Well I want to take a minute today and inform all of you about a concept that I have been working on for the past year and am about to unveil it to my current patients undergoing treatment. The name of the program is Cancer Coach. The purpose of the program is to give every single patient with a diagnosis of cancer the opportunity to have someone as their advocate from the time of diagnosis through the end of treatment and into follow up care.
As those of us that have been affected by cancer, we know how trying and scary the diagnosis can be to ourselves, our loved ones, and our family and friends. When you hear the words, “You have cancer” it changes ones life forever. It brings many thoughts and emotions. It may even strike fear deep within.
What if everyone that was diagnosed with cancer also had a person assigned to them to help them through their journey? A person that has medical experience but can relate to patients; their needs, their fears, their wants, their emotions. A person to help them navigate the confusing and fragmented health care system. A real life person to be their point of reference to help with everything from community resources and support groups, to insurance and finances, to the emotional well being, to the impact of family dynamics.
Would it help? Would it increase a patients ability to concentrate on getting better, staying positive, and fighting this disease head on?
I believe it would. So much so that I did the research on other programs. Whether it is the American Cancer Societies “Navigator” program or to more traditional “coaching” programs where other cancer survivors act as a contact person for those currently undergoing active treatment. All of these programs have good and bad points, but none of them really meet all of the needs of a cancer patient.
The program I have taken a year to create, and am now implementing will hopefully be dynamic and will alleviate all of the short comings that other programs have experienced.
This is how the program will work: At the time that a patient is called by their specialist and informed that they know have cancer, they will also be introduced to their Cancer Coach. At this point in time, the “Cancer Coach” will contact the patient either via phone if the specialist asks, or at the first appointment at the cancer center.
At the first introduction, the Cancer Coach will briefly introduce themselves to the patient and their family members and let them know that if their is any help, information, or issues that they are to contact their Coach immediately. The Coach will then begin to explain to them their role as a resource.
If the patient and/or family members decide that they would like to have the Cancer Coach take notes during their initial consultation with the Medical and/or Radiation Oncologist, then they may do so. The Coach has the ability to take notes on the conversation, the diagnosis, and other important information that is discussed during the consultation. The Coach will leave the room during the physical exam.
After the consult, the Coach can then follow up with the patient and family members and go over the notes and the treatment plan that was created for the patient. The Coach can also begin to coordinate schedules for any other tests or appointments that need to be made for the patient. If rides are an issue, then the Coach can begin to work on this issue as well. Perhaps there are some insurance questions, the Coach will begin to help answer and address these questions as well.
By the time a patient leaves, they will have a hand typed letter that simply explains what each physicians treatement plan is for their diagnosis. They will have the coordinated schedule in front of them as well to make it as convenient as possible for the patient. They will also have all the contact information for their physicians, the cancer center, as well as their Coach. This will allow any further questions or concerns to be addressed by the same person each time.
The Coach will be able to meet with each patient and follow up to make sure that all of the patients needs are being met. Perhaps the patient needs some help with quitting smoking, the Coach will be able to address this with programs that are offered with in the Health System or within the community. Maybe a patient is having difficulty eating, so the Coach can assess this and give suggestions, or if nutritional support is needed, that they can make arrangements with the appropriate staff.
The Coach becomes a partner with the patient to address any and all issues or help that the patient may need during their journey. By doing so, it will allow more time for the patient to concentrate on getting better. Leaving those things that we typically worry about such as work, insurance, money, how we are viewed by our loved ones and ourselves, and trying to navigate a dysfunctional health system to their Coach. Thus allowing a patient to concentrate on getting better and beating Cancer.
If you have any further questions or concerns, or would like to learn more, please feel free to contact me directly at: Cancergeek@gmail.com I will answer any and all comments or questions within 24 hours.
I just wanted to let everyone that I have not forgotten about the site, I am in the middle of the vital stages of construction for a new cancer facility. I am still answering emails and will be creating some new posts soon. I also was just awarded membership to the Healthcare Bloggers Code of Ethics.
As always, if you or a loved one have any other questions, comments, or concerns; if you would like more information in regards to another cancer related topic, please contact me at: CANCERGEEK@GMAIL.COM
Yesterday was the last day of the month of October and I thought it would be nice to end the month with the topic of Breast MRI for Breast Cancer. One has to remember, that with all of these tools, Ultrasound, Mammography, PET, MRI, Genetic Testing, and Hormone Testing that none of them on their own are the best diagnostic test, but in the correct combination based on each patients particular diagnosis, they can be essential tools that will lead to the best possible outcomes.
There have been several studies done to look at the benefits on the use of MRI with breast cancer. A report published by the American Cancer Society states that the addition of breast MRI along with traditional mammography in young, high-risk patients improve the screening success which leads to earlier detection.
This group of women, young and at high-risk, tend to have a larger majority of women that may decide to have a prophylactic mastectomy and to also have their ovaries removed. This is done to prevent them from developing breast cancer. The point is, that just because a woman may be at a high risk, it does not mean that they will 100% definitely develop breast cancer. If we can improve the ability to screen in this population of patients, and lead to better and earlier detection rates, then we can also offer less invasive surgeries, with better cosmetic and emotional outcomes for patients.
According to the data and article published by the ACS on their website on March 28, 2007 (Full Article) that they have changed their guideline to state that women with a high-risk of developing breast cancer and that our young, would benefit from the addition of MRI along with yearly mammograms. This screening protocal would allow women to have the greatest ability for earlier detection which would hopefully lead to better outcomes and survival rates.
MRI scans are more sensitive than traditional mammograms but they also are less specific then mammography as well. What this means, is that MRI might be able to detect smaller lesions that might be missed on a typical screening mammogram, but at the same time, the test is not as definitive to indicate whether or not those lesions detected are cancerous in nature. This also means that lesions detected by MRI and not by mammography would need to have additional follow up. This might mean more unnessecary biopsies, studies, and other invasive prcedures for a woman to have to go through, and thus more anxiety during the process.
“As with other cancer screening tests, MRI is not perfect and in fact leads to many more false-positive results than mammography,” explains Christy Russell, MD, chair of the ACS Breast Cancer Advisory Group and co-author of the new guideline. “Those false-positives, which can lead to a high number of avoidable biopsies, can create fear, anxiety, and adverse health effects, making it imperative to carefully select those women who should be screened using this technology.”
The most current and up to date American Cancer Society guidelines for breast screening are as follows:
1. For women with an average risk of developing breast cancer, that begining at age 40, an annual physical examination and mammograms should be done.
2. For women with a high-risk for breast cancer, physical examination, screening mammograms, and breast MRI should begin at age 30.
According to research published in the New England Journal of Medicine: Vol.351:427-437 July 29,2004 Number 5, (Full Article) they were able to verify that breast MRI was more sensitive then mammography in the detection of cancerous lesions in the breast.
The researchers felt that there wasn’t enough data for the use or benefit of using MRI for the screening of breast cancers in women. So what the researchers decided to do was to begin with the high-risk population of women. That would be a group of women that have a genetic or familial predisposition to developing breast cancer. They would then take this group of women and use mammography, along with physical examination, and breast MRI to see if there was any improvement in finding lesions at an early stage in this population of high-risk women.
There were a total of 1909 women enrolled on the study, including 358 women with a germ-line mutation for breast cancer. These women had a minimum of at least a 15% increased risk for developing breast cancer. The patients were then followed for about 3 years. During this time, patients would under go a clinical breast exam every 6 months and then a mammogram and a MRI every year. These imagining studies were then read independently by 2 seperate qualified radiologists. The findings of the cancers detected on MRI were then compared with the characteristics of breast cancers found in two different age-mathced control groups.
What they found in the 1909 women that were on the study for almost a 3 year period was that 51 cancers (44 invasive breast cancers, 6 DCIS, and 1 lymphoma) and 1 lobular carcinoma in situ were detected. The sensitiviy (ability to detect an abnormal looking lesion) and the specificity (ability to determine its cancerous) for each modaility was as follows:
Clinical Breast Examination: 17.9% and 98.1%
Mammogram: 33.3% and 95.5%
Breast MRI: 79.5% and 89.8%
In another study published in the American Journal of Radiology (Full Article) they took a prospective look at 46 patients that had a positive lesion detected on mammogram, ultrasound, or both, and then were found to be malignant with biopsy. They took this group of women and imaged them with Breast MRI. In their study they found that breast MRI was 100% successful in detecting malignant lesions within the breast. It was able to dtermine in 73.7% of the cases that the lesions were benign or malignant, meaning that the lesions needed additional work up studies.
This study also found that breast MRI was able to detect another additional 37 lesions, 23 of which were found to be cancerous, that were not intially detected by mammogram or ultrasound imaging. Breast MRI was then able to detect another 4 (9%) cancerous lesions in the opposite breast. The addition of MRI to these women only increased in an additional 14 biopsies for what was found to be benign lesions.
In this specific study, the additional information from breast MRI, mainly in having disease present in the opposite breast, resulted in a slight incremental increase in women deciding to have a mastectomy versus breast conserving surgery.
Both of these studies are imporant because it shows that when breast MRI is used in high-risk patients it will allow for earlier detection of potential breast cancers. This will then lead to earlier treatment intervention and have a significant increase in a women’s survival with this disease. In the latter of the studies, it is imporant since it shows that in early stage breast cancers, the additional information obtained under breast MRI may impact and change that patients treatment planning and management. It also means that there is a significant ability to catch other breast lesions in the opposite breast.
As always, if you or a loved one have any other questions, comments, or concerns; if you would like more information in regards to another cancer related topic, please contact me at: CANCERGEEK@GMAIL.COM
Well this week is the official American Society for Therapeutic Radiology and Oncology meeting in Los Angeles, CA. It is always a wonderful meeting with a lot of good information for other oncologists (cancer doctors) and other cancer care professionals. This is typically where a lot of studies will be reported on, results from clinical trials, new methods, new techniques, and where new and exciting treatments are unveiled and shared with everyone in attendance. It is a wonderful place full of knowledge and cutting edge techniques all surrounding the treatment of cancer.
In a report released on-line by ABC medical news unit, reported by Katharine Stoel Gammon (full report) they talk about a study that was released on the 29th of October by Dr. Harry Bartelink from the Netherlands Cancer Institute in Amsterdam. This study takes a look at the 10 year data for women with breast cancer that receive a “boost” to the cancer bed at the end of their typical radiation therapy treatments.
What the study found was that women that received this additional “boost” to the original site of the breast cancer are almost 2x more likely to be cancer free after 10 years then women that did not receive the additional boost. This seemed to have the strongest survival benefit in women under the age of 40, yet all women seemed to have a benefit from the additional radiation “boost.”
Dr. Bartelink stated that he was very pleased with the results of the study. He said that more then 80% of women were alive after 10 years. He also stated that even though only 5% of all breast cases involve women under the age of 40, that it is still very beneficial since this subgroup of women also tend to have the highest rate of recurrences. This is due to the fact that women under the age of 40, have a lot more years to live, allowing the potential for the cancer to come back over that amount of time.
Treating early stage breast cancer typically involves a lumpectomy (removal of the breast cancer itself from the breast) followed by a course of radiation therapy. This course of treatment typically take 6 to 8 weeks of time. Patients receive radiation 5 days a week. The entire breast is at risk for a recurrence, so the radiation treatments involve the entire breast tissue during this time.
The one thing to consider, is that the data also states that if a women is going to have a recurrence, 90% of the time that recurrence is going to happen at the same site of where the original breast lesion was discovered. Due to this fact, the entire breast will need a lower dose of radiation as compared to the lumpectomy site itself. This “boost” allows the lumpectomy site to get a higher dose of radiation with minimal additional side effects.
The biggest side effect in this small additional dose is fibrosis (scar tissue) at the lumpectomy site. The standard average seen is about 1%, with the additional “boost” it may rise to about 4%. This can be decreased back to the 1% with better surgical techniques. The other side effects that some patients may experience with this additional boost are redness, a slight swelling, and perhaps a bit more tenderness.
The one good thing for all of us to remember, is that in the US, in the vast majority of cancer centers, that this additional “boost” has been the standard of care for many years. So this means that most women that have received radiation for their breast cancer have already received an additional boost to the original breast cancer site. The “boost” to the lumpectomy site is also performed with electrons, which is a much lower energy, and does not penetrate as deeply as the radiation to the entire breast. This allows for the dose to be aimed more precisely at just the lumpectomy site and sparing more of the normal tissues. As you can see in the above picture, the circled area on the breast with the blue in the top image is the area that will be treated with the “boost.” In the lower picture, the area that is highlighted in pink is the lumpectomy cavity that will receive the additional “boost.”
If you question if you received this additional boost, try to remember your breast cancer treatment. You most likely received the majority of your treatment from the machine being in two different spots. If you received the additional boost treatment, it would most likely been at the end of your treatment, the last 5 days, and the machine would have only been in one spot. The therapists would have placed a “cone” onto the machine, and this would direct the boost to the lumpectomy site. You would also notice that the machine was really close to you as well. The machine would have looked and been positioned much like the picture above.
As always, if you or a loved one have any other questions, comments, or concerns; if you would like more information in regards to another cancer related topic, please contact me at: CANCERGEEK@GMAIL.COM or CANCERGEEK@CANCERGEEK.COM
This is a video that was done for Breast Cancer Awareness. The two people on the show are Dr. Edie Krueger who is a radiation oncoligist and Andy DeLaO who is a director of oncology services, as well as a radiation therapist and a medical dosimetrist.
It is a really well done video speaking on the importance of Breast Cancer Awareness and the role of Radiation as a treatment option for women with Breast Cancer.
If you have any other questions, comments, concerns or if you or a loved one need any help with anything else, please contact me at: CANCERGEEK@GMAIL.COM
In an early release of the Journal of Clinical Oncology on-line dated Oct. 22, 2007 is a report on a study conducted at the University of Minnesota on the increase of patients choosing to have a mastectomy performed on the opposite unaffected breast in order to prevent cancer in the future. For women diagnosed with Breast Cancer, it has always been an option to have the entire breast surgically removed. As more and more data has been collected, and more in depth studies have been conducted, there has been a trend for more women to choose to have Breast Conserving Surgery versus the entire removal of the Breast affected with cancer. However, this study conducted at the University of Minnesota has seen a gradual yet significant increase. In 1998 there was about 1.8% of all breast cancer patients decided to have both breasts removed. As of 2003, the data collected at the University of Minnesota has shown an increase to 4.5% of all patients.
The study analyzed data from a small fraction of the estimated 200,000 women who receive a breast cancer diagnosis each year in the U.S. If these figures are accurate, it could be seen that there is an average of 8000 to 10,000 women a year choosing to have this elective surgery done. The name of the surgery is called: Contra-lateral Prophylactic Mastectomy (surgical removal of opposite breast not affected with breast cancer.)
Some patients decide to have this major operation because they just want the best option for survivability. There is the thought process that I just want this thing out of my body. I want to do everything in my power to give me the best opportunity to defeat this cancer from ever coming back in the future. By removing both breasts, some patients feel that this is the best choice for them.
The studies lead author, Dr. Todd M. Tuttle, chief of surgical oncology at the University of Minnesota started the study because so many of his patients were requesting to have the procedure performed. Dr. Tuttle said that he was surprised that so many patients were deciding to have the unaffected breast removed as well. He noticed the trend was moving upwards and that it shows no signs of leveling off, even as breast conserving surgery (lumpectomy) expands and becomes more popular.
He stated that some of his patients have said that they just want to be done with it. They do not want to have to think about breast cancer ever again, or to have to deal with having another mammogram performed, or to go through another biopsy, then the waiting of finding out if it is back or if it isn’t.
The thing that is VERY important for patients to realize is that even thought the breast is removed, and that the risk of recurrence is drastically reduced, it does not mean that the risk is zero. This is because there is still some breast tissue that remains behind. Surgeons are good, but there is no way that they can ensure that every single piece of breast tissue has been removed from the patient. Another thing to remember is that its the initial cancer diagnosis that poses the greatest threat to a patient’s life.
The study used data from cancer surveillance registries covering about a quarter of the United States to identify 152,755 patients whose cancer was diagnosed in one breast from 1998 to 2003. The rate rose steadily, with 4.5 percent of all patients who received breast cancer diagnoses in 2003 having the surgery, up from 1.8 percent in 1998.
In those patients that chose to have a mastectomy for the breast that was found to have cancer, 11% (2003) decided to have the other breast removed for prevention of future breast cancer as well. This was up from 4.2% in 1998. Patients with stage I breast cancer choose to have the procedure done more often then those patients with more advanced and aggressive breast cancer.
Younger women, white women and women with a previous cancer diagnosis were more likely to opt for a contra-lateral prophylactic mastectomy, the study found, as were women who had lobular histology, meaning the cancer started in the lobules or milk-making glands of the breast.
What the researchers are also noticing is that there are two extremes being seen by patients with Breast Cancer. One group decides to have lumpectomy, or a minimal surgery, and the other group decided to have a both breasts removed. There are fewer women deciding to just have one breast removed.
The most important thing for all of us to remember is that education is the best tool for all of our patients, family members, and loved ones. In order for patients to make the best decision for themselves, we need to arm them with all of the facts surrounding their disease and diagnosis. Before any patient makes a decision to have surgery, they should also meet with a Radiation Oncologist as well as a Medical Oncologist to know all of their treatment options up front. This allows a patient to have all of the information in front of them in order to make the best decision based on their cancer type, life style, and personal needs. A patient may decide that having a lumpectomy and radiation followed by Tamoxifen or Femara is a far better choice for them physically, emotionally, and personally versus having both breasts removed.
If you as a patient feel that you are not armed with all of the information prior to making a decision, remember that you have every right to tell the physicians to slow down, that you want a second opinion, and that you want to meet with the entire team of physicians in order to make the best informed decision around the type of cancer you have.
As always, if you or a loved one have any other questions, comments, or concerns; if you would like more information in regards to another cancer related topic, please contact me at: CANCERGEEK@GMAIL.COM or CANCERGEEK@CANCERGEEK.COM
As we all know this month is National Breast Cancer Awareness month here in the U.S., but world wide there is a awareness for Breast Cancer this month as well. Breast Cancer in the most researched and widely publicized topic of all cancers. It is great because we are making some wonderful strides in the detection, prevention, and treatment of Breast Cancer. This has helped to save more lives, keep more women from experiecing devastating and life changing side effects, as well as keeping more mothers, sisters, daughters, and friends on this earth.
In Australia there was a new online calculator that was developed to help educate and caluculate the risk that a women may have for developing breast cancer. It is really nice since it is online and is relatively accessible to most people in the world. It is also very robust since it goes through all of the major contributing risk factors for women, and also gives women the option to click and learn more about each of the risk factors.
Dr. Helen Zorbas of the National Breast Cancer Centre said in a report released earlier today that, “One in three women think that a knock or bump to the breast increases their risk significantly yet they don’t believe that alcohol poses any risk for breast cancer.”
This goes to show how confusing all of this information can be for all of us at times. I mean each day there are several reports published saying this thing or that thing has been linked to Breast Cancer. There are also a lot of myths out there as well that have been linked to Breast Cancer. I have seen in my own patients that all of this information on risk factors, family history, genetics, and alcohol consumption can be very confusing.
I personally have always had a general rule of thumb that I have shared with my female patients in regards to some simple factors that they can control.
Drinking one alcoholic beverage per day increases your risk by about 10%. Consume 2 drinks per day, and it raises by about 20%. This means on a daily basis. This also does not mean that you can save all of your drinks and binge on one night either. Unfortunately, it doesn;t work that way.
Exercising for 45 minutes a day can decrease your risk for developing breast cancer by about 6%. Increase that to 2 days a week, and you decrease your risk by 12%. This accumulates as well, so there is a good argument for physical activity and excercse.
I took an indepth look at the online calculator and found it be very user friendly and helpful. There are also links along the way that allows one to read about more information on each of the risk factors that you are asked about. At the end, it also gives you a good explanation on what you might be able to do to change some of these risk factors, what to watch for, and more information on each factor.
As always, this can not take the place of yearly physical exams, screening mammograms, breast self exams, and being aware of changes that you are experiencing with your own body. This is just another tool to help you in the fight and prevention against Breast Cancer, and if you are at a higher risk, to then arm yourself with the correct tools to give yourself the best chance for survival of this disease.
As always, if you or a loved one have any other questions, comments, or concerns; if you would like more information in regards to another cancer related topic, please contact me at: CANCERGEEK@GMAIL.COM or CANCERGEEK@CANCERGEEK.COM
Today I want to take some time and touch on a topic that is up for some debate. The use of IMRT (Intensity Modulated Radiation Therapy) in the use of breast cancer. First off, it is probably important to explain exactly what IMRT is and what it does.
IMRT is like painting with radiation. As you can see in this picture of Einstein, which was made by a linear accelerator, using IMRT to do so. It allows the physician and dosimetrist to create a plan that allows us to deliver a high amount of radiation to the areas that are very important to get a radiation dose to, such as the lumpectomy cavity, and then to decrease and limit the amount of radiation exposure to normal and critical organs, such as the lung or the heart on a left sided breast cancer. In the example above, the darker areas would be those exposed to more radiation, and the lighter areas received less amounts of radiation. You can see how precise this can be when done correctly.
Know that we know what IMRT is, and a simplistic definition of what its purpose is set to accomplish, I think it is now appropriate to take a closer look at IMRT for Breast Cancer. The traditional or standard or care for breast radiation is a 3D plan typically consisting of two tangential fields. It may look something like this:
As you can see in the above picture, there would be a field that comes from the upper left hand side, and entering the patient, and another field that would be coming from the bottom right hand side and then entering the patient as well. Since this is a left sided breast cancer, you can also that there is a small portion of lung (orange color) and heart (pink/magenta color) that is included in the treatment fields.
Since the breast tissue goes all the way down to a patients chest wall, or for simplicities sake, rib cage, there has traditionally been about 1.5 to 2.0cm of lung included in most physicians breast plans. This is to ensure that all of the breast tissue is being included in the radiation field, and that even with the motion of patient breathing, that the breast is always targeted with the radiation that is being administered to the patient.
In this slide above, you can see the difference between a breast IMRT plan (Left) and a conventional “standard of care” plan on the right. If you pay close attention to the images on the right hand side, you will notice the arrows pointing towards the areas labeled hot spots. This is the one down fall with conventional, or tradition breast radiation. The radiation is trying to be delivered to a large area of tissue, and trying to deliver and dose that is the same through out. Unfortunately, we all know that breast tissue is not a nice little box that is the same size in all directions.
Due to this factor alone, there tends to be these hot spots in the areas of breast tissue that happen to be thicker, have more tissue overlapping itself, such as underneath the breast tissue and next to the rib cage of a woman, or perhaps where there is not enough breast tissue. We then try to “compensate” for this difference in breast tissue with the use of a device that we call a “wedge”.
From this picture you can see that it does look like one would think, like a wedge of metal. It is placed in the machine and will try to help and compensate for the differences in breast tissue for a specific patient. Unfortunately, it isn’t a perfect world and there are only so many things that wedges allow physicians to manipulate the radiation beam in order to make it more precise in treating the breast. It does not allow us to eliminate or diminish hot spots as drastically as IMRT.
In these instances, patients may end up having some skin reddening or even experience the skin breaking down and in some situations, a severe burn and weeping of the skin happens.
The above photo happens to be a more severe case of what a patient may experience. As I said, not all patients experience a case to this extreme, but I think the point and case is made that there is an increase in radiation delivered to some of these areas of the breast that do not need that much radiation, and with that, comes some unnecessary skin reactions that a woman should not have to go through if at all possible.
This is where IMRT comes into play.
IMRT is made up of many tiny little beams about the size of a pencil referred to as beam-lets. These beam-lets can be thought of like an older dot matrix printer. In using all of these small little numerous beam-lets, to form one larger beam, it allows the physician and the dosimetrist to develop a highly conformal and precise delivery of radiation to the patients.
Again in this picture you can see the difference between the two plans. The one of your left is the typical conventional plan and the one on your right is the IMRT plan. You can see first hand how the IMRT plan on the right allows the radiation oncology team to focus the field more intensely on the tumor area itself and limit the dose to nearly normal tissues.
In order to accomplish this, the physician needs to plan ahead and really think through his outcome that he ideally would like for the patient. The physician will have to look at all the scans, and then actually sit down at a computer and contour, or draw over all of the breast tissue that he wants to be treated. He will then also need to draw other areas of interest that he may want to avoid, such as the lung or the heart if a left sided breast cancer. At times physicians will also make sure to draw a seperate area around the lumpectomy cavity, where the tumor was removed. This is to make sure that this area received a bit more radiation then the rest of the breast tissue. The rationale is that close to 85% of the time if a patient is going to recur, its going to be locally at the sight where the original tumor was located.
Once this is all done, the computer is then put to work to develop a plan that will achieve all of the physicians desired outcomes and taking into consideration the limitations that the physician also wants to consider. For example, the physician wants the entire Breast to be treated to a dose of 50.4cGy, and wants the lumpectomy area to get a bit more radiation, and go to a dose of 60.4cGy. Perhaps the physician wants to limit the amount of radiation to the heart to less then 10% of the total dose, and wants there to be no hot spots greater then 5mm in any dimension. The computer takes all of this into consideration, and the dosimetrist helps to maneuver the plan in order to get the outcomes that the physician wants for his patient.
What happens is that a plan is generated that allows little deposits of varying doses to be places all along the breast tissue in order to achieve the type of outcome and plan that the physician would ideally like for his patient. It may look something like this:
In this view, you can see the different columns are at different heights. This represents the amounts of radiation being deposited in any one particular area of the breast tissue. The largest columns may be right at the original sight of where the tumor was located. The area that is the shortest in height may be at the underside of the breast, where a skin reaction is most likely to occur. In doing this, it allows the radiation to be “painted” onto different areas within the breast tissue at different intensities.
So why is all of this important and why do we need Breast IMRT?
1. More conformal dose to the Breast: The natural taper of the breast produces hot spots in ranges of 3% to 20%. Even with the use of wedges, these hot spots are still very noticeable and can still produce some substantial side effects for patients. IMRT can drastically reduce these hot spots.
2. Lower dose to the Heart and Lungs: Dose is fairly low in all cases on left sided breast cancers, however, with the use of IMRT the dose that is administered to the heart and lung can be lowered even more. In one study done abroad, it was shown that the dose to the left lung and ventricle could be reduced to less than 500cGy, or less then 10% of the prescription dose. In patients that have pre-existing conditions such as Congestive Heart Failure or decreased lung function, this improvement can be drastically significant in their overall health.
3. Lower dose to the opposite breast: In some recent data published be a group from the Netherlands and presented at ASCO, they took a look at 999 women that were previously treated for Breast Cancer. What they saw was that in women ages 40 years and younger, that they had an increase risk of developing Breast Cancer in their opposite breast by as much as 60%. IMRT can drastically reduce the amount of radiation being deposited to the opposite, or unaffected breast in comparison to the scatter radiation it typically receives from conventional methods.
4. Field with in a field: The fact that IMRT allows physicians to increase the amount of radiation being deposited in a certain area means that a patient can receive their overall breast radiation as well as their boost to the tumor site at the same time. This decreases the overall number of times that a patient has to come in for their radiation treatments. This can be a bit more convenient for patients.
As always, if you or a loved one have any other questions, comments, or concerns; if you would like more information in regards to another cancer related topic, please contact me at: CANCERGEEK@GMAIL.COM or CANCERGEEK@CANCERGEEK.COM
With the month of October being National Breast Cancer Awareness Month, we tend to see lots of specials on TV, on the news, radio, or even at local events talking about the importance of awareness. We hear statistics and figures on women, the likelihood for developing Breast Cancer, the prognosis, even new research and rugs that have been recently approved for use in the medical field. We learn about the importance of early screening and detection, and the annual push to get your mammograms done.
Yet there is one thing that we forget to talk about, or maybe it is too taboo to talk about in plain sight for everyone to read and learn about, Male Breast Cancer. That’s right, its not just a disease that affects women, but men can develop the disease too. In fact, we all hear about the genetic disposition that occurs in about 10% of all women diagnosed with Breast Cancer, the expression of BRCA 1 or BRCA 2 genes. Men can carry this gene as well, and if they do, their chances for developing Breast Cancer can be just as high as women.
In the US there have been approximately 2030 cases of Male Breast Cancer. Of those 2030 cases, there have been about 450 deaths as well, this is according to the NCI data. (NCI:MEN) Of course, this only makes up about 1% of all cases of Breast Cancer, but yet, it is still important for us to realize that this disease can strike men as well.
Typically this type of Breast Cancer will develop in men around the ages of 60 and 70. Some of the signs and symptoms are much like that in women. It is important for men to think about noticing changes in their breasts, or if it is safer to say, Pecs, but to notice any slight changes. Men will typically notice a lump just like a woman does in Female Breast Cancer.
Another common change is something that we call: Gynecomastia.
This refers to the increase in the amount of Breast Tissue present in a male. This does not necessarily mean that it increases your risk for developing breast cancer. It does however represent that there is an increase in the amount of Estrogen that is present in a man’s body. As we have learned from some of my other articles, an increase in Estrogen in the body may lead to someone developing Breast Cancer. This holds true for men as well.
If Breast Cancer happens to be discovered in a male, then he should undergo similar testing that a female would go through as well. This would include a physical exam by a physician to see if there is any palpable lump noticed in the Breast Tissue. If it happens to be something of concern, then a man should also be ordered to have a mammogram, ultrasound, and biopsy as well to give confirmation that it is in fact Breast Cancer, and what stage of cancer it is.
Some other important factors to keep in mind in regards to Male Breast Cancer: If a man is in a family that happens to have a high number of relatives that have developed Breast Cancer, of if they know that their family is a carrier of the BRCA1 or BRCA2 gene, that they may want to consider a consultation with a medical professional that specializes in Genetics. This will help to see if one is at an increase risk for developing Breast Cancer, or for that matter, any other type of cancer. Men with a known family history of Breast Cancer and a mutation in the BRCA genes are typically also at an increase risk for developing Prostate Cancer as well.
Other risk factors for men include increased levels of Estrogen, alcohol use, obesity, cirrhosis of the liver, and Klinefelter Syndrome. A history of Radiation Therapy to the chest may also increase the chances for a male developing Breast Cancer as well.
In the US, the chances for Breast Cancer developing in African American Men is slightly higher then it is in Caucasian Males. Internationally, there is a high incidence for Male Breast Cancer in countries such as Uganda and Zambia. In contrast, in Asian Countries, there seems to be the lowest number of Male Breast Cancer Cases.
Due to the lack in numbers of men with Breast Cancer it has been hard for the medical community to conclude as to what all of the risk factors are, and what the cause has been for the slight and steady increase that has been seen over the last couple of years. Since the numbers are so small, most of the research has been conducted on small retrospective cases or from extrapolating data from Female Breast Cancer studies. Due to this factor, it is also unrealistic for any one institution to conduct a prospective clinical trial into the best treatment option for men with Breast Cancer.
The treatment option of choice for most men with Breast Cancer has been mastectomy.
As always, if you or a loved one have any other questions, comments, or concerns; if you would like more information in regards to another cancer related topic, please contact me at: CANCERGEEK@GMAIL.COM or CANCERGEEK@CANCERGEEK.COM
As I promised the other day, I wanted to take a moment and to talk about a study that was conducted by the National Surgical Adjuvant Breast and Bowel Project (NSABP) in support from the National Cancer Institute (NCI). This trial is the first of its type to ever compare the effectiveness of two seperate drugs. The drug more commonly known as Tamoxifen (Novaldex) is already known and proven to reduce the risk of breast cancer in those women that have a higher risk for developing breast cancer. This trial compared Tamoxifen with a new drug called Raloxifene (Evista) and compared them head to head to see if the new drug, Raloxifene, was just as good, or maybe even better then Tamoxifen. The name of the study was the STAR Trial. STAR simply stands for Study of Tamoxifen and Raloxifene Trial.
So the STAR Trial began enrolling women in the study in 1999. The cirteria for being on the study was that participants had to be:
Women
In good health
Age 35 or older
Post menopausal and at a high risk for breast cancer based on the GAIL model.
The study began as I said in July of 1999 and was done accepting participants to the study as of November 2004. There were a total of 184,461 women that went through the risk assessment for the trial. Of that, 96,368 were eligible for the trial because of their increased risk for developing breast cancer. Of that, there were a total of 19,737 women who choose to enroll on the study. Of the patients on the study, 93.4% were causasion, 2.5% African American, 2.0% Hispanic/Latino, and another 2.1% other minorities.
A couple more things that we should all be aware of as well. According to the GAIL Model, a score of 1.66 is enough to significantly increase your risk for developing Breast Cancer with in the next 5 years. The majority of patients on the STAR Trial fell into much higher scores from the GAIL Model. About 30% of women had a GAIL score of 2-2.9, another almost 31.5% of patients on the trial had a score of 3-3.9. There was also almost 27% of women on the trial had an increased risk of 5 or higher according to the GAIL Model.
If you want to see more specifics about the people on the study and their age groups, pre existing conditions, and other aspects of the diversity of participants, you can find that information here: STAR Enrollment Stats.
Women were enrolled in one of 2 arms of the study. The first arm was: 20mg of Tamoxifen and a placebo. The other arm was: 60mg of Raloxifene and a placebo. Patients in both arms of the study had to take the medication daily, for a total of 5 years. There were over 500 sites in the US, Canada, and Puerto Rico that took part in this large comparison trial.
Star Results:
The initial results from this STAR trial comparing the use of Tamoxifen to Raloxifene in post menopausal women 35 years and older with a increased risk for breast cancer showed that both drugs reduce the risk for Breast Cancer by about 50%.
Since 1998, only Tamoxifen was available to patients as the only option to help prevent invasive Breast Cancer in women. With this study, women now have another option in Raloxifene to help reduce the development of Invasive Breast Cancer. This is very important due to the fact that Tamoxifen has rare, but very significant side effects.
In women who took Raloxifene those rare side effects were drastically reduced. The women in the arm that took Raloxifene for 5 years had fewer incidences of Uterine Cancers (36%), Blood Clots(29%), and Cataracts. The STAR Trial also conveyed that menopausal side effects such as hot flashes were mild to moderate and that the quality of life was the same for both drugs. Tamoxifen and Raloxifene are both known to help with Osteoporosis in women too.
One more important finding from this STAR Trial is that Raloxifene did NOT show an impact on the development of Lobular Carcinoma In Situ or Ductal Carcinoma In Situ. By contrast, Tamoxifen has shown clinically to reduce the risk of both of these precancerous or noninvasive breast cancers by one-half. (For more study facts click here: STAR)
This does NOT mean that if you take Tamoxifen or Raloxifene that you can forego yearly physical exams, screening mammograms, or self breast exams. These tools are still the best chances for early detection and better outcomes for women that develop Invasive Breast Cancer. What it does do, is for those women that are found to be at a potentially higher risk for developing an Invasive Breast Cancer, they now have another tool to help them fight this disease.
As always, if you or a loved one have any other questions, comments, or concerns; if you would like more information in regards to another cancer related topic, please contact me at: CANCERGEEK@GMAIL.COM or CANCERGEEK@CANCERGEEK.COM
Well this week is the official American Society for Therapeutic Radiology and Oncology meeting in Los Angeles, CA. It is always a wonderful meeting with a lot of good information for other oncologists (cancer doctors) and other cancer care professionals. This is typically where a lot of studies will be reported on, results from clinical trials, new methods, new techniques, and where new and exciting treatments are unveiled and shared with everyone in attendance. It is a wonderful place full of knowledge and cutting edge techniques all surrounding the treatment of cancer.
If you question if you received this additional boost, try to remember your breast cancer treatment. You most likely received the majority of your treatment from the machine being in two different spots. If you received the additional boost treatment, it would most likely been at the end of your treatment, the last 5 days, and the machine would have only been in one spot. The therapists would have placed a “cone” onto the machine, and this would direct the boost to the lumpectomy site. You would also notice that the machine was really close to you as well. The machine would have looked and been positioned much like the picture above.
In an early release of the Journal of Clinical Oncology on-line dated Oct. 22, 2007 is a report on a study conducted at the University of Minnesota on the increase of patients choosing to have a mastectomy performed on the opposite unaffected breast in order to prevent cancer in the future. For women diagnosed with Breast Cancer, it has always been an option to have the entire breast surgically removed. As more and more data has been collected, and more in depth studies have been conducted, there has been a trend for more women to choose to have Breast Conserving Surgery versus the entire removal of the Breast affected with cancer. However, this study conducted at the University of Minnesota has seen a gradual yet significant increase. In 1998 there was about 1.8% of all breast cancer patients decided to have both breasts removed. As of 2003, the data collected at the University of Minnesota has shown an increase to 4.5% of all patients.
The study analyzed data from a small fraction of the estimated 200,000 women who receive a breast cancer diagnosis each year in the U.S. If these figures are accurate, it could be seen that there is an average of 8000 to 10,000 women a year choosing to have this elective surgery done. The name of the surgery is called: Contra-lateral Prophylactic Mastectomy (surgical removal of opposite breast not affected with breast cancer.)
The most important thing for all of us to remember is that education is the best tool for all of our patients, family members, and loved ones. In order for patients to make the best decision for themselves, we need to arm them with all of the facts surrounding their disease and diagnosis. Before any patient makes a decision to have surgery, they should also meet with a Radiation Oncologist as well as a Medical Oncologist to know all of their treatment options up front. This allows a patient to have all of the information in front of them in order to make the best decision based on their cancer type, life style, and personal needs. A patient may decide that having a lumpectomy and radiation followed by Tamoxifen or Femara is a far better choice for them physically, emotionally, and personally versus having both breasts removed.
As we all know this month is National Breast Cancer Awareness month here in the U.S., but world wide there is a awareness for Breast Cancer this month as well. Breast Cancer in the most researched and widely publicized topic of all cancers. It is great because we are making some wonderful strides in the detection, prevention, and treatment of Breast Cancer. This has helped to save more lives, keep more women from experiecing devastating and life changing side effects, as well as keeping more mothers, sisters, daughters, and friends on this earth.
Exercising for 45 minutes a day can decrease your risk for developing breast cancer by about 6%. Increase that to 2 days a week, and you decrease your risk by 12%. This accumulates as well, so there is a good argument for physical activity and excercse.
From this picture you can see that it does look like one would think, like a wedge of metal. It is placed in the machine and will try to help and compensate for the differences in breast tissue for a specific patient. Unfortunately, it isn’t a perfect world and there are only so many things that wedges allow physicians to manipulate the radiation beam in order to make it more precise in treating the breast. It does not allow us to eliminate or diminish hot spots as drastically as IMRT.
If Breast Cancer happens to be discovered in a male, then he should undergo similar testing that a female would go through as well. This would include a physical exam by a physician to see if there is any palpable lump noticed in the Breast Tissue. If it happens to be something of concern, then a man should also be ordered to have a mammogram, ultrasound, and biopsy as well to give confirmation that it is in fact Breast Cancer, and what stage of cancer it is.
As I promised the other day, I wanted to take a moment and to talk about a study that was conducted by the National Surgical Adjuvant Breast and Bowel Project (NSABP) in support from the National Cancer Institute (NCI). This trial is the first of its type to ever compare the effectiveness of two seperate drugs. The drug more commonly known as Tamoxifen (Novaldex) is already known and proven to reduce the risk of breast cancer in those women that have a higher risk for developing breast cancer. This trial compared Tamoxifen with a new drug called Raloxifene (Evista) and compared them head to head to see if the new drug, Raloxifene, was just as good, or maybe even better then Tamoxifen. The name of the study was the STAR Trial. STAR simply stands for Study of Tamoxifen and Raloxifene Trial.
So the STAR Trial began enrolling women in the study in 1999. The cirteria for being on the study was that participants had to be:
A couple more things that we should all be aware of as well. According to the GAIL Model, a score of 1.66 is enough to significantly increase your risk for developing Breast Cancer with in the next 5 years. The majority of patients on the STAR Trial fell into much higher scores from the GAIL Model. About 30% of women had a GAIL score of 2-2.9, another almost 31.5% of patients on the trial had a score of 3-3.9. There was also almost 27% of women on the trial had an increased risk of 5 or higher according to the GAIL Model.
Since 1998, only Tamoxifen was available to patients as the only option to help prevent invasive Breast Cancer in women. With this study, women now have another option in Raloxifene to help reduce the development of Invasive Breast Cancer. This is very important due to the fact that Tamoxifen has rare, but very significant side effects.