Awareness Into Action: A Simple Guide to the Chemotherapy Menu

As I discussed in yesterday’s blog, not all women benefit from chemotherapy; tests like the Oncotype DX can be helpful, but may not be widely available across the country.  In the meantime, here is the simple guide to the chemotherapy menu for those women who we know will likely benefit from chemotherapy.

1.  Women whose breast cancers express the growth factor, Her 2:  by and large, these women benefit from targeted therapy with Herceptin, a drug that blocks the Her 2 receptor.  These women also benefit from chemotherapy, of the standard variety – which usually includes a taxane and anthracycline, but not always.

2.  Women whose breast cancers express an estrogen receptor but not Her 2:  these represent the majority of breast cancers in America.  These women benefit from targeted hormonal therapy, like tamoxifen or aromatase inhibitors (Arimidex), that block the receptor and prevent the cancer cell from growing.  Some of these women, especially those with large tumors or positive lymph nodes, will also benefit from standard varieties of chemotherapy – but the largest survival benefit comes from anti-hormonal therapy, and this is why yesterday’s blog discussed Oncotype DX and its use in distinguishing which of these patients will derive additional benefit from standard chemotherapy.

3.  Women whose breast cancers express none of the receptors that are normally tested for; these women’s breast cancers are estrogen receptor negative, progesterone receptor negative and Her 2 negative.  These are called “triple negative” cancers.  These women benefit from chemotherapy only.  However, researchers are hard at work looking at some of the other genes that are found in triple negative breast cancers so that targeted therapies for these tumors can be developed.

There is no crystal clear roadmap through the chemotherapy menu, but the three broad categories, and their specific treatments, are the generally accepted guide for medical oncologists who are treating women with breast cancer today.

Reference

Winer EP, The Evolving Role of Adjuvant Chemotherapy, Cancer Res 2009;(Suppl):(24) December 15, 2009, 484s

Awareness Into Action: Not every breast cancer patient needs chemotherapy.

The single best intervention to increase survival from breast cancer has been chemotherapy.  Surgery helps, yes.  And radiation therapy helps, a bit.  But, overall, it is chemotherapy that really saves lives.  So why don’t all women get chemotherapy?  Because not all of them need it.  For some women, surgery and radiation therapy are sufficient.  How do doctors know which women will benefit from chemotherapy and which will not?

Scientists are now able to looks at the genes associated with different, individual breast cancer specimens to assess the likelihood that the cancer will recur and, in the process, assess the benefit of chemotherapy.  The most commonly used test for this analysis is called Oncotype DX and it uses a panel of 21 genes to see if a particular patient would benefit from having additional chemotherapy.  It is especially useful in the post-menopausal patient who has an estrogen-positive tumor that we know responds to agents like tamoxifen and aromatase inhibitors.  Onctotype DX looks at the expression of genes in such a patient to see if, in addition to hormone therapy, a course of chemotherapy would provide a survival advantage.

If you, or someone you know, has been diagnosed with breast cancer and are considering chemotherapy, be sure to ask your doctors about Oncotype DX to see what the gene array analysis that this test provides might suggest as beneficial for your case.

Awareness Into Action: Using the internet to improve public health.

People who eat a natural, plant-based diet have much lower rates of heart disease, chronic disease and cancer.  Most of these people live in countries that are not fed from the aisles of the modern supermarket, aisles loaded with foods that will surely, if slowly, kill you.

Michael Pollan’s new book, Food Rules, is trying to help change the unhealthy eating patterns rampant in our society, and he got a wonderful boost from Jane Brody’s article in the New York Times today.  I, too, can recommend his book – with one provision:  drinking alcohol on a regular basis is known to increase a woman’s risk for breast cancer, so modify this rule and drink only very occasionally.

Other research now shows that using the internet, particularly sites that provide tips for how to get more fruits and vegetables in the diet, can be very powerful as a tool to improve public health.  Dr. Christine Cole Johnson of the Henry Ford Department of Biostatistics and Research Epidemiology led a study of participants who were given online information to help them get more fruits and vegetables into their daily diet.  Three groups were formed:  one given online tips only, one given online tips that were tailored to their specific needs, and one given tailored tips and motivational encouragement that included personal interviews and followup.  All groups improved their consumption of fruits and vegetables; but those who received the personal touch did best of all.  We need information; and we need support.  We need both.

I would like to suggest that Congress, in its push to create a jobs program, fund a national public health initiative to create an online nutritional website that is current, updated regularly and interactive.  It can’t hurt, and I bet it would help.

In the meantime, here is a tip for getting at least 6 servings of fruits and vegetables into your diet everyday:

Have a fruit and a vegetable at every meal; 2 x 3 = 6!

The breakfast vegetable can be carrot juice (which is what I use to swallow my vitamins), or just a carrot that you munch while making your cereal and green tea.  It could also be tomato juice, or a 1/2 cup of grape tomatoes that you munch while making breakfast, etc.

And, here is the recipe for the vegetable soup I made yesterday while waiting for hourly reports of snow accumulation from the blizzard south of Madison, New Jersey.   I call it Blizzard Soup.

BLIZZARD SOUP

2 Yukon gold potatoes

2 large carrots

one yellow onion

2 stalks celery with a few celery leaves attached

Wash the vegetables well.  Dice.  Put into a pot.  Cover with water and bring to a boil.  Turn down the heat and simmer for 20 minutes.

12 Kalamata olives

2 zucchini

1/2 teaspoon salt

freshly ground black pepper

Wash the zucchini well; quarter and slice into 1/4 inch pieces.  Add to the soup.  Chop the olives into small pieces, add to the soup along with the salt and pepper to taste.  Simmer another 15 minutes.

4-5 leaves of green Swiss chard

Wash the chard well, trim the leaves from their ribs and chop into 2 inch pieces.  Add to the pot and simmer 15 minutes.

1/2 cup quinoa

Add the quinoa to the pot, simmer another 15 minutes.  Turn off the heat.  Let the soup cool just a bit and serve.

I think you will find this soup quite delicious.  It has virtually no fat but protein (from the quinoa) and plenty of vegetables, green and otherwise.

Enjoy.  Be well.  Have fun with the Super Bowl tonight.  (I like Manning.  Sorry, Saints.)

Reference

Henry Ford Health System (2010, February 4). Online programs improve fruit and vegetable consumption

Awareness Into Action: 40% of all cancer deemed preventable, as per IUAC

The International Union Against Cancer (IUAC), an organization based in Geneva, has just issued a report in which they declare that 40% of all cancers worldwide are preventable if only we applied the knowledge we presently have about ways to do this.

At least nine viruses are known to cause cancer. For many of these cancer-causing viruses, like human papilloma virus and hepatitis B virus, vaccines already exist that can prevent the disease – but they need wider distribution and public health advocacy to get them to the patients.

Smoking cessation, reduced sun exposure, a healthy diet and moderation of alcohol consumption are the other important risk reduction strategies for the prevention of cancer.  Despite the preponderance of evidence of the efficacy of these risk reduction strategies, they are woefully underutilized by public health organizations.

Public health organizations are not the only ones missing the opportunity for the PURE CURE, prevention.  Breast cancer foundations, such as Susan G. Komen For The Cure, The Avon Breast Cancer Crusade, and the American Cancer Society, are guilty of promoting treatment over prevention at least 98% of the time.  Take a look at the percentage of funding for the primary prevention of breast cancer, or discovery of its causes, on any of these organizations’ websites and the math jumps out at you:  funding treatments trumps funding preventions in all by the rarest instances – and usually the “prevention” involves taking some drug.

Even the story line focuses on treatment:  the brochure for the 2010 Avon Walk for Breast Cancer declares, “We’re in it to find a cure … so that women and men can get the screening, support and treatment they need … for better treatments, improved detection and a cure.”  Noble, and the exact same story line at Komen, but not 21st century leadership.  Breast cancer leadership requires a fundamental modification of the conversation about breast cancer research.  Yes, by all means, continue to fund treatment innovations; but, come on, it’s time to focus on prevention, the PURE CURE.  It’s the best way to take care of the majority women, and it’s also the best way bend the cost curve in healthcare overall..

I repeat:  breast cancer is a preventable disease.  It is preventable in 30-40% of cases.  It is time that breast cancer foundations accept their responsibility to promote, really promote, prevention strategies by redistributing their grants so that 30-40% of the money is spent understanding the causes and targeting primary prevention of the disease – the PURE CURE.

Awareness Into Action: Real News – Nanotechnology Kills Individual Cancer Cells

Fifty-one years ago a Nobel physicist, Richard Feynman, suggested the possiblity of one day having the technology that would allow us to alter individual atoms and molecules.  That day has arrived, and the new technology, called nanotechnology, has been used successfully to FIND and KILL individual cancer cells.  Obviously, this is a much better approach than trying to cut out tumors with a knife or blast them, and surrounding normal tissue, with radiation therapy.

Researchers at Rice University, working in collaboration with scientists at the Lykov Institute in Belarus, have developed “nanobubbles” that can find individual cancer cells, get inside them, and blow them up.  They’ve conducted successful experiments using their search-and-destroy nanobubbles to eradicate leukemia cells and cancer cells from head and neck tumors.

This is very exciting breakthrough research.  I think it will have enormous potential when applied to breast cancer.  Stay tuned.  And when you hear the term “nanotechnology,”  listen up.

Reference

Dmitri Lapotko, Rice University (2010) February 5, Physicists kill cancer with nanobubbles.

Awareness Into Action: Drink Green Tea – But Let It Cool First

I am writing this blog, as I do all my morning posts, while enjoying my second cup of green tea.

Over a decade of research on the health benefits of green tea suggest that its antioxidants, particularly the catechins, have the power to lower the risk of cardiovascular disease and cancer.

A study of 500 Japanese women with early-stage breast cancer showed that those who drank 2 cups of green tea per day prior to their surgery had a lower risk of recurrence.  Larger clinical trials need to be done to confirm these early findings, but all of the epidemiologic and laboratory data seem to point in the same direction:  green tea is good for you.

Green tea is less processed that black or smoked tea, so the concentration of antioxidants is higher.  However, a recent study showed that it is better to let your tea, green or black, cool just a little before you drink it.  People who drink hot tea within two minutes after is is poured were five times more likely to develop esophageal cancer than those who let the tea cool for at least four minutes.

Adding lemon to your tea may be a neat trick, as citrus increases the absorption of its antioxidants.

Reference

Dr. P Boffetta, Tish Cancer Institute, Mt. Sinai School of Medicine, British Medical Journal

Awareness Into Action: Raisins Are Better Than Grapes

Researchers have said that diet is the single most important modifiable risk factor for the prevention of breast cancer. There is no reason to think that this is not true and, hence, every reason to be mindful of ways to improve one’s diet every day.

Grapes are known to contain antioxidants, substances that scavenge free radicals and prevent unnecessary damage to our DNA.  It turns out that the antioxidants found in raisins are 300% higher than in grapes.

When fruits are dried, their nutrients are concentrated; this explains the power raisins have over grapes.  Furthermore, raisins are available year round and are easier to store than grapes.  They are a good source of fiber and minerals, and make an excellent, handy snack.  (Keep some in your purse and car!)

Beware:  raisins, like all dried fruits, contain higher amounts of sugar, so stick to 1/4 cup at a time = 110 calories.

Reference

University of California, Berkeley Wellness Letter, 2010.

Awareness Into Action: Increasing Soy Reduces Breast Cancer Recurrence

For at least ten years, the value of adding soy protein to the diet in the hope of reducing the risk for breast cancer has been the subject of heated debate.  Soy contains isoflavones, estrogen-like substances, that been shown to increase the growth of breast cancer cells in culture.  However, Asian women, whose diets are typically high in soy protein, appear, from epidemiological studies, to have a reduced risk for breast cancer. Furthermore,  several studies of Asian women have shown that as the level of dietary soy protein increases the risk for breast cancer decreases.  With this kind of conflicting data it is hard to know what to recommend to patients who wish to modify their diet in such a way as to reduce their risk of breast cancer or breast cancer recurrence.

Dr. Shu from Vanderbilt University studied more than 5000 breast cancer survivors and found that those whose diets were highest in soy protein – up to 11 grams per day – lowered their risk for breast cancer recurrence by 32%. More importantly, these women lowered their risk of death by 29%. Dr. Shu’s conclusion:

“Among women with breast cancer, soy food consumption was significantly associated with decreased risk of death and recurrence.”

This new study may help shed some light on the benefits of soy protein for women with breast cancer who want to do everything they can to prevent recurrence of their disease.

Reference

Xiao-Ou Shu, MD, PhD, Soy food intake and breast cancer survival, JAMA, 2009; 302(22): 2437-2443

Awareness Into Action: Is There Nothing Else To Offer But Drugs For The Prevention Of Breast Cancer?

Dr. Cuzick of the Queen Mary University of London provided the keynote address on “Advances in Preventive Therapy” at the San Antonio Breast Cancer Symposium last December.  The new drug, lasofoxifene, a tamoxifen-like drug, showed promise but needed more work.  An update on the tamoxifen and raloxifene prevention trials showed that there was continued benefit after treatment completion – an important finding that I suggest women discuss with their oncologists.

Dr. Cuzick also pointed out that several biomarkers for the preventive effect of tamoxifen have been identified.  And, as unpleasant as this may be, the appearance of endocrine symptoms (like hot flashes) predicts the effectiveness of tamoxifen and arimidex in the women who take these drugs.

Dr. Cuzick discussed the long-term preventive effects of arimidex on reducing the incidence of contralateral breast cancer. As for the statins as chemopreventive agents against breast cancer – the data are mixed, therefore conclusions cannot yet be made.

And, finally, it seems that aspirin can prevent breast cancer if taken for at least ten years.

Dr. Cuzick’s thorough and interesting discussion of the ways to prevent breast cancer focused  on one strategy only:   drugs – tamoxifen, arimidex, aspirin, lasofoxifene.  The talk might more aptly have been titled,  ”Chemoprevention As A Strategy For The Prevention Of Breast Cancer.”  Now, without a doubt, these drugs can be helpful; indeed, they can even save lives. But there are other, more cost-effective risk reduction strategies, with little or no side effects, that should have appeared somewhere at the San Antonio conference, if not directly within Dr. Cuzick’s presention:  exercise, avoidance of alcohol, maintenance of ideal body weight, avoidance of all exogenous synthetic hormones and smoking cessation.

Non-pharmaceutical breast cancer prevention strategies represent fertile ground for public discussion -and implementation – ground that is yet untilled by those in San Antonio who are charge of the vision for breast cancer research.

I would like to suggest that at next year’s San Antonio Breast Cancer Symposium a public health care advocate be invited to present data on non-pharmaceutical strategies for the Prevention Of Breast Cancer.  A breath of fresh air, sorely needed, to help with the swallowing of all those pills.

Reference

Cuzick J, Advances in Preventive Therapy, Cancer Res 2009; 69(Suppl.):(24). December 15, 2009

Awareness Into Action: Women Still Afraid Of Losing Their Breast

At least six large randomized clinical trials have demonstrated, beyond doubt, that lumpectomy and radiation therapy produce the exact same overall survival rates compared to mastectomy for the treatment of early-stage breast cancer.  Yet mastectomies are still done, and are being done in increasing numbers, despite the wide availability of breast conservation.  This is unfortunate, both for the women who are losing their breasts unnecessarily and for many women who think they might have breast cancer and are afraid to go to the doctor because they are also afraid of losing their breasts.

A paper presented at the San Antonio Breast Cancer Symposium last December points out this fear quite dramatically.  Dr. Bourdeanu and colleagues from the City of Hope Medical Center in Duarte, California reported their findings on “Barriers to Treatment in Patients with Locally Advanced and Inflammatory Breast Cancer.”  They start the discussion by pointing out that “despite a decrease in breast cancer mortality due to increased awareness and more effective screening, many patients still present for treatment after extended delays in diagnosis . . . resulting in greater likelihood of regional and distant metastasis.”

When the researchers asked the patients in their study why they had delayed in seeking medical attention, 35.2% said it was because “they were concerned about losing their breast.”

Women need to be more aware that, in the vast majority of cases,  breast cancer can be treated with lumpectomy followed by radiation therapy.  Even in those women who begin with very large tumors, neoadjuvant chemotherapy – i.e., chemotherapy given as the first step in treatment, in an effort to shrink the tumor and document clinical response in an individual patient – shrinks the tumors in well over 50% of cases and makes lumpectomy far more likely.

Women need not fear mastectomy – because in the majority of cases it is simply not necessary.  It might be the right choice for a given patients, after she has considered all of her options, and only when she clearly understands that it will have no impact on her overall survival.  However, for most women, lumpectomy is feasible and certainly preferable.  Please pass it on.

Reference

Bourdeanu L, Barriers to treatment of patients with locally advanced and inflammatory breast cancer, Cancer Res 2009; 69(Supp): (24). December 15, 2009