Category Archives: Cancer Recurrence

Prostate Cancer Watchful Waiting-Success or Failure?

Know the whole truth about watchful waiting.

Know the whole truth about watchful waiting.

Are you contemplating ‘watchful waiting’ for your early stage prostate cancer? Does your family practice or internal medicine doctor have all of the details or just the headlines?  Sometimes this strategy can be a big gamble. The roll of the dice can lead to no progression of your disease or painful spread of the disease.

The September 14, 2016 issue of the prestigious New England Journal of Medicine published an article that showed that survival at 10 years was nearly identical for men who elected watchful waiting compared to those who had surgery or radiation therapy.  Nonetheless, the devil is in the details.  The results clearly showed that those men who elected watchful waiting had a higher likelihood of metastasis or spread to the bone compared to those men who underwent surgery or radiation therapy.

“The clinical significance of this finding is that with the use of active monitoring, more men will have metastasis and the side effects of salvage treatment (meaning at least lifelong intermittent androgen deprivation therapy), which are not inconsequential,” wrote Dr. Anthony D’Amico, chief of genitourinary radiation oncology at the Dana-Farber Cancer Institute in Boston.

From my point of view, there are pluses and minuses to watchful waiting.  But in Dayton, Ohio many physicians simply read the headlines of the article without carefully looking at the details of watchful waiting. In my experience, few men and their doctors follow  the guidelines that have been published concerning watchful waiting.

For example, Dr. Laurence Klotz from Toronto critically analyzed the outcomes of watchful waiting for men with low to intermediate risk prostate cancer.  Dr. Klotz reported his findings at the May 2016 meeting of The American Urologic Association.  Dr. Klotz found that the risk of prostate cancer death at the 15 year mark was only about 5%.  Dr. Klotz protocol is one of the most generous compared to the protocol from Johns Hopkins.  In fact, only 20% of men who present with prostate cancer would qualify for the Hopkins protocol compared to 50% in the Toronto protocol.

The Toronto protocol calls for the following for men with Gleason score 6 or lower prostate cancer with so called non-extensive disease or low percent of positive biopsies. The current protocol that Dr. Klotz adopts is:

  • Eligibility: Most men with Gleason score 6 prostate cancer or lower, and a PSA less than 15 ng/ML.
  • Workup: MR scan and targeted biopsies are done for all men with high-volume Gleason score  6 prostate cancer
  • Follow-up: PSA every 6 months
  • Confirmatory biopsy or MR scan within 1 year.  If the MR is negative and there is a low risk disease, biopsy is optional.
  • Repeat MR/biopsy every 3-5 years until age 80.

In my experience in Dayton, Ohio few men have insurance coverage for MR scans and even fewer will submit to repeat biopsies.

So if you elect watchful waiting, you need to know the real risk of recurrence.  That is to say, just getting a PSA every 6-12 months will not cut it if you truly want to catch prostate cancer early and avoid spread to bone.

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

Breast Cancer Genetics Equals 50% Less Chemo

Genetics testing shows that 50% of breast cancer patients do not need chemotherapy.

Genetics testing shows that 50% of breast cancer patients do not need chemotherapy.

Wouldn’t it be great if you knew whether or not your breast cancer will come back? If a crystal ball could help you decide what type of treatment to have now. Chemotherapy and/or Radiation Therapy? Double Mastectomy vs. Lumpectomy? Will I develop distant metastasis – cancer spread to other organs like bone, brain, liver or lung?

Genetics Testing Can Now Answer Some of These Questions

The landmark breast cancer study called MINDACT showed that breast cancer patients deemed clinically high risk by their doctors but low risk by a genetic study (called MammaPrint) had identical survival whether or not the women had chemotherapy or not.  The 5 year rate of surviving without distant metastasis was 95.1% in those women with clinical high risk features but low genetic risk for their breast cancers. The MammaPrint test is a genetic study on your actual breast cancer itself, not on your normal tissues. It is not like testing for BRCA1/2.

50% Less Need Chemo!

Dr. Martine Piccart, chair of the MINDACT study that enrolled 6,693 women in 9 countries, told Onc.Live, “The important message here is, among the clinically high risk patients, the clinical use of MammaPrint is associated with almost a halving of the use of chemotherapy.”  That is a big number.  What the MINDACT study showed is that half of those women whose doctors thought they had high risk breast cancer did not need chemotherapy at all.

The MammaPrint genetic study was able to sort out those women who really need chemotherapy and those who did not.  And that is because many of those high risk breast cancer women really had a low genetic risk for a recurrence.  So it’s genetics, not size that matters in breast cancer treatment.

From my point of view as a breast cancer specialist, the MINDACT study is huge, providing  level I evidence – the best scientific evidence – that MammaPrint can spare many women the side effects and cost of chemotherapy.

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

Is Late Night Snacking Putting You at Risk for Breast Cancer Recurrence?

kitchenclosedFasting for 13 or more hours at night, including sleep, just may help reduce the risk of breast cancer recurrence.  And the effects were huge – a 36% higher risk for breast cancer recurrence for women who did not fast. This study of 2,413   non-diabetic women with early-stage breast cancer was published in the March 31, 2016 issue of JAMA Oncology.

Dr. Ruth Patterson, the senior author of the study, told Medscape Medical News “To our knowledge, this is the first paper examining nightly fasting and breast cancer progression.”  Dr. Patterson went on to say, however, that “the data are not mature enough to make clinical or public health recommendations.”

 As always, the study raised more questions that it answered.  And is likely to take a decade of research to confirm these results.  But I believe the current results are simple and yet profound.  So do what your grandmother always told you, “The kitchen is closed after dinner.”  This simple recommendation of not eating after dinner results in a huge decrease in the chances for breast cancer cure after treatment.

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

 

5 Things You Need to Know When You Finish Cancer Treatment

Here is a blog post that Dr. Hughes wrote a while ago. It is a favorite of his patient’s so we thought it was worth repeating.

5 Things You Need to Know When You Finish Cancer Treatment

Now what? Is that it? Am I done with cancer? How do I keep it away? How do I know it’s not back? Why do I feel lonelier now than I did during treatment?

Eating Healthy is part of the Top 5

Eating Healthy is part of the Top 5

These questions often plague a cancer survivor. It can be frightening to finish treatment. For the past few months you have seen physicians, nurses, therapists and other health care professionals sometimes daily; and now you are on your own. Here are 5 things I tell my patients.

  1. Make sure you have a treatment summary and a survivorship plan from each of your cancer specialists. And make sure that your primary care physician has a copy too.
  2. Understand that the transition from cancer specialists back to your primary care physician may result in a lot of anxiety for you and your family. That is normal. And o.k. Trust this doctor.
  3. Make sure you and your primary care physician keep a watch for signs of late treatment side effects. Let your primary care physician know about any new symptoms that you may experience. While I don’t want you to become paranoid, I do want you to communicate with your doctor. If in doubt, call your specialist.
  4. Keep up to date screening recommendations for people with your type of cancer. Follow the survivorship plan carefully. Also continue to have the recommended screenings for other types of cancers. Just because you had one type, unfortunately doesn’t make you immune to others
  5. Embrace new healthy habits, like a good diet and daily exercise. You have been given another chance. Make the best of it.

Many survivors have a New Normal. It will take some time for your body to find this new normal. Your energy levels, eating habits, and appearance may have changed. Find out what is best for the new you. Worrying about recurrence is a part of this new normal. It can be healthy as long as it doesn’t consume you. Following these 5 steps can help you to be a healthy, happy survivor. Our nurses will be happy to help you create your survivorship plan.

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.

“Where Hope Is” – Our Logo is still True Today

Where Hope Is

Where Hope Is

“WHERE HOPE IS” – OUR LOGO IS STILL TRUE TODAY

When I opened the doors at First Dayton Cancer Care in 2003 there was an air of excitement about the new center and the new technologies-and rightly so. I opened the center because I felt the people in Dayton deserve the best medical treatments offered anywhere in the world. I still believe that.

But I was quietly proud of our logo “Where Hope Is.” I have proven this yet again by bringing the CyberKnife Radiotherapy System to my clinic. Hope can now be restored for patients who had prostate cancer originally treated with standard radiation and now have a recurrence. Rather than years of hormone injections and lasting side effects, the CyberKnife offers a far superior treatment alternative.

WHEN PROSTATE CANCER RECURS AFTER STANDARD RADIATION                                     CYBERKNIFE MAY BE YOUR ANSWER

For many patients whose prostate cancer recurred after radiation, all is not lost. There are now real options- not just “observation” or “palliative” hormone treatments. Many patients go straight to years of hormone shots because there is the perception by urologists that there are no good local treatment options. And that “salvage radiation” is of use only after surgery. The side effects from years of hormone treatments can be devastating to a man’s quality of life.

But Dr. Donald Fuller, a pioneer in CyberKnife, reported on treating prostate patients whose cancer relapsed after IMRT, permanent seed implants and even proton therapy. The 2-year PSA control rate was 83%. And late side effects were minimal and occurred in fewer than 10% of patients-none involving the rectum (ASTRO meeting, 2014).

WHICH RECURRENT PROSTATE CANCER PATIENTS ARE ELIGIBLE?

The following criteria are factored into the medical decision to treat a recurrent prostate cancer patient with CyberKnife:

  1.   a history of prostate cancer treated with radiation
  2.  no complications higher than grade 1 from the previous radiation
  3.  recurrent prostate cancer confirmed by biopsy
  4.  greater than 2 years from prior radiation
  5.  no evidence of spread to lymph nodes, bone or other organs

 REAL HOPE 

Real hope is treatment in 5 visits or less. Real hope is better outcomes and fewer side effects. Real hope is no surgery, no incision, no pain. Real hope is exquisite precision due to real time tumor tracking. Real hope is little interruption to your daily life. Real hope is a better quality of life. Real hope is beating cancer. Real hope is the CyberKnife.

Why Should You Stop Smoking During Lung Cancer Treatment?

Wear a White Ribbon for Lung Cancer Awareness.

Wear a White Ribbon for Lung Cancer Awareness.

Let’s face it. There’s a lot of guilt that goes along with smokers who have lung cancer. Every week my patients tell me “I tried to quit” or “Why should I bother quitting now?” Most lung cancer patients don’t seem to get a lot of sympathy. You don’t see people wearing the white ribbon for lung cancer like the pink ribbon for breast cancer. I don’t see a lot of Hollywood celebrities lining up to go to bat for lung cancer patients. Where are all the 5K runs for lung cancer?

With all that said, many cancer specialists give little more than lip service to telling patients to stop smoking once diagnosed. Why beat them up even more psychologically when we, as their doctors, are asking them to undergo surgery, chemotherapy and radiation? But two major studies may change all that. In the first study, Dr. Meredith Shiels and her colleagues at the National Cancer Institute found that stage I lung cancer patients who survived their first lung cancer but continued to smoke were more than twice as likely as “never smokers” to die (J Clin Oncol 2014: 32; 3989-3995). That’s a big number.

In the second key study, Dr. Yoshikazu and co-workers critically looked at 1,649 patients with locally advanced lung cancer harboring the EGFR mutation. Once again, the conclusion was that survival was significantly better in “never smokers” than in patients with a history of smoking.  All is not lost though. All patients with advanced lung cancer, regardless of smoking or not, benefited from chemotherapy (The Oncologist 2015:20; 307-315). 

 As a cancer specialist who meets with early stage and advanced stage lung cancer patients every day, these remarkable studies tell me that I need to be ever more mindful about getting my patients to stop smoking. Mere lip service is not going to cut it. I know, deep down, that I do the patients and their families no favors if I just ignore their smoking. And it’s just not the doctor’s concern. It will take a group effort with all cancer care providers, family doctors, nurses, technologists and even care takers. Just like chemotherapy and radiation, my lung cancer patients may not like it, but “stop smoking” will be part of the survivor plan.

5 Things You Need to Know When You Finish Cancer Treatment

Eating Healthy is part of the Top 5

Eating Healthy is one of the 5

Now what? Is that it? Am I done with cancer? How do I keep it away? How do I know it’s not back? Why do I feel lonelier now than I did during treatment?

These questions often plague a cancer survivor. It can be frightening to finish treatment. For the past few months you have seen physicians, nurses, therapists and other health care professionals sometimes daily; and now you are on your own. Here are 5 things I tell my patients.

  1. Make sure you have a treatment summary and a survivorship plan from each of your cancer specialists. And make sure that your primary care physician has a copy too.
  2. Understand that the transition from cancer specialists back to your primary care physician may result in a lot of anxiety for you and your family. That is normal. And o.k. Trust this doctor.
  3. Make sure you and your primary care physician keep a watch for signs of late treatment side effects. Let your primary care physician know about any new symptoms that you may experience. While I don’t want you to become paranoid, I do want you to communicate with your doctor. If your physician has any concerns, he will send you to see your cancer specialist. You can always contact your specialist if you are not satisfied.
  4. Keep up to date screening recommendations for people with your type of cancer. Follow the survivorship plan carefully. Also continue to have the recommended screenings for other types of cancers. Just because you had one type, unfortunately doesn’t make you immune to others.
  5. Embrace new healthy habits, like a good diet and daily exercise. You have been given another chance. Make the best of it.

Many survivors have a New Normal. It will take some time for your body to find this new normal. Your energy levels, eating habits, and appearance may have changed. Find out what is best for the new you. Worrying about recurrence is a part of this new normal. It can be healthy as long as it doesn’t consume you. Following these 5 steps can help you to be a healthy, happy survivor.

 

Releasing Your Body’s Own Immune System to Combat Cancer

Using your own body to fight cancer.

Using your own body to fight cancer.

After decades of painstaking research, a number of recent clinical trials have shown that the patient’s own immune system can be used to attack cancer cells. In the January 22nd issue of the New England Journal of Medicine, two separate reports provide even more data on the emerging role of immune therapy in the treatment of metastatic cancer. Immunotherapy for cancer has now focused on the class of drugs called immune checkpoint inhibitors. These drugs are actually antibodies themselves, and inhibit the body’s own natural brakes on the immune system.

The first article described better survival for patients with metastatic melanoma, the deadliest form of skin cancer, who received the drug nivolumab. Results of this study strongly support the approval of nivolumab as first-line treatment for many patients with metastatic melanoma. The second article showed a very high response rate of 87% to nivolumab for patients with Hodgkin’s lymphoma in whom chemotherapy failed.

Dr. Drew Pardoll, M.D. PhD, co-director of the Johns Hopkins immunology program, stated that “I divide pharmaceutical companies into two categories. They’re in immunotherapy up to their eye balls or they want to be.” This is an exciting time in medical research. We are just beginning to understand how powerful our own immune system can be with the right help.

Another class of drugs focuses on inhibiting immune cell molecule called CTLA-4. There are now at least 3 examples of successful immune mediated tumor rejection after treatment with radiation therapy and CTLA-4 checkpoint blockade. Importantly, each of these studies used short course/high dose radiation therapy combined with the CTLA-4 antibody. Two studies again focused on metastatic melanoma, and another one focused on metastatic lung cancer. I believe that we are just at the dawn of integrating short course/high dose radiation therapy, such as that delivered by the CyberKnife, with immunotherapy. In the coming decade, there will continue to be exciting advances with these new modalities to improve patient’s quality of life.

It now looks like the time and money spent in tumor immunology is paying real dividends for patients. The hope is that the immune checkpoint drugs can be combined with traditional forms of cancer therapy, like surgery and radiation therapy, to treat even more cancers. Stay tuned.

Exercise Each Day Will Keep Cancer Away

Exercise is More Fun Together

Exercise is More Fun Together

February is National Heart Month. We are all wearing red to increase heart health awareness. What is good for the heart, is good for cancer prevention. You can reduce cancer recurrence by up to 40% by making this one simple lifestyle change!

We all know that exercise can help prevent heart disease. What’s equally true is that routine exercise can not only prevent cancer, but also help to prevent cancer recurrence. Exercise has proven to decrease the risk of colorectal cancer, postmenopausal breast cancer, uterine cancer and possibly prostate cancer. Other major studies have shown that routine exercise can also reduce the risk of cancer recurrence once you have been cured of the disease. Major studies in breast cancer and colorectal cancer have shown that routine exercise can reduce the risk of recurrence by as much as 25-40%. Let’s look at breast cancer, specifically triple negative breast cancer, the most deadly form of the disease. A study published in January 2015 in the Journal of Cancer, showed that routine vigorous exercise can increase the levels of a hormone called Irisin. Irisin was shown to have 2 major effects. First, irisin decreases cancer cell movement, an essential component of metastasis or cancer spread. Second, irisin was shown to increase programmed cancer cell death or cancer cell suicide. These results were shown in the test tube, but may have profound effects for cancer patients.

Doctors say do “routine vigorous exercise”. Does that mean you need to run marathons to prevent cancer? I don’t think so. But I do know that 3-4 hours per week of exercise is better than 1-2 hours. I don’t know whether aerobic exercise is better than strength training for cancer prevention. So what do I tell my patients? I tell them to exercise 30-45 minutes each day for 6 days of the week. I recommend alternating “strength days” with “aerobic days”.

I practice what I preach.  I take my dogs for long walks on Monday, Wednesdays and Fridays; and do Pilates on Tuesdays, Thursdays and Saturdays. It is never too late to start. At every age, at every stage of cancer prevention, or cancer survivorship; there are far reaching benefits.  Keeping Cancer Away is one of them!