My Tumor Shrunk!

"The snake oil salesman is still alive."

The US Food & Drug Administration (FDA) has put up a web site to protect consumers against scams. 

One of the articles suggests "Red Flags", aka treatment claims that should tickle your antennae.  Among them, (& I quote):

• "Treats all forms of cancer"
• "Skin cancers disappear"
• "Shrinks malignant tumors"
• "Non-toxic"
• "Doesn't make you sick"
• "Avoid painful surgery, radiotherapy, chemotherapy, or other conventional treatments"

Now, how in the heck does one avoid spluttering when presented with these claims— usually in combination, mind you!  For an idea of what goes through my head, think on a Lothario-in-heat who promises the sun, moon, & stars, who inflates his person & worth then stands on his head... all in the pursuit of droll short-term ends.  In both cases, shrewd calculations are made of the “sweet nothings” that perceived suckers are wanting to hear.

Transferring my old blog....

This blog was started in 2006 at a Philippines-based site.  From the outset, it had received its share of clicks, but only a small fraction of those came from local readers.

I'm a great fan of Google products.  Let's see what Blogger's interface can do.  So far, its been interesting...

Choosing an Oncologist in the Philippines - Part 2

Part 1--> here.

Which type/s of oncologist/s do you need?  Now, you may be a Mensa member but this area is a matter of information, not IQ.  Further, if you’re a take-charge CEO with a bundle of money, take care not to drown in it.

• A trained surgical oncologist?  Exceedingly rare.  Its not the same as “cancer surgeon”, you know.
• A gynecologic oncologist?  Yes, they do exist as a superspecialty to treat malignancies of the female reproductive tract.
• A marrow transplant specialist?  Oh my.  Count them on the fingers of one hand.
• A sarcoma pathologist?  Ditto.
• Many other instances apply, I’m afraid.

Best thing to do– go to a big cancer center.  Ask for a multidisciplinary meeting.  Don’t see a single specialist alone– lay your case before The Team.

• Seek a second opinion.
• Can parts of the treatment plan be executed at another hospital?  Many of the docs cover smaller/cheaper institutions.  Major cancer centers can also refer you to a gamut of networked specialists, from provincial areas to large first world institutions.  Your options would be greatly expanded.
• “…but this is my budget.”  The Team will discuss current standards of care, ie, “best”/ideal treatment.  Frequently, there are alternatives that would not sacrifice outcome significantly.
• “Do you have ongoing clinical trials for me?”  You don’t pay to go on a trial.  The investigational medication is usually provided by the pharmaceutical companies.  

Pitfalls next.

Choosing an Oncologist in the Philippines - Part 1

Okay, so a cancer has been diagnosed.  Just when you need your wits about you 100%, you're in a daze.  You're told to see a "cancer expert”. Not feeling ready?  Doubting the diagnosis?  Do it anyway, but make sure that the "expert" is a bona fide oncologist.

When to see the specialist/s?  ASAP.  Before anything else, know what it is that must be done.  Many times, you’ve got just one chance to do it right.

But which specialist/s?  If you have insurance, your choices may be limited to specific physicians.  A few professional societies are working on this one (on the premise that patients should have the right to choose from its accredited membership).  Great idea to have corporate considerations out of the way–

If the hospital is specified by your health coverage, that’s another issue.  Does the hospital have the necessary expertise and facilities available?  Sub-specialty physicians tend to stay close or within institutions that can enable them.  Some illustrative examples:

• Would your general surgeon be familiar with sentinel lymph node mapping? 
• What would a laparoscopic surgeon do without a laparoscope? 
• Even if the newer IMRT (intensity modulated radiation therapy) is ideal for head & neck cancer applications, its available only in a handful of centers. 
• Continuous infusion chemotherapy would be given on an in-patient basis if there are no ambulatory pumps.

Next:  Which type/s of oncologist/s do you need?  

Its a Business (too)

Had a discussion with The Kid on the appropriateness of business courses in a medical school curriculum.

Does it make sense?  In a word, “YES!”  You’ve gotta learn to talk the talk, especially by mid-career.  Part of The Job is dealing with administration and, even if you aren’t any smarter 15 years into your practice, you will be called upon to give your “sage advice”. 

On a more personal level, if only I’d had similar exposure before my mind was caught up in a highly technical specialty, then I wouldn’t be at the mercy of account managers, insurance brokers, & real estate pros.  As someone trained to consider & research each case management decision, who is frequently cast in the role of a take-control resource person & “expert”, I suspect that I delegate too much to the Money People. 

A disaster waiting to happen?  Maybe.  After all, to “Death and taxes’, add the inevitability of “Decline”.

Previous Comments

Really nice post. I LOVE IT.
Posted by Noah Berkowitz at December 6, 2011, 9:32 am

 

Beware the Jabberwock

There basic rationale behind "high-tech" cancer treatments should never be too esoteric for the end-user.

Sadly, a time comes when there’s little more than symptomatic management in your arsenal to fight stage IV cancer. These days, a surprising number of such heavily pretreated patients opt to try touted “high-tech” treatments. If there’s no ongoing mainstream protocol to conflict with, after stating that no personal judgement is possible in the absence of sufficient data, I do little to stop them.

If US$ 100,000 + is just a drop in their bucket, who am I to say that the cost of this hope is too high?

Upon their return, those patients who’d left in fair overall condition can even have a new gleam in their eye. I’m truly happy for them but, when they try to get me to concede that the treatments had worked, I resort to grunts & wordless Gioconda smiles. If pressured to speak: “Well, if you feel good, then it was useful”.  If pressured further, then one bites one’s lip to answer truthfully… in one’s head:

www.buckcash.com

Patient: “The treatments are genuine breakthroughs– its the only explanation. If it walks like duck, and squawks like a duck, it IS a duck.” (Me: I used to think so, till Danny DeVito’s duck suit turn in “Batman”...)

Patient: “They’ve been published in journals. Its very scientific.” (Me: Both the NEJM & the JCO Editorial missed out on this paradigm shift?)

Patient: ”They use your language.  They did scans, cryotherapy, chemotherapy, and a gene thing. We don’t even have those therapies here or in the USA Centers yet.”

(Me: O frabjous day! To use "My Language", yet wax poetic in paraphrase: It really is brillig, the way these slithy toves do gyre and gimble in the wabe… Because all mimsy are the borogroves, and the mome raths outgrabe!)

The Business of Hope

Who knows just when certain masses & ulcers were first noted to be markers of an untimely end? Whenever that may have been, the universal horror of these dreaded signs surely led to the lobby that hatched The Expert Cure.

Ancient Burr Hole

Its a safe bet that empirical wisdom and glib promise are ancient competitors in The Business of Hope…and, with both restrained & gung-ho operators catering to the desperate, regulatory entities weren’t far behind. Since antiquity, insiders like Hippocrates appealed for professional high-mindedness & discipline, while Big Brother legislated for consumer protection (just to be sure). Its less clear how the ancients dealt with organizations that offered premium mantras & herbs, oils & zaps, off-protocol cryosurgery & brachytherapy, infusions &  delusions– all in the name of superior enlightenment. The sick don’t always die on the table after all, not with Hammurabi’s minions so ready to cut surgeon’s hands off in observance of The Code. These days, most patients are discharged in fair condition, a few wads poorer perhaps, wistfully wishful in spirit, some of them seeding radioactive beads to mark their routes home. The Hansels & Gretels of modern fairy tales.

Why in heck do oncologists prescribe toxic therapies if an easier fix is truly available anyway? Why are they so sure that they’re the Good Guys? Even their clinical trials are fraught with possible side effects that they insist on detailing. Are they little more than a bunch of over-schooled sadists? Speaking for myself, I can see that telling patients only that which they wish to hear, using technology for uncharted indications, seeming pro-active or ”aggressive” in the face of severely limited benefits– these would all fatten my bank account, but… oh, well. If only embolization could eliminate my choke reflex…

OK, so I can’t say that mainstream medicine is the true fount of knowledge, much less of wisdom. (Didn’t the mainstream once proclaim that the world was flat?) Still, if I have to make sense of it all by subscribing to an underlying principle, the Scientific Method will just have to do.

We sure could use an independent cancer information agency at this technology- laden predatory time! Do we really expect the public to understand “Level 1, Level 2″ as they trawl nccn.org for their own edification? Note how the folks who endlessly agonize over the choice of a car can swiftly surrender their reason to panderers in their hope for miracle cures. This, despite all reproducible evidence to the contrary. Well, don’t you do it! If Fate has stolen away Good Health, don’t voluntarily bundle Logic into his loot bag. As with cars, ask for specs. Most basic questions can be answered by Yes and No (beware of Ifs and Buts). Does decreasing tumor bulk always translate into increased survival time or quality of life? Does tumor disappearance on a PET-CT scan mark a cure? If I go for “gene therapy”, is the production process or quality of the drug reliably checked by an independent party (can I be given plain old saline with no one the wiser)? Is the ultimate outcome of a treatment known for a reasonable period? If yes, were those outcomes vetted by the frequently dreaded but useful peer review process– or would personal endorsements do for those purposes?

Primum Non Nocere. Above all, do no harm. In Oncology, physician adherence to this dictum is critical but, I suspect, its Primum Utilis Esse that’s dead-on. “Above all, be useful.”

Lovely Bones

If you ever wondered what an experienced physician is thinking while examining your breasts, these pictures provide some hints.

EIZO, a Japan-based designer-manufacturer of professional display equipment, came out with a truly memorable calendar for 2010 through its European arm. I don’t know that their models were aware that this was to be their most revealing assignment, but there they were, in classic Playboy poses, wearing such flawless bones.  Which reminded me...

The first time that I’d had a notably attractive person in my office, we had literally bumped into each other in the elevator just a few minutes before, without knowing that we were destined to meet. After the shock of recognition on my part & some cursory apologies, I did the predictable thing and looked… hard, just like the rest of the folks in the elevator (which had become eerily quiet).  Walking a bit to the side of this surreal being in the corridor, I was busily in awe of long eyelashes and the perfect nose, thinking “Such killer abs!"  Then we both turned into my clinic. I had to quickly abandon furtive assessment for an overt clinical stance– “Did I miss something? What could be wrong with this one?”  

In such a reflexive manner is general fitness, a purposeful walk, and a fabulously toned behind transformed into mere clues to overall performance status in the continuing challenge presented by each patient. I don’t know if its dehumanizing, but each person across the clinic table intially presents a dominant agenda in the form of a challenge. A puzzle! Like the crosswords of The New York Times, they can then elicit excitement only in direct proportion to degree of difficulty and complexity of solution.

I can still spot great gluteals in the elevator, though.

Alternative Medicine for Cancer

I haven’t been back to this site in months & am happy to see that the site administrator has taken out the ads. In February, there was some type of Google robot that picked out blog keywords in order to display “matching” links of possible interest. For a while at least, there was this weird situation wherein the blogger was promoting caution in the choice of cancer management tracks in a panel beside links for Chinese herbs, colonics, and such.

When reading the word “alternative” with respect to cancer treatment, I assume that the writer sits on the side of Western medicine & its data-driven standards of care. “Alternative” is a substitute for the therapies I was trained to administer, not even “complementary” to my service.  (”Complementary” seems to belong to another category altogether.)   I know so little about alternative, complementary, natural-holistic, integrative or what-have-you that, in truth, I tend to give a blanket admonition against their use while on active Western-style systemic antineoplastics, or at least until I’ve read up on specific items. Paranoid?  To be honest, my drugs are toxic enough without the possibility of further interactions with unnamed components labelled as “miscellaneous".  I have the same paranoia about Western-style medications with insufficient data on their use & side effects anyway.

Perhaps a serious look at China No. 1, mushrooms, mega-vitamins, etc is warranted on an international scale. At the moment I just say that patients can take their chances with poorly documented “medicines” when I have nothing else to offer.

 

Previous Comments

i found alot of article here -> www.cancerhelps.com

Posted by adam at August 7, 2010, 1:09 pm

That is known that money can make people disembarrass. But how to act if somebody has no money? The one way only is to try to get the loan or just bank loan.

Posted by GloverAlissa at September 21, 2011, 8:35 pm

Diagnosis = Cancer (How Does It Feel?)



Best Friends, Victor-Gabriel Gilbert.

Recently, an old pal was diagnosed to have cancer in the course of routine screening.  It soon developed that, in his panic, my every word was allowed to supersede his usually uber- methodical decision process.  This may have had more to do with friendship and trust rather than my profession as he has loudly ribbed me about being a "relentless drug pusher" in the past. Whatever, it made me antsy that he wouldn't even entertain referrals to other oncologists.  Suboptimal!  In my mind, I may have defensively screened myself off for more than just a bit in order to buy some objectivity, so much so that, in hindsight, I'd become stern.

For while the best approach may be clear as day, just how in the heck patients summon the will to stay the course is beyond me.  In the case of friends, I prefer the job of pure emotional support of that will.  In fact, its the only job I should be doing in that situation, if I'm to reach for the old "Eureka!", i.e., the elegant clarity of rational management in a complex case.  

One can so easily become overburdened by this business when the distance that a clinic desk affords is breached. 

As usual, my friend taught me a few things, and the experience highlighted some truisms in clinical practice.

• Fostering acceptance of a dire diagnosis is a major job. 
• Primary physicians should be congratulated for all their patients who actually walked into an oncologist's clinic.
• I should pat myself in my back for all the times that I was entrusted with a stranger's care.  Why I accepted it as a routine aspect of the job before now is incomprehensible.
• Patients simply don't go for a tough fix until they've overcome their initial shock.  "Me, cancer!?"
• Success at making objective assessments does not imply that the patient has overcome his subjective assessment of you.
• Your recommendations, no matter how sound, become suspect when your foibles are hilariously familiar.
• In the absence of family, peer "sharing" by cancer survivors should not be expected to take up the entire slack.
• "Sharing" among cancer patients can lead to either "acceptance" or uncontrollable fears.Support groups should have clear guidelines on how to approach individual patients.  Big sign on each forehead: Caution– vulnerable!   
• For all our sakes, I should avoid my doctor-friends when I need personal medical advice.

Local Costs of Anti-Cancer Drugs

A new comment on the post #44 "HER-2 Positive Early Stage Breast Cancer" is waiting for your approval.

• …Welcome to the ____ Family! We invite you to visit us at www.____.com and find our great medicine prices. We provide serious and first class service to all our customers 24/7. If we don’t carry a medicine you need just let us know and we will be more than glad to assist you! To show you our gratitude for past purchases and to offer you one more reason to continue purchasing with ____.com We are offering a limited time 30% discount include on all our medicines. We will keep on giving you the best price and service in the market. Welcome and enjoy your visit to www.____.com

I found this in my mailbox, along with similar North American offers for drug purchase over the Net. Its interesting to note that the list price of many drugs is significantly less in the Philippines even when 30% discounts apply overseas. We're also spared the additional costs of airmail and taxes. 

Third world pricing– what a huge mercy! Somebody Up There must feel pity about the absence of government subsidies because the costs of the newer drugs indicated for systemic cancer treatment seem to be miraculous hereabouts. In many instances, we can even afford to ignore the small differences between "original" and "copy".

As for the mindboggling biologics… patients who sourced or once contemplated importing cetuximab from the US gasped when the product was finally entered into the local market. With their subsequent savings, they could afford a US trip each month had they wished it.  Et tu, Neulasta?

 

Previous Comments

Dear Sir,

How much is Cetuximab in the Phils?
How effective is it for those who have the metastatic colorectal cancer?

Posted by carlo at January 12, 2008, 5:13 pm

Sorry for the late reply.
Cetuximab is expensive relative to other therapies for metastatic colorectal cancer. That fact holds true for the entire Planet Earth. Its use as a single agent or in combination with chemotherapy is supported by solid evidence for specific colorectal cancer disease settings but… yes, in those settings it affords benefit in terms of response & survival time. It is not curative.

Posted by oncodoc at February 18, 2008, 11:05 am

A Filipino Cancer Blog

I was looking through the usage statistics of the cancer blog just now.  Its interesting to note that 3/4 of all visitors access the site from the US, Canada, and Germany.  The balance hail from China, Malaysia, Indonesia, and the Philippines.  So what would increase local traffic?

Frankly, the blog was started out of a frustration with certain aspects of care as noted in my own Philippines-based oncology practice:  the lack of adequate health benefits & frequent misallocation of limited personal funds, the fairly low level of cancer awareness amongst patients, and the absence of true multidisciplinary professional interaction. It seemed to make sense to point the Filipino public to the peer-reviewed sites via links, overriding the impact of any primary physician biases by the weight of evidence. Its not working very well, as half-expected. Its easy to see why, but how can a government agency or NGO help?

• Write in Filipino & major dialects.  But how to describe breast cancer surgery in the vernacular? A pro job.
• Terminology & level of technical info.  Editor needed! I suspect that even my own patients think I’m glibly opinionated and nerdy.
• Improve access.  Can you imagine a typical Tarlac farmer resorting to the Net for info?   Perhaps print, video, or health center lectures would be more effective. Getting high-profile non-doctors to educate the public would be a dream scenario.
• Identify & target high risk populations. Cancer prevention is always the best & cheapest path.
• Neutrality.  I did say that I was opinionated.
• Focused agenda & constancy.  My life isn’t all oncology, much less blogging. Dissemination of cancer info for local consumption would be a major full-time undertaking, albeit a worthy one.

Dietary Fat and Breast Cancer

I have a sister who prefers to be described as Rubenesque.  Indeed, Peter Paul Rubens would have surely loved her, and we won't have her in any other way!  But...

R.Ventura, Instrument, 2004

Women (who serve as an inspiration to us all as our mothers, sisters, partners, daughters, friends, & associates) are still hounded by a deadly disease.  The big 2006 Breast Cancer meeting has just concluded, however, and a few new findings of great interest were presented, adding to our present understanding of our common enemy.

Notable among many others… The WINS Womens Intervention Nutrition Study interim analysis was reported & subsequently published in the JNCI.  This was a low-fat dietary intervention trial conducted among women diagnosed with early breast cancer after completion of surgery, postoperative hormonal &/or chemo treatments, with or without radiation, as indicated.  It seems that reduction in dietary fat to the point that sustains a modest weight loss may reduce cancer relapse rates.  While merely an initial report, these findings combined with the now-familiar fat phobias of the cardiovascular & metabolic folks speak for habitual caution from the general public.  A lifestyle shift may be needed for some– an overwhelming thought!– but, at the very least, its time that we started reading the nutritional facts on food jars.

 

   Previous Comments

Breast cancer is the most common cause of cancer in women and the second most common cause of cancer death in women in the U.S. While the majority of new breast cancers are diagnosed as a result of an abnormality seen on a mammogram, a lump or change in consistency of the breast tissue can also be a warning sign of the disease. Heightened awareness of breast cancer risk in the past decades has led to an increase in the number of women undergoing mammography for screening, leading to detection of cancers in earlier stages and a resultant improvement in survival rates.
Posted by Dentist Fort Myers at February 26, 2010, 2:24 pm

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
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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.