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When Is a Full Mastectomy Appropriate for Metastatic Breast Cancer Patients?

September 29, 2020/in BC Insist Treatment, BC Newly Diagnosed, BC Treatment & Clinical Trials, BC Video ND, BC Video TC, Breast Cancer, Breast Cancer Programs, INSIST! Breast Cancer, MBC Newly Diagnosed, MBC Treatment and Clinical Trials /by Kara Rayburn

When Is a Full Mastectomy Appropriate for Metastatic Breast Cancer Patients? from Patient Empowerment Network on Vimeo.

Dr. Stephanie Valente discusses mastectomy for metastatic breast cancer patients, including common misconceptions around breast cancer surgery.

Dr. Stephanie Valente is the Director of the Breast Surgery Fellowship Program at Cleveland Clinic. More about this expert here.

Transcript:

Dr. Valente:

So, there are a lot of reasons that a woman undergoes a mastectomy. The first one is choice. So, anytime somebody is diagnosed with breast cancer, they actually have the choice of whether or not they want to remove their whole breast. So, even if their cancer is small, they do have the option of removing the whole breast. If the cancer is smaller, they might have the option to save the breast, which is called a lumpectomy.

Sometimes cancer is found, and it’s a little bit more advanced where saving the breast is not an option. So, the cancer is larger than a lumpectomy would allow. And sometimes that’s what’s called the extent of disease. So, the amount of breast tissue that’s involved requires a majority of the portion of the breast to be removed.

So, just because a woman has breast cancer that’s made its way out of the breast, into the lymph nodes, or beyond – so, metastatic cancer – doesn’t necessarily mean that she needs a mastectomy. So, just because you’ve got metastatic cancer doesn’t necessarily mean that the breast needs to be completely removed.

So, I think that one of the biggest misconceptions is that the more aggressive somebody is with their surgery, the better their chances with survival.

And again, taking a step back and saying you can choose a more aggressive surgery, but a more aggressive surgery doesn’t necessarily mean it gets you out of chemotherapy or it gets you out of radiation therapy. Those things are recommended, independent of a woman’s choice for the type of surgery that she may or may not pick.

Understanding Metastatic Breast Cancer Resource Guide

September 28, 2020/in BC Access and Affordability, BC Insist Guides, BC Newly Diagnosed, BC Resource AA, BC Resource ND, BC Resource TC, BC Treatment & Clinical Trials, Breast Cancer, INSIST! Breast Cancer, MBC Newly Diagnosed, Metastatic Breast Cancer /by Kara Rayburn

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Metastatic Breast Cancer: Accessing the Best Treatment For YOU

September 23, 2020/in BC Insist Treatment, BC Newly Diagnosed, BC Treatment & Clinical Trials, BC Video ND, BC Video TC, Breast Cancer, Breast Cancer Programs, INSIST! Breast Cancer, MBC Treatment and Clinical Trials, Metastatic Breast Cancer /by Kara Rayburn

Metastatic Breast Cancer: Accessing the Best Treatment For YOU from Patient Empowerment Network on Vimeo.

How could genetic testing results impact your metastatic breast cancer treatment options? In this INSIST! Breast Cancer webinar, Dr. Julie Gralow discusses essential testing, the latest targeted therapies and emerging breast cancer research.

Dr. Julie Gralow is the Jill Bennett Endowed Professor of Breast Medical Oncology at the University of Washington, Fred Hutchinson Cancer Research Center, and the Seattle Cancer Care Alliance.

Download Program Resource Guide

Transcript:

Katherine:

Welcome to Insist Breast Cancer, a program focused on empowering patients to take an active role and insist on better care. Today, we’ll discuss the latest advances in metastatic breast cancer, including the role of genetic testing and how this may affect treatment options. I’m Katherine Banwell, your host for today’s program, and joining me is Dr. Julie Gralow. Welcome, Dr. Gralow. Would you introduce yourself?

Dr. Gralow:

Hi, thanks, Katherine. I’m Dr. Julie Gralow. I’m the Jill Bennett Endowed Professor of Breast Medical Oncology at the University of Washington, Fred Hutchinson Cancer Research Center, and the Seattle Cancer Care Alliance.

Katherine:

Excellent, thank you. Before we begin the discussion, a reminder that this program is not a substitute for seeking medical advice. Please refer to your own healthcare team. Well, Dr. Gralow, let’s start by helping people understand how breast cancer is staged. Could we go through those stages?

Dr. Gralow:

The staging of breast cancer has traditionally been by something we call anatomic staging, which has the tumor size, the number of local lymph nodes involved, and whether it has metastasized beyond the lymph nodes. So, that’s TNM – tumor, nodes, metastases. And so, that’s the classic staging, and based on combinations of those things, you can be a Stage 0 through Stage 4. Stage 0 is reserved for ductal carcinoma in situ, which is a noninvasive breast cancer that can’t generally spread beyond the breast, so that’s Stage 0, and then we go up for invasive cancer.

Interestingly, just a couple years ago, the big group that oversees the staging of cancers decided that in breast cancer, that TNM – the size, the lymph nodes, and the location beyond the lymph nodes – is not good enough anymore, so they came up with a proposal for what we call a clinical prognostic stage, which is a companion to the traditional TNM staging.

What they were getting at here was it’s not just how big your cancer is, how many lymph nodes, or whatever, it’s also at the biology of your cancer. So, this new clinical prognostic stage takes into account the estrogen and progesterone receptor of your cancer, the HER2 receptor at the grade, which is a degree of aggressiveness, and then, if your tumor qualifies, one of the newer genomic testing profiles that we use in earlier-stage breast cancer, such as the Oncotype DX 21-gene recurrence score or the MammaPrint 70-gene assay.

So, all of that goes into account now, and the whole point here is that the estrogen receptor, the HER2, the grade, and some of these genomics may actually make more difference than how many lymph nodes you have, where the cancer is, and how big it is, so it’s not just the size, but also the biology of the cancer that we’re trying to include in the new staging systems.

Katherine:

In this program, Dr. Gralow, we ’re focusing on metastatic breast cancer. Would you explain when breast cancer is considered to have metastasized?

Dr. Gralow:

That’s a great question because technically, if the lymph nodes in the armpit – the axillary area – are involved, that does represent spread beyond the breast, but if it stays in the local lymph node areas, it’s not technically called a metastatic or Stage 4 breast cancer. So, metastatic breast cancer would have traveled beyond the breast and those local lymph nodes, and some common sites would be to the bone, to the lungs, to the liver, less commonly – at least, up front – to the brain, and it could also travel to other lymph node groups beyond those just in the armpit and the local chest wall area as well.

Katherine:

What about subtypes? How are they determined?

Dr. Gralow:

The main way that we subtype breast cancer right now is based on the expression of estrogen and progesterone receptor, the two hormone receptors, and the HER2 receptor, the human epidermal growth factor receptor. So, to date, those are the most important features when we subtype, and so, a tumor can either express estrogen and progesterone receptor or not, and it can overexpress or amplify HER2 or not, and if you think that through, you can come up with four different major subtypes, in a way, based on estrogen receptor positive or negative and HER2 positive or negative.

When all three of those are negative, we call that triple negative breast cancer, and that’s about 18-20% of all breast cancers as diagnosed in the U.S. And then, when all three are positive, we sometimes call it triple positive, and the reason that we subtype is because we know that those different subsets act differently and that we have different drugs to treat them with, and we’ve got great drugs in the categories of hormone receptor positive and HER2 positive, and increasingly, some recently hope in a new drug approval or two in triple negative breast cancer as well.

Katherine:

For a patient to get diagnosed, what are the essential tests?

Dr. Gralow:

So, we’re talking about metastatic breast cancer here, and in the U.S., maybe up to 10% or slightly less of breast cancer is technically Stage 4 or metastatic at diagnosis. That means at the time we first found it in the breast, it had already spread beyond. So, an important thing that we’ll do with a newly diagnosed breast cancer is especially if there are a lot of lymph nodes are involved or the patient has symptoms that might say there’s something in the bone, liver, or lung is staging.

So, we’ll use scans – maybe a CAT scan, bone scan, or PET scan – and we will look at whether the disease has gone beyond the breast and the lymph nodes, and if so, where. So, maybe 8-10% of breast cancer diagnosed in the U.S. already has some evidence that it has spread beyond the breast, but the most common way that metastatic breast cancer happens is that a patient was diagnosed possibly years and years ago, treated in the early-stage setting, and now it comes back, and that is the most common presentation for metastatic breast cancer, and sometimes that can be due to symptoms.

As I said, if it comes back in the bone, maybe that’s bone pain. If it’s in the lung, it’s a cough. There are symptoms. Sometimes, it’s because we’ve done a blood test or something and we find some changes there.

And so, when a breast cancer has recurred, it’s really important to document that it’s really breast cancer coming back, first of all, and so, if we can, we generally want a biopsy, and we want to stick a needle in it if it’s safe to do, and look and verify that it looks like breast cancer, and also, it’s really important that we repeat all those receptors that we talked about from the beginning because it can change.

So, a cancer up front 10 years ago could have been positive for estrogen receptor, but the only cells that survived – mutated, changed – were estrogen receptor negative, so what comes back could be different. So, it’s really critical to get that biopsy, repeat the estrogen/progesterone receptor and HER2, and also, in an ideal world, now that it’s 2020 and we’re moving more toward genomics, to do a full genomic profile and look for other changes and mutations that could drive our therapeutic options.

So, staging, knowing where the cancer is, getting a good baseline by understanding where it is and how big it is so that we can follow it and hopefully see that it’s responding to treatment, and then, repeating all of the biology components so that we know what the best options are for treatment are really critical.

Katherine:

Right. How can patients advocate for a precise breast cancer diagnosis, and why is that important?

Dr. Gralow:

Well, all those things I just mentioned are key. Knowing exactly where it is so that we can monitor it – for example, if the cancer has come back in the bones, we would add what we call a bone modifying agent, a drug like zoledronic acid or denosumab – Zometa or – which can suppress bone destruction from the cancer, but if it’s not in the bone, we wouldn’t add that.

And, we want to have a good look everywhere so that we can see if it’s responding because sometimes, the tumor can respond differently in one area than another. Also, I think it’s really important to know what your treatment options are by doing that biopsy, getting a full panel, and looking at potentially hundreds of genes that could be mutated, deleted, or amplified so that we know what our treatment options are.

And, we’re not going to use all the treatment options up front, so it’s helpful for knowing that if this treatment doesn’t work or is too toxic, what are the second-line or third-line options? So, we make sure that there’s what we call good staging up front so we know where the cancer is, and then we make sure that we’ve looked at it as best we can in 2020 with all the genomics.

That would give us the best chance of being tailored – individualized – to the tumor. Sometimes, if we can’t biopsy it, like with a needle that would go into a liver spot, then increasingly, we’re looking at what we call liquid biopsies, and that can be drawing the blood and seeing if we can find parts of the tumor, whether it be the DNA or the RNA that’s floating around in the blood, and sometimes we can get that information out of the blood as well.

Katherine:

All right. Dr. Gralow, when you meet with patients, what are some of the more common misconceptions that you hear related to diagnosis?

Dr. Gralow:

Well, I think people do confuse – especially at an early diagnosis – that the metastases, the travel to the local lymph nodes, is not the same as a metastatic breast cancer, so we spend some time talking about how it’s still curable and not considered a distant metastasis if the lymph nodes are in the armpit or up above the collarbone, and so, that’s something that we spend some time talking about.

This whole term of “metastatic recurrence” – unfortunately, when you start looking online and get your information from Dr. Google, you read right away that it’s no longer curable, and in 2020, yes, that’s true. That’s probably the most specific statement that we can make. We are not going with curative intent, which means we treat for a defined amount of time, and then all the disease goes away, and we stop treatment, and then you go on with your life, and it never comes back. That would be cure.

But, I think it’s really important to point out that much of metastatic breast cancer can be highly treatable, and what we hope to do – and certainly, at least a subset of metastatic breast cancer – we want to convert it more to what we would call a chronic disease, and so, think of it more like hypertension, high blood pressure, or diabetes. These are diseases that we generally don’t cure with treatment, but that we can control with drug therapy, which sometimes has to be adjusted, and if we don’t control it, we can get some bad complications.

So, that’s not all metastatic breast cancer, unfortunately – we can’t convert all of it do something where we can use a therapy for a long time that keeps it in check and where you have a pretty good quality of life – but we’re hoping that more and more, we’re getting targeted therapies and more specific treatments to patients so that we can convert more patients to a more chronic kind of situation.

Katherine:

So, it’s something that patients live with.

Dr. Gralow:

Right.

Katherine:

Many people are confused about genetic testing. They often think that it relates to ancestry or physical traits like hair and eye color. What’s the role of genetic testing in breast cancer?

Dr. Gralow:

Well, you can do genetic testing of the patient’s inheritance, which is how most people think of genetic testing, and that’s actually really important and increasingly important in metastatic breast cancer to do your own inheritance. Have you inherited a gene that was associated with how your cancer developed? Because now, we actually have a class of drugs called PARP inhibitors that are approved for tumors that have a BRCA1 or BRCA2 mutation with them. Most of those mutations were inherited, but not all. Sometimes they can develop as well.

So, now, when my patient – if she didn’t previously have genetic testing for an inherited risk for breast cancer either coming from mom or dad’s side of the family, a lot of people do have that up front, especially if they’re younger at diagnosis or they have a lot of family members with breast cancer. If she didn’t have that genetic testing done previously, at the time of the metastatic occurrence, I’m going to recommend that that be done because knowing if the cancer is associated with one of these DNA repair genes – BRCA1, BRCA2, some other genes – we have a new treatment option, which is an oral pill that actually is highly effective if the tumor has a mutation in one of these.

But, we can also – so, that’s genetic testing of the patient’s own DNA, but we can also do what we call genetic testing – or genomic testing, if you will – of the genes of the cancer. What were the changes in the DNA at the gene level that caused a normal breast cell over time to develop into a cancer cell that’s now growing without responding to our body’s checks and balances? So, what were those mutations, deletions, or amplifications in the tumor itself?

So, we’ve got the patient’s genetics, we’ve got the tumor’s genetics, and both of those come into play when we’re making our best treatment recommendations and trying to understand what the right approach is.

Katherine:

How is testing administered?

Dr. Gralow:

So, for our inherited testing, those gene changes can be found in every cell in the body, so we can do that from a simple blood test where we just look at the blood cells. We can actually do it with our sputum and with a cheek swab, even. You can get enough of the DNA from the inside of the mouth to do that.

For a tumor’s genetics, we need some of the tumor, so that’s either done with a biopsy into the metastatic site or, as I mentioned before, increasingly, we’re exploring the potential for a liquid biopsy – so, drawing some blood and then trying to find pieces of the tumor that are shed into the blood.

Katherine:

What advances have there been in testing?

Dr. Gralow:

Well, it used to be – just going back a couple of years ago – that we didn’t do a lot of this genetic testing or genomic profiling of the tumor because we didn’t have many – the term is an “actionable mutation.” So, if we found something, would we do something with it? Did we have a drug we could use to do it? But, more and more and more, even in breast cancer, we’re finding actionable mutations that would drive therapy.

For example, in estrogen receptor positive breast cancer, we have a new class of targeted therapies called PI 3-kinase inhibitors – a drug called alpelisib or Piqray was approved in the last couple of years in that category – and it only is effective in estrogen receptor positive breast cancer that has a mutation in the PI 3-kinase gene. So, that would be something we’re looking for in the tumor’s genes, and actually, we need to know that there’s a mutation to even get the drug approved for treatment because it doesn’t work if you don’t have that mutation.

Increasingly, we’re finding some changes that can happen in the estrogen receptor gene and the HER2 gene, interestingly, so that you can have estrogen receptor expressed on your tumor, but over time, that tumor might develop an estrogen receptor mutation so that it stops responding to certain drugs that target the estrogen receptor.

And so, that’s called an ESR1. That’s the name of the estrogen receptor gene – an ESR1 mutation – and that would tell me probably not going to respond as well to a drug in the class we call aromatase inhibitors, but might respond better to a drug in the class that we call the selective estrogen receptor degraders like fulvestrant or Faslodex, is the name of a drug in that class.

We’re also finding that you can have what we call activating mutations in HER2, and they can be present whether the tumor overexpresses HER2 or not, and we’ve got some ongoing clinical trials looking at if the tumor doesn’t have extra HER2 on its surface – so, it doesn’t have extra HER2 protein, but at the gene level, it’s got an activated HER2 gene – we can use certain types of HER2 therapy to treat it, and we’re testing that right now in clinical trials.

So, could we even use some HER2 drugs even though technically, the tumor would be classified as HER2 negative? So, fascinating increasing information that we’re understanding, and I also mentioned before we can inherit mutations in genes such as BRCA1 and 2, but fascinatingly, the tumor can acquire those mutations. Even if we didn’t inherit a mutation, we can see mutations in the BRCA1 and 2 gene – we call those somatic as opposed to germline mutations. So, “germline” means it’s in every cell in your body, but “somatic” means the tumor somehow acquired this over time.

And so, we’ve done – we just presented some very early results of a trial, and we’re expanding this trial, looking at if you didn’t inherit a BRCA1 or 2 mutation, so technically, you don’t qualify for a PARP inhibitor, but if the tumor acquired a mutation and we can prove that with testing the tumor’s DNA, then we have seen responses from these PARP inhibitors, so that opens up another whole class of treatments, and there are other DNA repair genes that actually may be qualified as well that we can inherit or that can be acquired by the tumor.

So, more and more, we’re doing this genomic profiling, and it is leading to results that would give us possible treatment options.

Katherine:

Dr. Gralow, the goal of this program is to provide the confidence and tool for patients to advocate for the essential tests to get best care personalized to them. Are there specific tests that patients should make sure they have?

Dr. Gralow:

Well, there are a lot of assays out there to do this genomic profiling or genetic testing of the tumor, so I don’t promote any one. Various institutions do it and do it well, various companies do it, but I think every metastatic patient should have the tumor looked at in this kind of profiling.

I also think every metastatic patient should advocate for having a biopsy of their cancer, and if a biopsy cannot be done safely in the recurrence, then see if they could get a liquid biopsy – have blood drawn to find it. So, I think that patients should be asking about this. Sometimes, insurance won’t always cover it, and so, my job as a treating physician is to advocate for that, to do an appeal.

More and more, because we have so many actionable mutations in breast cancer now, I’m not having insurance decline, but occasionally, it does, and then it’s our job as the healthcare providers to make the case that yes, this will impact the patient, and yes, it should be covered by insurance.

Katherine:

You’ve been referring to a number of terms. Patients may have heard the BRCA or “braca” that relate to breast cancer in genetics. Would you give us an overview of common mutations in breast cancer?

Dr. Gralow:

So, of the mutations that we can inherit, the first two that were discovered were BRCA1 and BRCA2, and for all breast cancer – not just metastatic, but all breast cancer – we think that maybe 5-10% of breast cancer is the direct result of the inheritance of a strong gene that gives you a high – not 100%, but a high likelihood of developing breast cancer.

So, for BRCA1 and 2, these two genes are associated predominantly with breast and ovarian cancer, and if you live out your normal lifespan, you could have up to a 75-80% chance of getting one of those two cancers, and breast cancer being more common. Also, some association with some other cancers including, interestingly, prostate cancer, which we’re learning more about.

So, BRCA1 and 2 are the most common, and they tend to be found – because they have such a high association with the risk of breast and ovarian cancer, they tend to be found in families that have a lot of other breast cancers, and also breast and ovarian cancer presenting at a younger age. So, you’ve inherited a gene that leads to a high predisposition, and the cancer occurs earlier.

So, whereas the average age of diagnosis of breast cancer in the U.S. is 61-62 most commonly, in a patient who’s inherited a BRCA1 or 2 gene mutation, it’s closer to 40-42 – so, a lot younger. And then, there are a variety of other genes that can be inherited that are either much less common or have a weaker link. So, for example, there are genes called CHEK2 or PALB2, ATM, P53 – I just mention that because some of the listeners will potentially have one of those mutations or have heard it. Those are either rarer or they’re associated with a weaker chance of getting cancer.

So, those might be more commonly found in a family that doesn’t have a lot of cancer in it because a carrier – the mother or the father – and their other relatives would have maybe only a 30% chance of getting breast cancer in some cases. So, there would be a lot of carriers who don’t get cancer.

So, as I mentioned earlier, I think it’s really important – especially right now in metastatic breast cancer – that pretty much everybody, even if you didn’t have a strong family history, even if you weren’t diagnosed at a young age, get tested because if we find one of these inherited mutations, we now have some additional treatment options, especially right now, approved for BRCA1 or 2, but clinical trials going on for many of these other genes.

Katherine:

How do these mutations affect disease progression and prognosis?

Dr. Gralow:

So, most of the genes I’ve mentioned – in their normal state, they’re critical, actually. They’re called DNA repair genes, and their job in our life is when we accidentally make a mistake when we’re replicating our DNA and two cells are dividing, if there’s a mistake in the DNA, they go in and repair it. And, we’ve got all kinds of mechanisms to try to prevent mutations from happening as cells divide, and BRCA1 and 2 are a key part of that, and so, they’re fixing it.

So, if you inherit a mutation in one of those genes, you still have some ability to repair any routine mistakes that are being made, but over time, you have less ability, and then, if you get a cancer that has a deficiency in BRCA1 or 2, those cancers can be more sensitive to certain kinds of chemotherapy that affects DNA repair.

So, for example a class of chemotherapy agents called the platinum drugs – carboplatin and cisplatin – may be more effective in BRCA1- or 2-mutated cancers, also more generally in triple negative breast cancer because they can be more similar to BRCA1-mutated cancers in a lot of ways.

So, to go back to your original question, once a cancer has developed in a patient who has a BRCA1 or 2 mutation, we treat that cancer for what it is. So, it might have developed estrogen – have estrogen receptor on the surface or HER2, so we treat it as the subtype that developed, and actually, the chance of cure is just the same for BRCA1-associated breast cancer as it would be for one that doesn’t have a BRCA.

But, the chance of getting a second breast cancer – a totally new breast cancer – would be higher unless you chose to remove both of your breasts and the bulk of your breast tissue. So, decisions like surgery – if you had a known BRCA1 mutation, we’d treat the cancer you have now aggressively and for cure, but when you talk about your surgery options, we’d say doing more aggressive surgery, like removing both of your breasts – that’s not gonna improve your chance of surviving the cancer you have now, but it will markedly reduce the chance of getting a second breast cancer.

So, you could consider that as an option for surgery – not to improve your chance of this cancer, but to reduce the chance of another breast cancer. So, your surgery decisions might be impacted by knowing your BRCA1 or 2 mutation. And then, clearly, if you had metastatic breast cancer, knowing if you had the option of a PARP inhibitor, one of the drugs in that class could be – you could have a different treatment option for drug therapy.

Katherine:

Well, Dr. Gralow, what other factors should be taken into consideration with a treatment route?

Dr. Gralow:

I always like to think of the treatment decision as relying on three factors, and the first relates to the tumor factor, the cancer factor.

So, we talked a lot about the biology, the estrogen receptor, the HER2, the genomic profiling. So, that’s critical, but there are two other components that we need to really strongly consider when trying to devise the right treatment regimen. One of those is patient factors, and not just the patient’s genetics, but are they pre- or post-menopausal?

What is the age? Where are they in life? Are they young with young kids? Are they working, and is that an important priority for them? Are they older and with grandchildren, and they don’t need to work? What is it that would be critical? What are the patient’s priorities here, and what are their fears, what are the things they would – what would be really important as we plan a regimen? And so, the patient factors which would be patient priorities and where they are in life right now.

And then, there’s factors related to the treatment itself, which would include not just how effective it is, but – and, this is really important when trying to decide regimens – what are the side effects of a regimen? For some patients, hair loss is a big deal, and we can put it off as long as possible – maybe choosing the first couple regimens don’t cause hair loss sometimes.

But, for other people, that doesn’t matter to them. For some, we have oral – some regimens, and that could keep them out of the infusion room, and others actually – I’ve had patients who actually like coming into the infusion room regularly so that they can review the side effects and get the reassurance provided by it. So, we’ve got different route of administration of the drugs, different side effects. If you already had, for example, a neuropathy – a numbness/tingling of fingers and toes – from treatment that you might have gotten for early-stage disease, we’d probably want to avoid drugs where that’s their major side effect in the metastatic setting and that would increase that even further.

We’ve got some drugs that cause a lot of toxicity to our GI system – nausea, vomiting, or diarrhea – and other drugs that don’t. And so, understanding what symptoms the patient already has and actually tailoring the treatment based on some of the side effects of the drug could also be done, as well as how they’re administered. So, again, patient factors, tumor factors, and then, factors related to the treatment itself all come into play when we make decisions.

Katherine:

There have been so many advances in breast cancer research. What are you excited about in research right now?

Dr. Gralow:

Well, every single drug that’s been approved, every single new regimen that’s been approved in breast cancer is the direct result of clinical trials, and this is a major part of my career, is to help patients get access to clinical trials and run important clinical trials that could lead to new discoveries – is this regimen better? What’s the toxicity?

Because until we have a cure for breast cancer, we need to do better, and we need to research better treatment options. So, doing trials, having access to clinical trials where you can participate, help move the science forward is key.

I think where we’re moving with breast cancer is the more we’re understanding the patient and the tumor, the more we’re realizing every single breast cancer is different, actually, and whereas when I started my training 20-plus years ago, breast cancer was breast cancer – we weren’t even using HER2 yet, we were just learning how to use estrogen receptor, and we kind of treated everything the same – now, we’re subsetting, and subsetting, and subsetting. Even in triple negative breast cancer now, which is about 18-20% of breast cancer, we’re subsetting.

Does that triple negative breast cancer have PD-L1, which is associated with being able to get immunotherapy drugs? Does it express androgen receptor? Because sometimes, even a breast cancer that doesn’t have estrogen or progesterone receptor can express the androgen receptor, like prostate cancer, and we can use some prostate cancer drugs. So, even triple negative breast cancer we’re subsetting and subsetting, and could that triple negative breast cancer be associated with a BRCA1 or 2 mutation, and then we can use the PARP inhibitors?

So, I’m actually really excited about that we’re learning more and more, and subsetting, and not treating breast cancer as one size fits all, and if we can better tailor the treatments to the patient and the tumor, that we are going to get to the point where I can tell my patients yes, we can get cures in metastatic breast cancer.

Katherine:

For patients who may be hesitant to speak up – to advocate for themselves in the process – I’m gonna start again. For patients who may be hesitant to speak out for themselves and advocate for their own care and treatment, what advice do you have?

Dr. Gralow:

You have a whole team who’s behind you, and I’m the MD on the team, but I’ve got a nurse practitioner, and a nurse, and a scheduler, and a social worker, and a nutritionist, and a physical therapy team, and financial counselors. I’ve got a whole team who works with me. And so, a patient might be hesitant to speak up during the actual appointment with their physician. It’s a short amount of time. I would recommend come into it with written-down questions because things go fast. You don’t get a lot of time with your doctor.

Things go fast, but don’t come in with 25 questions, either. Pick your top few that you want to get taken care of this visit because if you come in with 25 or 30, you’re gonna lose the answers to most of them. Maybe bring somebody with you who’s an advocate and a listener for you who could be taking notes, so you can process and you don’t have to write it down, or ask if you can record it. It’s really important if you’re newly diagnosed or maybe there’s a progression and you’re going on a new treatment. That’s okay too.

But, I would also say you have a whole team behind you, so sometimes, if you don’t have time or if you’re hesitant to speak up in your doctor’s visit, you can ask the nurse, or maybe you can ask the social worker for help, even. See if there’s support groups around.

Interestingly, we’ve got a peer-to-peer network where patients can request to talk to somebody else who’s matched to them by some tumor features, and their stage, and things like that. Maybe finding somebody else who’s gone through something similar, and somebody independent to talk to instead of relying on your family.

It can also be really helpful to talk to a therapist or a psychologist about your fears, and sometimes, you want to be strong for your family, strong for your children and all, but you need a safe space with somebody that you can just express your fears and your anger if that’s what’s going on, or your depression or anxiety to while you’re trying to hold a strong face for others in your family. So, I would encourage patients to look at who is the whole team and talk to the other members of the team as well, and sometimes, they can help advocate.

Also, find somebody who might be able to come to your appointments with you, somebody who will help you advocate or remind you – “Didn’t you want to ask this question?” – or be another set of ears that you can process it with afterwards.

Katherine:

Dr. Gralow, we’ve covered a lot of useful information today for patients. Thank you so much for joining us.

Dr. Gralow:

Thank you, Katherine.

Katherine:

And, thank you to all of our partners. To learn more about breast cancer and to access tools to help you become a proactive patient, visit powerfulpatients.org. I’m Katherine Banwell.

Screening for Breast Cancer: Is It Worth It?

February 10, 2020/in BC Podcasts T, BC Testing, Breast Cancer /by Kara Rayburn

This breast cancer podcast was originally published by JN Learning here.

Coverage of Breast Cancer Screening and Prevention Services

February 5, 2020/in BC Access and Affordability, BC Blog AA, Breast Cancer /by Kara Rayburn

This was originally published by The Kaiser Family Foundation on September 26, 2019 here.

Among women in the United States, breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death. In 2016, an estimated 3.5 million women in the U.S. were living with breast cancer. The Affordable Care Act (ACA) and many state laws have provisions that assure that most women with private insurance, Medicaid, and Medicare have coverage for breast cancer screening services. This typically includes screening mammography for the general population of women, but also can include genetic testing and preventive medications for high-risk women over the age of 35. This factsheet discusses breast cancer screening and prevention services, and reviews the scope of private and public insurance coverage, as well as access to those services for women in the US.

Breast Cancer in the United States

Breast cancer is the most commonly diagnosed cancer among women in the U.S. and makes up 15% of all new cancer diagnoses. Approximately 1 in 8 women (12.8%) will be diagnosed with breast cancer during their lifetime.

In 2019 there will be an estimated 268,600 new cases of female breast cancer and 41,760 deaths attributable to breast cancer.
Breast cancer is most commonly diagnosed among middle-aged and older women, with 70% of new cases diagnosed among women 55 and older (Figure 1).

Figure 1: Seven in Ten Cases of Breast Cancer are Diagnosed Among Women 55 and Older

Most breast cancers are diagnosed at an early stage. Sixty-two percent of breast cancers diagnosed are localized, meaning they are found only in the part of the body they started, while 6% of cases diagnosed have metastasized, meaning the cancer has spread to other regions of the body.
Risk factors for breast cancer include but are not limited to: a family history of breast cancer, genetic predispositions, personal history with breast cancer, breast density, obesity, drinking alcohol, early menstruation, delayed childbearing and having fewer children.
In the U.S., while white women have the highest incidence of breast cancer, black women have higher breast cancer mortality rates (Figure 2). These disparities are likely attributable to a combination of factors, such as differences in stage at diagnoses, tumor biology, and genetics, as well as disparities in access to screening, follow up care and treatment.

Figure 2: White Women Have the Highest Incidence of Breast Cancer, but Mortality Rates are Higher Among Black Women

Although very rare, men can develop breast cancer. In 2019, there will be approximately 2,670 cases of male breast cancer diagnosed and 500 deaths.

Coverage for Breast Cancer Screening and Prevention

While several health organizations issue guidelines for breast cancer screening and prevention, private insurance coverage of preventive services under the ACA is governed by recommendations from the United States Preventive Services Task Force (USPSTF) and the Health Resources and Services Administration (HRSA). Under these guidelines, private group and individual insurance plans and state Medicaid expansion programs must cover the following breast cancer screening and prevention services at no cost to the consumer: 1) screening mammography at least every 2 years and as frequently as once a year for women ages 40 to 74 with average-risk for breast cancer; 2) genetic counseling and testing for mutation of the BRCA1 and BRCA2 genes in some women with a personal or family history of breast, ovarian, fallopian tube, or peritoneal cancer; 3) preventive medication for some women with elevated risk of breast cancer and at low risk for adverse medication effects (Table 1). Some medical professionals recommend other services, such as screening MRIs for women at higher risk for breast cancer, but these services are not currently subject to the ACA’s preventive services coverage requirement.

Table 1: Breast Cancer Preventive Services Covered Without Cost-Sharing
Preventive Service	Target Population	Recommendation
Breast Cancer Screening (HRSA & USPSTF)	Women ages 40 to 74 with average-risk for breast cancer (HRSA)Women age 50-74 (USPSTF)	Screening mammography at least every 2 years and as frequently as once a yearScreening mammography every 2 years
BRCA- Related Cancer: Risk Assessment, Genetic Counseling and Genetic Testing (USPSTF)	Women with a personal history or family history of breast, ovarian, tubal, or peritoneal cancer or ancestry associated with BRCA 1 and/or 2 gene mutation	Primary care clinicians should assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 (BRCA1/2) gene mutations with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing.
Breast Cancer: Medications for Risk Reduction (USPSTF)	Women age 35+ at increased risk for breast cancer	Clinicians should offer to prescribe risk reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effect

NOTE: Women with family members with breast, ovarian, tubal, or peritoneal cancer should be screened with one of several screening tools designed to identify a family history that may be associated with an increased risk of breast cancer.
SOURCE: Kaiser Family Foundation. Preventive Services Tracker. As of September 2019.

Mammography

Mammography is a low-dose x-ray procedure that provide images of the internal structures of the breast and is the most common screening test for breast cancer.
Current HRSA guidelines, which define no-cost coverage standards for private insurance, recommend biennial screening mammography to start no earlier than age 40 and no later than age 50 for average-risk women and continue through at least age 74, while the USPSTF breast cancer screening guidelines recommend biennial screening mammography for women aged 50 to 74, and states that starting mammography screening before age 50 should be an individual decision based on preference and patient values. The USPSTF also concludes that there is insufficient evidence to assess the benefits and harms of screening mammography for women 75 years and older.
In 2015, 58% of women ages 40-49 and 72% of women ages 50-74 reported having had a mammogram in the past two years (Figure 3). Overall, between 2000 and 2015, mammography rates stayed relatively stable. Black women (70%) and women with some college education and more (71%) have the highest mammography rates (Appendix Table 1).

Figure 3: Mammography Use in the United States by Age Group and Insurance Coverage

Mammography rates vary by state. Ohio and Kansas reported the highest mammography rates (81%) in the nation, while Connecticut reported the lowest rates at 61% (Figure 4 & Appendix Table 2).

Figure 4: Mammography Rates Vary Across States

Research shows that women with insurance coverage are more likely to report having had a mammogram in the past two years. In 2015, only 30% of uninsured women ages 40 to 64 reported having had a mammogram in the past two years compared to 72% of privately insured women and 58% of women with Medicaid coverage (Figure 3).
Most professional guidelines suggest starting mammography after age 40, but 47% of women believe women without a family history of breast cancer should begin mammography screening before age 40 (Figure 5).

Figure 5: Almost Half of Women Think Women Without Family History of Breast Cancer Should Begin Mammography Screening Before Age 40

Genetic Testing and Screening for BRCA1/BRCA2 Mutations

Mutations to BRCA1 and BRCA2, tumor suppressor genes, increase the risk of female breast and ovarian cancers, as well as Fallopian tube, peritoneum, pancreatic, and skin cancers. While almost 13% of women in the general population will develop breast cancer at some point in their lives, 72% of women who have inherited the BRCA1 mutation and 69% of women who have inherited the BRCA2 mutation will develop breast cancer by the age of 80.
Factors associated with an increased likelihood of having a harmful BRCA1 or BRCA2 mutation include: breast cancer diagnoses before age 50, cancer in both breasts, both breast and ovarian cancers in the same individual, multiple cases of breast cancers, two or more BRCA1 or BRCA2 related cancer deaths in the family, cases of male breast cancer, and being of Ashkenazi Jewish descent.
Currently, the USPSTF recommends that primary care providers screen women with a personal or family history of breast, ovarian, tubal, or peritoneal cancers or have an ancestry associated with BRCA 1/ 2 gene mutations with one of several screening tools for an increased risk in BRCA genetic mutations. The USPSTF recommends that women with positive screenings receive genetic counseling and if necessary BRCA genetic testing.

Preventive Medication

The use of medications to help reduce the risk of or delay the onset of cancer is called chemoprevention. The drugs tamoxifen, raloxifene, and aromatase inhibitors reduce primary breast cancer risk in postmenopausal women.
The USPSTF recommends that clinicians should discuss and offer to prescribe these risk-reducing medications to some women 35 and older who are at an increased risk for breast cancer and at low-risk for adverse medication effects. Women who are not at an increased risk for breast cancer should not take these medications.

Coverage and Utilization of Services

Most women with public and private insurance have coverage for breast cancer screening services, but the scope of coverage can differ based on the type of insurance plan, how they qualify for Medicaid, and in the case of Medicare, where they live. While there are programs to assist uninsured and underrepresented women, these programs only reach a fraction of eligible women.

Private Individual and Group Insurance Plans—The ACA requires most private group and individual insurance plans, including most employer plans, to cover all services rated by the USPSTF with an “A” or “B” without consumer cost-sharing, as well as preventive services for women recommended by HRSA. Plans must cover the full cost of mammograms starting at age 40, genetic screening for high-risk women, and breast cancer preventive medication for high risk women under this policy.
Medicaid— Women who qualify for Medicaid based on their state’s decision to expand Medicaid under the ACA are entitled to the same screening and preventive services as women who are covered by private insurance. For women who qualify based on other traditional eligibility pathways, breast cancer screening and preventive services are considered “optional” under traditional Medicaid programs and the scope of coverage is determined by the state. A 2015 state survey of Medicaid programs, however, found that most states cover breast cancer screening and prevention services under expansion and traditional eligibility pathways.
Medicare—Medicare Part B covers annual screening mammograms at no-cost for women 40 and over. Coverage for BRCA genetic testing is not required nationally, but may be covered in some regions based on local coverage determinations. Women enrolled in a Medicare Part D drug plan who are at high risk for breast cancer may have coverage for chemoprevention drugs, but there is no requirement for Part D plans to cover these drugs without cost sharing.
TRICARE—TRICARE, the public program for military personnel and dependents, covers screening mammography for women 40 and older, BRCA genetic counseling, and chemoprevention, but is not required to offer coverage without cost-sharing. Out-of-pocket costs for consumers vary by an individual’s specific level of TRICARE coverage and active duty status.
The National Breast and Cervical Cancer Early Detection Program (NBCCEDP)—The NBCCEDP helps low-income, uninsured, and underinsured women gain access to breast and cervical cancer screening, diagnostic services, and referrals to treatment. Uninsured and underinsured women are eligible for the program if they are at or below 250% Federal Poverty Level (FPL) and are between the ages of 40 to 64 for breast cancer screenings. Although about 10% of U.S. women are eligible for the NBCCEDP breast cancer screenings, the program only serves about 11% of those who are eligible. In 2017 almost 192,000 women received NBCCEDP funded mammograms.
The Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA)—Passed in 2000, the BCCPTA gives states the option to extend Medicaid coverage to uninsured women under 65 who are diagnosed with breast or cervical cancer through NBCCEDP screening programs. Although all states adopted this option, states have different eligibility requirements. In 20 states and DC, women are only eligible for Medicaid coverage if their screening and diagnosis was paid for by NBCEEDP funds; in 14 states women are eligible for Medicaid if their provider receives NBCEEDP funds or the services provided fell within the scope of the NBCEEDP grant; and in 16 states women are eligible for Medicaid coverage for treatment regardless of where they were screened as long as they meet the other eligibility criteria. In 2013, almost 57,000 uninsured women with a breast cancer diagnosis gained Medicaid coverage through the BCCPTA.
While many women now receive no-cost coverage for mammography services, women who get diagnostic mammograms, those who get preventive services out-of-network or who are in grand-fathered plans may be subject to co-payments, cost-sharing or deductibles. In the 2017 Kaiser Women’s Health Survey, 16% of women with private insurance reported paying out-of-pocket costs for a mammogram, compared to 3% of women with Medicaid coverage and 11% of uninsured women.

Appendix Table 1

Appendix Table 2

Appendix Table 2: Mammography Rates by State, 2014-2016

Percent of women ages 40 and older who report having had a mammogram within the past 2 years

State	All Women	White	Black	Hispanic	Asian & Native Hawaiian or Pacific Islander	American Indian/ Alaska Native
United States	73%	73%	78%	72%	72%	67%
Alabama	73%	71%	79%	n/a	n/a	68%
Alaska	79%	79%	83%	70%	n/a	n/a
Arizona	75%	71%	79%	67%	n/a	n/a
Arkansas	76%	75%	80%	77%	77%	n/a
California	75%	73%	81%	60%	72%	n/a
Colorado	78%	76%	n/a	79%	79%	n/a
Connecticut	61%	62%	n/a	47%	n/a	n/a
Delaware	73%	73%	79%	72%	n/a	n/a
DC	67%	67%	73%	69%	n/a	n/a
Florida	74%	74%	80%	73%	n/a	n/a
Georgia	63%	62%	n/a	n/a	n/a	68%
Hawaii	71%	72%	74%	57%	n/a	63%
Idaho	74%	74%	76%	n/a	n/a	n/a
Illinois	74%	72%	78%	73%	n/a	n/a
Indiana	77%	77%	n/a	n/a	n/a	60%
Iowa	78%	77%	84%	77%	69%	71%
Kansas	81%	81%	81%	83%	82%	n/a
Kentucky	75%	75%	79%	72%	78%	n/a
Louisiana	76%	77%	75%	72%	59%	69%
Maine	68%	67%	71%	n/a	n/a	n/a
Maryland	69%	68%	77%	79%	n/a	n/a
Massachusetts	68%	68%	n/a	54%	n/a	66%
Michigan	69%	70%	70%	55%	n/a	56%
Minnesota	68%	67%	69%	70%	70%	n/a
Mississippi	78%	78%	n/a	n/a	n/a	n/a
Missouri	75%	74%	80%	79%	71%	n/a
Montana	65%	65%	n/a	66%	n/a	64%
Nebraska	74%	74%	77%	79%	67%	63%
Nevada	76%	76%	78%	62%	n/a	71%
New Hampshire	72%	73%	n/a	n/a	n/a	67%
New Jersey	73%	72%	78%	70%	n/a	88%
New Mexico	70%	70%	76%	67%	61%	63%
New York	68%	67%	70%	62%	n/a	72%
North Carolina	69%	70%	n/a	62%	n/a	n/a
North Dakota	72%	72%	76%	69%	n/a	n/a
Ohio	81%	81%	75%	80%	n/a	n/a
Oklahoma	72%	71%	77%	58%	n/a	n/a
Oregon	75%	75%	n/a	n/a	n/a	71%
Pennsylvania	72%	72%	78%	n/a	n/a	n/a
Rhode Island	69%	69%	72%	66%	73%	64%
South Carolina	67%	68%	n/a	61%	n/a	n/a
South Dakota	66%	66%	72%	n/a	n/a	n/a
Tennessee	73%	73%	n/a	n/a	n/a	n/a
Texas	75%	75%	84%	70%	61%	n/a
Utah	71%	71%	75%	64%	73%	62%
Vermont	72%	72%	75%	n/a	n/a	n/a
Virginia	75%	76%	76%	n/a	n/a	n/a
Washington	63%	64%	n/a	60%	n/a	n/a
West Virginia	76%	77%	83%	74%	76%	n/a
Wisconsin	64%	67%	n/a	74%	64%	n/a
Wyoming	79%	n/a	n/a	79%	n/a	n/a

Breast Cancer Treatment and Side Effects

February 5, 2020/in BC Resource TC, BC Treatment & Clinical Trials, Breast Cancer /by Kara Rayburn

This was originally published by breastcancer.org here.

In recent years, there’s been an explosion of life-saving treatment advances against breast cancer, bringing new hope and excitement. Instead of only one or two options, today there’s an overwhelming menu of treatment choices that fight the complex mix of cells in each individual cancer. The decisions — surgery, then perhaps radiation, hormonal (anti-estrogen) therapy, and/or chemotherapy — can feel overwhelming.

Breastcancer.org can help you understand your cancer stage and appropriate options, so you and your doctors can arrive at the best treatment plan for YOU.

In the following pages of the Treatment and Side Effects section, you can learn about:

Planning Your Treatment: What types of treatment are available, the most likely sequence of treatments, treatment options by cancer stage, and fitting treatment into your schedule.
Getting a Second Opinion: Reasons for getting a second opinion about your treatment plan, how to go about getting one, and what to do once you’ve got it.
Surgery: Breast-conserving surgery (lumpectomy), mastectomy, and lymph node dissection, and what to expect from each. Also included: Prophylactic surgery and breast reconstruction.
Chemotherapy: How chemotherapy works, who should get it, different types and combinations, and side effects and how to manage them.
Radiation Therapy: How radiation therapy works, who it’s for, advantages, side effects, and what to expect when you get it.
Hormonal Therapy: The link between hormones and breast cancer and how different groups of drugs — including ERDs, SERMs, and aromatase inhibitors — can affect that link. Also covered: Side effects of hormonal therapies.
Targeted Therapy: How different drugs work, who should get them, how they’re given, side effects, and major studies.
Immunotherapy: What is immunotherapy, different types of immunotherapy, and who it’s for.
Complementary and Holistic Medicine: How complementary medicine techniques such as acupuncture, meditation, and yoga could be a helpful addition to your regular medical treatment. Includes research on complementary techniques and ways to find qualified practitioners.
Drugs for Treatment and Risk Reduction: A reference list of drugs used to treat and reduce the risk of breast cancer, including how they work, to whom they are typically given, and side effects.
Treatments for Pain: Ways to treat cancer- and treatment-related pain, including types of medications and tips on talking to your doctors about pain.
Treatment Side Effects: A reference list of side effects and ways to manage them.
Lymphedema: All about lymphedema, including who is at risk, what to watch out for, how to reduce risk of lymphedema flare-ups, and how to find a lymphedema therapist.
Clinical Trials: What clinical trials are and how they work, why they’re important, and how to find trials that may be appropriate for you.

A New Standard of Care for HER2-Positive Metastatic Breast Cancer?

February 5, 2020/in BC Podcasts TC, BC Treatment & Clinical Trials, Breast Cancer, MBC Treatment and Clinical Trials, Metastatic Breast Cancer /by Kara Rayburn

This podcast was originally published by Dr. Rashmi Murthy on December 11, 2019 on breastcancer.org here.

Dr. Rashmi Murthy, assistant professor of breast medical oncology at the University of Texas MD Anderson Cancer Center in Houston, discusses the results of the HER2CLIMB study that she presented at the 2019 San Antonio Breast Cancer Symposium showing that the experimental medicine tucatinib offers benefits to people diagnosed with HER2-positive metastatic breast cancer and may be a new standard of care.

Listen to the episode to hear Dr. Murthy explain:

A summary of the study results
Why this study included people with brain metastases
The side effects of tucatinib
Why she thinks the results are practice changing

5 Things Newly Diagnosed Breast Cancer Patients Should Know

February 5, 2020/in BC Newly Diagnosed, BC Resource ND, Breast Cancer /by Kara Rayburn

This was originally published by Cynthia Demarco on April 19, 2019 on MD Anderson Cancer Center here.

If you’ve just received a breast cancer diagnosis, you probably have a lot of questions: What type of breast cancer do I have? How advanced is it? Do I qualify for any clinical trials? Can my doctor provide the treatment I need?

Before you start making treatment plans and scheduling appointments, here are five things to know.

Get an accurate diagnosis before starting treatment

Not all breast cancers are the same, so it’s important to get an accurate diagnosis right from the start. This is particularly true if you have a rare or very aggressive form of the disease, such as inflammatory or triple-negative breast cancer.

That’s because the type of breast cancer, as well as its stage and location, can determine the types of treatment you’ll be offered, as well as those you’re not eligible for.

“We offer precise treatments based on precise diagnoses,” says Lavinia Middleton, M.D. “That’s why I believe everyone should get a second opinion. A second opinion can be a game-changer. About 25% of our patients will see a change in their diagnosis.”

Where you go first for breast cancer treatment matters

All patients who come to MD Anderson will have their diagnoses confirmed by our doctors. This ensures that your cancer is both correctly identified and accurately staged — two crucial steps in determining which treatment plans you’ll be offered.

“Your first shot is your best shot at beating cancer,” says Makesha Miggins, M.D. “So, when patients come to us after they’ve already been elsewhere, their cancer treatment is often more challenging. That’s why I tell people to come to MD Anderson first.”

“If my cancer had been just a little more advanced, it would have been considered stage IV, and my care would have been palliative instead of curative,” adds Jenée Bobbora, an inflammatory breast cancer survivor. “But my doctor insisted that my cancer was at stage IIIc, not IV, so my treatment included chemotherapy, a double mastectomy and radiation. And I’ve shown no evidence of disease since 2003.”

Seek out the experts for your breast cancer diagnosis and treatment

It’s also critical to choose a cancer center with extensive experience in treating your particular type of breast cancer.

MD Anderson sees thousands of breast cancer patients annually, and has entire teams of specialists focused on specific types of breast cancer, such as triple-negative and hereditary cancers.

“Not only can we identify rare types of cancer with confidence, we can also keep women from having invasive diagnostic procedures for conditions that are not cancer,” says Therese Bevers, M.D.

“Breast cancer can have so many different variables,” adds Kelly Hunt, M.D. “And each one influences our treatment recommendations, because each one can significantly impact a patient’s response to different therapies. It’s critical to know these things before leaping in, because often by doing chemotherapy or targeted therapy first, we’re able to shrink the tumor and eradicate cancer in the lymph nodes involved. That means we can do less surgery and still have excellent long-term results.”

Consider clinical trials for your breast cancer treatment

Clinical trial options exist for virtually every type and stage of breast cancer. But some clinical trials for breast cancer are limited to patients who have not yet begun treatment. That’s why it’s important to discuss your options with your physician as early as possible.

Over the past few years, clinical trials at MD Anderson have allowed our breast cancer patients to avoid double mastectomies, have tumors removed painlessly without general anesthesia, and explore more personalized treatment options.

“My trial was unique because I was able to start with traditional chemotherapy and move on to other treatments only if that didn’t work,” says breast cancer survivor Barbara Lewis, of the immunotherapy clinical trial she participated in. “Only seven months after diagnosis, there were no traces of cancer in my body. That’s about the best result you can get.”

Make multidisciplinary care mandatory

No matter what type of breast cancer you have, it’s crucial to seek treatment at a cancer center that offers multidisciplinary care. This approach, which was pioneered here at MD Anderson, brings together all of the specialists you’ll need for your care — such as oncologists, surgeons, radiation oncologists, etc. — to formulate your treatment plan.

Coordinating patient care as a team ensures that every aspect of an individual’s situation is taken into account from the start. It also makes it easier for your care team to adapt and make changes to your treatment as it evolves.

“It’s all about preserving options,” Hunt says. “I see patients all the time who were treated elsewhere with surgery first, when that might not have been the best approach. Now, they need more surgery or other treatments. And they’re painted into a corner, because they have fewer options. Our comprehensive approach means patients don’t have to go through multiple procedures to get the best results.”

Multidisciplinary care also gives patients easy access to any additional support services they might need, such as social work counselors, dietitians, physical therapists, lymphedema specialists and support groups.

“My gynecologist gave me the name of three Houston oncologists to choose from, but it was up to me to check them out,” adds Helen Vollmer, on the challenging start to her breast cancer journey. But once she got to MD Anderson’s Breast Multi-Team Clinic, “It was all confined to one, incredibly caring place with a team who talked to each other and, more importantly, to me.”

Examining the Link Between Gestational Diabetes and Breast Cancer

October 29, 2019/in BC Blog ND, BC Newly Diagnosed, Breast Cancer, PEN Blog /by Kara Rayburn

Approximately 12% of all U.S. women will develop invasive breast cancer during the course of their lives. There are a number of common risk factors associated with breast cancer, such as excessive alcohol consumption, obesity, genetic mutations like BRCA1 and BRCA2, and a family history of breast cancer. In recent years, the link between diabetes, and particularly gestational diabetes, and cancer has been examined more closely to determine whether this group of women are especially at risk. A better understanding of gestational diabetes and its long-term effects make it significantly easier to understand its link to breast cancer.

What exactly is gestational diabetes?

Gestational diabetes develops during pregnancy and can, when untreated, cause health complications for mother and baby. When a woman has gestational diabetes she will display high blood sugar levels that typically return to normal after the pregnancy. Although any complication during pregnancy can be alarming, it is important to note that gestational diabetes can generally easily be controlled through a healthy diet, regular exercise, and in extreme cases, medication. While gestational diabetes does not necessarily result in serious complications, it is important to be aware of the risks for both mom and baby.

The link between gestational diabetes and breast cancer

Although women with gestational diabetes do not present an increased risk of breast cancer according to studies that have been conducted, it does increase their risk of contracting type 2 diabetes later on. In fact, up to 10% of all women who had gestational diabetes will develop type 2 diabetes according to the National Institutes of Health. This can occur anywhere from within a few weeks after delivery to months or even years later.

Type 2 diabetes proven to increase breast cancer risk

The risk for developing breast cancer is significantly higher among women with type 2 diabetes according to findings published in Diabetes Care. Postmenopausal women above the age of 50 are most at risk with a 27% increased risk of breast cancer. Type 2 diabetes triggers a number of changes in the body such as high insulin level, high glucose levels, and increased inflammation that may increase breast cancer risk. The connection between type 2 diabetes and breast cancer may also be a two-way street as breast cancer survivors could be at an increased risk of developing diabetes following chemotherapy.

Despite gestational diabetes not having a direct impact on breast cancer risk it can, in a more indirect way, increase the risk. By following a healthy lifestyle after a gestational diabetes diagnoses it is possible to reduce the risk of type 2 diabetes later in life which has directly been linked to the onset of breast cancer.

Ten Things I Wish I Had Known When I was Diagnosed with Breast Cancer

October 21, 2019/in BC Blog ND, BC Newly Diagnosed, Breast Cancer, PEN Blog /by Marie Ennis-O'Connor

As soon as the first golden leaves of autumn appear on the trees a feeling of sadness starts to descend over me. I’m catapulted back over the years to a late September day. A day that’s etched forever on my mind. The day I was diagnosed with breast cancer.

In the weeks that followed my diagnosis, I became enveloped in a sea of pink as Breast Cancer Awareness Month took place. But when October came to an end and the pink ribbon wearers disappeared, I was left wearing the everyday reality of the disease. Over a decade has passed since then and yet I still feel a sense of sadness when I think of that time and all I had yet to learn and go through. I can’t help wondering how much my experience might have been different if I had known then what I know now.

One thing I now know is that we owe it to those who come after us to share our hard-earned wisdom. So in that spirit, here are ten things I wish I had known back when I was a newly diagnosed patient. I hope sharing these lessons may make the path towards recovery that little bit smoother for others who are new to this journey.

1. Everything in your life is about to change

Once you’ve been baptized in the fire of cancer your life as you knew it will be irrevocably changed. The apparent randomness of a cancer diagnosis can shake your sense of identity to its very core and afterwards nothing will ever feel certain again. Cancer invades not only your body but every other area of your life, including your relationships, family life, friendships, finances, career, and even your sense of self. You may be surprised to find the people you thought you could count on disappear from your life. At the same time, you will be surprised to find support can also come from unexpected sources.

2. Online support is real

Among those unexpected sources will be the people you meet online. Online communities may be virtual but they are no less real in terms of support and advice. On Facebook and Twitter you can find patient communities which will be an invaluable source of information and support to you. Check out the #BCSM Twitter chat – a weekly chat for breast cancer patients and their caregivers.

3. You will feel fearful and anxious

One of the most common emotional and psychological responses to the experience of cancer is anxiety. Cancer is a stressful experience and normal anxiety reactions present at different points along the cancer pathway. Anxiety is a natural human response that serves a biological purpose. It’s the body’s physical “fight or flight” (also known as the stress response) reaction to a perceived threat. You may experience a racing or pounding heart, tightness in the chest, shortness of breath, dizziness, headaches, upset tummy, sweating or tense muscles. All of these signs indicate that sympathetic arousal of your nervous system has been activated, preparing you to stand your ground and fight or take flight and run away from danger.

Try this coping tip. When we are fearful and anxious we tend to breathe more shallowly. Shallow breathing, which doesn’t allow enough oxygen to enter our bodies, can make us even more anxious. Practice taking some slow deep abdominal breaths. Deep abdominal breathing slows the heart down and lowers blood pressure. The advantage of focussing on the breath is that it is always there with us. We can turn to it anytime we are feeling anxious.

4. You are your own best health advocate

Although you may be reeling from the news of a cancer diagnosis, it’s important that you learn as much as you can about your diagnosis and what treatment options are available. In this article, you will learn which questions you should ask your healthcare team and where to find reliable and trustworthy information to become better informed about your health condition.

5. Your will experience brain fog

Cognitive impairment, to a lesser or greater degree, can affect you both during and after your treatment. You may have the feeling that your cognitive abilities are slower and less acute than before – almost as if your brain is shrouded in a fog. We call this the “chemobrain” effect and the effect may persist for months or even years after treatment ends. A more formal term – post-cancer cognitive impairment (PCCI) – is used by researchers to describe a group of symptoms, which include slow mental processing, difficulty concentrating, organizing, and multitasking.

PCCI symptoms can also include:

memory loss – forgetting things that you normally remember
struggling to think of the right word for a familiar object
difficulty following the flow of a conversation
confusing dates and appointments
misplacing everyday objects like keys and glasses

It’s still not clear how many people with cancer get chemobrain or which drugs cause it. However, there are several things that you can do to help you cope with its symptoms. Read this article for more information.

6. You will experience bone-crushing tiredness

We all know what it’s like to feel tired – physically, mentally, and emotionally, but usually after some relaxation and a good night’s sleep, we are ready to take on the world again. When you have cancer, though, rest often isn’t enough. You experience a persistent, whole-body exhaustion. Even after adequate sleep or rest, you will still feel tired and unable to do the normal, everyday activities you did before with ease.

A lot of cancer patients don’t report fatigue to their doctors because they think that nothing can be done for it. In fact, there are things that can be done to alleviate the debilitating effects of cancer-related fatigue. If left untreated, fatigue may lead to depression and profoundly diminish your quality of life, so it’s important that you speak to your doctor if fatigue is an issue for you. Read How To Cope With Cancer-Related Fatigue for more tips and information.

7. You may be surprised by feelings of guilt

Cancer-related guilt is a complex emotion. You may feel guilty and worry that your lifestyle choices somehow contributed to a cancer diagnosis. If you learn that you carry the BRCA1/2 gene, you may feel guilty that you could pass this gene mutation on to your children. Or you may feel guilty that your cancer was diagnosed at an earlier stage than a friend or family member who has a worse prognosis. These feelings of guilt may surprise you, but it’s a perfectly normal reaction to a traumatic life event like cancer. Read How Do You Deal With Cancer Guilt to learn more about this topic.

8. You will feel pressured to stay in a positive frame of mind

I admit I caved in at the beginning to pressure to stay strong and positive when I was first diagnosed with breast cancer. I did it because it reassured the people around me. While I accept that for some people maintaining a positive attitude is a valid coping mechanism, for myself and many others, the pressure to always show our sunny side is a denial of our pain, anger, grief, and suffering. I now believe by promoting this attitude in the face of cancer, we create unfair expectations and deprive patients of an outlet for their darker fears. This is my personal viewpoint, and it’s one that I don’t expect everyone to share. However, I mention it here so that those who are newly diagnosed don’t feel they have to always present a smiling face to the world. It really is ok to express your fears, your sadness, your anger, and your grief too.

9. You will need time to grieve

While many people think of grief only as a reaction to bereavement, we can feel grief after any kind of loss. When we step back and look at the cancer experience we see that grief and loss are a fundamental part of the experience. Some of our losses are tangible, for example losing our hair, and some are more intangible, such as the loss of trust in our bodies.

Coping with the losses associated with cancer is challenging. Grief brings many emotions with it. Patients, as well as caregivers and family members, may go through emotions of anger, denial, and sadness. While there is no right or wrong way to grieve, there are healthy ways to cope with the pain and sadness that, in time, can help you come to terms with your loss, find new meaning, and move on with your life.

10. Cancer doesn’t end when treatment does

I wish I had been better prepared for how I would feel when cancer treatment ended. I just assumed I would pick up where I had left off and get on with my life as if cancer was no more than a blip. I wish someone had told me that cancer doesn’t end when treatment does. Sometimes, there can be a code of silence surrounding the aftermath of cancer treatment. There is an expectation that when you walk out of hospital on that last day of treatment, your cancer story has ended. But in many ways it’s only just beginning.

I now know that cancer is more complicated than simply being disease free and that a physical cure doesn’t mark the end of the healing process. Adapting to changes in energy and activity levels, adjusting to altered relationships at work and in your personal relationships, coming to terms with a changed body image, and managing pain and treatment side effects are some of the things you will face in the post-treatment phase of recovery. Be compassionate and gentle with yourself as you move through this stage of your cancer journey. Don’t judge yourself or feel pressured by others to try to hurry this stage along.

Wrapping Up

Being diagnosed with cancer is a life-changing event. You will go through many emotions and experiences throughout the roller-coaster ride of diagnosis, treatment, and beyond. Each person will experience it in their own way. While there’s no right or wrong way to go through the experience, it’s important that you don’t ever feel as if you have to go through it alone. Reach out at each step of the way and find someone who understands what you are going through and can offer you the support you need.

Marie Ennis-O'Connor

A Stanford Medicine X e-Patient scholar, Marie Ennis O’Connor is an internationally recognized keynote speaker, writer, and consultant on global trends in patient engagement, digital health and participatory medicine. Marie’s work is informed by her passion for embedding the patient voice at the heart of healthcare values. She writes about the experience of transitioning from breast cancer patient to advocate on her award-winning blog Journeying Beyond Breast Cancer.

hcsmmonitor.com/

Breast Cancer Before 40: How Can I Preserve My Fertility?

October 8, 2019/in BC Newly Diagnosed, BC Video ND, BC Video WN, BC What's Next, Breast Cancer, PEN Blog, Uncategorized /by Kara Rayburn

Breast Cancer Before 40: How Can I Preserve My Fertility? from Patient Empowerment Network on Vimeo.

Dr. Stephanie Valente discusses fertility preservation in breast cancer patients under the age of 40 and the potential for pregnancy following treatment.

Dr. Stephanie Valente is the Director of the Breast Surgery Fellowship Program at Cleveland Clinic. More about this expert here.

Related Program:

Breast Cancer Before 40: What You Should Know

Transcript:

Dr. Stephanie Valente:

So, another issue that is really important for young women is discussing fertility preservation. And this really needs to happen at the time of their diagnosis. So, we know that the cytotoxic agents that we can give females just through chemotherapy can decrease the ovary and the ability for these women to have menstrual periods after chemotherapy. So, the ability for them to get pregnant naturally.

As well as some of the medications. So, somebody who has a breast cancer that is estrogen positive, the recommendation is for these women to be on hormone suppressant medicine for five to 10 years after their breast cancer diagnosis and treatment, therefore not being able to be pregnant while on these medications. So, talking with young women when they get diagnosed about their family planning and their fertility options up front before they have surgery or chemotherapy is really beneficial.

And whether or not they need to see a fertility preservation specialist. If they want to consider IVF. Or if they have a gene, looking at genetic testing for their future offspring. So, these are all conversations that really need to happen before these women begin chemotherapy if they need it.

And the good thing is that at the young women’s clinic, these fertility specialists are embedded in the clinic. So, they are able to get an appointment with them right away. And a lot of times if these women do want to undergo fertility preservation, that can happen within 10 days of seeing the specialist. So, it really doesn’t delay their care. And we do know that it is safe even with the breast cancer diagnosis.

The other thing is that we do offer a medicine which is a GRNH agonist which will kind of essentially shut down the ovaries during chemotherapy to help protect them so that when a young woman is done with chemotherapy, it helps the ovary kind of get back to normal a little bit sooner.

So, it sounds good in theory. Unfortunately, it’s not something that is covered by insurance companies right now. And so, fertility preservation is expensive. And so, the good thing is there are a lot of groups that put together packages and stuff for these young women to be able to afford it. But it is pretty pricey. So, for those that can afford it, it is a great option. And a lot of them do take advantage of it. I think there are a lot of misconceptions about it. Number one is that patients don’t really know if it’s safe.

Number two, they are scared about their overall diagnosis and a potential delay and 10 days might make some of them afraid that doing that is a good option. Another thing is when these women come in with a diagnosis of breast cancer, they see a surgeon, a medical oncologist, a radiation oncologist, a plastic surgeon.

And so a lot of times an extra appointment at that point in time is just really overwhelming for these women. So, our goal is to kind of refocus and say, “Hey, the good news is that with our modern therapies you’re going to be here for a long time. So, let’s plan for the future now so that in the future you’ve got options.”

Breast Cancer Before 40: What You Should Know

October 8, 2019/in BC Newly Diagnosed, BC Testing, BC Treatment & Clinical Trials, BC Video ND, BC Video T, BC Video TC, Breast Cancer, PEN Blog /by Kara Rayburn

Breast Cancer Before 40: What You Should Know from Patient Empowerment Network on Vimeo.

Dr. Stephanie Valente reviews key information for women under the age of 40 with breast cancer, including risk, treatment approaches and the role of genetic testing.

Dr. Stephanie Valente is the Director of the Breast Surgery Fellowship Program at Cleveland Clinic. More about this expert here.

Related Program:

Breast Cancer Before 40: How Can I Preserve My Fertility?

Transcript:

Sure. So, when we talk about breast cancer in young women, usually we are referring to women under the age of 40. And the prevalence for breast cancer in general is one out of eight women. For women under the age of 40, it’s about a seven percent incidence of breast cancer. So, it’s about a seven percent incidence in the general population in the United States. So, that’s about 12,500 women per year are diagnosed under the age of 40 with breast cancer.

So, the prevalence has pretty much been the same over the years. We used to think that women diagnosed at a younger age had a more aggressive breast cancer. But the more we look at things, the more we realize that women under the age of 40 usually are diagnosed at a later stage because it’s not something that somebody in their 20s or 30s is thinking that a breast lump equates to cancer. So, these women unfortunately present at a later stage.

Many times, it’s because they are pregnant, breastfeeding or just not having any family history where the first thing they think of when they get a lump is that they actually have breast cancer.

So, the first thing is women under the age of 40 usually present at a later stage, meaning that they have larger cancers, and the cancers because they are larger have had more time to spread to the lymph nodes. So, these women they don’t necessarily have more aggressive breast cancers than older women, it’s just that it’s found at a later stage.

So, the treatment options are the same for young women with breast cancer. So, depending on the size of the tumor and the size of her breast, women are given the option for a lumpectomy which usually is follow by radiation versus a mastectomy. And studies have shown that either surgical choice is a good option for women. And that one surgery doesn’t make a young woman, or an older woman live any longer.

That the survival for breast cancer is based on stage not the choice of surgery that they pick.

So, one of the first things is that women under the age of 50 – the average age for breast cancer in the United States is between 64 and 68.

So, if you are under the age of 50 or under the age of 40 there’s a higher chance that maybe these women carry a gene that would increase the risk of getting breast cancer. And so nowadays, we test over 21 genes. But these genes can increase their risk of getting breast cancer not only in the breast they have the breast cancer in, but in their other breast as well. It also increases the risk for other types of cancers such as ovarian cancer. And they could potentially pass this gene on to their kids.

So, sometimes women – and this is the great thing about academic medicine. Everything is changing so quickly with the modern research. So, a lot of times a woman who is triple negative, which is an estrogen receptor negative breast cancer.

If they are genetic positive for the BRCA gene, they qualify for certain medications or chemotherapy that we know targets specifically that type of cancer and their gene. So, that’s why it is important for some of these women to get genetic testing to see if the certain chemotherapy regimens or medicines that we have would benefit their type of cancer.

So, one of the things for any woman diagnosed with breast cancer at a young age is to offer those women genetic testing. And sometimes it can be a relief or sometimes it can be very challenging for these women to think, “Oh my gosh. I have this gene. I’m at increased risk for more cancers.” And that potentially they could pass that on to their children.

So, having the women who come in meet with a genetics counselor to go over the risks. And the reality is that of all the women under the age of 50 that test for the gene, only 10 percent actually carry the gene.

So, the good thing is that 90 percent most likely don’t have the gene. But it still is an anxiety provoking thing for these women to go through.

Another thing is that these women a lot of times are younger. So, they have either two things – young children to take care of which is extremely difficult to mange an already stressful motherhood. You throw in a diagnosis of cancer, whether or not there is a dad involved or a father that needs to help out with these kids. A lot of times their families need to help out. So, we have a psych oncologist that’s part of our team. And it’s really great. How do you tell your kids you have cancer? And how do you manage kind of day-to-day life with going through this? So, that’s another great program that is offered. And importantly for a woman who doesn’t have children but maybe desires to have children or even to have more children than the ones that she has,
looking at fertility options for young women is huge.

So, we know that some of the chemotherapy that we give breast cancer patients decreases their ability to have children in the future. So, the chemotherapy can shut down the ovaries. So, sometimes women – and this is the great thing about academic
medicine. Everything is changing so quickly with the modern research. So, a lot of times a woman who is triple negative, which is an estrogen receptor negative breast cancer.

So, the one thing is that I tell these women that breast cancer takes a good year between chemotherapy if they need it, surgery, radiation of they need it and the whole process of recovery. That is really takes a good solid year before they are kind of done going to their doctor’s appointments. But the reality is that for an early stage breast cancer, studies have show for young women the overall survival is over 92 percent. So, I say, “This is going to be a tough year. We are going to get through this together. And the good thing is that you are going to be alive in five, 10, 15, 20 years. And so, our goal is to get you the best quality of life not only now but in the future.”

As far as hope for young women with breast cancer, things are changing so fast. The medicine that’s out there – we’re doing these studies where women are getting chemotherapy and by the time they get to surgery about 40 to 60 percent of the tissue that I take out has no residual cancer. That’s phenomenal. That means that the medications that these women are getting are working really well for their cancer. And so, the hope is that in 10 years I don’t have a job because the medicine that they are getting works so well that the cancer can be removed without needing surgery. And so, I think in our lifetime we will find either a cure or a complete resolution of breast cancer.

Fact or Fiction: 10 Common Breast Cancer Myths Busted

October 24, 2017/in BC Blog ND, Breast Cancer, Marie Ennis-O'Connor, PEN Blog /by Marie Ennis-O'Connor

October is Breast Cancer Awareness Month, and while many of us may think there is already plenty of awareness of breast cancer these days, it’s quite surprising how many myths exist alongside the facts. Some breast cancer myths still continue despite a lack of evidence. A survey found that agreement with the phrase: “It seems like everything causes cancer” is on the increase. The danger is that when people believe this, confusion and misinformation about risk factors also increase. This can lead to unnecessary worry and can even hinder good prevention and treatment decisions. So let’s untangle the facts from the fiction by busting ten of the most common myths which persist about breast cancer.

Myth #1: Finding a lump in your breast means you have breast cancer

Fact: Most breast lumps are caused by benign (noncancerous) changes, cysts, or other conditions.

Breast tissue is changing all the time because of fluctuating hormone levels, especially during times of menstruation and breastfeeding. It’s important to be aware of how your breasts normally look and feel, and know what changes to look for.

Take Action: While most breast lumps will not turn out to be cancer, lumps that feel harder or different from the rest of the breast (or the other breast), or change over time, should always be checked by your doctor.

Myth #2: Feeling pain in your breast is a symptom of breast cancer

Fact: Most breast cancers do not cause pain in the breast (although some do).

Many women experience breast pain or discomfort in the week leading up to their period. The pain usually goes away after menstruation. Other breast conditions, such as mastitis (an infection of the tissue of the breast that occurs most frequently during breastfeeding), may cause a more sudden pain.

Take Action: If you have breast pain that is severe or persists and is not related to the menstrual cycle, you should be checked by your doctor.

Myth #3: Breast cancer is a hereditary disease

Fact: Only 5% to 10% of breast cancers are thought to be hereditary. The other 90% are largely due lifestyle and environmental factors.

The risk in a person believing this myth is that they might think there is nothing they can do to prevent breast cancer if it is already in their family. Genetic testing can help you understand your inherited risk and allow you to make choices about your future care.
Some high-risk women also choose to have a prophylactic mastectomy to decrease their risk.

Take Action: Cancer is a complex group of diseases with many possible causes, including lifestyle factors such as smoking, diet, and physical activity. Lower your risk of developing breast cancer by maintaining a healthy weight, exercising regularly, and limiting the amount of alcohol you drink.

Myth #4: Only women get breast cancer

Fact: While the incidence of breast cancer in women is significantly higher than in men, men can get breast cancer.

Many people don’t think of men as having breasts. In fact both men and women have breast tissue, although men have much smaller amounts than women. According to the National Breast Cancer Foundation, men carry a higher mortality than women do, primarily because awareness among men is less and they are less likely to assume a lump is breast cancer, which can cause a delay in seeking treatment.

Take Action: Know the signs of male breast cancer. Symptoms include a hard lump underneath the nipple and areola and color change in the surrounding area.

Myth #5: Breast cancer only occurs in post-menopausal women

Fact: While it is true that the older a woman is, the higher her breast cancer risk becomes, breast cancer does occur in younger women.

Although breast cancer in young women is rare, more than 250,000 women living in the United States today were diagnosed with it under age 40[1]. In young women, breast cancer tends to be diagnosed in its later stages and be more aggressive. Young women also have a higher mortality rate and higher risk of metastatic recurrence (return of breast cancer in areas beyond the breast).

There is no effective breast cancer screening tool yet for women under 40, most of whom have dense breast tissue that prevents routine mammograms from being a useful screening tool.

Take Action: Being breast aware is very important. Become familiar with how your breasts normally look and feel and, if you notice a change, you should see your doctor as soon as possible.

Myth #6: Wearing an underwire bra causes breast cancer

Fact: Claims that underwire bras cause breast cancer have been widely debunked as unscientific.

According to the myth, wearing your bra every night or for too long daily prevents your pores from being able to breathe. Sweat accumulates and toxins build up which are believed to cause breast cancer. Another version of this myth is that wearing a bra which is too tight or sleeping in your bra can cause breast cancer. The American Cancer Society (ACS) states “we do not know of any epidemiologic studies published in scientific journals that suggest bras directly contribute to breast cancer.”

Myth #7: Deodorants can cause breast cancer

Fact: There is no evidence to back the claims that deodorants and antiperspirants cause cancer.

People sometimes worry about whether chemicals in common products such as cosmetics or toiletries could cause cancer, but there is no good scientific evidence to show that these products affect the risk of cancer. According to Breastcancer.org, even the strongest antiperspirant doesn’t block all perspiration in the armpit. Most cancer-causing substances are removed by the kidneys and released through urine or processed by the liver. Toxins are cleared by lymph nodes and not by the sweat glands.

Take Action: If you still have concerns about the link between antiperspirants and breast cancer, see the NCI fact sheet on Antiperspirants/Deodorants and Breast Cancer for more information.

Myth #8: Breast cancer is a single disease

Fact: Breast cancer is not one disease, but a complex group of different types of tumours.

Until quite recently, breast cancer was thought of as one disease, so everybody got much the same treatment, which led to overtreatment for some patients. We now know that at a molecular level tumors act and respond to treatments differently. Researchers have to date classified breast cancer into 10 different subtypes. Having a more detailed system of tumor categories can help tailor treatment to individual patients and predict women’s survival more accurately.

Myth #9: Stress causes cancer

Fact: The scientific evidence that stress causes cancer is not conclusive.

Despite studies which show weak evidence of an association between stressful events and a diagnosis of cancer, many people still hold the belief that stress is a factor in causing cancer. It’s unrealistic to think we can avoid stress completely. Everyone feels stressed at some point in their lives. But long periods of stress can cause mental health problems such as anxiety and depression and can contribute to physical health problems such as high blood pressure, heart disease, and ulcers. It makes sense then to get our stress levels under control.

Take Action: Adopt healthier coping mechanisms, such as learning stress-management techniques, taking the time to eat healthily and exercising more.

Myth #10: Mammograms cause breast cancer

Fact: While mammograms do involve radiation exposure, the dose used is extremely low.

A mammogram (an x-ray of the breast) currently remains the gold standard for the early detection of breast cancer. Mammograms can detect lumps well before they can be felt, and the earlier that lumps are caught, the better one’s chances for survival. While it’s true that radiation is used in mammography, the amount is so small that any associated risks are tiny when compared to the benefits.

Take Action: According to the National Cancer Institute, the standard recommendation is an annual mammographic screening for women beginning at age 40. Base your decision on your physician’s recommendation and be sure to discuss any remaining questions or concerns you may have with your physician.

To wrap up, certain myths about breast cancer, though inaccurate, can nevertheless seem to make sense when we hear them repeated often enough. While some risk factors for breast cancer are out of our control, knowing and understanding our risks will help us make the best choices possible for ourselves and our loved ones.

[1] Young Survival Coalition statistics on breast cancer in younger women.

For information on galactocele, please check out the blog What is a Galactocele, and What Can I Do About It? and 12 Breast Cancer Myths And Facts You Should Be Aware Of

Marie Ennis-O'Connor

hcsmmonitor.com/

Six Lessons Learned From Breast Cancer

October 19, 2015/in BC Blog ND, BC Blog WN, BC Newly Diagnosed, BC What's Next, Breast Cancer, Marie Ennis-O'Connor, PEN Blog /by Marie Ennis-O'Connor

“The period of greatest gain in knowledge and experience is the most difficult period in one’s life.” — Dalai Lama

Writing in Oncology Times, radiation oncologist, Matthew Katz MD, described cancer as an illness of transformation. “Biologically” he wrote, “it represents a change in growth and homeostasis. Metaphorically, a cancer diagnosis can transform how you see yourself and the way you experience life afterward.” When the dust settles after the cancer storm has passed, it is not uncommon for patients to reappraise their lives. Cancer forces us to slow down and look at what really matters. Caught up in the routines of daily living, it is easy to avoid doing this; but cancer stops us in our tracks and pushes us to the edge of what is familiar. With cancer there is no hiding place; its sharp glare strips away pretence and artifice, revealing the true nature of our lives and relationships.

Cancer is an invitation to take stock and re-examine your life, to discover ways of leading a more meaningful and fulfilling life. Richard G. Tedeschi, PhD, professor of psychology at the University of North Carolina Charlotte, reports five common growth outcomes from interviews he conducted with trauma survivors.

A deepened appreciation of life.
Enhanced relationships with others.
An appreciation for personal strength and endurance.
Setting out on new pathways or pursuing new interests and opportunities.
Spiritual growth and development.

As part of breast cancer awareness month, I extended an invitation to six women to share what they have learned from their personal experience of breast cancer. Their answers to the question, “what did cancer teach you?” reflect the themes identified by Dr Tedeschi. The women’s experiences span a trajectory of breast cancer from recent diagnosis and active treatment, to several years’ post-treatment.

Elizabeth McKenzie, a licensed psychologist who lives in Seattle, WA, was diagnosed with breast cancer in 2012. She learned to appreciate the value of stillness and find healing in solitary pursuits.

“When I was diagnosed with cancer in 2012, I knew that I had just been enrolled in a crash course with countless learning objectives. Some of the lessons, however, have been unexpected.

I learned to appreciate stillness, the silence in life. I am an extroverted person. I work as a child/adolescent psychologist. I am married. I am a mother. I am a daughter and a sister. I have many friends. Before cancer, I thought that the foundation of my life was largely my connection with others. The time I was forced to be alone to heal from many surgeries for my own health, led to my pursuing other solitary pursuits, mindfulness meditation, nature photography, personal writing, and exercise.

Over time, I have learned that my individual experience was also part of that foundation; to have time alone to live in mindful stillness is a basic need for my mental and physical health, one that I had long neglected. In working on this solitary foundation, I have also strengthened my connection with others. I am now giving serious consideration to attending a residential mindfulness retreat, one that would require that I be silent, except for counseling with teachers, for 3-7 days. That is something that in the past, I would have considered myself neither able to do nor willing to give myself that kind of time. Today, I feel emotionally and physically ready for the experience of being by myself, with myself, surrounded by nature, for days on end. This gives me sense of peaceful willingness, a gentle hopefulness, in a life full of uncertainty.”

Becky Hogue, a PhD Candidate (Education) at the University of Ottawa, was diagnosed with breast cancer in 2014. Becky wanted to share a cautionary tale so others could learn from her hard-earned experience.

“When I think back about one thing that I’ve learned, it is that treatments change over time but advice is full of ‘old wives tales’ which are often based upon older treatments. This was never more poignant than during my last round of AC chemotherapy. Throughout AC chemo, I had been suffering from nausea. I knew from support group that people who tolerated it well only had nausea for three to five days. I had nausea for at least eight days. Given I was on a 13-day cycle, this meant more days with nausea then without. Now, my nausea was never really bad. When I complained to my oncologist, he asked me “when was the last time you threw up?” Never. My nausea was never that bad, it just lingered.

The folks at support group (especially those a year or so ahead of me) would talk about different nausea meds. The meds I was on were not the meds that everyone was talking about. I found myself wondering if I should be on different meds? In my mind, a change of meds would mean less nausea. I would tolerate the chemotherapy side effects so much better.

What I didn’t realize was that these different nausea meds were the old school meds. The meds my oncologist had me on were the new ones. People in support groups, and some of the older chemo nurses, were not familiar with the new meds. The recommendations I was getting about ‘what works’ were ‘old wives tales’, and I bought into them instead of trusting my oncologist.

For my last bout of AC chemo, I tried a different combination of anti-nausea meds. My oncologist was away, so his nurse practitioner changed my meds (in part because I asked for it). I’m sure that if my oncologist was there, he would have explained that I was on the new meds, but also that they were doing their job. I didn’t know the other option was the older option. I didn’t realize that the folk lore about the effectiveness was in part just because it was the older meds. The new meds had not been around long enough to be part of the lore. With the change my nausea was no better, but the side effects of the meds were much worse. I ended up with terrible mouth sores (so bad I needed liquid morphine to manage the pain). One of my biggest regrets regarding my treatment was that I changed anti-nausea meds for the last cycle of AC chemo. I had forgotten my own advice. I had forgotten who I had decided to trust (my oncologist), and let the ‘lore’ effect my treatment.

This tale is meant to be a cautionary one. Not so much about seeking advice, but about remembering that people who have followed this path before you did so at a different time. The treatment options (and side effect management options) available to you today may not be the same ones that were available for someone else a year ago. Although older treatments may work, chances are the newer ones are better. Before changing treatment plans based upon what you are hearing on the net or in support groups, ask yourself ‘is this an old tale’? And finally, decide who you are going to trust, and trust them.”

Audrey Birt, a two-time breast cancer survivor, focussed on lessons of courage, connection and resilience.

“Cancer taught me I’m more resilient than I would have believed, it helped make me braver. It also taught me that life cannot be controlled. This made me more able to live in the moment and for the moment and that’s probably not so good for my bank balance but it’s great for my life balance in a way. It taught me to reengage with writing through my blog and in a funny way it changed my life and connection to others. But it also taught me my fragility and that’s a lesson I’m still learning, one day at a time!”

Author of From Zero to Mastectomy, Jackie Fox, has written of how breast cancer “gave me part of myself back”.

“One of the obvious benefits of cancer is reconnecting with friends and family, but old loves like art and music may reappear in your life as well. In my case, I started writing poetry again. I hadn’t written or published anything for nearly 20 years and I really thought that part of my life was over. I’m so grateful to have it back and I hope I never lose it again.”

Liz O’Riordan was diagnosed with breast cancer in July 2015. From her unique perspective as a consultant breast surgeon, she is learning what it’s like to be a patient from the other side.

“Being a patient in my own speciality has opened my eyes to a lot of little things that could be changed to improve patient care. I learned that the language of cancer is completely different for a patient compared to a doctor. I have been made acutely aware that some of the phrases I’ve used in clinic when breaking bad news, that I’ve heard others say, or come up with myself, now make me cringe. A lot of women get recalled from screening with tiny low grade cancers (<1cm), and I’ve said “If you’re going to get breast cancer, this is a good one to have”, or “You’re lucky that we caught it early”. All of these phrases were said with good intentions, to try and reassure the women that they were unlikely to die of their cancer, and would not need chemo. And most women are still in shock, so I never see them truly react to what I have just said. But no cancer is a good one to have, and no-one is lucky to get cancer. I will pay close attention to what I say to patients in the future.”

The final lesson is one of authenticity and integrity, something Eileen Rosenbloom who was diagnosed with breast cancer in June 2010, believes cancer cannot take away.

“Although I often felt like cancer was a thief that had taken everything from me, being so ill also created an opportunity to see what it could never take — the very essence that is me. Sometimes I’d look at my eyes in the mirror and think: There I am, right there. I’m still me. It felt empowering to realize no matter how dark things got, I still had control over some part of myself. My very essence remained intact, even if stripped down to a raw version without any frills.”

Whatever place you are at with a diagnosis of breast cancer, there are lessons to be learned. These will be unique to you; but you can also learn from those who have walked this path before you. Reach out to them, and lean on their experience to help make the way a little smoother for your own journey.

Marie Ennis-O'Connor

hcsmmonitor.com/

Tag Archive for: breast cancer

Transcript:

Transcript:

Breast Cancer in the United States

Coverage for Breast Cancer Screening and Prevention

Mammography

Genetic Testing and Screening for BRCA1/BRCA2 Mutations

Preventive Medication

Coverage and Utilization of Services

Appendix Table 1

Appendix Table 2

Get an accurate diagnosis before starting treatment

Where you go first for breast cancer treatment matters

Seek out the experts for your breast cancer diagnosis and treatment

Consider clinical trials for your breast cancer treatment

Make multidisciplinary care mandatory

What exactly is gestational diabetes?

The link between gestational diabetes and breast cancer

Type 2 diabetes proven to increase breast cancer risk

1. Everything in your life is about to change

2. Online support is real

3. You will feel fearful and anxious

4. You are your own best health advocate

5. Your will experience brain fog

6. You will experience bone-crushing tiredness

7. You may be surprised by feelings of guilt

8. You will feel pressured to stay in a positive frame of mind

9. You will need time to grieve

10. Cancer doesn’t end when treatment does

Wrapping Up

Related Program:

Transcript:

Related Program:

Transcript:

Myth #1: Finding a lump in your breast means you have breast cancer

Myth #2: Feeling pain in your breast is a symptom of breast cancer

Myth #3: Breast cancer is a hereditary disease

Myth #4: Only women get breast cancer

Myth #5: Breast cancer only occurs in post-menopausal women

Myth #6: Wearing an underwire bra causes breast cancer

Myth #7: Deodorants can cause breast cancer

Myth #8: Breast cancer is a single disease

Myth #9: Stress causes cancer

Myth #10: Mammograms cause breast cancer

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