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.

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.

1 August 2017

A meta-analysis recently published in JAMA Oncology evaluated studies that reported on therapies for cancer-related fatigue (CRF). CRF is very common, can persist for years after treatment, and is exacerbated by depression, anxiety, sleep disturbance and pain – which can also be long-term effects of cancer therapy. The authors focused on papers that reported the effects of pharmaceutical treatment, psychological therapy, and exercise.

In evaluating 113 randomized trials in adults with cancer, they found that exercise and psychological interventions as well as the combination of both reduce cancer-related fatigue during and after cancer treatment, and that these therapies were significantly better than pharmaceutical therapy. Age, cancer type (breast vs other cancers) or exercise mode (aerobic, resistance, or combined) were not associated with effectiveness of the intervention – patients of all ages, with all types of cancer equally experienced improvement in cancer-related fatigue.

As this was a meta-analysis, a review of multiple previously published studies, limitations include lack of detailed information on race, education level, socioeconomic status and other demographic factors in all studies – this can limit how the results may be applied to specific populations. The majority of studies evaluated were among breast cancer patients or survivors. Studies set different levels of fatigue as entry criteria, and in some studies it was not well defined. In addition, they found some studies had not been registered on ClinicalTrials.gov.

Despite the limitations, this study was important as it clearly demonstrated the benefit of exercise and psychological interventions to improve CRF. The authors recommend that these should be considered first-line therapy recommendations rather than pharmaceutical approaches.

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.

26 December 2016

Approximately 75% of breast cancers express the estrogen receptor – we term these breast cancers ER positive (ER+) or hormone-sensitive. Endocrine therapy refers to using medications to exploit this cancer cell property. Tamoxifen is used in premenopausal women and it blocks the estrogen receptor. In post-menopausal women, aromatase inhibitors (AI) are used which prevent estrogen from being produced (primarily in the fat cells after menopause).

In June, a study was presented which suggested that 10 years of endocrine therapy in post-menopausal women might be superior to 5 years of treatment, which had been the standard. The study noted that disease free survival was improved and development of new breast cancers were reduced in the extended therapy patients, but there were more side effects. A conclusion was that extended therapy might be appropriate for higher risk patients – those who based on certain tumor factors we suspect might have a higher risk of recurrence. A challenge has been that we do not have good tests to tell us with certainty which patients will truly benefit from a longer course of therapy.

At the 2016 San Antonio Breast Cancer Symposium, 3 studies were presented which addressed the issue of extended endocrine therapy in post-menopausal women. In all 3 studies, extended endocrine therapy with an AI did not improve disease free survival, in contrast to the study presented in June.  A lack of survival benefit does not mean that extended therapy is not worthwhile, as noted in this ASCO Post article, and one of the studies did show improvements in distant metastases and contralateral (other side) breast cancers. Dr. Michael Gnant, who discussed the studies at the meeting, noted that “The trials did not reach the necessary statistical levels to demonstrate a clear benefit for aromatase inhibition extension. Extending aromatase inhibitor therapy may be a good idea for many patients after 2 to 5 years of tamoxifen, but after initial treatment with an aromatase inhibitor, the benefits and risks must be carefully balanced on an individual basis. We are going to need the ‘art of medicine’ here.”

While ER+ breast cancers tend to be “better behaved”, we know that these patients are at risk for relapse many years after initial treatment. This knowledge has to be balanced with the real side effects women experience from taking the medications. Common side effects of the AIs include joint and bone pains, vaginal dryness, hot flashes, and bone loss. Deciding whether or not to continue on the medications in the setting of significant side effects is also difficult for patients, who then have concerns about “not doing enough” to reduce the risk of cancer recurrence. More research is needed to develop both tests to help predict which patients will actually benefit from extended therapy, and treatments with fewer side effects,

 

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 November 2016

Cancer treatment takes a physical and mental toll. As patients progress from active treatment into the survivorship phase, many become frustrated that they cannot “bounce back” as quickly as they would like. Getting back to “normal” may not be realistic – many of us are doing way too much even on a good day, and ignore the warning signs telling us to slow down. Cancer is a major jolt, and all energy gets diverted for treatment. After treatment, there are new physical and mental limitations, and priorities may need to be re-set.

A study recently published in the Journal of Clinical Oncology may help explain why patients have such a difficult time getting back to their pre-treatment self. Researchers postulated that cancer treatment may trigger an accelerated aging process in some cancer survivors. They measured inflammatory cytokines (proteins that are important in cell signaling) in cancer survivors and a control group of patients without cancer. There were no differences before treatment, but after 18 months, breast cancer survivors had higher levels of these inflammatory markers compared to the control group. In addition, higher levels of inflammation correlated with increased comorbidity (other medical problems) in cancer survivors.

The authors suggested (although this was not shown in their study) that with longer follow up time, the excess inflammation may contribute to poorer health and premature mortality in the cancer survivor group.They postulated that cancer treatment may trigger an accelerating aging process in cancer survivors and they stressed the need for longer followup and more study to determine the biology behind these effects.

Many cancer patients express that they feel they have “aged beyond their years”. This study suggests that the cancer treatments themselves may indeed contribute to the aging process. The study authors noted that their results underscore the need for breast cancer survivorship care to include recommendations for exercise, diet and weight management programs, as well as screening for and treatment of other medical conditions.

2 October 2016

October is National Breast Cancer Awareness Month (NBCAM), which means pink is everywhere. Stores start setting out pink merchandise towards the end of September, and the displays often rival Christmas merchandising. How did this happen?

The original pink ribbon was actually peach. A woman by the name of Charlotte Haley made them in her home, and handed them out with cards stating: “The National Cancer Institute annual budget is $1.8 billion, only 5 percent goes for cancer prevention. Help us wake up our legislators and America by wearing this ribbon.” Ms. Haley was then approached by SELF magazine and breast cancer survivor Estee Lauder, who wanted to use the ribbon as part of a breast cancer awareness issue. Ms. Haley turned them down as she didn’t want her efforts to become overly commercialized. As the magazine and Ms. Lauder needed a symbol, the pink ribbon was born. The Susan G. Komen Foundation handed them out at their 1991 race, and in 1992 it officially became the symbol of NBCAM.

Many women who have been treated for breast cancer wear pink to signify their struggles with the disease. Family members and friends often wear pink to show their support of a loved one. For some, wearing pink is an important show of strength and solidarity. However, not everyone feels comfortable with being “branded” in such a way – a patient once asked me “I don’t HAVE to wear pink, do I?” Men with breast cancer have traditionally been left out from such movements, although the pink and blue ribbon now is used for male breast cancer awareness campaigns.

We all want do do something to help end a disease that impacts so many. Many organizations host  “save the *** (boobies, tatas, etc)” campaigns, all in the name of breast cancer awareness. Awareness is important – increased awareness is one reason that many women no longer feel embarrassed about going to a physician when they feel a lump in their breast. Not everyone is aware – there are still women and men diagnosed at later stages, especially in minority and underserved populations. But awareness and early detection do not equal cure. Awareness is not enough. Research is needed. Why do some women and men develop breast cancer? Why do some breast cancers spread? Why do some patients respond to treatment and some do not? Why do 40,000 women in the US alone still die due to metastatic breast cancer? We do not have prevention, and we do not have a cure.

Money is needed to fund worthy research projects, initiatives aimed at improving access to care as well as support programs. However, pink merchandise is not necessarily the answer – we can’t shop our way out of breast cancer. It is important in October and all year to “think before you pink“. The term “pink washing” has been applied to the practice of some organizations using pink for the sole purpose of raising their own brand awareness. A tag noting “in support of breast cancer awareness” sometimes means just that – no dollars donated, just “awareness”. Some of the marketing campaigns even promote products that may actually increase breast cancer risk, such as alcohol .

Directly donating to organizations that perform or fund cancer research is one way to help. Patients with breast cancer also need support services. There are many organizations ranging from large national ones to local community nonprofits that provide a variety of free services such as transportation, counseling, financial aid to cover insurance gaps, and even childcare. Before you donate to a nonprofit organization, first confirm that they are legitimate – Charity Navigator, GuideStar, or a similar site can help. In addition, do some basic research – make sure that the organization’s mission is aligned with your preferences. Do you want to help fund education or awareness campaigns, support services, research on metastatic disease, or research on prevention? A quick review of an organization’s mission statement can ensure that you are donating to a cause that you support.

So this fall, think twice about buying those pink breath mints. If you want to make a purchase to honor a loved one, make sure you know whether or not any money will be donated for breast cancer research, education, or support. If you are donating to an organization, make sure that organization is funding programs that you support.

Also realize that you also don’t need to spend a lot of (or any) money to make a difference. Nonprofit organizations and cancer centers are usually happy to have volunteers. If you want to make it more personal, offer to cook meals, do a few loads of laundry or clean the house for someone you know who is being treated for breast cancer. Provide transportation (and company) for appointments. Offer to take someone’s kids for the afternoon so the patient can get some rest. The possibilities are endless.

This October, you can make a difference, and it doesn’t have to involve purchasing a pink kitchen appliance.

Updated 1 October 2019

25 August 2016

Patients with metastatic (Stage IV) breast cancer often undergo frequent blood tests and scans to monitor for disease progression. But is there such a thing as too much testing?

A study recently published in the Journal of the American Society of Clinical Oncology evaluated the use of blood tests (tumor markers) and body imaging scans (such as PET, CT, or bone scans). The Medicare-SEER database was used to identify women diagnosed with metastatic breast cancer from 2002-2011, and billing codes were then assessed to determine test utilization. Among 2460 eligible patients, 36.7% were “extreme users” of disease monitoring tests, defined as greater than 12 blood tests and/or 4 body imaging scans in a 12 month period. Medical costs were 59.2% higher in these patients.

Metastatic breast cancer is not curable. Patients with Stage IV breast cancer often are treated with some form of chemotherapy, hormonal therapy, or targeted therapy for life. The location and amount of tumor in the body are monitored using blood tests and body imaging, and treatments are adjusted if the disease progresses. How much monitoring is appropriate varies depending on the individual situation and whether or not a patient is participating in a clinical trial (some trials have specific requirements for testing). However, the authors of an accompanying editorial note that no clinical trial requires monthly blood tests or body imaging more than four times per year.

Intuitively, it would seem that the sooner progression is identified and treatment initiated (or changed), the better the prognosis. However, that is not yet the case. As novel treatments are discovered, this may change over time. But for now, more testing only adds to higher costs. As Dr. Leonard Lichtenfeld, the Deputy Chief Medical Officer of the American Cancer Society noted in his blog post: “No one likes to think of costs when it comes to medical care and especially when saving lives. But while a lab test or an imaging study may not make a difference to our care or the outcome of our illness it certainly does make a difference to our pocketbook. And even worse, it may give us a false sense of comfort when it doesn’t accurately reflect a change in our disease, or send us down another perhaps more toxic path of treatment when it wouldn’t make a difference to do so.”

23 June 2016

Many patients realize that follow up appointments with their treating doctors are a routine part of cancer care. However, I am occasionally asked by patients why they need to continue seeing me or their oncologist after treatment has ended.

A recently published study demonstrates that many patients do not understand why follow up care is important. Dr. Annette Berendsen, of the University Medical Center Groningen in The Netherlands, interviewed 61 women with a history of early-stage breast cancer, to determine what they thought the aims of follow up were. These women had been treated on average 7 years prior to being surveyed.

Dr. Berendsen and her colleagues found that most of the women thought that follow up was to detect recurrence and to receive reassurance as well as psychological support. However, 12 of the 61 patients interviewed stated that they were unsure about the purpose of follow up, and that some women incorrectly believed that breast cancer could not recur after 2-5 years of follow up.

According to the American Society of Clinical Oncology, the purpose of follow up care is to “keep patients in good health, manage side effects from treatment, find out if cancer has returned, and screen for other types of cancer, along with providing emotional support.”

As physicians, it is important that we educate patients about why follow up is important, signs and symptoms to look for, and the role of various tests. The National Comprehensive Cancer Network publishes guidelines for patients with breast cancer. The table below notes the follow up recommendations for patients with Stage I and II breast cancer. Patients should be encouraged to ask questions if they are not sure why office visits or tests are recommended.

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