Monthly Archives: October 2015

Can Breast Cancer Patients Skip Chemo? There’s an Easy Way to Know

A simple 21-gene assay can determine if chemo is needed.

A simple 21-gene assay can determine if chemo is needed.

The Dreaded Call About the Results of Your Breast Cancer Surgery

It’s now been 8 weeks from the time you noted that lump in your breast. You’ve already gone through the mammograms and the biopsy.  You’ve had the lumpectomy done, and the surgeon said it’s also important that the lymph nodes are examined. You get excited by the great news that there was no spread to the lymph nodes in your armpit. But now your surgeon bursts your balloon and tells you that may need more treatment, even chemotherapy, because your breast cancer was nearly an inch wide.  Chemo too? Really?  Why do I have to take that stuff?

The Value of Genetic Testing 

For decades, the size of a woman’s breast cancer dominated the discussion of whether or not chemotherapy was needed. But all that has changed dramatically with the advent of gene testing for women with early stage breast cancer. A new study supported a decade-long practice of using the 21-gene breast cancer recurrence risk test, otherwise known as Oncotype DX, to decide whether or not a woman needs to undergo chemotherapy.

The TAILORx trial enrolled 10,253 women with breast cancer who had so-called “favorable disease.”  That is to say, their breast cancers were hormone receptor positive, HER-2 negative and with no spread to the lymph nodes. The physicians who piloted the study looked at a small portion of these women – only 1,626 women or 15.9% of all the enrolled women with breast cancer to be precise – who had low Oncotype DX scores. The low Oncotype DX score breast cancer patients were then treated with tamoxifen or an aromatase inhibitor such as anastrozole or both for 5 years – BUT with no chemotherapy.

Remarkably, 99.3% of those women with low risk, early stage breast cancer had no metastatic spread to other organs, like bone, brain, liver, or lung.  In a press release, Dr. Kathy Albain from the Loyola University Medical Center in Chicago, one of the lead doctors said, “There is outstanding survival with endocrine therapy alone. The test provides us with greater certainty of who can safely avoid chemotherapy.”

Just think, less than a decade ago, many of these women with breast cancer would have been treated with hormonal therapy AND chemotherapy. At that time, the medical oncologist’s decision was essentially based on anatomy; the size of the tumor was the most important feature of a woman’s breast cancer. But now it’s the biology of the breast cancer, the genetic changes in the tumor itself, that now takes center stage.

So What’s a Woman with Breast Cancer To Do?

Simply put, the Oncotype DX test has been used by breast cancer specialists for a decade without a confirmatory trial.  And now woman have confirmation from a well-run study of over 1,600 breast cancer patients. The Oncotype DX test is expensive, about $4000, but the test is covered by most insurance companies, including Medicare and Medicaid. And it is definitely cheaper than chemotherapy. Importantly, the Oncotype DX test isn’t a same day or next day test. In fact, the test takes about 2 weeks to get back results; plenty of time to recover from breast cancer surgery before making a decision about chemotherapy or hormonal therapy or both.

So I think it’s important for breast cancer surgeons, radiation oncologists, and medical oncologists to discuss the role of the Oncotype DX test before a woman finalizes her breast cancer treatment plan. Oncotype DX is one more step in the direction of “precision medicine” for women with breast cancer.

So keep in mind that the most important advances in breast cancer treatment are not only news to you, but also your well-meaning friends and family.

If you have any questions about your breast cancer, please feel free to call me, Dr. Edward Hughes, at 855-Dayton1.

 

Put an End to Mammogram Purgatory

An exam with 3D mammography is as easy as the 2D exam you are accustomed to.

An exam with 3D mammography is as easy as the 2D exam you are accustomed to.

Imagine you’re sitting at home and getting ready to make dinner for your family.  The phone rings and it’s the Breast Center on the other end of the line.  Then you hear the words “There is something on your mammogram that the radiologist says doesn’t look quite right.  When can you come in again for another mammogram?”  You mutter a few words and agree to go in next week.  And suddenly your world has changed.  It’s the dreaded mammogram call back.  Welcome to “Mammogram Purgatory.”  Is that spot a cancer or isn’t?  It will now take weeks to find out.

 But all that has now changed with the new technology called 3-D mammography. Study after study has shown that 3-D mammography reduces “call backs” by 15-30%.  And it’s more accurate than standard 2-D mammography in detecting cancers, about 25-40% more accurate.

WHAT IS 3-D MAMMOGRAPHY?

So what is a 3-D mammogram?  It’s also called “tomosynthesis” and it’s done at the same time as the standard 2-D mammogram.  For the woman undergoing the screening mammogram, it takes only a few more seconds for the 3-D study.  Women won’t notice the difference.  With high speed computer technology, the 3-D images are reconstructed so that the radiologist can look at your breast in 3-D, more accurately knowing whether or not that spot on the mammogram is a cancer, benign cyst, or even a blood vessel.  Medicare and Medicaid approved the technology in January 2015, although private insurers have been reluctant to jump on board  the new technology.  For the radiologist, there is more time in reading the 3-D mammogram, and not all insurance companies will reimburse a doctor for that extra time and expertise. Slowly but surely I think the private insurance companies will catch up.  In addition, the 3-D mammogram machine costs a lot more than the standard 2-D mammogram.  And many hospitals have been hesitant to invest in a machine that can cost anywhere from $500,000-$700,000.

WHAT DO THE EXPERTS THINK?

At the recent 2015 meeting of the American College of Surgeons, Dr. Sarah Friedewald, chief of breast imaging at Northwestern University Medical Center in Chicago, said “Digital mammograms show benefits for women younger than 50, but 3-D benefits women of all age groups…Within 5 years it will be the standard of care.  All patients should be screened with tomosynthesis.”

3-D mammograms are also beneficial for follow-up studies for women who underwent lumpectomy and radiation therapy.  If you have any questions about breast cancer screening or your own breast cancer, please call me, Dr. Edward Hughes, at 855-DAYTON1.

The Disturbing New Trend in Breast Cancer Treatment

You have a right to ask a lot of questions to find what is best to treat your breast cancer.

You have a right to ask a lot of questions to find what is best to treat your breast cancer.

The Halsted radical mastectomy changed my grandmother’s life in the mid 1960’s. The Halsted radical was a disfiguring, morbid operation. And she was never the same woman again. She did survive her breast cancer, but the long-term effects of the operation, both physical and emotional, were devastating.

From 1895 to the mid 1970’s, the vast majority of women in the US with breast cancer underwent the Halsted radical mastectomy. Shocking as it now seems, American surgeons failed to analyze their results for nearly 75 years. But Dr. Bernard Fisher and his colleagues in Pittsburgh changed all that in the 1970’s with proven scientific techniques showing that lumpectomy and radiation had the same results as mastectomy, with far fewer side effects. And the woman was able to keep her breast. But in the beginning, Dr. Fisher was harshly criticized for his studies yet in the end he showed that more surgery is not always better.

More Chemo Is Not Always Better

Surprising as it seems to my breast cancer patients, chemotherapy is a relative newcomer to breast cancer treatment. The Halsted radical mastectomy was first performed in 1895 and the first patient treated with radiation therapy for cancer was in 1897. But over the past several decades, chemotherapy and targeted immune-therapy, like Herceptin, have yielded good results.

But the history of chemotherapy for breast cancer also had a dark side – in the late 1980’s the idea that “mega doses” of chemotherapy can cure breast cancer started to gain traction. In fact, the doses of chemotherapy were so high that a woman needed her bone marrow to be “rescued”  by a bone marrow transplantation. From the late 1980’s to the late 1990’s, bone marrow transplantation was big business and every hospital, whether community or academic, needed a transplant program. Yet, medical oncologist (chemotherapists) learned their lesson relatively quickly and proved that “mega doses” of chemotherapy were certainly not better than lower doses. So, in my mind, it’s remarkable that bone marrow transplantation for breast cancer had such a short survival. Remember that Halsted’s radical mastectomy had only been laid to rest 20 years earlier after 75 years of being the standard of care.

So What Will the Arc of History Say about Double Mastectomy?

Double mastectomies have now become disturbingly common. Movie star after movie star have announced their surgeries in great detail. I’ve yet to read a single article about what’s happened to them years later. I need to see the follow up data to be convinced that it does not cause other health problems later in life.

But even movie stars and cancer specialists cannot dispute the fact that double mastectomy does not increase breast cancer survival rates, not even by a single day. Just like bone marrow transplantation in the 1990’s, double mastectomy is big business for hospitals. Double mastectomy is a lot of surgery, both on the part of cancer surgeons as well as plastic surgeons. And most of the women need extensive rehabilitation once they leave the hospital. It’s been a big driver of breast cancer clinics at community and academic centers.

So will double mastectomy go the way of the Halstead radical mastectomy and bone marrow transplantation? Only time will tell. But at the end of the day, I cannot recall another type of cancer, in women or men for that matter, that’s had a 100 year history of overtreatment. Why that fact stands alone remains to be seen.

If you have any questions about your breast cancer, feel free to call me or make an appointment.  I’m Dr. Ed Hughes at 855-Dayton 1.

 

Lung Cancer Patients can Live Longer with this FREE Treatment

Stopping smoking can add 6 months to a late stage lung cancer patient.

Stopping smoking can add 6 months to a late stage lung cancer patient.

The cold hard facts are becoming crystal clear – patients with Stage IV lung cancer patients who quit smoking, live 6 months longer than those who continue to smoke.  “In cancer, that’s a lot,” remarked Dr. Bernard Fortin, one of the lead researchers in the soon to be published study just reported at the 16th World Conference on Lung Cancer in Denver last month. So how does that compare with the new blockbuster drugs called “immune checkpoint inhibitors” like Yervoy, Keytruda and Opdivo?  Surprisingly, stopping smoking compares quite well.  In fact, locally advanced lung cancer patients treated with those immune checkpoint inhibitors survived 9.2 months longer, compared to those patients treated with chemotherapy alone.  That’s a difference of only 3 months.  And at a cost of $10,000-$12,000 per month.  So locally advanced lung cancer patients can live 6 months more, just by putting down cigarettes. Not to mention the cost savings from that alone. Whether or not combining quitting smoking and treating with immune checkpoint inhibitors allows patients to survive even longer remains to be seen. 

So What’s a Patient To Do? 

Cancer specialists always want good data before making clinical decisions.  And now cancer doctors really do have a few good studies.  Those who attended the recent World Conference on Lung Cancer learned that most lung cancer patients are genuinely interested in quitting smoking-at least 3 studies supported that statement as reported in the Lung Cancer Advisor.

Dr. Kenneth Ward of the University of Memphis, the lead researcher of one such study, did have a personal note about his own father who was diagnosed with lung cancer a few years ago.  “He wanted to quit, but getting the attention of his physicians, his personal physician and his oncologist, to give him any help quitting was difficult.  That just wasn’t on their radar.  There were too many other important things to do.” 

That certainly is a sobering statement for all healthcare providers to think about.  Helping lung cancer patients to quit smoking may just be as important as prescribing a $10,000 a month drug.  But sitting down and spending time with patients to motivate them to quit smoking may just be harder to do.  As cancer specialists, we can spend a lot of time belly aching about electronic health records, insurance companies and Obama care, but we can no longer overlook the need to help our lung cancer patients quit smoking. 

If you have any questions about lung cancer or any other cancer, please feel free to call me, Dr. Edward Hughes, at 855- DAYTON1.