4 January 2021

Earlier this year, I posted preliminary findings from our survey of the online “Going Flat” community – patients who underwent mastectomy without breast mound reconstruction. I am happy to announce that our peer-reviewed manuscript* has just been published in the Annals of Surgical Oncology.

I was inspired to research this topic as several studies have noted that patients who do not undergo reconstruction have poorer quality of life and satisfaction compared with those who have reconstruction. However, there are a growing number of support and advocacy groups dedicated to women who decline reconstruction, and we wanted to assess their experience. We partnered with patient advocates to ensure that we were asking appropriate and relevant questions. The results presented here are slightly different than the abstract – this is not uncommon as the abstract represents preliminary or “first review” findings. After doing a “deep dive” into the responses, our results are as follows:

Demographics and timing of going flat:

  • 931 women completed the survey, mean age was 49 (range 25 – 85)
  • Most patients were white (94%), had private insurance (71%), and were from the US (79%) although 22 countries were represented
  • 85% did not undergo breast mound reconstruction at the time of mastectomy
  • 15% initially had reconstruction that was subsequently removed

 Top reasons for going flat were desire to avoid a foreign body such as an implant, and perceived lower complication rate. 51% of patients stated that their breasts were not important for their body image.

Communication:

  • 65% stated that they received adequate information about their surgical options
  • 22% experienced “flat denial” – they were not initially offered the option to go flat, their surgeon was not supportive of their decision or tried to talk them out of the procedure, or extra skin was intentionally left in case the patient changed her mind.

Satisfaction with outcome:

  • 74% agreed or strongly agreed that they were satisfied with their surgical outcome
  • Strongest predictors of satisfaction were surgeon support of the patient’s decision to go flat and having adequate information about surgical options.
  • Patients who reported that their surgeon had an exclusive breast surgery practice were less likely to be dissatisfied
  • Factors most associated with flat denial include low level of surgeon support, high flat denial score, higher BMI (body mass index), and those undergoing unilateral (one side) versus bilateral (both sides) mastectomy

Our findings reveal a need for additional research into factors that impact patient satisfaction as well as for surgeon education on how to optimally support women who are not interested in breast mound reconstruction. In addition, surgeons should be trained in techniques to perform an aesthetic flat closure, or partner with their plastic and reconstructive surgical colleagues so that they can provide optimal results for their patients.

On behalf of my co-authors, we would like to thank all who shared and participated in the survey!

*If you are not able to access the full study and would like a copy, please email me: contact at drattai dot com

28 December 2020

There are unique challenges faced by young women with breast cancer. One is that they may not have had the opportunity to have children at the time of their diagnosis. Unfortunately, while there have been studies supporting the safety of fertility workup and egg / embryo harvesting prior to breast cancer treatment and pregnancy after treatment, these treatments are underutilized.

At the recent San Antonio Breast Cancer Symposium, a large meta-analysis of breast cancer outcomes after pregnancy was presented by Dr. Matteo Lambertini. The researchers reviewed 39 studies evaluating pregnancy after breast cancer. They found that patients with a history of breast cancer were less likely to become pregnant compared with the general population but their evaluation did not specifically evaluate women trying to conceive – it is possible that some did not try. Compared with women in the general population, those who had been treated for breast cancer were more likely to deliver prior to full term and to have lower birth weight babies.

Importantly, Dr. Matteo and colleagues found that there was no significantly increased risk of birth defects, and patients who became pregnant after breast cancer actually had lower risks of death and disease recurrence compared with those who did not become pregnant. In addition, they noted that pregnancy appeared safe regardless of BRCA mutation status, lymph node status, receipt of chemotherapy, and amount of time between breast cancer treatment and pregnancy.

An unrelated Swedish study also recently found that women who underwent fertility preservation had a higher live birth rate, and had better overall survival after breast cancer compared with women who had not undergone fertility preservation.

I very clearly remember early in my practice having a discussion with a 44-year old single woman who was childless. Her comment “I never thought I might want to have children until you told me it might not be possible” has stuck with me – we cannot make assumptions about our patients desires or preferences. The findings of these studies should serve as a reminder for physicians that fertility issues should be discussed with ALL women of child-bearing age before treatment is initiated. Patients should feel empowered to initiate the discussions if their oncologist does not. 

2 November 2020

Endocrine therapy is a key component of breast cancer treatment for those with both early stage and metastatic hormone receptor-positive disease. However, side effects can be significant, and many patients do not complete recommended therapy. Our recent study* showed that over 90% of women and men prescribed endocrine therapy experience treatment-related side effects, and approximately 30% discontinue treatment early. 

Musculoskeletal issues such as bone pain, joint pain and stiffness, and bone loss (osteopenia and osteoporosis) are among the most common side effects related to aromatase inhibitors (AIs). A recent review by Gupta et al* discussed several side effect mitigation strategies and the evidence behind them. The most effective included exercise including yoga, acupuncture, duloxetine (brand name Cymbalta), treatment breaks, changing to a different AI, or changing from an AI to tamoxifen.

In my accompanying editorial*, I noted that there are barriers to successfully managing side effects, including cost, access and adherence to structured exercise programs and acupuncture, reluctance to add a new medication which comes with its own side effects, and anxiety regarding treatment breaks both on the part of the patient and their oncologist. In addition, none of the side effect treatments have been found to be universally effective. In fact, in our survey, only 41% of respondents noted that any side effect management was effective.

Clearly a new approach is needed, focusing on open and active communication between the patient and his or her oncologist. Endocrine therapy is often the “last” phase of breast cancer treatment, and patients may not remember conversations held at the time of diagnosis regarding benefits and side effects of endocrine therapy. Re-visiting the role of endocrine therapy, along with associated side effects and management techniques should occur before treatment. The absolute benefits of treatment should be clearly discussed – statements such as “this will reduce your risk of recurrence by 50%” are not meaningful unless a patient understands what her absolute risk of recurrence is – are we trying to reduce a 50% recurrence risk down to 25% or a 5% recurrence risk down to 2.5%? 

Common and expected side effects, such as bone and joint pains, hot flashes, cognitive dysfunction (commonly termed “chemo-brain”) and impact on sexual function should be discussed, along with the evidence-based strategies to help manage these symptoms. In our study, patients noted that peer support (such as an in-person or virtual support group) as well as a website that provided clear information about side effects and management would be helpful, but these were not often provided. Patients also noted that an in-person or virtual visit with their physicians to discuss side effects would be helpful – this should ideally occur within 4-6 weeks of treatment initiation so that issues and concerns can be promptly addressed. 5-10 years is a long time to take a medication that is having a significant impact on quality of life – it is important that patient concerns are heard and addressed at every visit. 

*If you are not able to access the full study and would like a copy, please email me: contact at drattai dot com

10 October 2020

Breast implants that are used for reconstruction or cosmetic augmentation can have either a smooth or textured surface, and plastic and reconstructive surgeons may prefer one or the other type of implant for various reasons. Last year, the US FDA recalled several types of textured implants manufactured by Allergan due to their link to breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). BIA-ALCL is not thought to be associated with an increased risk of breast cancer, and is generally treated by removal of the implant and associated fibrous capsule (more information on BIA-ALCL and the FDA recall here).

A study recently published in JAMA Surgery* found that women who underwent post-mastectomy reconstruction using textured implants had a higher rate of breast cancer recurrence compared with those who had reconstruction performed with smooth implants.

The retrospective study was performed in South Korea, and evaluated the outcomes of 650 women (total of 687 implants) who underwent mastectomy and implant reconstruction for breast cancer, from 2011 – 2016. 413 of the implants were textured and 274 were smooth. Mean age was 43.5 and the majority of patients had early stage (I or II) breast cancer. 15% received postoperative radiation therapy and 44% received postoperative chemotherapy.

There were 28 breast cancer recurrences over the study period (4%). Local recurrences (in the chest wall area) were the same in both groups. 10 patients experienced distant recurrence (metastatic disease), and all had received textured implants. 

One cannot conclude from this study that the breast cancer recurrence was due to the textured implants, and limitations of the work include the retrospective nature. Larger, multi-institution studies are likely. In the meantime, it is reasonable for patients who are planning on implant reconstruction to discuss implant type, associated risks, and alternatives with their plastic surgeon.

*If you are not able to access the full study and would like a copy, please email me: contact at drattai dot com

17 August 2020

Last year, we asked the online breast cancer community to participate in a survey to assess experiences with endocrine therapy (ET). We are proud to announce that the study has now been published, in the Journal of Cancer Survivorship*.

First of all, I would like to thank all of the participants – we surpassed our accrual goals and this is the largest survey of ET use by patients who participate in online breast cancer communities! 

About the respondents:

  • 111 respondents did not start the recommended ET, and concern about side effects was the primary reason
  • Of those who took ET (2407), 2353 were women and 54 were men
  • Most of the women (74%) were post-menopausal
  • Mean age at diagnosis was 50 for women (range: 23-82) and 54 for men (range: 24-73)
  • Most (87%) were diagnosed at Stage 1-3
  • 100 (4.2%) were diagnosed with de novo Stage 4 / metastatic breast cancer
  • 12% of those diagnosed at an early stage eventually developed Stage 4 / metastatic breast cancer

Treatment:

  • Aromatase inhibitors (AIs) were the most commonly used medication
  • 91% of respondents reported at least one class of side effect that they felt was related to treatment (92% of women and 74% of men)
  • Musculoskeletal and general physical changes (such as weight gain and unhappiness with body image) were the side effects most commonly reported by women
  • Men most commonly reported sexual and cognitive / mood side effects
  • 33% (33% of women and 50% of men) discontinued therapy early
  • 9% reported that they took treatment breaks or discontinued therapy early either without informing their medical team or against their medical team’s advice

Side effect management:

  • 3 classes of side effect management strategies were felt to be most helpful:
    • Healthy diet, exercise, physical therapy
    • Complementary therapy such as yoga, acupuncture and meditation
    • Vitamins, supplements and herbs including medical marijuana 
  • Only 41% of respondents noted any relief from side effect management strategies

Medical team communication: (multiple responses permitted so this category did not add up to 100%)

  • 70% felt supported by their medical team in attempting to discuss side effects
  • 32% were made to feel that they should be better able to handle side effects or that the side effects were not related to treatment
  • 7% did not discuss side effects with their treatment team, feeling that there were more important issues to discuss, that there was not enough time, or they did not feel comfortable

Some other findings:

  • Respondents with early-stage and metastatic breast cancer reported similar side effects and management experiences, even though these two groups of patients have very different supportive needs
  • Men who responded to our survey were less likely to report side effects but more likely to discontinue therapy early compared to women – more information is needed about the experience of men with breast cancer and those taking endocrine therapy

Clearly, there is room for improvement in terms of medical team support and understanding. In addition, as only 41% of respondents noted any relief from side effect management strategies, we need more effective treatments for ET-related side effects. Thank you to all who participated in this survey! We are hopeful that your responses and comments will inspire researchers devote more time to addressing these important issues.

*If you are not able to access the full study and would like a copy, please email me: contact at drattai dot com

7 June 2020

An abstract presented at last week’s virtual meeting of the American Society of Clinical Oncology focused on whether or not there is a benefit to surgery for the primary breast tumor in patients with metastatic, or Stage IV, breast cancer.

Metastatic breast cancer (Met-BC) is when the breast cancer spreads beyond the breast and underarm lymph nodes. Common sites of metastases include the lungs, liver, bones, and brain. Anyone diagnosed with breast cancer has the potential to develop metastatic disease, but approximately 5-10% of patients are found to have Met-BC at the time of initial diagnosis, known as de-novo Stage IV. For these patients, it has been controversial whether or not to recommend some form of breast surgery (lumpectomy or mastectomy) to remove the primary tumor. Some studies have shown a survival benefit when the primary tumor is removed, but widespread adoption of the results of these studies has been limited because in many of these studies, patients who underwent surgery were younger, healthier, and had a lower volume of metastatic disease compared with the general population of patients with Met-BC.

Dr. Seema Khan presented the results of the ECOG-ACRIN Research Group E2108 study. In this study, patients who had stable Met-BC (after 4-8 months of treatment) were randomized to either surgery or no surgery for the primary tumor. The two study groups were well-matched for age, race, and breast cancer subtype. With a median follow up of 59 months, there was no improvement in overall survival or in progression-free survival. Local progression (cancer continuing to grow in the breast) was more common in patients who did not undergo surgery (25.6 versus 10.2% at 3 years). At 18-month assessment, health-related quality of life was significantly worse in those who underwent surgery, but no differences were observed at the 6-month or 30-month assessment intervals.

During her presentation, Dr. Khan acknowledged that there may be situations where surgery for the primary tumor is a reasonable option in the setting of Met-BC. She noted that there is room for individualization, but stressed that as there is no survival benefit and no improvement in quality of life, surgery for the primary tumor in the setting of Met-BC should not routinely be performed. 

It is important to note that any medical meeting abstract, whether an oral presentation or poster, has been evaluated by the meeting program committee but has not been subject to rigorous peer review as would occur with a formal manuscript submission. Abstracts often do not include the full set of results, and additional findings may be included in the eventual publication, some of which may be different than those presented in the abstract. We look forward to the peer-reviewed publication when it is available. 

22 May 2020

Going Flat after mastectomy refers to not undergoing breast mound reconstruction after breast removal. Some patients are not candidates for reconstruction or it is not recommended, however many women may choose to “go flat” even when breast mound reconstruction is an option. This past October, we posted a research survey aimed at better understanding motivations to forgo reconstruction and to identify factors associated with postoperative satisfaction among patients who participate in online breast cancer communities.

The abstract and poster are now posted on the virtual meeting platform of the American Society of Breast Surgeons. Our findings include:

Demographics and timing of going flat:

  • 940 women completed the survey, mean age was 53 (range 25 – 84)
  • Most patients were white (94%), had private insurance (70%), and were from the US (74%) although 22 countries were represented
  • 85% (801/940) did not undergo breast mound reconstruction at the time of mastectomy
  • 15% (139/940) initially had reconstruction that was subsequently removed

 Top 2 reasons for going flat:

  • 72% desire to avoid foreign body such as an implant
  • 71% perceived lower complication rate from the surgery

Communication:

  • Only 64% were initially offered going flat as an option
  • 30% felt that their surgeon did not support their decision to go flat

Satisfaction with outcome:

  • 74% agreed or strongly agreed that they were satisfied with their surgical outcome
  • Age, race, bra cup size, and history of prior breast mound reconstruction were not associated with postoperative satisfaction
  • Strongest predictors of satisfaction were having adequate information about surgical options and surgeon support of the patient’s decision to go flat

Our findings reveal a need for additional research into factors that impact patient satisfaction as well as for surgeon education on how to optimally support women who are not interested in breast mound reconstruction.

It is important to note that any medical meeting abstract, whether an oral presentation or poster, has been evaluated by the meeting program committee but has not been subject to rigorous peer review as would occur with a formal manuscript submission. Abstracts (including ours) do not include the full set of results. It is not unusual for additional findings to be included in the eventual publication, some of which may be different than those presented in the abstract. However, we feel that these results are an important starting point for better understanding of patient motivations for going flat, and also point to a need for improved communication on the part of surgeons. We are in the process of completing a full analysis of the data and look forward to sharing the peer-reviewed publication when available. 

On behalf of my co-authors, we would like to thank all who shared and participated in the survey!

25 April 2020

I was asked to help the UCLA Jonsson Comprehensive Cancer Center team develop some infographics to help answer some common questions that patients with cancer may have regarding their treatment, office visits, and risk of infection. As always, good communication with your medical team is important – so reach out and ask if you have questions or concerns.

24 April 2020

A new drug was recently approved by the US Food and Drug Administration (FDA) for the treatment of metastatic breast cancer – breast cancer that has spread to other areas of the body, such as the bones, liver, lungs or brain. Sacituzumab govitecan (Trodelvy), which is given by intravenous infusion, was granted accelerated approval to treat metastatic triple negative breast cancer in patients who have already been on 2 prior treatments for their disease. 

Triple negative breast cancer accounts for approximately 15% of breast cancers. It is more common in younger patients, African Americans, and those with a BRCA1 gene mutation. It can be very challenging to treat since there is no specific cellular target, such as the estrogen receptor or Her2/neu protein. Patients with triple-negative breast cancer very commonly receive chemotherapy but the disease may come back or progress despite aggressive treatment.

Sacituzumab govitecan is an antibody-drug conjugate, which is an antibody that is combined with a chemotherapy drug. The antibody targets a protein (trophoblast cell surface antigen-2, or trop-2) on the surface of the cancer cell, and the chemotherapy drug causes breaks in the tumor cell DNA, which leads to cancer cell death. The FDA approval was based on a non-randomized (meaning all patients received the study drug) study of 108 patients who were experiencing disease progression despite receiving between 2 – 10 prior treatment regimens. Among the study participants, approximately 33% experienced a partial or complete tumor response to the medication. Median duration of treatment response was nearly 8 months. Severe adverse reactions included diarrhea, neutropenia (low white blood cell counts), anemia (low red blood cell counts), fatigue, nausea and vomiting. 2 patients stopped treatment due to side effects.

Any advance in the treatment of metastatic breast cancer is welcome news. It is hoped that as new drugs are developed, a longer-lasting response to therapy will be achieved. 

Additional Information:

19 April 2020

The US Food and Drug Administration (FDA) has recently approved a new treatment for patients with metastatic breast cancer. Tucatinib (Tukysa) was approved for use in combination with 2 other agents, trastuzumab (Herceptin) and capecitabine (Xeloda) in patients with unresectable (too advanced to remove with surgery) or metastatic (spread to other areas of the body, such as bone, liver, lungs or brain) Her2/neu over-expressed breast cancer (Her2+). Tucatinib is approved for patients who have already been treated with one or more anti-Her2/neu treatments.

Tucatinib is a an oral (pill) medication known as a tyrosine kinase inhibitor. Results of the Her2CLIMB trial were presented in December at the San Antonio Breast Cancer Symposium. The study enrolled 612 patients with metastatic or unresectable Her2+ breast cancer who had received at least one other Her2+ targeted agent but were experiencing progression of disease. Unique to this study was that almost half of the participants had metastases to the brain – often these patients are excluded from clinical trials.

Some of the key findings were that in patients who received tucatinib with trastuzuab and capecitabine versus those who received trastuzumab and capecitabine alone:

  • Median progression free survival was 7.8 months versus 5.6 moths
  • Median progression free survival for patients with baseline brain metastases was 7.6 versus 5.4 months
  • Median overall survival was 21.9 versus 17.4 months
  • Confirmed objective response rate was 40.6% versus 22.8%

Serious adverse reactions occurred in 26% of patients and 6% of patients had to stop treatment due to adverse reactions. The most common side effects were diarrhea, hand-foot syndrome, nausea, fatigue, liver toxicity, mouth sores, decreased appetite, abdominal pain, headache, anemia and rash.

The approval of tucatinib provides another option for patients with aggressive breast cancer, including those who have brain metastases. However, as previously discussed, this study is a reminder of how far we have to go to achieve a reliable and long-lasting treatment response in patients with metastatic breast cancer.

Additional Information: