8 May 2017

As a past-president of the American Society of Breast Surgeons I am probably more than a little biased. However, as always, the annual meeting held April 26-30th in Las Vegas was terrific. Topics including the full spectrum of breast disease, including benign and high risk lesions, genetic testing, breast cancer diagnosis and treatment including medical and radiation oncology updates, and metastatic disease.

The press briefing highlighted 3 abstracts which showed that:

  • Modern therapy for inflammatory breast cancer is associated with better outcomes than historically seen
  • Post-treatment lymphedema is related to a combination of treatments including surgery, radiation therapy, and chemotherapy – not just from surgery
  • Patients with DCIS have a 5 year risk of developing a cancer in the other breast of 2.8% and a 10 year risk of 5.6%, and patients should be discouraged from undergoing bilateral mastectomy for this condition. Developing a new cancer in the previously treated breast was twice as likely as developing a new cancer in the opposite breast, and the use of tamoxifen reduced the likelihood of any recurrence.

Dr. Nathalie Johnson moderated a pre-meeting course on Building a Breast Cancer Survivorship Program. I was invited to speak on Traditional Versus Virtual – Options for Patient Support and Education. Just as it can be challenging to choose between cake and ice cream (2 really good things), patients note advantages to both in person and online support and education. It doesn’t have to be one or the other – do what works for YOU! My slides are posted on SlideShare.

During the general sessions, a few topics stood out to me:

Dr. Shelley Hwang from Duke University spoke on DCIS subtyping and overtreatment. She noted that DCIS now comprises over 20% of all mammographically detected breast cancer. It is considered a “non-obligate precursor” of invasive cancer – the rate and likelihood of progression to invasive cancer are not clearly known. However, it is clear that some patients will never exhibit progression to invasive disease, and she discussed this in the context of thyroid and prostate cancer – two situations where we know that treatment in some patients will not provide the patient any benefit. The challenge is to sort out which patients will benefit from treatment and which ones will not. The COMET study is currently enrolling patients with low grade DCIS to in an attempt to help answer these questions.

Dr. Virginia Herrmann from Washington University in St. Louis spoke on non-genetic breast cancer risk factors. This is an important topic and I believe one that doesn’t get covered enough. She noted that hormone replacement therapy does increase risk – although the incremental risk is small and is seen only after about 5 years of use. However, longer term use does result in higher risk. Increased body mass index (BMI) is associated with risk – the risk of breast cancer is 30% higher in patients with a BMI greater than 31 kg/m2 compared to a BMI of 20 kg/m2. She noted that there is a linear relationship between alcohol intake and cancer risk, noting a 10% increase in risk for each 10 gm/day (for wine this is a little over 3 oz) increment in alcohol consumption. The risk is most associated with post-menopausal breast cancer, although in the study she quoted, only alcohol intake during age 50s was associated with an increased risk of postmenopausal breast cancer. She noted the association of ionizing radiation and breast cancer, and young women who received mantle (chest area) radiation for Hodgkin’s lymphoma have a markedly increased risk for developing breast cancer. She noted that breast cancer risk is increased in smokers, correlated with smoking intensity and duration. Finally, she noted the increased risk of breast cancer among soldiers stationed at Camp LeJune related to contaminated drinking water (tetrachloroethylene and trichloroethylene).

Dr. Tiffany Traina, a Memorial Sloan Kettering medical oncologist, gave a brief presentation about triple negative breast cancer: Searching For the Magic Bullet. There are several promising treatment strategies including targeting androgen receptors, the use of PARP-inhibitors in patients who have BRCA gene mutations, antibody-drug conjugates, immune modulating approaches, and targeted therapies based on tumor genomic profiles. Stay tuned – much more to come over the next few years related to this aggressive breast cancer subtype.

Dr. Lisa Newman, from the Henry Ford Health System in Detroit, spoke on Breast Cancer Outcomes: Disparities versus Biology. I have heard her speak on this topic multiple times over the years and always enjoy her excellent presentations. She noted that the incidence of breast cancer in black women is increasing, now close to that in white women. However, mortality rates for black women are higher than those for white women. There is an increased frequency of triple negative breast cancer in black women. She is involved in a research initiative evaluating the association between African ancestry and high risk breast cancer in white American women, African American women, and women in Ghana, including studying novel aspects of tumor biology and breast cancer stem cells – she is asking the question “are there differences in the oncogenic potential of mammary tissue that are associated with ancestry”? She concluded with what I felt was a powerful slide – 60% – 43% – 20%. Those were the survival rates for passengers on the Titanic who were in 1st – 2nd – 3rd class. She noted that healthcare outcomes are often dependent on access to care, and ended with a quote from Dr. Martin Luther King, Jr.: “Of all the forms of injustice, inequality in health care is the most shocking and inhumane”.

Dr. Stephen Edge, from the Roswell Park Cancer Institute, gave an update on the new American Joint Commission on Cancer staging system (AJCC 8th edition). Currently we stage breast cancer based on tumor size and lymph node status. However, it is recognized that that tumor biology plays an important role in prognosis and in some patients it may be more important that tumor size. The new staging system will incorporate tumor grade, Her2/neu status, ER/PR status, and Oncotype Dx status (if available) and should more accurately reflect prognosis. There are 422 lines in the new staging system – it will be impossible to memorize! Thankfully, he noted that the AJCC is working on a staging app.

The last day of the meeting held some great sessions, and the meeting room remained packed up until the very last minute. Dr. Ann Partridge from Dana Farber discussed special considerations in the young breast cancer patient. She noted that the disease is different, the patients are different, and the treatments should be different. Younger women have a higher likelihood to have more aggressive subtypes such as Her2/neu over-expressed and triple negative, and have lower survival rates than older women – even in those with the ER positive breast cancer. However, she cautioned not to over-treat patients based only on age. She noted that young age is not a contraindication for breast conservation, and that there is no clear improvement in mortality in patients who undergo more extensive surgery. She noted the need for improvements in treatment and support, including focused research and guidelines, which should lead to better outcomes.

Dr. Irene Wapnir from Stanford spoke on fertility preservation issues. She noted the various fertility options including medications and procedures. She also reviewed the POSITIVE trial, which will be assessing the risk of breast cancer relapse in patients who temporarily stop endocrine therapy to permit pregnancy, as well as to evaluate factors associated with successful pregnancy after interruption of endocrine therapy. She also stressed that fertility preservation should be discussed with any woman of childbearing age, whether or not she has had a prior pregnancy or a child – physicians won’t know what is important to their patients unless we ask!

Dr. Katherina Zabicki Calvillo from Dana Farber discussed breast cancer in pregnancy. She noted that 0.2-4.0% of breast cancers are diagnosed in pregnant patients – about 1 in 3000 pregnancies. She also noted that given the overall delay in childbearing (and the association of increasing age with breast cancer), the incidence of pregnancy-associated breast cancer will increase. Delays in diagnosis are related to hormonal changes which affect breast tissue making the exam more challenging, and that many patients and physicians assume that masses are related to pregnancy. She stressed that pregnancy termination is usually NOT required, but a multidisciplinary team approach is required. Many of these patients present in more advanced stages, but stage-for-stage, the prognosis is similar to non-pregnant patients with breast cancer. Chemotherapy can be given after the first trimester, but hormonal and Her2/neu targeted therapy should be avoided. She noted that mastectomy should be performed in the first and early 2nd trimester, and discussed the challenges of immediate reconstruction. Breast conservation could be considered in the late 2nd or 3rd trimester with post-lumpectomy radiation planned for after delivery.

Dr. Kevin Hughes from the Massachusetts General Hospital reviewed research studies that have found that in women over the age of 70 with early stage breast cancer, radiation therapy after lumpectomy may not be necessary.  The CALGB 9343 study showed that survival rates were the same whether women received radiation therapy or not. Radiation therapy did reduce the likelihood of cancer returning in the breast (local recurrence) from about 4% in the untreated patients to about 1% in the treated patients (after 5 years of follow up). However it is important to realize that the majority of women in that study were treated with endocrine therapy, which can help reduce the risk of local recurrence. As with many decisions regarding breast cancer treatment, a careful discussion of the risks and benefits of each option is necessary.

Dr. Tina Hieken from the Mayo Clinic gave a very interesting talk on the microbiome and the impact on breast cancer. We normally co-exist with many bacteria – we have ten times the more microbial cells compared to human cells. These microbes carry out metabolic reactions that can be essential to human health. The genetic material (genome) of our microorganisms is called the microbiome. She and her colleagues studied breast tissue from women with and without breast cancer and found that the background breast microbiome is different in women with breast cancer compared to those with benign conditions. She concluded by noting that the future may involve using a microbial pattern to predict breast cancer risk, exploiting the microbiome to enhance treatment response, and that there may also be implications for a cancer prevention vaccine. The Washington Post recently covered her research – definitely worth a read for more information.

Dr. Anthony Lucci from MD Anderson discussed the “Ongoing Saga of Circulating Tumor Cells”. We would all like to see the day when a blood test can tell us with certainty if cancer has developed or returned – but we’re not there yet. After reviewing several studies evaluating both circulating tumor cells (CTC) and circulating “cell free” DNA, he concluded that this information does provide prognostic information in both metastatic and non-metastatic patients, but is not in the current ASCO or NCCN guidelines for guiding treatment. Combining the CTC status with response to preoperative chemotherapy may identify a low risk subset of patients, but noted that additional studies are needed before we can reach the ultimate goal which is improving outcomes by monitoring and responding to CTC and cell free DNA levels.

Dr. Manjeet Chadha from Mount Sinai spoke on repeat lumpectomy after prior lumpectomy and breast radiation. Traditionally, mastectomy has been recommended if cancer returns after lumpectomy and radiation therapy. On average, there is about a 10% risk of “in breast” recurrence after lumpectomy and radiation, but this will vary based on tumor and treatment type. She reviewed several studies evaluating the different types of focused or partial breast radiation that may be used in selected patients who experience recurrence of their breast cancer. She also called for additional studies in this area.

One of the last talks was by Dr. Mehra Golshan from Dana Farber. He spoke about the decision whether or not to operate on patients with breast cancer who present with Stage IV (metastatic) disease. Traditionally, we have not recommended surgery for patients with metastatic breast cancer as these patients were not expected to have long survival, and it was not felt that removal of the main tumor would impact survival. Evaluating existing studies has also been challenging because while some have shown a benefit to removal of the main tumor, the patients who underwent surgery in those studies tended to be younger and healthier. He concluded by noting that surgery in patients with Stage IV breast cancer is not standard of care, but some studies do support this practice. It is recommended that these patients be evaluated in a multidisciplinary forum and that treatment choices be individualized.

 I returned from the meeting exhausted but energized. In addition to the scientific content, the meeting is an opportunity to connect with friends and colleagues across the country. I’m already looking forward to ASBrS 2018!

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

13 December 2016

A study published in the journal Cancer concluded that women with larger social networks have better breast cancer (BC) outcomes. In noting that large social networks predict lower overall mortality in healthy populations, the researchers analyzed a group of women who were already participating in four cohort studies. They evaluated associations between social networks within 2 years of a BC diagnosis and outcomes. Among 9267 women, there were 1448 recurrences and 1521 deaths. 990 of the deaths were due to breast cancer. In the patients studied, they noted that:

  • Socially isolated women were more likely to be Caucasian, college-educated and nulliparous (never had children)
  • Socially isolated women were less likely to be physically active and were more likely to be smokers, drink more than the recommended amount of alcohol, and be overweight
  • Women who were socially isolated were more likely to undergo lumpectomy and were less likely to receive chemotherapy and hormonal therapy
  • There were no associations between social isolation and age, menopausal status at diagnosis, cancer stage, and treatment with radiation

Regarding outcomes:

  • Women with smaller social networks had a higher risk of recurrence, BC specific mortality and overall mortality
  • Adjustments for lifestyle and treatment factors attenuated the associations with recurrence and mortality, but the associations remained statistically significant
  • Social network associations with recurrence and breast cancer specific mortality were stronger for patients with Stage I and II BC  compared to Stages III and IV
  • Associations between social networks and outcomes did not differ based on age, time since diagnosis, ER/PR status, Her2/neu status, or treatment
  • Being “unmarried / unpartnered” was associated with worse BC specific and overall mortality for older but not younger white women or non-white women (any age)
  • Community ties predicted lower risk of BC specific and overall mortality in older white and Asian women but not in other groups
  • Religious participation was not associated with outcomes

So what to make of this study and these findings? The first point to make is that this study notes associations, or correlations – not cause and effect. Cause and effect cannot be determined from this type of cohort study, and a randomized controlled trial to assess the relationship between social networks and breast cancer outcomes would be impossible. While the authors attempted to control for many variables, the study population was not representative of the average US breast cancer population. In addition, there was no assessment of the quality of the social networks, a point I raised in a CNN.com interview regarding the study.

Cancer treatment is challenging even for those with a large supportive social network. No one should have to feel they are going it alone – there are many resources for help and support, but you may need to ask (hard to do for many independent women!). However, if you are one of those women (like me) who keeps her social network very small, this study should not prompt more worry during an already stressful time.

Correlation does not equal causation, by Lisa Simpson:

28 January 2016

Due to improvements in diagnosis and treatment, patients who have undergone cancer therapy are living longer than ever. The American Cancer Society estimates that there are approximately 15.5 million people living in the United States who have been treated for cancer, and that number is likely to increase.

Cancer survivors not only cope with the normal effects of aging, but their long-term health is impacted by the cancer treatments, including surgery, radiation therapy, chemotherapy and targeted agents including hormonal therapy. Healthy lifestyle behaviors can help to reduce the risk of chronic medical conditions such as heart disease, diabetes and more. Healthy behaviors may also help reduce the likelihood of cancer recurrence. So how well do cancer patients take care of themselves?

Researchers at the University of Oklahoma evaluated data from a national health survey conducted by the Centers for Disease Control known as the Behavior Risk Factor Surveillance System. They evaluated data from approximately 400,000 patients without a history of cancer and approximately 47,000 patients with a history of cancer.  The researchers found that US cancer survivors were not more likely than the general population to engage in all healthy lifestyle behaviors. Of current cancer survivors, 16% were smokers, 33% were physically inactive over the past 30 days, 66% were overweight or obese, 5% were heavy drinkers, and 82% did not consume at least 5 daily servings of fruits / vegetables. Rates of smoking, and alcohol intake were better than the average population, rates of obesity and inactivity were worse and the average population and fruit / vegetable consumption was not statistically different between the two groups.

The authors noted that “cancer survivors are at increased risk for comorbid conditions, and acceptance of healthy behaviors may reduce dysfunction and improve long-term health. Ultimately, opportunities exist for clinicians to promote lifestyle changes that may improve the length and quality of life of their patients.”

The following is a slide presentation from a talk given to primary care physicians about survivorship issues in breast cancer patients. While it was geared towards physicians, I think that many patients will find the information helpful.

7 December 2015

The American Cancer Society and the American Society of Clinical Oncology have just released updated guidelines for breast cancer survivors. The purpose “is to provide recommendations to assist primary care and other clinicians in the care of female adult survivors of breast cancer”.

Patients and physicians are well aware that health concerns do not end when cancer treatment is over. The guidelines outline potential signs of recurrence, note appropriate tests to help detect recurrence, review general health recommendations, and discuss management of long-term side effects. It is important that patients who have been treated for any type of cancer remain vigilant regarding their health. Changes or new findings should be reported to your physician, and efforts should be made to maintain a healthy diet, weight and lifestyle.

I encourage every patient to review the guidelines. If you have questions or concerns, do not hesitate to inform your oncology or primary care physicians. Education and open communication are important in order to maximize quality of life after cancer treatment.

ACS / ASCO Breast Cancer Survivorship Care Guideline

 

9 November 2015

The American Society of Breast Surgeons Foundation has just launched a patient information website – Breast360.org. The site was developed by breast surgeons, and patient advocates have had input and oversight during the entire process. Please take a look, and feel free to provide feedback if you have a suggestion for additional content.

 

14 September 2015

A study just published in JAMA Internal Medicine found that a Mediterranean diet (MeDiet) supplemented with extra virgin olive oil (EVOO) was associated with a lower rate of breast cancer.

Dr. Miguel Martinez-Gonzalez and co-authors were studying the effects of dietary interventions in men and women at high risk of cardiovascular disease. While the study was not initially designed to evaluate the effects of dietary interventions on the rates of breast cancer, the authors reported on some interesting findings.

Men (age 55-80) and women (age 60-80) at risk for cardiovascular disease (due to diabetes or at least 3 of the following: smoking, hypertension, elevated LDL, low HDL, overweight, obesity, family history of premature cardiovascular disease) in Spain were randomized to a MeDiet supplemented with EVOO (one liter per week for the family), a MeDiet supplemented with mixed nuts (30 grams / day), or a control diet (advice to lower overall fat intake).

During a median follow up of 4.8 years, 35 cases of malignant breast cancer were demonstrated in 4282 women. Breast cancer information was not available for 122 of the women. Women in the MeDiet + EVOO group had a 62% lower incidence of breast cancer compared to the control group (68% reduction when controlled for age, body mass index, exercise and alcohol intake). Women in the MeDiet + nuts group had a non-significant reduction in breast cancer incidence compared to the control group. The women who had the lowest incidence of breast cancer consumed at least 4 tablespoons of EVOO per day.

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There are several limitations to this study. Participants were white postmenopausal women, living in Spain, at risk for cardiovascular disease, so the study results may not apply to other populations. The rates of breast cancer observed in the study are very low, and we do not know if women had mammograms or if all were free from breast cancer at study enrollment. Also, while the relative risk reduction was significant, the actual risk reduction was less so: 2.9 women per 1000 / year in the control group developed breast cancer. 1.8 / 1000 / year developed cancer in the MedDiet + nuts group, and 1.1 / 1000 / year developed cancer in the MedDiet + EVOO group.

While the polyphenols and other compounds in EVOO have been shown to have certain anti-cancer effects in some cell culture studies, it is very premature to suggest that EVOO alone will prevent the development of breast cancer. The MeDiet is high in mono-unsaturated fats (EVOO, nuts, fish, and lean meats), low in saturated fats and dairy, and high in vegetables and fruits. While olive oil is one component of a healthy diet, total caloric intake, saturated fat intake, and quantity of vegetables and fruits consumed are all important. Simply adding olive oil to a diet that is otherwise unhealthy or adding olive oil to a diet that contains more calories than appropriate is unlikely to improve overall health or reduce the rate of breast cancer development.

Dr. Mitchell Katz, in an editorial accompanying the study, noted that despite the study limitations, the MeDiet “… is known to reduce the risk of cardiovascular disease and is safe. It may also prevent breast cancer.” My recommendation based on this and other studies is not to simply supplement your current diet with olive oil, but evaluate your entire diet. Look at your current sources of fat, your current intake of fruits and vegetables, as well as total caloric intake. Olive oil may or may not turn out to be a “magic” ingredient, but many of us can benefit from incorporating components of the MeDiet into our daily routine.

Additional information on diet and lifestyle

16 October 2013

This is one of my most comprehensive interviews to date. It aired on Santa Clarita Valley TV and I had the opportunity to discuss a wide range of topics, including breast self-exams, male breast cancer, genetic testing for breast cancer, “pink washing” and more! Many thanks to SCVTV as well as Tami Edwards and Dave Caldwell, for spending so much time on such important topics.

15 January 2013

Much has been written regarding the role of soy and breast cancer, but much confusion remains. While research in this area is active, here is what we know:

Soy is an isoflavone, a class of chemical that has weak estrogen-like activity.  We know that women in Asian countries, following a traditional diet, have a lower incidence of breast cancer than women in the US. Their diet consists of large quantities of soy foods starting at a young age. However they eat soy in a natural form – they do not eat “foods” such as soy hot dogs or take soy in supplement form. Research has shown that consuming large quantities of natural soy products starting at a young age seems to confer some estrogen resistance to the breast tissue, which may account for the lower incidence of breast cancer in the Asian population.

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