Category Archives: Breast Cancer

BREAST CANCER: SIZE MAY NOT MATTER

Genetic testing shows aggressiveness of even small breast cancer tumors. It was once thought the smaller the more benign, we know that is not always the case.

The decision to treat breast cancer patients with chemotherapy used to be easy, didn’t it?  Breast cancer patients whose tumors were small didn’t need chemotherapy.  Or maybe just hormonal therapy.

But the biology of an individual woman’s breast cancer may change  all that.  We’re now in the age of “precision medicine.”  To put it another way, your breast cancer specialist may now be able to custom tailor your treatment to your specific breast cancer’s genetic makeup.

ARE SMALL TUMORS LESS DANGEROUS?

In the study of 6,693 women in Europe, a total of 826 breast cancer patients had very small (less than 1 cm) breast cancers and no spread to the lymph nodes.  By use of a special genetic test (called MammaPrint) on the breast cancer itself, the doctors were able to identify 23.7% of women who were “low risk” by the old criteria but “high risk” by the new genetic test.  The key result was that the “high risk” breast cancer patients with small cancers did better on chemotherapy.  In fact, the 5 year survival rate was 98.5% with chemotherapy, but only 95.8% without it in those women who were “low risk” by the old criteria but “high risk” by the MammaPrint genetic test.

The results of this clinical trial (called MINDACT) was recently reported in the September 2017 meeting of the European Society for Medical Oncology held in Madrid, Spain.  Dr. Evandro de Azambuja of The Jules Bordet Cancer Institute in Brussels commented on the study and said “Small, node-negative tumors can be very aggressive, even if they are classified as low clinical risk.  Tumor biology needs to be taken into account when deciding adjuvant treatments in this patient population.”  And Dr. Konstantinos Tryfonidis, the senior author of the MINDACT trial, of the European Organization for Research and Treatment of Cancer in Brussels said “Our results challenge the assumption that all small tumors are less serious and do not need adjuvant chemotherapy.”

If you have any questions about the treatment of your breast cancer -with chemotherapy, hormonal therapy, or radiation therapy- please feel free to call me, Dr. Edward Hughes, at 855-Dayton1.  I guarantee that I will see you in 1-3 days.

Breast Conserving Therapy vs. Mastectomy?

Are cancer patients listening to the media more than their own doctors? Angelina Jolie's double mastectomy is not the right choice for most woman.

Are cancer patients listening to the media more than their own doctors? Angelina Jolie’s double mastectomy is not the right choice for most woman.

The past year America has been overwhelmed by the race for the Presidency.  Every day we hear speeches from the Presidential candidates.  The next day we hear from the “fact-checkers” who disprove a lot of the candidates’ claims.  But do facts really make a difference anymore?

That’s the question I have been asking for the past 25 years about lumpectomy and radiation therapy(breast conserving therapy) for early stage breast cancer patients.  Do the facts really make a difference anymore in a country where more and more early stage breast cancer patients undergo mastectomy?

Breast Conserving Therapy vs. Mastectomy

In a landmark study of 7,552 Dutch women with early-stage breast cancer (T1 N0), Dr. M.C. van Maaren and co-workers showed that women treated with lumpectomy and radiation therapy had a significantly better 10 year metastasis-free survival compared with those women treated with mastectomy.  Their study was published in the internationally prestigious journal Lancet Oncology, June 22, 2016 issue.

Are these new and surprising facts?  Not at all.  For the past 25 years, study after study-many with level I evidence, the best medical evidence-have shown that lumpectomy and radiation therapy is at least equivalent to mastectomy in terms of breast cancer control and survival.  Yet the number of women undergoing mastectomy in America continues to increase.

Why Not Mastectomy?

Mastectomy has profound side effects, both physically and emotionally.  But the facts have shown for decades that breast conservation with lumpectomy and radiation therapy is just as good as mastectomy, if not better.  The new Dutch study confirms that it is better for those women with small breast cancers, less than 2 cm and without spread to the lymph nodes.

I believe it is by duty as a breast cancer specialist to make my patients aware of the facts, and not give in to the current, popular trends.

If you have any questions about your breast cancer, please feel free to call me, Dr. Edward Hughes, at 855 Dayton 1.  I have a ‘no excuses’ approach to cancer care, one that beings with the patient and ends with wellness for a better quality of life.

I have written about lumpectomy and radiation therapy being at least as good if not better than mastectomy in a number of my previous blogs. Learn more by reading posts on January 19, 2016October 13, 2015; and August 4, 2015.

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.

Lymphedema Causes in Breast Cancer Survivors

photo credit:theplasticsurgerychannel.com

photo credit:theplasticsurgerychannel.com

When you hear that you need breast cancer surgery, your first thought is getting the best treatment.  With your focus on cure, you might forget the talk about side effects, especially a condition called lymphedema. 

Lymphedema is the buildup of lymph fluid in the hand, arm, breast, or armpit on the same side that you had your breast cancer surgery.  Swelling, pain, and reduced movement can occur-months or years after surgery-causing more emotional upset and lower quality-of-life. 

Study clears up confusion about Lymphedema Causes

Dr. C. M.  Ferguson and colleagues at the Massachusetts General Hospital in Boston looked at 632 newly diagnosed breast cancer patients between 2009 and 2014.  Their study was published in the March 1 issue of the internationally recognized Journal of Clinical Oncology (J Clin Oncol 2016; 34:691-698). 

The primary goal of the study was to measure the actual risk of a number of common situations faced by breast cancer patients each and every day after surgery.  Dr. Ferguson and colleagues conclusively showed that common situations like blood draws, intravenous injections, and blood pressure readings in the same arm as the surgery are not associated with lymphedema.  Importantly, air travel and injury to the arm are also not conclusive causes of lymphedema. 

The main possible causes of lymphedema are axillary lymph node dissection surgery, lymph node radiation, cellulitis infection, and obesity. 

As a breast cancer specialist, I can now assure my breast cancer patients with real facts. The common events in their care after surgery like blood draws, blood pressure reading, and intravenous injections in the same arm appear not to be major causes for lymphedema.  Is this study practice changing?  Probably not. Many more women need to be studied and for a longer time.  But the study is a good first start. It may allow breast cancer survivors some peace in not having to worry about these routine medical procedures.

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

 

Your Risk for Breast Cancer-Genetics vs. Lifestyle?

Did your genetics put you at risk for breast cancer or your lifestyle choices?

Did your genetics put you at risk for breast cancer or your lifestyle choices?

In a landmark study in 2015, Dr. Bert Vogelstein of the Johns Hopkins School of Medicine showed that 2 out of 3 breast cancers are due to bad luck – changes in your DNA caused by lifestyle choices.  But if nature deals you a bad set of genes, all is not lost.  There is hope. 

By analyzing genetic and lifestyle risk factors for breast cancer in over 26,000 women, Dr. Nilanjan Chatterjee of the Johns Hopkins School of Public Health concluded the 28.9% of all breast cancers could be prevented. In fact, women with the highest genetic risk factors were no more at risk if they did not smoke, drink a lot of alcohol, use hormonal therapy at menopause, or had maintained a normal body weight.  Dr. Chatterjee’s study was reported in the May 26, 2016 issue of the Journal of the American Medical Association Oncology.  

Healthy lifestyle changes really are important to prevent cancer.  Even if you have a family history of breast cancer.  A 30% reduction in your risk of breast cancer is under your control.  So eating right, exercising, and getting yearly mammograms are key to not only preventing breast cancer but catching it early. 

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

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.

 

BREAST CANCER: THE TOP 5 THINGS YOU NEED TO KNOW

Over 8,000 breast cancer researchers and clinicians attended the San Antonio Breast Cancer

Know the results of these 5 research studies to help make treatment decisions.

Know the results of these 5 research studies to help make treatment decisions.

Symposium meeting in December 2015.  Here are some of the key highlights that I though would be important to our breast cancer patients.

1. Lumpectomy and Radiation Therapy Is Better Than Mastectomy

In a 10 year study of 37,000 women in the Netherlands, the relative risk of death was 20% lower in women who underwent lumpectomy and radiation therapy versus mastectomy alone.  The 10 year overall survival was 76.8% with lumpectomy and radiation therapy versus only 59.7% with mastectomy alone.  Importantly, the overall survival benefits held even for women who had lymph node positive disease.

  1.  With Lumpectomy and Radiation Therapy, It’s a Good Idea to Stop Smoking

Over 40,000 women were studied by the Early Breast Cancer Trialists’ Collaborative Group.  The results were clear cut-those women who underwent lumpectomy and radiation therapy but continued to smoke were at increased risk for lung cancer and heart disease.

The study was somewhat dated as the median time to entry into the study was 1983. And breast radiation therapy has improved dramatically over 30 years.  But I believe these results still ring true.

3. Skipping Chemotherapy Altogether in Postmenopausal Women with Breast Cancer

Post-menopausal women with the so-called luminal A subtype breast cancer can consider skipping chemotherapy altogether and still expect a good prognosis even when node positive (ER/PR positive, HER-2 negative). Analysis of the “old” Danish Breast Cancer Cooperative Group 77B Trial finally confirmed what many clinicians already thought: Patients with low risk breast cancer do not need chemotherapy.

4. Heart Medications Protect against Herceptin Damage

In the MANICORE  study, women taking both the beta-blocker bisoprolol (Concor) and the ACE inhibitor perindopril(Converyl, Aceon) preserved heart function.  The study may be a life saver for many of those breast cancer patients who take Herceptin for months. Herceptin is known to cause heart damage.

5. Preventing Breast Cancer Recurrence In Women with DCIS: Anastrozole May Be Just As Good As Tamoxifen

The IBIS DCIS Trial and the NRG/Oncology/ NSABP-35 trial showed that the drugs are equally effective. Anastrozole is my choice because of its fewer side effects.

Be sure that you consider these 5 facts when you are making decisions about the treatment plan that is best for you. The goal should be do treat your breast cancer without causing further health issues.

If you have any questions about your breast cancer treatment, please feel free to call me, Dr. Edward Hughes, at 855-DAYTON1

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.