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Second Primary Cancers

29 December 2020

Anxiety related to the possibility of cancer recurrence is common among those who have been treated for cancer. However, less common is the awareness that an entirely different cancer may develop, known as a second primary cancer (SPC). Reasons for second primary cancer include general risk factors such as aging (a risk factor for many cancers), lifestyle factors that may have contributed to the initial cancer such as smoking, alcohol intake and obesity, and genetic factors including known deleterious genetic variants (such as BRCA 1 or 2) or links between cancers even in the absence of a known mutation (breast cancer survivors are at increased risk for colon cancer).

In a study recently published in the Journal of the American Medical Association*, researchers used the SEER database and evaluated data from patients diagnosed with cancer between 1992 – 2011. They evaluated those who survived at least 5 years from their initial diagnosis. Among 1.54 million, the most common first primary cancers (FPC) were breast in women and prostate in men. For the entire cohort, approximately 10% developed a SPC. The risk of developing and dying from a SPC was greater than expected compared with the general population for 18 and 27 of the 30 FPC respectively among men and 21 and 28 of the 31 FPC among women.

Second primary cancer likelihood depended on type of primary cancer. However, as this was a retrospective database review, the researchers were not able to take into account initial treatment such as radiation or chemotherapy, that could influence the development of a new cancer. They found that cancers associated with smoking or obesity accounted for “substantial portions” of SPC incidence and deaths. These cancers included lung, bladder, oral / throat, colorectal, pancreatic, uterine (endometrial) and liver cancers.

In an accompanying editorial*, Ganz and Casillas noted that primary care providers and patients need to be aware of the possibility of second primary cancers. Relevant screenings should be ordered, and they noted that patients who had received both chemotherapy and radiation are well known to be at elevated risk for SPC. They also stressed that special attention should be paid to survivors of young adult cancers, and physicians need to be aware of their prior treatments and whether those treatments may convey an increased risk for SPC (such as radiation for Hodgkin’s lymphoma increasing subsequent breast cancer risk.

Ganz and Casillas commented that continued attention needs to be paid to the lifestyle factors that can influence cancer development including alcohol, tobacco and obesity. They noted that many FPC and SPC  related to tobacco are due to prior exposures, but there remain opportunities to reduce continued and future use, which could impact SPC risk especially among young adult cancer survivors. 

Perez et al, in a separate editorial*, proposed a more comprehensive approach to address  tobacco use and obesity including better and more widespread access to education, addiction management and obesity treatment programs. They also stressed that as some cancer treatments are carcinogenic, it is important to avoid imaging tests and some types of cancer treatments when not necessary or when less toxic alternatives exist. They concluded by stating that “A combination of less carcinogenic oncologic therapies and healthier lifestyles may help us protect future cancer survivors from facing cancer yet again.”

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

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Vitamins and Chemotherapy

19 December 2019

A study recently published in the Journal of Clinical Oncology* found that the use of some vitamins and supplements before or during chemotherapy treatment for breast cancer was associated with increased recurrence and mortality rates.

Vitamins and supplements may interfere with or prevent the desired chemotherapy or radiation therapy effect of cell death, so it is common practice to advise patients to stop (or not to start) taking vitamins and supplements while undergoing treatment. The patients in this study were all undergoing chemotherapy for breast cancer, using the same medications, but with different dosing schedules. The treatment regimen was doxorubicin (also known as Adriamycin), cyclophosphamide and paclitaxel, commonly referred to as AC-T. Patients were surveyed on vitamin and supplement use prior to starting chemotherapy and after treatment. Median follow up was 8.1 years.

There were 1134 patients included in this study. 251 experienced a recurrence and 181 died – these patients were more likely to be older, Black, post-menopausal, have a higher body mass index, and have poorer tumor prognostic factors including 4 or more positive lymph nodes, and estrogen / progesterone receptor or Her2/neu negative tumors. 17.5% reported use of any antioxidant (vitamin A, vitamin C, Vitamin E, carotenoids, and co-enzyme Q12) during chemotherapy treatment and 44% used multivitamins.

The findings included:

  • Use of antioxidant supplements both before and during chemotherapy was associated with an increased risk of cancer recurrence and death, but the numbers were not statistically significant
  • The researchers were not able to determine if there was any specific relationship between the use of individual antioxidant supplements and risks of recurrence or death. There was a relationship with vitamin A but analysis for this supplement only included 5 patients
  • There were no relationships between use of antioxidants only before or only during treatment and outcomes
  • Vitamin B12 use both before and during chemotherapy was associated with increased risk of recurrence and death 
  • Iron use during chemotherapy was associated with higher recurrence risks as was use both before and during treatment 
  • Omega 3 use both before and during treatment was associated with increased recurrence risk but not death
  • There did not appear to be any association between recurrence or survival and the use of multivitamins, vitamin D, glucosamine, melatonin, acidophilus, folic acid, or vitamin B6

One of the authors’ conclusions was that “we found some support for the notion that use of dietary supplements during chemotherapy could have a negative impact on recurrence and overall survival.” It is important to stress that this was an observational study, which means direct cause and effect cannot be determined. Relative, not absolute risks, were reported. In addition, the number or women who reported taking non-multivitamin supplements was just under 200. While news reports noted that supplements were associated with a 40% increased risk of recurrence a weaker association with death, these numbers did not meet statistical significance. The authors noted that “a review… in 2010 concluded that insufficient evidence existed with regard to safety of dietary supplements to make recommendations, and that may still be the case.”

Despite the limitations of this study and the inability to draw firm conclusions, it is still recommended that patients who receive a recommendation for chemotherapy or radiation therapy inform their medical team of all vitamins and supplements that they are taking, and it still is considered best practice to avoid antioxidant supplements while undergoing treatment.

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

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Can We Prevent Breast Cancer?

6 October 2019

The headline was promising: “Breast Cancer Awareness Month: 3 Ways to Prevent and Detect the Disease” – but the word “prevent” always gets my attention. Can we really prevent breast cancer?

As always, the context is important. When we look at populations, large groups of individuals, there is no question that a healthy diet, regular exercise, and limitations in alcohol intake will result in reduced rates of breast cancer (and other disease) development. So for populations, yes, we can prevent disease. Unfortunately it’s not that simple when it comes down to the individual level. Cancer, even breast cancer, is not one disease. People are complex and there are multiple factors influencing the likelihood of disease development in any one individual. For example, breast feeding lowers risk, but a woman who breast-fed her children is not immune from developing breast cancer. On an individual level, the best we have is risk reduction.

What’s the harm in using the term prevention when discussing risk factors at an individual level? It is not uncommon for a patient newly diagnosed with breast cancer to start second-guessing all of her life choices, and feeling guilty that she caused her disease:

The reality is that one can do everything “right” and still develop breast cancer and one can have a high alcohol intake and junk-food diet and never develop the disease. In the majority of individuals, we cannot determine exactly why breast cancer develops. We are all looking for answers and for control. Adopting a healthier lifestyle with known risk factors in mind will help contribute to a longer and healthier life. But there are no guarantees. Life is for living, and it’s too short to be burdened with guilt if disease does develop.

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Decline in Cancer Deaths

9 January 2019

The American Cancer Society has just published their updated “Cancer Facts and Figures”, documenting cancer incidence and mortality rates. When combined by disease site, cancer death rates have decreased by 27% from 1991-2016, resulting in approximately 2.6 million cancer deaths avoided. From 2007 – 2016, cancer death rates have declined approximately 1.8% per year for men, and 1.4% per year for women. From 2006 – 2015, rates of cancer development increased approximately 2% per year for men and were stable for women.  It is anticipated that there will still be more than 1.7 million new cancers diagnosed and 600,000 cancer-related deaths in 2019.

The most common cancers in men are lung, prostate and colorectal, and the most common cancers in women are breast, lung and colorectal. Breast cancer accounts for 30% of all new cancer diagnoses in women.

Lung cancer is the most frequent cause of cancer-related deaths in both men and women. Much of the decline in incidence and mortality is attributed to a decline in smoking rates, but it important to note that many cases of lung cancer occur in non-smokers. Rates of new lung cancer cases have decreased by 3% per year in men and 1.5% per year in women, and these differences are not fully explained by smoking rates – especially in cases of lung cancer in younger women. In addition, while lung cancer related deaths in men decreased by 48%, women only experienced a 23% reduction in death rates. 

Improvements in screening and treatment have resulted in a decreased number of deaths due to lung, breast colorectal and prostate cancer, and breast cancer death rates decreased approximately 40% from 1989 – 2016. However, there has been a modest increase in breast cancer incidence, in part due to the association of breast cancer development with post-menopausal obesity as well as alcohol intake. 

While the prostate cancer death rate has decreased, there has been some flattening of the curve from 2013-2016. This may be related to more recent guidelines that do not recommend routine testing of the prostate-specific antigen (PSA) in patients without symptoms.

Colorectal cancer death rates declined 53% from 1970 – 2016, but in patients younger than age 55, new cases of colorectal cancer have increased almost 2% per year since the mid 1990s

Death rates in cancers related to obesity, including pancreatic and uterine cancer, have been increasing. Deaths due to liver cancer have also risen, with an increasing number of cases related to obesity rather than alcohol and chronic hepatitis.

There has been a decline in the racial gaps in mortality rates, but blacks are still 14% more likely to die of cancer compared to whites (33% 25 years ago). While this is encouraging, the economic gap is growing, especially related to cancers that have seen improvements due to early screening and treatment, improved nutrition and smoking cessation.

It was noted that cancer risk increases with age, and those over 85 account for approximately 8% of all new cancer diagnoses. Cancer is also noted to be the 2ndleading cause of death, after heart disease in this population. There may be many challenges to diagnosis and treatment in older adults due to the presence of co-existing medical conditions as well as other factors. 

It is important to note some limitations of the report. Information is gathered from several sources and data may be incomplete. The current report notes incidence rates through 2014 and survival data through 2015. 

The general downward trend in cancer incidence and improvement in survival is encouraging, but there is much work to be done.

Additional Information:
KPCC Air Talk interview with Dr. Attai
American Cancer Society Press Release
American Cancer Society “Facts and Figures”

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Body Fat, BMI, and Breast Cancer

10 December 2018

Being overweight after menopause is associated with an increased risk of breast cancer. But a new study suggests that our traditional measure of overweight, the body mass index (BMI) may not tell the whole story.

A recent study, published in JAMA Oncology, performed detailed body composition analysis on 3000 women who were of normal BMI. They found that among these women, those with increased levels of body fat (especially in the truncal area – “belly fat”) had higher risks of estrogen receptor positive (ER+) breast cancer compared to women with lower body fat levels. In addition, the women with higher body fat levels also had higher levels of inflammatory markers as well as other metabolic abnormalities. 

This suggests that maintaining a healthy weight may not be enough. Muscle mass declines with age, so even if weight is stable, there is a slow but steady increase in body fat. Regular exercise can certainly help to maintain muscle mass and it also helps decrease the level of inflammatory markers. 

The authors note that more study is needed to better understand the links between body fat and breast cancer, but it is very clear that there is no way around it – exercise is essential for good health.

Additional Information:
NBC News: Belly fat increases risk of breast cancer despite normal BMI
CNN – Body fat levels linked to breast cancer risk in post-menopausal women

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Highlights from the 2018 American Society of Breast Surgeons Annual Meeting

10 May 2018

The American Society of Breast Surgeons held their Annual Meeting in Orlando, FL from May 2nd – 6th. As usual, it was well attended – the meeting is known for being very practical and full of information that breast surgeons can bring back to their practices to help improve patient care.

I’ve picked a few topics to highlight in this post: Genetics, Imaging, Local Therapy, Systemic Therapy, Immunotherapy, Liquid Biopsy, Diet and Hormone Therapy, and Changing Paradigms. The following are comments expressed by the meeting speakers. My own comments will be noted in bold italics.

Genetics:

  • BRCA 1 mutation carriers are more likely to have triple negative breast cancer.
  • BRCA 2 mutation carriers are more likely to have ER positive, Her2/neu negative breast cancers.
  • The risk of a 2nd breast cancer in BRCA mutation carriers on average is about 2% per year depending on the specific mutation and the age of affected relatives. It can approach 60-80% in some patients. This increased risk of a new breast cancer is why bilateral mastectomy is often recommended. Removal of the opposite breast may result in improved overall survival but results from studies are mixed.
  • For BRCA mutation carriers, it is recommended that clinical breast exam (breast exam by the physician) be performed every 6-12 months. From age 25-29 annual MRI is recommended, and from age 30-75 annual mammogram (3D mammogram or tomosynthesis was recommended) along with MRI was recommended. It was stated that this screening regimen has not been shown to improve survival, but the screen-detected cancers were less likely to have lymph node involvement. No specific recommendation was made for imaging or exam after bilateral mastectomy.
  • MRI every 6 months has been suggested by some, but there are concerns about gadolinium (a heavy metal material which is the contrast agent used for breast MRI) buildup.
  • Removal of the ovaries is recommended around age 40.
  • In patients with BRCA mutations who undergo salpingo-oophorectomy (removal of the ovaries and fallopian tubes), estrogen replacement therapy has not been shown to increase subsequent breast cancer risk. However, combined estrogen / progesterone therapy may increase subsequent breast cancer risk. It was suggested to consider removing the uterus at the time of ovary removal, so that estrogen alone could be used (if the uterus is not removed, estrogen alone could increase the risk of uterine cancer).
  • There are many other genetic mutations that have been identified that have a variable association with increased breast cancer risk. It was stressed that family history and other factors need to be considered when these less common mutations (such as CHEK2, ATM, PALB2 and many more) are present, before recommending mastectomy.
  • It was stressed that the presence of a variant of unknown significance (VUS) should NOT prompt aggressive surgery.
  • A study was presented that demonstrated that current breast cancer genetic testing guidelines exclude almost half of high-risk patients, and a recommendation was made for testing of all breast cancer patients regardless of age, family history or other factors.

Breast Imaging:

  • Dense breast (as determined by mammogram) reduces the sensitivity of mammograms, and also is associated with an increased risk of breast cancer.
  • It was stressed that determination of breast density is subjective and studies have shown significant variability in grading of breast density. Automated methods of assessing density are being evaluated.
  • 34 states have dense breast notification legislation. Some have supplemental screening (such as ultrasound) legislation (California does not).
  • An advantage of tomosynthesis (also known as 3D mammogram) in patients with dense breasts is that it decreases the likelihood of callbacks and improves the cancer detection rate
  • Abbreviated (3 minute scan) MRI shows promise for screening.
  • There is an ECOG/ACRIN study planned which will evaluate abbreviated MRI versus tomosynthesis in women with dense breasts.
  • Contrast-enhanced mammography is superior to digital mammography but it requires an IV contrast dye, and there is currently no ability to biopsy lesions seen only with this technique.
  • It was stressed that automated whole breast ultrasound (ABUS) should not replace mammography.
  • Molecular breast imaging has a much higher radiation dose due to the need to inject a radioactive material and cost is higher than other imaging modalities. There are only about 100 units in the US.
  • In addition to BRCA mutation carriers, patients who have a history of chest wall radiation at a young age (most commonly for treatment of Hodgkin’s lymphoma) or those who have a lifetime risk of breast cancer over 20% (assessed by various computer modes) should have annual MRI in addition to mammograms for surveillance.

Loco-Regional (breast and underarm lymph nodes) Therapy:

  • Recurrence of cancer in the breast (known as a local recurrence) was previously thought to be related to “disease burden” – the amount of tumor and size of clear margins. According to Dr. Monica Morrow, this has led to an “obsession” with margins, wider surgical resection than necessary, and the overuse of MRI.
  • Due to improvements in systemic therapy (chemotherapy and endocrine therapy), local recurrences have decreased over time.
  • Local recurrences are largely a function of tumor biology – more aggressive tumor types are more likely to recur. Bigger surgery does not overcome bad biology.
  • The rates of contralateral (opposite side) new breast cancer have been decreasing in the US; currently <1% at 5 years for patients who do not have a genetic mutation.
  • Updated 2018 ASTRO guidelines endorse hypofractionation (a shorter course of radiation therapy) in a larger group of patients.
  • There are 3 trials that will evaluate whether or not radiation therapy can be avoided in selected patients – LUMINA, IDEA and PRECISION.
  • ~30% of patients undergoing “direct to implant” reconstruction (no temporary tissue expander) need a second surgery. One of the plastic surgeons that I work with notes that “reconstruction is a process not a procedure!”
  • Managing expectations of the reconstruction process is important so patients don’t get frustrated and feel like their reconstruction has “failed.”
  • Post mastectomy radiation worsens outcome from implant reconstruction; severe capsular contracture occurs in about 30% of patients.
  • If radiation is performed on the permanent implant instead of the tissue expander, the rate of reconstruction failure goes down by 50%.
  • Many plastic surgeons prefer that autologous (patient’s own body) reconstruction be performed after radiation to avoid shrinkage of the flap. A tissue expander could be placed at the time of mastectomy which will be removed after radiation when the flap procedure is performed.
  • Lymphedema risk is about 25% with axillary node dissection versus 6-8% with sentinel node biopsy. In certain patients over age 70 with ER+ breast cancer, sentinel node biopsy can be avoided – this was also covered in the Society of Surgical Oncology’s Choosing Wisely statements. However, it is also important to take into account whether or not the patient will be treated with radiation and/or endocrine therapy. Sentinel node biopsy is also not recommended for most patients undergoing lumpectomy for DCIS. The SOUND trial is evaluating the use of axillary ultrasound to try to determine if this can help select patients who do not need sentinel node biopsy.

 Systemic Therapy:

  • The use of genomic tumor testing could avoid the use of ineffective (for the specific patient depending on tumor profile) chemotherapy in up to 50,000 patients per year.
  • Neoadjuvant (before surgery) chemotherapy is most commonly used to decrease tumor size so that patients have a higher likelihood of being able to undergo lumpectomy instead of mastectomy.
  • About 50% of patients who have positive lymph nodes before chemotherapy are converted to node-negative due to chemotherapy prior to surgery, and they may be able to avoid full axillary node dissection.
  • Response to neoadjuvant chemotherapy varies by tumor subtype. Her2/neu and triple negative breast cancers are more likely to respond compared to ER+ and Her2/neu negative tumors.
  • Technical considerations to improve the accuracy of sentinel node biopsy after neoadjuvant chemotherapy including the use of 2 dye agents to map the nodes and removal of at least 3 lymph nodes.
  • A multidisciplinary approach for management of patients who are being considered for neoadjuvant chemotherapy was stressed.
  • Recurrence patterns are different for ER+ versus ER- disease. Patients with ER+ breast cancer are at risk for late recurrence, even 20 years after treatment – the highest risk is in patients with multiple involved lymph nodes. Patients with ER- disease tend to recur earlier (within the first 2-5 years), and then the likelihood of recurrence decreases.
  • Recurrence in the breast is a marker of increased risk for development of metastatic disease.
  • Premenopausal patients who have “low risk” disease could consider stopping tamoxifen after 5 years. It is recommended that patients with “high risk” disease consider 10 years of tamoxifen therapy.
  • Postmenopausal patients who are considered “high risk” could consider 10 years of an aromatase inhibitor, although there is not currently data that shows this approach improves survival. Prolonged therapy in these patients does reduce the likelihood of developing a new breast cancer and reduces the likelihood of breast cancer recurrence.

Immunotherapy / Liquid Biopsy:

  • A brief session was held covering immunotherapy and liquid biopsy.
  • Immunotherapy for breast cancer has not had the success seen in melanoma, lung cancer, colon cancer and bladder cancer.
  • The combination of chemotherapy and a modified herpes virus has shown some promise in patients with triple negative breast cancer.
  • It is likely that immunotherapy treatments will vary depending on tumor subtype.
  • Circulating tumor DNA may predict metastatic disease 8-12 months before evidence of tumor spread – but we are not yet able to improve patient outcomes based on this information. Therefore, circulating tumor cell and circulating cancer cell DNA assessments are not recommended for routine clinical use.
  • It was predicted that “liquid biopsy” will eventually be used routinely to help manage breast cancer patients.

 

Diet and Hormone Replacement Therapy:

  • A low fat diet improved the likelihood of death from breast cancer only in obese women.
  • Currently there is more information regarding the impact of dietary fat versus dietary sugar on breast cancer risk. Dr. Rowan Chlebowski, who has been a lead author on the Women’s Health Initiative studies, stated that due to an increasing number of reports suggesting that sugar may impact breast cancer development, they plan to look more closely at this.
  • Insulin resistance is associated with cancer specific and all-cause mortality in postmenopausal women.
  • One of Dr. Chlebowski’s conclusions was to “avoid body fatness.” Unfortunately, specific guidance on how to best accomplish this was not discussed!
  • The risk of breast cancer associated with hormone replacement therapy (HRT) is greater if it is started around the time of menopause versus 3-5 years later.
  • Breast cancer risk in women taking HRT is higher in women with extremely dense breast versus fatty replaced breasts. The biggest risk from HRT is in lean women with extremely dense breasts. The lowest risk from HRT is in women with a body mass index (BMI) > 35 with fatty replaced breasts.
  • Combination estrogen / progesterone HRT should be avoided in lean (BMI <25) women especially if they have dense breast tissue.
  • The Black Women’s Health Study found no increased breast cancer risk if HRT use was <10 years, but cancer risk was increased if use was >10 years. Other studies showed either no risk or no association of risk from HRT with race.

 

Changing Paradigms – Avoiding Surgery for DCIS and Neoadjuvant Patients

  • Active surveillance is being evaluated for ductal carcinoma in-situ (DCIS). Over 60,000 cases of DCIS are diagnosed per year in the US. Not all cases of DCIS will progress to invasive cancer, and the likelihood of progression is lowest in low grade DCIS. In these patients, less than 10% develop invasive cancer in the same breast after 10 years and over 20% die from other causes within 10 years of diagnosis.
  • There are 3 ongoing clinical trials are evaluating active surveillance for low risk DCIS (LORIS, LORD, and COMET). The COMET trial is the only study open in the US. DCISOptions.org has additional information about DCIS and the COMET trial.
  • Some patients who undergo chemotherapy prior to surgery are found to have no residual tumor after the area has been removed, termed pathologic complete response (pCR).
  • Prompted by patients asking “why do I need surgery?” if it appears that all cancer has resolved after chemotherapy, researchers at MD Anderson Cancer Center are evaluating whether surgery can be omitted in patients who appear to have a pCR after chemotherapy. Patients who have no apparent tumor based on post-chemotherapy imaging (including MRI) undergo core needle biopsies. If these biopsies show no tumor, patients taking part in the study will undergo radiation without surgery.
  • Similar studies are taking place in the Netherlands, Germany, and the UK.
  • Henry Kuerer from MD Anderson stated that “surgeons have an obligation to study possibility of no surgery – and we must ensure safety and efficacy with well-designed trials.
  • Several types of ablative therapy (destroying the tumor without surgery) are being evaluated including cryoablation (freezing), laser, and transcutaneous (no needle puncture or scar) high frequency ultrasound.

Lifetime Achievement Award

Dr. Ernie Bodai, the breast surgeon who spearheaded the Breast Cancer Research Stamp, was honored with a lifetime achievement award. It was fascinating to hear his story and how one man (with a little help) got congress to change a law.

This post has not been endorsed by the American Society of Breast Surgeons

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Breast Cancer Treatment and Risk of Heart Disease

1 February 2018

February is heart health month!

It is well known that some breast cancer treatments including certain chemotherapy agents, trastuzumab (brand name herceptin – used for Her2/neu over-expressed cancers), and radiation therapy have the potential to cause damage to the heart. Echocardiograms and other monitoring tests are often performed during and after treatment for patients receiving certain chemotherapy medications and trastuzumab. We also try to tailor our treatment as much as possible to the individual patient’s tumor when treatment recommendations are made. Genomic tests such as the Oncotype Dx or MammaPrint help identify “low risk” patients that do not need chemotherapy.

In addition to regular monitoring, it is important that women who have been treated for breast cancer focus on the lifestyle factors that can improve heart health, such as regular exercise and a healthy diet. Women over 65 who have been treated for breast cancer are more likely to die of heart disease than the breast cancer, and all of the factors that improve heart health also decrease the risk of breast cancer recurrence.

Washington Post – Breast Cancer Treatments Can Raise Risk of Heart Disease
Forbes Online – Reasons Not to Freak Out About Risk of Heart Disease After Breast Cancer

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Acupuncture for Joint Pains

7 December 2017

An abstract presented at the San Antonio Breast Cancer Symposium found that acupuncture can be very helpful in patients who develop joint pains related to aromatase inhibitor (AI) treatment.

The study evaluated the use of acupuncture in post-menopausal women who had been treated for early stage breast cancer. 226 patients were enrolled. 110 underwent true acupuncture, 59 underwent sham acupuncture (needles inserted very superficially into non-treatment points) and 57 patients were placed on a waitlist (did not receive any treatment). Patients treated with true or sham acupuncture were treated twice a week for 6 weeks, followed by weekly sessions for 6 weeks. After 6 weeks, patients in the true acupuncture group had significantly lower pain scores compared to the other 2 groups. Even though the intervention was for 12 weeks, the significant improvement in pain scores for the patients treated with true acupuncture held up for 24 weeks. The primary adverse effect reported in the true and sham acupuncture groups was bruising.

AIs are a form of endocrine therapy, important in the treatment of estrogen receptor positive breast cancer. While they can significantly reduce the risk of recurrence, they are associated with a variable incidence of side effects including joint / muscle pains and hot flashes. Some women find the pains decrease after a few months of treatment. Weight loss (if overweight) and regular moderate exercise can help with symptoms. However, anywhere from 10-30% of patients stop their medications early due to negative impacts on quality of life.

A caution regarding these results is that they were presented in abstract, or preliminary form – a full paper with complete results has not yet been published. However, as acupuncture has very few side effects and is well tolerated by many patients, there seems to be little downside to trying a course of therapy if joint pains develop on endocrine therapy.

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Alcohol and Cancer

10 November 2017

The American Society of Clinical Oncology (ASCO) has just released a statement on alcohol and cancer. They note that the importance of alcohol consumption as a contributor to cancer development is under appreciated, and that in the US, approximately 3.5% of all cancer deaths are related to alcohol intake. While the association between alcohol intake (especially heavy consumption) has been known for some time, this is the first formal statement from ASCO on the subject. Alcohol intake is most strongly linked to head and neck, esophageal, liver, colon and breast cancers.

Moderate drinking is defined as one alcoholic drink per day for women and two per day for men. The greatest risk appears to be in those who drink heavily, although there does not appear to be a “safe” level of intake. In a New York Times article, Dr. Clifford Hudis, the chief executive of ASCO, noted that “The more you drink, the higher the risk. It’s a pretty linear dose-response”. ASCO did not recommend that people stop drinking altogether, but they did suggest that more education for both oncology providers and the public is needed about the relationships between alcohol consumption and cancer.

Of course, people who never drink alcohol can still develop cancer, and some who are heavy drinkers will not. Alcohol intake is just one of many lifestyle factors that can contribute to increased risk. And as Aaron Carroll writes, also in the New York Times, “maybe any increase in risk is too much for you”. If you do drink, I recommend that women limit their alcohol intake to 3-6 drinks per week – and don’t save up your weekly allowance for Friday or Saturday night! I think Dr. Carroll’s conclusion stated it best: “The absolute risks of light and moderate drinking are small, while many people derive pleasure from the occasional cocktail or glass of wine. It’s perfectly reasonable even if a risk exists — and the overall risk is debatable — to decide that the quality of life gained from that drink is greater than the potential harms it entails.”

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Cancer Risk Factors and Financial Impact of Cancer Treatment

24 October 2017

A national survey performed by the American Society of Clinical Oncology showed that many Americans are unaware of key cancer risk factors, including obesity, alcohol, lack of exercise, tobacco use and sun exposure. While doing “everything right” certainly is no guarantee of a healthy life (for example, many patients who develop lung cancer do not smoke) being aware of the lifestyle factors associated with cancer may lead to better health choices. In addition, all of these lifestyle factors are also associated with a lower likelihood of heart disease, diabetes, and other illness.

An additional finding of the survey was that 27% of respondents noted that either they or an immediate family member (who has / had cancer) took specific actions to decrease treatment costs including skipping appointments, postponed or didn’t fill prescriptions, skipped cancer medication doses, or cut cancer medications in half. We cannot hope to improve cancer outcomes without addressing the issues of cost of care and disparities in access to care.

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