Triple-Negative Early Breast Cancer

Joan Miró. Portrait of Mrs Mills in 1750

Modern technology has greatly improved the diagnosis & treatment of the malignant diseases.  Here's one of many instances for Breast Cancer.

When a patient has a biopsy or definitive surgery for non-metastatic breast cancer, the tumor specimen itself is screened for receptors for estrogen, progesterone, and the growth factor effector called “Her2″ (aka cErbB2).  The results are predictive of response to a specific therapy type, thereby limiting guesswork among medical oncologists in the choice of appropriate drugs.  The tests are also prognostic, i.e, they hint at the natural course and outcome of the disease.  When assays for estrogen & progesterone receptors as well as for Her2 yield insignificant levels, the breast tumor is designated “triple-negative”. 

This is one area where an all-negative result is bad news.  That morbid bunch, ie., the oncology folks– they wear big smiles when tumors have lots of hormone receptors (estrogen & progesterone).  Although one can’t really say the same for her2-positive disease, at least effective targeted therapy is now widely available for affected patients.  No such luck for triple-negative breast cancer for which the rate of distant failure is known to be significantly higher and where the prognosis remains immutably dicey for high-risk patients.  In non-metastatic disease, good chemotherapy is still the only meaningful systemic cancer treatment option at this time.

Many trials now focus on this subset of patients.  Hopefully, science will be able to offer more in the near future.

Previous Comments

I have the triple negative diagnosis. Diagnosed by core needle biopsy. I am not African American nor Hispanic. My tumor was just less than 2cm. (stage I). I had a lumpectomy. I had Mammosite radiation therapy. The tumor was recognized as grade 2 infiltrating ductal carcinoma. I would have liked for my doctors to have shared all of this research with me and allowed me to be a partner in determining what is my best chemo treatment option. My doctor chose for me, T4 X CA4. Based on what I have read this is probably standard treatment for patients in my situation. But I would like for someone to have acknowledged that the onocologists just don’t know what is really appropriate for this triple negative population until more research is completed.
Also, I wanted the receptor pathology redone on the actual tumor as opposed to relying only on the core biopsy specimen. I was told that this was not standard medical practice, and I shouldn’t pursue that route since rarely are mistakes of this type made. It seemed to me that a test that determined so much in terms of treatment options should be tested twice on all triple negative patients.
I would appreciate a reply
Posted by Janet Littlejohn at June 2, 2007, 3:25 am

Hi. Yes, those so-called “dose-dense” AC-T adjuvant protocols are backed by solid evidence.
Receptor pathology testing on core biopsy specimens, when done at a validated laboratory, should be alright. Results are more dependent upon technique than the anatomic source of the tumor specimen. As you know, even in newly diagnosed stage IV disease (where radical surgery is not an option), cores can be relied upon to do a good job for a competent lab.
Posted by oncodoc at June 9, 2007, 6:31 am

I am triple negative - diagnosed in April. At time of diagnosis - the tumor was 3.5 cm, lymph node pos, grade 3. Course of treatment: dense dose chemo (4 a/c 4 t), radiation & surgery. During the 2 weeks between dx and chemo, the tumor doubled in size, and spread to more lymph nodes. My chemo therapy will end this month, the tumor is almost non-exisitant so I will probably have a lumpectomy.
I would like to know what the odds are of reoccurance? What can I do to improve my chances of avoiding reoccurance?
Posted by Lydia Thomann at July 15, 2007, 10:20 pm

The persons who can best help you with these questions are the members of your medical team. There’s a lot I don’t know. For example, the number of nodes you’d started out with are a key element in prognosis. Likewise, the outcome of the surgery will have an impact on the risks of recurrence & subsequent management. For example, patients with pathologically negative nodes and breast after neoadjuvant chemotherapy have a better risk profile than those with persistent disease.
Good luck.
Posted by oncodoc at July 16, 2007, 7:51 am

Question, I was diagnosed with triple negative, stage 3, grade 3 (2 tumours both positive for cancer) and had 5 out 8 lymph nodes test positive. I underwent 4 rounds of AC and 4 rounds of Taxol (dose dense) followed by 16 radiation treatments. My follow up was a mastectomy with TRAM reconstruction. I had a mammogram in March on other side and all was clear. I subsequently found a lump a few months later, underwent another mammo and ultrasound both showing nothing but doc is concerned and wanted another opinion. Onc had a feel and said ‘it didn’t feel like cancer’. My left side didn’t ‘feel like cancer or show like cancer either’ but 2 years later I was dx’d stage 3. Am I being paranoid?
Posted by Jode at August 5, 2007, 10:41 am

No, you’re not being paranoid. Besides, it seems that your doc has similar doubts– hence, his search for a second opinion.
Mammography with ultrasound does not pickup 100% of breast cancers. I guess you’d fallen into the minority subset that first time around with your left breast lesions. When the index of suspicion is high in the face of a negative mammo, there are other tests.
As to “feel” of a breast mass– well, imaging won’t be necessary if that were a reliable indicator. Oncologists are trained to be suspicious, especially in cases with a prior history of breast cancer. They’ll not go with “feel” alone.
Posted by oncodoc at August 5, 2007, 11:14 am

I am a triple negative - diagnosed Feb/04 tumor size 1.75 cm, State 1, Grade 3, 1 out of 3 lymph node involement. Lumpendectomy and Lymph Node Dissection. Took 2 out 6 cycles of CFE. Unable to receive chemo ever again. Had 5 wk radiation with 1 wk boost
How high is my risk for reocurrence or metasticies. Doctor told me 92%. Everything that I have read says 77%. I’m confused
Posted by Paula at September 19, 2007, 3:16 am

You’ll need a bit more info to make a good assessment of recurrence risk. You can input the necessary data yourself at ADJUVANT! (www.adjuvantonline.com)
Posted by oncodoc at October 4, 2007, 5:34 pm

Hello! I had minor surgery on January 11, 2008. The biopsy tested positive for mucinous carcinoma. On January 25, upon the advise of my surgeon, i had mrm on my left breast. Thereafter, er pr results are positive 50% and 85% respectively. Her2 is negative. I was diagnosed Stage 2, nodes negative. My oncologist advised 6 cycles of chemotheraphy using Evista, to be followed by hormonal treatment after i graduated chemothrapy.
I have a strong family background of cancer. My mother had mrm on her left breast though she was clear of cancer before she died. My uncle died of throat cancer, and the first cancer patient i knew in the (same) family was the brother of my grandfather whom i remembered succumbed to bone cancer. Lately, a distant cousin of mine in my father’s side was diagnosed with breast cancer stage 3.
My question is, is it safe for me to try alternative medicine? I was hoping that good diet, mainly vegeterian diet, cleansing of the body and stress reduction can help me combat this battle. Thanks for your reply!
Posted by maria rona arnan at February 17, 2008, 10:29 pm

Hi. Although all approved drugs are meant to be treatments, Evista (raloxifene) isn’t “chemotherapy” in the traditonal sense. What’s more- at this time, it isn’t a standard “adjuvant” for breast cancer after surgery. It is NOT one of the drugs currently recommended to decrease your risk of cancer recurrence.
Good diet & exercise are complementary to conventional anti-cancer treatment, not “alternative”.
A certain amount of anxiety is normal after a diagnosis of cancer. I find that when the patient understands her risks and the benefits of further treatment, stress is greatly reduced. Control is given back to the patient.
So what is your estimated risk for recurrence and what benefit will adjuvant treatment give you? What is the best type of treatment & what data supports the choice? To ease your mind, talk with your medical oncologist. Ask as many questions as necessary. Make careful but informed decisions in this matter.
Posted by oncodoc at February 18, 2008, 10:32 am

Hi, I was diagnosed 07/09. Stage 1 (1.2 cm, nodes neg 0/21, and M0). Biopsy took out entire tumor– followed by mastectomy where no other carcinoma was found in the specimen; no signs of metastes (the report reads). Triple negative, grade3. I am 41 yrs old. Scheduled to meet with onc in the next couple of weeks. Could you tell me what to expect to hear from onc given above details? I am dreading chemo, do I have alternative options? Thank you!
Posted by ConiT at August 11, 2009, 12:14 pm

You must be offered adjuvant chemotherapy. I assume that you’re premenopausal. You also made note of other risk factors– hormone receptor negative & high-grade. You won’t benefit from her2/neu antibodies or hormone treatments.
Posted by oncodoc at August 15, 2009, 2:36 pm

I was diagnosed Stage 1 triple neg in 08. I have chemotheraphy, no radition (suggestion from onc) and a double mastectomy. I found a lump in my pelvic area. Went to onc and she is worried (even though ob/gyn was not. Onc scheduled me for a zillion scans and I am not pleased with the reports I am reading. I am African American and under 40. (diagnosed at 33) 77% chance this crap is back? I don’t have boobies anymore (but the reconstruction is amazing) but does this mean it is somewhere else.
Posted by NBC's mom at March 19, 2010, 11:07 pm

I don’t know if there is a metastasis. How does the biopsy report of the new lump read? Some patients tell me I’m “paranoid”. Its an occupational hazard to worry, I suppose.
Your age bothers me. The double mastectomy– were you tested for genetic predisposition?
Posted by oncodoc at March 25, 2010, 10:27 pm

This is awesome!
Posted by Watch Pinoy Show at October 13, 2010, 12:48 pm

hi there my mom has a grade 2 ductal carcinoma. she went through MRM last Sept. and the result for Er-Pr, Her2 was triple negative which was really bad to hear from the doctor, i just coudn't stand the fact that my mom is dying, now, she's in Stage2B. the doctor recommends 6 cycles of chemotherapy of generic brand which is the cheaper one. but, then the doctor told us that it was not an asurrance of great healing, he give us another option, the very expensive one,… i just wanna is there another hope for us? any other possible way to treat my mom? pls reply as soon…
XXXXXXXXXXXXXXXXXXXXXXXXXXX
At this time, adjuvant therapy of triple-negative breast cancer still involves both taxane- and anthracycline- containing chemotherapy, usually AC–> weekly paclitaxel (although other protocols exist). There are several very promising studies that use other drugs in the pipeline, including BEATRICE (+ bexacizumab), Cetuximab, and Ixempra. At this time, your mother is best enrolled in such a clinical trial.
Best of luck– oncodoc
Posted by Nina at October 22, 2010, 1:20 pm

Im 57 years old. Below is my clinical diagnosis:
Breast cancer, St.II (T2N0M0)
MRM right breast, invasive ductal carcinoma nuclear grade 2, histologic grade 3, tumor size =2.8 cm. in widest dimension, ductal carcinoma-in-situ, comedo, cribriform and solid patterns (approximately 25%), with perineural invasion, no definite lymphovascular invasion, fifteen (15) axillary lymph nodes: negative for metastasis, all surgical margins free of tumor, nipple unremarkable, skin: seborrheic keratosis, non-tumoral breast parenchyma: fibrocystic change with florid ductal hyperplasia, apocrine metaplasia and microcalcifications.
ERA = positive
Staining intensity = +3
Percent tumor cells stained = +5
PRA = positive
Staining intensity = +3
percent tumor cells stained = +5
C-erb-2(her-2-Neu) = negative
After surgery I was placed in hormonal theraphy (aromasin), should I also get intraveneous chemo? Thank you.
Posted by Leixa at October 23, 2010, 11:06 am

Postmenopausal T2 N0, high grade, with perineural invasion. Strongly hormone receptor positive, but her2/neu negative.
Yes, hormone therapy is appropriate, and for postmenopausal women, aromatase inhibitors (like anastrozole/Arimidex) are best.
Will chemo add an additional benefit?
In the past, we made recommendations based on little more than gut-feeling . These days, they have the 21-gene assay, Oncotype DX, to help decide on this exact issue.
Posted by oncodoc at November 1, 2010, 4:03 am

HER-2 Positive Early Stage Breast Cancer

Juan Luna, Una Bulaquena, 1895

It used to be that when certain non-metastatic breast cancers were found to be markedly her-2 positive, they went into my "hope for the best, but expect the worst" category.

Overexpression of human epidermal growth factor receptor-2 (her-2) occurs in a third of breast cancers, and is a marker of an aggressive tumor. A gene mutation causes an excess production of this cancer growth promoter, conferring a clinical "profile" that science has begun to characterize. Myself, I obsess about occult metastases and drug resistance in these instances. When presented with her-2+(IHC+3 and/or FISH+) malignancies, the oncologist knows that certain chemo drugs are preferable, that hormonal agents aren't likely to suffice, & that the use of biologicals is optimal.

Anti-her2 monoclonal antibody surfaced years ago. As a biological "targeted therapy", it specifically seeks out the cancer promoter protein. Whether given alone or in combination with other drugs like chemotherapy, trastuzumab (Herceptin) is still finding all its indications. Its fabulous that we can now use this agent in early stage breast cancers. Did you know that herceptin use after potentially curative surgery decreases recurrence rates by half in high risk cases? I can afford to be more optimistic these days.

Not all breast cancers would benefit from the incorporation of Herceptin into a postoperative regimen, possibly not even all her-2 FISH+ cases if the risks are not sufficiently high. Discuss these points ad nauseum with your oncologist.  

Technorati Tags: metastatic breast cancers, epidermal growth factor receptor, chemo drugs, growth factor receptor, epidermal growth factor, growth promoter, gene mutation, cancer growth, curative surgery, drug resistance, clinical profile,herceptin,biologicals,oncologist

Previous Comments

After two years doing well on Herceptin and Zometa, the tumor in my sternum was growing again, so I had radiation, the results of which you can see in the photo. Subsequent scans showed that the radiation worked on the bone tumor, but that it’s now in my liver. So on to regular chemo.

Posted by Breast Cancer Stages at March 9, 2010, 6:16 pm  

Birth Control Pills and Breast Cancer

Young women who present with breast cancer are usually asked, "Are you on the Pill?"  Suspicions about causality have lain heavy in the gut of clinicians for decades.  As with hormone replacement therapy in menopause, we lacked evidence of direct malignant transformation to support our meddling in the bad old days.  By mid-2005, however, the credible folks at IARC released a monograph that classified oral contraceptives as group 1 carcinogens.  And now, a meta-analysis published in the Mayo Clinic Proceedings further validates what doctors have been warning women about for years.

To be sure, neither oral contraceptives nor hormone replacement therapy will disappear from store shelves soon.  Despite side effects, they do have applications for which a risk:benefit estimate is appropriate before use.  The aforementioned papers also have some stingers:  the IARC had noted confounding mixed effects for oral contraceptives, with risks increased for some cancers but decreased for others.  They'd also included data from now-defunct preparations that incorporated higher doses of hormones.  In its turn, the meta-analysis used case-control studies found through medical literature databases– not from the more compelling individual data from randomized trials.

Its not cancer prevention so much as risk avoidance, but consumer awareness is similarly critical:  oral contraceptives and postmenopausal estrogen therapy are now ranked up there with notorious chronic hepatitis B/C infections, asbestos, and plutonium as human carcinogens.  Consult a physician before using birth control pills and hormone replacement therapy.  There may be safer alternatives for what ails you.

 

Previous Comments

you’re killing me!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Posted by inesita at November 23, 2006, 6:57 pm

I just recently discovered your Blog and appreciate you sharing your bout with breast cancer with the world. but this site also search best knowledge breast cancer.
http://www.Freebreastcancerguide.com
“
Posted by Amasch Hilbert at September 19, 2008, 6:56 pm

MY 14 YEAROLD GRANDDAUGHTER WAS PRESCRIBED BIRTH CONTROL PILLS FOR HEAVY MENSES. I HAD BC AND MY DAUGHTER HAD BC AND 5 OF MY COUSINS HAD BC. ALSO ON MY DADS SIDE. I AM THE GRANDMOTHER , MY SON IS HER DADDY AND WE ARE CONCERNED ABOUT HER TAKING THE PILL. THANK YOU. LINDA ELLIS
Posted by LINDA ELLIS at December 3, 2008, 8:01 am

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Posted by hoodia gordonii at January 21, 2009, 5:48 pm

Be very careful if considering the birth control pill, Yaz. Yaz has been connected to stroke, heart attack, and other adverse events: http://www.yaz-may-cause-strokes.com/.
Posted by Cynthia at November 2, 2009, 8:09 pm

This bears repeating: The birth control pill, Yaz, has been linked to a number of adverse reactions, including strokes and lawsuits are growing over these issues. Here is some good information: http://www.yaz-may-cause-strokes.com/
Posted by Cynthia at December 22, 2009, 8:05 pm

Notes on Surgery for Breast Cancer

When buying a car, do you compare model specifications within a budget range?  If faced with breast cancer, would you similarly scrutinize the options?  Hope so.  Doctors are too fallible to bear the entire burden.  This job is tough enough as it is.

Biopsy of a suspicious breast mass may be accomplished by needle sampling or by open excisional biopsy.  When needle sampling is done, a "fine" aspiration biopsy will confirm the presence of malignant cells while a "core" can diagnose invasion and provide tissue for further processing.  As to open biopsy, if ever excision is contemplated within the context of a possible cancer, marking of margins or the inclusion of a rim of normal tissue around the mass must be done where feasible (in effect, a lumpectomy).  This is to minimize the need for further radical surgery.

If the breast mass biopsy is positive, staging is done & treatments are planned accordingly.  (How I hate it when stage IV patients have wasted time & money on pointless radical surgery before they get the treatment they really need!)  The staging tests ordered would depend on a thorough history & physical examination, but chest x-rays, mammography, a bone scan, liver ultrasound, or CT scans may be requested.  Special stains are sometimes done on the biopsy specimen at this point for hormone receptor assays & her2/neu (cerbB2) growth factor receptor, especially if preoperative treatments are contemplated.

In non-metastatic invasive breast cancer of the non-inflammatory type, an operation is always a component of cure.  For stages I & II, Breast Conserving Surgery is ideal in the absence of any compelling contraindication.  BCS, aka "lumpectomy" or "partial mastectomy", involves a wide excision of tumor with a cuff of normal tissue around it.  It entails subsequent radiotherapy but affords the same control rates as a standard modified radical mastectomy with better cosmetic results.  A better feel & shape than an implant in most cases anyway.  (By the way, while there are additional technical considerations, BCS is not prohibited for tumors near the nipple or where implants are in place.)  Axillary lymph node sampling is also done with BCS, through a separate armpit incision.  This sample extent depends upon whether you've presented with apparent node involvement or not.  If none are clinically evident, just a biopsy of the "sentinel node" may be done.  Axillary node status is just prognostic and not all nodes need to be removed.  The extent of their involvement gives your docs added staging information to guide postoperative treatments.

What should make you think twice about lumpectomy?  When is a modified radical mastectomy the better option?  Well, BCS requires re-excision should the margins of the lumpectomy specimen remain positive.  Radiotherapy is a necessary component, so those who can't take that treatment are best served by breast removal (eg. early pregnancy).  BCS is also suboptimal if tumors are multiple. The same is true if the mass is large relative to the breast's size, although preoperative (neoadjuvant) chemotherapy may be considered to enable BCS in such cases.

Where all things are equal and no contraindications to BCS exist, the important factor is the fully informed patient's preference.

As for surgeons… I know of a busy one who said that breast cancer operations are glorified excisions to sleepwalk through.  For a minute there, I'd thought that I was talking with God (or a neurosurgeon) but… no; This doc still comes alive for each hair-raising Whipple's procedure.  Would that all constructive thrill-seekers have that level of experience & expertise, not to mention stamina.  In reality, what may be almost reflexive & forthright for some is an uncommonly complex job for others.  Find yourself an oncology team with a great surgeon!

Previous Comments

Hi OncoDoc,
Good greetings. My wife was diagnosed of breast cancer wherein her tumor was located near her left nipple recently.
Her’s was diagnosed of still, on early stage II (2cmx2cm lump).
Upon reading your notes about surgery on breast cancer, I’m very much interested of having her done a breast conservation surgery.
Could you recommend anyone who can treat my wife here in the Philippines? Maybe you can help us.
I shall wait for your reply soon.
Thank you very much and God bless.
Posted by Jake Olano at November 18, 2006, 1:38 am

It depends upon the geographical location. Her medical oncologist would know a suitable breast surgeon for second opinion purposes.
Posted by oncodoc at November 25, 2006, 5:26 pm

Primary Liver Cancer: Prevention

Most liver cancers are metastatic, i.e., they involve the liver secondarily after initial development & growth in a distant site. Of those few malignancies that are native or primary to the liver, the most common is hepatocellular carcinoma ("hepatoma"). 

Risk factors for hepatoma include cirrhosis, diabetes, BRCA 1 & 2 gene mutations, aflatoxin exposure, alcohol abuse, & smoking but worldwide, the most common cause of hepatoma is chronic hepatitis virus infection. Of 6 known types, hepatitis B (HBV) & C (HCV) viruses are the main culprits & they are usually acquired via contaminated blood or needles in the context of tranfusions, tattooing, or drug abuse. Further, HBV is endemic in Asia and may also be sexually-transmitted, infecting even fetuses in utero. Once malignant transformation has set in, only surgery can provide a possible cure. Sadly, this is possible only for a few, since the infected liver may not have enough reserves to sustain a complete tumor resection (matched organ donors are hard to find), the tumors may be too numerous, involve more than one lobe, or are already affecting blood supply. All other treatments– chemotherapy, experimental targeted therapy, chemo-embolization, tumor ablation by RFA (unless tiny), radioisotopes etc– are in the realm of palliation.

How to protect yourself from hepatoma? Well, common sense says that one should avoid the risk factors under our control, including most substances that can damage the liver– drugs, excessive alcohol, pesticides, toxins. Use only sterile needles with your meds, insist upon properly screened blood products when transfusions are prescribed, and think hard before tattooing/piercing. Know the virus status of a sexual partner (tough without screening). Most important of all: vaccines exist for HBV that provide almost total protection for years. Even infants can be immunized– and they should be.

The easiest kind of "cancer treatment" is always prevention.

  

Previous Comments

Myself I have a secondary liver cancer, which is in my cse not curable, yet I keep myself awake by blogging about it to everybody (since the amount of visitors I get at home is soooo little)
A very big hug!
SK
How the pain was getting too much at:
http://www.metastaticlivercancer.org
Posted by See Kim at December 7, 2006, 1:00 pm

I thought of one more risk factor for primary liver cancer to share with your readers.
Hemochromatosis, or “iron overload syndrome”, is an additional cause of liver cancer, and affects one in 200 individuals in the United States. In reviewing your family history, ask if anyone has developed liver disease that was not related to hepatitis or alcohol abuse. Also ask if anyone has ever been told they have an elevated iron level.
Usually hemochromatosis is asymptomatic until serious heart or liver disease is present. Treatment is available that includes phebotomy (periodically “donating” blood to lower iron levels).
Thanks for your review and helping raise awareness!
Lynne Eldridge M.D.
Author, “Avoiding Cancer One Day At A Time”
http://ww.avoidcancernow.com
Posted by Lynne Eldridge M.D. at March 6, 2007, 9:40 am

A Few Basics on Cancer Trials

Maybe doctors and patients can help each other out.  We do have some locally available cancer trials in phases II-IV in the Philippines. 

Is someone that you know considering participation?  From my own knowledge of what's available hereabouts, current studies are mostly large, pharmaceutical company-sponsored, & international in scope (with a local arm).  Any doctor can refer you to these trials, if they are aware of them.  I hope that the Philippine Society of Medical Oncologists would list them all and post each center coordinator's contact details because there are eligibility issues for enrollment, with study-specific inclusion & exclusion criteria.  (For example, one project requires evidence of chemotherapy-induced anemia.)  Patient care will be coordinated by the study investigators while on the trial, in tandem with the participant's own doctors.  This is a plus– local investigators for the trials are board-certified & respected oncologists based in academic and/or major cancer centers.

Phase II & III trials usually provide both accepted & investigational cancer treatment, as well as all related medical services, laboratory & imaging.  Some phase IV trials give steep discounts (~50%) for the privilege of collecting your data while on standard treatment with their drugs.

As an oncologist, I prioritize these trials but have learned to expect resistance from patients AND doctors.  Misconceptions abound.  The trialists will not supplant the role of the primary physician.  Participants in these studies are not legally compelled to finish the process.  Patient well-being is secured by protocol checkpoints & side effects are minimized by constant protocol reviews.  Both active therapy & follow-up are under the direct supervision of respected oncologists, and their protocols may serve as treatment options where standard therapies don't exist or have run out.  But yes, not all side effects can be foreseen, nor can treatment benefit be guaranteed.  In fact, those issues may be part of the clinical questions to be answered, especially by the earlier phase trials. 

So– don't dismiss these trials upfront, but know what to ask the doctors in charge.  One of the requirements for a patient's enrollment is informed consent after all.

Types of Oncologists & the Team Approach

When it comes to cancer treatment, one of the most frequently asked questions is "What kind of Oncologist should I see?"  There are so many kinds of doctors who describe themselves as oncologists: pediatric, medical, radiation, surgical, gynecologic, neuro- &  psycho-... Which types are formally trained to do cancer surgery? drug treatment? radiotherapy?

Are they interchangeable?  In a word, NO!, and this is true on an international scale.  

Hieronymous Bosch  A barber doing Awake Neurosurgery!

Decades ago, before the advent of complex yet significantly better options, cancer was treated by Jacks- & Jills-of-all-trades.  (In fact, centuries ago, barbers did it all.)  These days, however, the management of cancer has become so complex that one can't reasonably expect a single physician to master the intricacies of each pertinent discipline.  It now takes a multi-disciplinary team to optimize treatment planning.  In such a team, each member brings his or her focused expertise to the table, and all considerations of the represented specialties are discussed.  Differences are threshed out to enable a coordinated "best" plan that is specific to each patient.  The beauty of this is that it actually costs a patient much less to consult such an empaneled team than it would to see each specialist separately.  Soon (where not yet applicable), the laws of supply & demand will move institutions to package their teams' services for the consumers' benefit.

Imagine updating oneself in multiple specialties for, say... Breast Cancer:   new surgical techniques with hands-on training, Mammosite brachytherapy and other recent radiation technologies, the 1001 clinical drug trials for invasive and non-invasive breast malignancies, for pre-operative, adjuvant, and metastatic settings.  Then review the status of each modality every 3 months when you haven't even finished going through the standards you'd started out with.  Now do the same for the different soft tissue sarcomas of the breast. Then all the other cancers possible in humans ....Phew! 

For basic information on oncologists, try these links--

1. Define "Oncologist". Check out your doctor's credentials, not a casual description.
2. "Cancer surgeon" on a card does not imply formal subspecialization. General surgeons hereabouts can claim this title without benefit of certification... and in good faith. There is considerable overlap between the jobs of a general "cancer" surgeon and a surgical oncologist, you see, but its the skills learned from experts where they differ. Just what is the advantage of having a formally trained Surgical Oncologist on one's management team? Its important for you to know what this rare bird can offer.
3. What is the extent of a gynecologic oncologist's duties?
4. The tough job of Pediatric Oncologists
5. What is a Medical Oncologist, & what do they do?
6. Radiation Oncologists vs. the UK's Clinical Oncologists
7. Then there are the "Neuro-oncologists", a very confusing term indeed. The surgical neuro-oncologists are neurosurgeons who have had the benefit of regimented clinical training in the surgical management of brain/spine/nerve tumors. Medical neuro-oncologists, on the other hand, may be neurologists or internist-medical oncologists who are proficient in the medical management of such tumors--ie, by treatment with drugs (vs the knife or radiation).

• From the outset, it is certain that the different neuro-oncologists must work as a team, with each member contributing knowledge from his/her area of expertise. But just who best speaks for each specific area? The fact that some  facilties overseas take on both surgeons amd medical people for non-surgical work in clinical (hands-on with patients) or research (hands-off) jobs in their neuro-oncology units contributes significantly to the difficulties in defining the subsequent roles of their products.   For this reason, the practice is not popular at major training centers.  It would take a wise and conscientious hospital credentials committee to define what a program has prepared a doctor for.
   

As for surgeons who administer systemic chemotherapy when a properly trained specialist is easily accessible in the area, let's just say that, outside of gynecologic oncology, I know of no other area where that practice is considered optimal in this, the 21st century.  Even when I was still in training, surgical oncology trainees at chemotherapy units were just "passing through", just as we had to sit through their hair-raising  audit sessions in similar outsiders' roles.  After all, we were already being trained to deal with each other in a proper context even then.

Deciphering an Oncologist's Credentials

An oncologist is a physician  specializing in the treatment of cancer.  By this definition, you can have a basic science PhD who develops drugs for cancer treatment but is not an oncologist (except for his lab rats).  When the drugs or procedures are finally tried in humans, the clinicians are called in.  Why?  Well, I doubt that even Mme. Curie would’ve felt qualified to plan modern brachytherapy for cervical cancer.

There are all sorts of oncologists.  Their qualifications can be checked with the appropriate subspecialty societies that certify them as such.  Competent certification verifies all training credentials, a potentially litigious process, and administers board examinations only to those who pass scrutiny.  Observership ("hands off"), graduate research fellowships (”lab jobs”), and program interruption aren’t quite the same as completed hands-on clinical instruction.  When granted, formal certification implies that the training facilities & program were adequate, that the candidate applies sufficient knowledge to actual cases, & that he is reasonably updated in his field. 

Certifying bodies, such as those of the PSMO (Medical Oncology), PROS (Radiation Oncology), also police their ranks.  Some other societies function more as interest groups and not as certifying bodies, such as the PSO (Philippine Society of Oncologists).  Anyway, these societies are behind all those letters appended to a doc’s name.  So many F's.  What do they mean? 

• Juan de la Cruz, MD, FPSO.  Dr de la Cruz passed the basic Medical Boards & is an F (Fellow) of the Philippine Society of Oncologists.  He is not necessarily a clinical oncologist.   He could even be a pathologist.
• Jose Juan, MD, FACS.  At the very least, Dr Juan is certified by an accredited surgical society in any country.  The American College of Surgeons does not administer examinations.  Better check what he is actually certified for and by whom.
• Crisostomo Ibarra, MD, FPCS, FPSO.  A certified surgeon.  We can’t tell if he trained for any of the surgical subspecialties but, like many general surgeons, he did join the the Philippine Society of Oncologists.
• Maria Clara, MD, FPCP, FPROS, PhD (Radiation Physics).  Dr Clara is clinician-scientist certified for Internal Medicine & Radiation Oncology, with postdoctoral work in radiation physics.  Among many other things she is an oncologist.
• Ida Rizal, MD, FPCP, FPSHBT.  An internist and hematologist, Dr Rizal is competent with blood-related malignancies like the leukemias too.
• Consolacion Damaso, MD, FPSMO.  Dr Damaso is either modest or lazy.  She is both a certified medical oncologist and internist-- unless she’s old enough to have escaped the requirement for PCP certification (”grandfather clause”) imposed years ago.  Strictly speaking, her credentials are MD, FPCP, FPSMO.
• Pediatric oncologists used to belong to the PSMO when there were but a handful of them, so some senior pediatric oncologists are FPSMO.

Confusing, isn't it?

Colorectal Cancer Mabs

Another monoclonal antibody, i.e. "MAb", has been approved by the US Food & Drug guys for the treatment of chemo-resistant metastatic colorectal cancer. This time, its Amgen's panitumumab (Vectibix), a purely human MAb that's priced to give ImClone's cetuximab (Erbitux) a run for the money.  Priced to cost 20% less, its "just" a Filipino-sized US$ 7000 per month for those who may have already failed a gamut of chemo options.

How best to tell folks with the right to know? My patients are well above average in our economic totem pole, yet only 2/3 of them can afford the costs of plain old FOLFOX6 chemo. I wonder what its like to be told that one's disease is back yet again, to know that there's a new fast-tracked targeted therapy for slowing it down, & then to agonize over whether one should sell more stocks or the children's future to avail of it.

To the Powers-that-be… Never mind the MAbs for now. Maybe just a national information & screening program that actually works.

Previous Comments

good day sir!

I’m Nina Bumanglag, a student at UPLB taking up biology. I’ll be having an undergraduate seminar regarding colorectal cancer next year on january 2007.

I was hoping if I could ask for your help about what sort of treatments your patients undertake, the most common and the likely reasons for chooisng it. Your insights would really help with the seminar I am about to undertake.

Thank you Sir and God Bless!

Nina Bumanglag

Posted by nina bumanglag at December 18, 2006, 9:12 am

Hello, Nina. Its a very broad topic. Management would depend upon whether its the colon or rectum that’s affected, the stage, the presenting symptoms, co-morbidities, etc. In fact, even in specialty fora, it helps when discussions are case-based.
Best look at the simplified algorithms for patients. For evidence-based info, look here–> http://www.nccn.org/default.asp
Posted by oncodoc at December 18, 2006, 1:12 pm

hello sir!
I’m a student doing research on colon cancer and its preventive medicines. I was just wondering if you happen to know the rate of colon cancer incidences in the philippines and who are the people commonly “attacked” by this type of cancer.
thank you and god bless!
Posted by ethel at January 16, 2007, 7:46 pm

Online sources for stats include Globocan (2002) at the IARC website. The DOH puts out stats as well. Beware of under-reporting– its a serious consideration hereabouts.
As to risk factors for colon cancer specific to the Philippine population, I’m not aware of any local population-based study in this area. Maybe you can do one. Western medical literature has extensive coverage of risk, however, and you can freely access the information online in both “health professional” and “patient” versions. (See “Links”)
Posted by oncodoc at January 16, 2007, 11:14 pm

Prostate Cancer Variables

Prostate cancer is a highly prevalent malignancy but, come to think of it, most medical oncologists I know have but a handful of cases. In my own clinic, prostate cancers are outnumbered by even the sarcomas & gliomas. Since the role of the medical oncologist is most active in stage IV of this disease, does this mean that majority of patients are diagnosed early & subsequently cured? Are even very advanced cases managed by another specialty? Are full options offered at all?

Since I don't work with a specialized urologic tumor group, the cases I see have already failed previous cancer treatment &/or are in a very advanced stage for which chemotherapy is contemplated. There are points in a case history that medical oncologists look into upon first evaluation to "know" an individual tumor. Many times in the course of such a review, the advantages of the tumor group concept is highlighted. Telling details may be found in the answers to the following:

First Presentation:

Risk category (eg. Partin tables, MSKCC nomograms) includes tumor extent, PSA, Gleason scores…
Choice & appropriateness of initial therapies
Type & extent of surgery, if applicable.
Brachytherapy details, if applicable. Ports too, if external beam irradiation.
Initial & subsequent hormonal manipulations

Treatment Failure/Relapse/Recurrence:

Duration of initial response, if any
Management of apparent "PSA failure"
Staging procedures
General health & other medical problems
Patient's wishes

What is this gibberish?! Well, if you're a patient, make it your business to find out. Ask, even if you must get another opinion from a specialty team. Prepare for the talk by checking out the NCCN guidelines.

Previous Comments

Hi, My Dad is being treated for Prostrate Cancer. He has been given Luprolex 3X (Apr 2008 to Dec 2008 - given every 3 months) He wants to know when it will stop? His PSA started 3000+, then 5.6, then 1.5 level. His health his improved. Pls advice. thank you.

Posted by Leonard Dy at January 2, 2009, 12:57 pm

In the old days, they just removed the testicles. That was permanent– and much cheaper. If he’s responding to hormonal manipulation alone (am assuming stage IV), I’m afraid that the end to leuprolide is not in sight. Or so one hopes. Docetaxel is the chemotherapy drug indicated when stage IV disease no longer responds to hormonal agents. Its so much tougher to take.
Posted by oncodoc at August 15, 2009, 2:46 pm

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Head and Neck Cancer: The Organ Preservation Option

Concomitant irradiation & chemotherapy can help preserve the normal anatomic outline in locally advanced head and neck cancer without sacrificing treatment efficacy. 

It seems that the latest outcomes of combined chemoradiation are comparable to those of radical surgery with further postoperative treatment.

True, chemoradiation requires focused expertise and is technology-dependent.  As such, this option is found only in the larger Centers. True, the addition of terrific induction chemo may further improve organ preservation rates or, if preliminary trial results hold up, even survival. 

Yes, well & good... but will function be preserved as well as anatomy?  And… can Filipinos afford these cancer treatments?   These are matters up for discussion, but not just amongst medical professionals.

Its obvious that doctors should get their acts together to organize Head and Neck cancer services at their institutions. The name of that game is multidisciplinary coordination, wherein radiotherapists, medical oncologists, subspecialty surgeons, and supportive services work to provide full options to the community.  It would be a shame if a life-saving opportunity is lost by improperly timed interventions.  The final decision is the patient's after all, and acceptance or rejection of risks, side effects, and costs is an exercise of their personal choice. 

Evidence-based information from all participating specialties is invaluable in this regard.  All patients deserve a multispecialty plan of action.

New Drugs for Kidney Cancer

This year, the star of the Atlanta show was kidney cancer, specifically, advanced renal cell carcinoma. For the longest time, I looked more to heaven than science to guide me in the treatment of this disease, being limited to drugs which, in many cases, made patients feel worse than the cancer. When those didn't work or ceased to work, one was exposed as clueless. Nobody likes a recipe book approach. Doctors are supposed to know & understand their enemy, but renal cell cancer was shrouded in mystery.

Molecular science is doing much to remove that shroud.  For me, the first hint of a better deal came in the effort to medically control the blood supply of tumors, for kidney cancer is just such a vascular bloody mess. Then came targeted therapy– the drugs that specifically interfered with cell signals to impact upon cell nutrition, reproduction, and death.  I can hardly keep up with the flood of new knowledge nowadays, or the variety of drugs shown to be active in this disease: the nibs (sunitinib, sorafenib), mTOR inhibitors, bevacizumab. One now dares to anticipate combinations in the immediate future.

When the leadership of a country with vast resources declares a "War on Cancer" as national policy, you can't help but hope that others will do likewise for the benefit of all. Attaboy!– its pay-off time.

Toons by Buck Cash.

Our Precious Girls

CANCERS of the CERVIX : Best measure is Prevention.

Human Papilloma Viruses (HPV) are a large group with 100+ subtypes that usually present as a self-limited infection. Certain HPV strains are known to be strongly associated with the genesis of cervical cancer, and similar mechanisms may apply to HPV+ cancers of the vulva, anus, and throat. Merck"s GARDASIL is a vaccine that was developed against known culprits HPV 6, 11, 16, 18. Three injections over six months are necessary for protection against infection by these subtypes which cause the majority of cervical cancer in the US. It is a pure preventive, not a targeted therapy. As such, it can't impact upon established disease. 

So then, given the predominantly sexual mode of HPV transmission, the question now arises– how young should girls be at vaccination to allow for maximum benefit from this new intervention? The US trials have looked at girls as young as 9 years of age. As a doctor, starting them in the pre-sexual years makes great sense to me. As a parent in a conservative society, it gives me pause: Will our girls read an implicit message there?

Social norms, religious objections, parental desires aren't nearly as straightforward as science. There lies the rub.

photo by timcunnup (photobucket)

Colorectal Cancer WebClips

There is no way that an oncologist can survive without the internet these days, not with the furious rate of developments in the field. Patients who mine the Web for info are best served by peer-reviewed sites (see links) for their own safety. Journal articles, commentaries, summaries etc need method & data evaluation, coupled with some insight into basic & clinical science. Discuss them with your physician.

COLORECTAL CANCER

• Screening: Radiographic "virtual" colonoscopy (actually, colonography) is not quite ready to replace optical colonoscopy for colorectal cancer screening. The most common complaint is that you can't biopsy suspicious lesions with the new procedure. Hmm… the GI guys are especially wary, while the x-ray people seem to be ardent fans. A cost comparison for the Philippines should be interesting. In any case, virtual colonography will have to do if the patient absolutely refuses standard endoscopy, is medically unfit for sedation etc, has a partial colon obstruction that a scope can't squeeze through… *Rex DK, Lieberman D. ACG Colorectal cancer prevention action plan: Update on CT-colonography. American Journal of Gastroenterology. 2006;101:1410-1413.

• Resectable Disease: A study in this month's JCO reports that physical activity may be an independent factor in reducing colorectal cancer's recurrence & death rates after definitive treatment. As the accompanying editorial says, "It's time to get moving!" *Meyerhardt JA, Heseltine D, Niedzwiecki D, et al: The impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: Findings from CALGB 89803. J Clin Oncol 24:3535-3541, 2006  

• Advanced/Stage IV: Chemotherapy-based cancer treatment leading to the disappearance of liver metastases on a CT scan/MRI/PET does not mean cure in the great majority of cases. Surgery must still be considered in this setting, where possible. *Benoist S, Brouquet A, Penna C, et al: Complete response of colorectal liver metastases after chemotherapy: Does it mean cure? Journal of Clinical Oncology 24: 3939-3945, 2006

Medical Oncology’s Nibs and Mabs

Targeted therapy is changing cancer treatment. 

Its a great time to be an oncologist. Tremendous toys!  Hats off to modern science-- if we forget about costs & exclusivity for a minute, we’d be dizzily restructuring our ongoing protocols.

Normal tissues grow & die in a controlled manner. They rely upon interactive signals and factors to initiate, then complete, important functions. In fact, the way cells obediently "go jump in the lake" on command may give you nightmares about dictatorships and the natural order of things. Cancer is the disease marked by loss of that order. The signals get messed up and the factors are mis-used. The abnormal cells keep growing & refuse to die. Sounds like a rebellion, doesn’t it?

Targeted therapy is one cool way to "salvage" the rebels.  It is great stuff! When you specify a tumor target, you avoid many side effects resulting from normal tissue injury or death (such as those caused by radiation & most chemotherapy agents).  Its not an entirely new idea.  Hormonal manipulation has been around for some time for tumors which express the corresponding receptors on their cell surfaces.  What’s new is that The Human Genome Project and other humongous brain trusts have clarified new tumor-specific targets for similar manipulation.  We can now zero in on teeny molecules inside of & exterior to the cancer cell, even on its blood supply.  By doing so, we are able to hinder cancer cell function, growth, & propagation while largely avoiding damage to other tissues.

I use a mnemonic to broadly classify the manner by which these targeted agents do their thing and, consistent with my personality, its by no means 100% scientific.  Nibs (imatinib, gefitinib, erlotinib, lapatinib, sunitinib, sorafenib, etcetera) interfere with signalling pathways which control functions like cell proliferation & death.  Mabs are antibodies that attach to predetermined molecules. They can block receptors to prevent growth factors from acting on the target cell, incite direct cell lysis by the patient’s own immune response, act as guides for killer isotopes attached to them, and so on. (Trastuzumab, bevacizumab, cetuximab, ibritumomab, alemtuzumab, rituximab). Then there are the cancer vaccines, which may someday effectively build up & use patients’ defenses against their own malignancies.

Can these amazing drugs take the place of chemotherapy? In a few instances, yes- esp in those malignancies where chemo doesn’t work well anyway, like Gleevec for GIST & Sutent for renal cell cancer. In many cases, however, the 2 treatment types are complementary or even synergistic, i.e., the benefit when given together is more than the sum of one treatment’s effect. Are they curative in very advanced disease? No. They do improve on the success rates of conventional therapies in more limited stages (as in "adjuvant" herceptin in breast cancer or rituximab added to chemo in certain lymphomas).

Thank you ImClone, Amgen, Genentech et al for the gazillions you invested in R&D. We wish you the Big Payoff that you deserve, so that you can do even more research. Through such efforts, cancer control & therapy may someday be a matter of prescribing the right pill.

But… when will the Indians & Chinese do decent clones for the benefit of those who don’t receive state health subsidies?  Politics again. Ahh me.

Image from Harper’s Weekly; 5 March, 1864

      

Previous Comments

We are a group of volunteers and starting a new initiative in a community. Your blog provided us
valuable information to work on. You have done a marvellous job!
Posted by renommierte Casinos at July 19, 2010, 7:09 pm

Having read this material, I have learned for myself a lot of the new. Thanks
Posted by college board at May 22, 2011, 1:49 am

My Paranoia and Cancer Vaccines

The latest best hope in oncology is cancer vaccine. The wave of the future, it has applications for both the treatment of existing disease & in the prevention of cancer in high risk populations.

The US Food & Drug guys have just approved another specific preventive– hurrah! – but, as of June 2006, none of the cancer treatment vaccines have passed muster. Although still strictly experimental for the targeted therapy of existing disease, we do have some insight now. Can vaccines effect a permanent cure? No signs of that yet. Can they make tumors shrink or disappear on imaging tests? You betcha! Will a good response significantly impact on length of survival or consistently upgrade quality of life? Hmm… wait & see. Are they safe? Zhou's 2006 article in BLOOD says there's a possibility that therapeutic vaccines may eventually worsen a patient's immune response to tumor– a not permanently insurmountable problem, just the identification of a new angle to address.

It makes sense to beware for now, don't you think? A stand is especially pertinent these days, when every other PhD & his mother are cooking up a home brew, with even less scrupulous types cashing in on the topselling product called "hope". Well, if we duly inform people about drug limitations & how incomplete our current understanding is, in toto, are oncologists already justified to offer therapeutic vaccines outside of a controlled clinical trial setting? Someone, please clue me in. I confess that in some instances, I'm reminded of psychic surgery's claims which require a similar leap of faith in an unregulated process. Its too much like a cash cow & so little like good science to offer up vaccines at tremendous costs in some parts of the world without even the pretense of a formal study– sans the critical details of procedure or provenance.

Common sense sayeth: in clinical medicine, the devil is in the details.

Thanks again to Mr Buck Cash

Wish on the moon

At home, everyone who's meant to sleep-in for the night has retired by 11p.  By 12a, one may steal mere pecks on cold noses– sadly, for us bear-hug enthusiasts.   Long-suffering help open up in PJ's to let this bedraggled cat in, serve dinner as a cold-core mess, then leave me to wind down with terminally blue journals & saxophones.  So when 930p comes around when there's still no hope of an early escape, I just may dig in for a solo flight, dine out with TIME magazine, then chat with those hospital-bound patients who share a similar insomniac fate. 

Mellow yellow-- no blues in the night.

You can learn a lot from patients, if you give up the time for a close listen.  Its a tough trade for domestic comforts but, given my idiosyncrasies, it sure beats Discovery Channel & my own worn fantasies.  Besides, I always did favor autobiographies, and there's hardly any b.s. between people in a life & death situation.  Nope, no time.  Then there's this inexplicable rapport.  Both hurts & highs flood the breach in my direction– a paradoxical control?   Its as though they mean to stamp out disease by force of personality. Well, my ears are right for this job. I do allow myself some empathy, but never pity.

So I listen and learn what Dizzy Gillespie was like, how a billion dollar enterprise was conceived, a mean politico's hopes for the country in his lean youth, how a farmer sold his own future to send a son through grad school, Japayuki travails, how MacArthur posed Leyte beach shots, the joy of dreams fulfilled, the lingering wonder over a beloved.  Lives well-lived, ends similarly so.  Then there are the stingers, sadder than any disaster dealt by fate: the lives filled with regret.   Unfaithfulness, abandonment, paths not taken, promises broken, what-ifs & should-have beens.  The willful sacrifice and irredeemable loss of that something they never knew.

Man! While we are young & stupid, we roll our eyes & close our minds to such tales.  Lately, this job has me reading regret like the Surgeon General's warning on a pack of smokes.

Blogging this

"We at MP Stat have reported before on tech-savvy physicians operating Web logs, but those physicians either assiduously avoided clinical content and used their blogs as psychological steam vents or presented Internet smorgasbords of personal and medical observations."  So says a 2004 article on the nominations for a clinical blog contest, as quoted in Pinoy MD's website.

This one got me thinking.  Anyone who has worked this job knows that there is a serious information problem among many cancer patients and their kin…and lots of ignorant or unscrupulous types lying in wait.  A lot of us would love to help, but where does one begin?

• Which is the demographic that will benefit the most from oncology treatment information?
• How would they access the information?
• What language do they speak / read?
• How do they finance their medical expenses?

Its not as simple as it had first seemed to me.  Educating the Philippine public about the cancer treatment options will not have the same impact as the drives on its prevention and early diagnosis.  We just don't have the national health benefits that would make it relevant as a large scale priority, translated into X number of dialects, maintained by Y committees– at considerable public expense.  On the macro level, infections are still the biggest of the major killers, not malignancies.  For the small subset that can afford to self-finance optimal antineoplastic therapy, how are their information requirements best served?  Are enough wired & online to make an official authoritative presence worthwhile?  And if government has other health priorities, who will serve these needs?  Who will watch for abuse, self-promotion, and quackery?  This is an interesting area for study– by whom… subspecialty societies?  NGO's?  tertiary hospitals?  All of the above, and more?