy for early stage breast cancer patients.  ASTRO has issued specific guidelines for early stage breast cancer patients who would be candidates for such treatment.

But acceptance has been slow.  Dr. Bekelman and co-workers from the University of Pennsylvania School of Medicine looked at the insurance claims of 14 major commercial health plans.  The results were astounding-only 34.5% of women were treated with short course radiation-despite the results of more than two decade of clinical studies.  The study was published in the March 2015 issue of ASCO Post.

Dr. Hughes and Dr. Marger at First Dayton Cancer Care have prescribed short course breast radiation for over a decade – experience counts.

As always, it’s good to have a second opinion.  If you have any questions about your breast cancer, call me Dr. Hughes at 855-Dayton 1.  I guarantee I will see you in 1-3 days after your call.

 

Mastectomy Always Takes Care Of the Breast Cancer, Doesn’t It?

The Truth Be Told

Twenty seven percent of woman who have had a mastectomy will have a local-regional recurrence in the chest wall or lymph nodes; this tragedy is preventable if the correct treatment is given in the beginning.

Don't make a deadly mistake by only have half of the treatment you need.

Don’t make a deadly mistake by only having half of the treatment you need.

For woman with a newly diagnosed breast cancer, the decision to undergo lumpectomy and radiation therapy or mastectomy-with or without reconstruction-or even a double mastectomy, feels like a big ocean wave hitting her again and again. As a radiation oncologist, I listen to women express their shock and say “I thought mastectomy takes care of everything.  I just want it out.”  Yet there are some breast cancer patients who benefit from radiation therapy even after mastectomy. 

The national guidelines call for radiation therapy after mastectomy if there are more than 3 positive lymph nodes or if the breast cancer measures more than 5 cm (2 inches).  There is still debate about whether women with only one positive lymph node benefit from radiation after mastectomy.  Why radiation after mastectomy?  Because some woman come down with a local-regional recurrence.  That is to say, the breast cancer comes back in the chest wall or in the surrounding lymph nodes even after mastectomy.  And that can be a grave situation.

Why Do I Need Radiation After Mastectomy? 

Dr. Naresh Jegadeesh and his co-workers at the Emory University School of Medicine looked at a group of women who had stage I or stage II A breast cancers who were treated with mastectomy.  Another group of women were treated with lumpectomy and radiation therapy.  All of these women had favorable, early stage breast cancer-their cancers were ER positive.  Chemotherapy was given depending upon the results of the 21-gene recurrence score.  The 21-gene recurrence score is a special test on the actual breast cancer itself, and measures the risk of the breast cancer spreading to other parts of the body.  Their results were published in the April 2015 issue of the Annals of Surgical Oncology.

The first key finding-and one that may be a practice changer-was that mastectomy patients with a 21-gene recurrence score >24 had a 27.3% chance of a local-regional recurrence versus 10.7% of those breast cancer patients with a recurrence score of <24.  Importantly, even for those women with a low 21-gene recurrence score, the chance of recurrence in the chest wall or lymph nodes was 10.7%.  Certainly, it was not 0%, a finding that shocks most woman whom I see who have undergone mastectomy.

The second key fact was that there were no differences in local-regional recurrences in women treated with lumpectomy and radiation therapy, regardless of their 21-gene recurrence score.

So What Does This Mean for Early Stage Breast Cancer Patients Who Undergo Mastectomy?

The vast majority of breast cancer specialists recommend radiation therapy after mastectomy only for those patients with large breast cancers and/or multiple positive lymph nodes.  But this study may change all that.

In this new era of “personalized medicine,” the genetic testing of the breast cancer itself may direct whether or not early stage breast cancer patients treated with mastectomy may benefit from radiation therapy.  The 21-gene recurrence score is typically done by medical oncologists to help decide, with the patient, on whether or not chemotherapy after mastectomy may be of benefit.  It seems to me that the 21-gene score results should also factor into the decision on whether to use radiation or not after mastectomy.

With a 27% chance of a local-regional recurrence in the chest wall or lymph nodes without radiation, the medical decision seems like a no-brainer to me.

And a recurrence in the chest wall or regional lymph nodes is grave-many of those women eventually die from their recurrent breast cancer.

If you have any questions about your breast cancer, please feel free to call me, Dr. Ed Hughes, at 855-DAYTON1.  I guarantee that I will see you in consultation within days of your call.