Younger, Early Breast Cancer Patients Often Undergo Unnecessary Staging, Imaging Procedures

bone scan

More than one third of younger, early stage breast cancer patients undergo unnecessary imaging procedures — including position emission tomography (PET), computed tomography (CT), nuclear medicine bone scans (NMBS) and tumor markers (TM) — at the time of staging and diagnosis, according to research from The University of Texas MD Anderson Cancer Center.

Presented at a poster session at the 2013 CTRC-AACR San Antonio Breast Cancer Symposium by Carlos Barcenas, M.D., assistant professor in MD Anderson’s Breast Medical Oncology, the study is the first to look at the issue of over-use of staging procedures, including imaging and tumor markers in the diagnosis setting, specifically in younger, early-stage breast cancer patients.

Over-testing and unnecessary procedures extends beyond cancer care across the healthcare continuum. To help address the issue, the American Board of Internal Medicine began “Choosing Wisely®,” an initiative encouraging physicians and patients to have conversations that encourage its reduction.

As part of its participation in the national campaign, last year, the American Society of Clinical Oncology (ASCO) generated a “top five list” which recommended against the use of CT, PET, TM and bone scan in the diagnosis and staging of early-stage breast cancer at low risk for metastasis. Rather, treatment guidelines clearly state that for women with early-stage breast cancer, the proper procedures for diagnosis include mammogram, ultrasound, clinical exam and blood work, said Barcenas.

Study Design: For the retrospective study, Barcenas and his colleagues analyzed claims from a national employer-based database of 42,651 women between 2005 and 2010 with an initial diagnosis of breast cancer. All were younger than 65 years old and had undergone a mastectomy, lumpectomy and sentinel lymph node biopsy. Patients who underwent axillary lymph node dissection were excluded from the study because this is considered a surrogate for node-positive disease. Claims for imaging and tumor markers were analyzed between the specific period of three months prior to surgery and one month post-surgery. Researchers stratified for age, geographical location, treatment and insurance coverage, HMO or PPO.

Results: The researchers found that 37 percent of early stage breast cancer patients had at least one claim for an unnecessary staging test, with minimal change in rate of that average over the five-year period. Of note, said Barcenas, 18 percent of the woman had tumor markers performed, which is a staging procedure with no role in the non-metastatic diagnosis setting. Undergoing chemotherapy had the highest association with overuse of staging procedures, with hormone and radiation therapy also associated with overuse.

Barcenas and the team also found regional differences in overuse trends, as well a higher rate of unnecessary procedures in women with PPO insurance coverage compared to those with HMO. Also, women with breast cancer under 35 years old were at higher odds of having one of these tests, he explained. Yet when diagnosed at such a young age, this patient population is perceived by the physician to be at higher risk of metastatic and/or aggressive disease.

My Take:  These findings clearly support the need for the ASCO recommendations. We must shift our focus to doing what matters for the patient and what’s proven to improve outcomes, rather than testing for the sake of testing I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: University of Texas M. D. Anderson Cancer Center (2013, December 13). Younger, early breast cancer patients often undergo unnecessary staging, imaging procedures.ScienceDaily. Retrieved December 28, 2013, from http://www.sciencedaily.com­/releases/2013/12/131213092852.htm

Does an Apple A Day Really Keep the Doctor Away?

woman eating apple fruit diet nutrition

Apples Are Both Nutritious and Delicious

This is the conclusion of researchers from the United Kingdom. To assess the potential benefits of putting more patients on statins, researchers used data from the Cholesterol Treatment Trialists’ meta-analysis that showed vascular mortality is reduced 12% for every 1.0-mmol/L reduction in LDL cholesterol. This was applied to the annual reduction in vascular mortality rates in UK individuals 50 years of age or older who were not currently taking a statin for primary disease prevention.

For the apple-a-day assessment, they used a widely published risk-assessment model (PRIME). This model includes a multitude of dietary variables, in which investigators can substitute different food choices to assess the effects on population health. The apple was assumed to weigh 100 g, and calorie intake was assumed to remain constant. This allowed investigators to assess the effect of substituting in one apple daily on vascular mortality in the UK population.

Briggs said he was surprised at how well the apples compared with statin therapy. However, he stressed the point is not to encourage patients to stop taking their medication. He points out that the UK has a “five-a-day” campaign to increase fruit and vegetable consumption, but 69% of the population do not meet the recommendations.

For statin therapy, offering the treatment to an extra 17 million individuals and assuming 70% compliance would prevent 9400 vascular deaths each year. Assuming 70% compliance with the apple, even though “apples are of course both delicious and nutritious,” say the researchers,the estimated reduction in vascular deaths (with apples) would be 8500. They add that prescribing statins to all those eligible would lead to 1200 cases of myopathy, 200 cases of rhabdomyolysis, and 12 300 new diagnoses of diabetes mellitus.

Having now studied the science underlying an apple a day for keeping the doctor away, the group jokingly states they will next “model the effect of inquisitiveness on feline mortality rates.”

I’m Dr. Michael Hunter, and believe that an apple a day is a smart way to help lower your cholesterol level. I must admit, we have some of the best apples in the world here in Washington state (USA).

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: An Apple (or Statin) a Day Will Keep the Doctor Away: Population Health Analysis. Medscape. Dec 18, 2013.

Does Eating Nuts During Pregnancy Reduce Baby’s Allergy Risk?

The children of women who regularly ate peanuts or tree nuts during pregnancy appear to be at lower risk for nut allergies than other kids, according to a new study published Monday.

The study, published in the Journal of the American Medical Association, is the first to demonstrate that a mother who eats nuts during pregnancy may help build up a baby’s tolerance to them after birth, its lead author, Dr. Michael Young, told CNN. The effect seemed to be strongest in women who ate the most peanuts or tree nuts — five or more servings per week, according to the study, which controlled for factors such as family history of nut allergies and other dietary practices.

Peanut and tree nut allergies tend to overlap, according to the researchers. There is currently no formally recognized medical guidance for nut consumption during pregnancy or infancy. In 2008, citing growing evidence that early exposure could be beneficial, the American Academy of Pediatrics retracted guidance suggesting that parents withhold tree nuts from children under the age of 3, saying there was “no convincing evidence” for delaying their introduction.

Young said more research will come out in 2014 assessing the impact of infant diets on nut allergies, which should give medical policymakers enough information to offer broad recommendations. Until then, it’s up to individuals and their doctors, Young said.

“We’re not providing cause and effect, so we have no basis for recommending diets,” one of the authors offered. But he adds that his team sees “no reason for pregnant women to limit their diets with an eye to allergy prevention in children.”

I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: http://www.cnn.com/2013/12/23/health/nut-allergy-study/index.html?hpt=hp_t2

Cranberries: Are There Health Benefits?

cranberry juice

Do cranberries play roles in Urinary tract infection (UTI) prevention, as a urinary deodorizer for incontinent patients, reducing type 2 diabetes, chronic fatigue syndrome, scurvy, pleurisy, or have other potential benefits?

  • UTI: Some (but not all) studies show significant reduction in the risk of recurrent UTI’s in the elderly, hospitalized patients, and pregnant women. However, we have no reliable evidence shows effectiveness for treating UTI, once it is established. Suggested doses are as follows: Cranberry juice cocktail (26% cranberry juice) 10-16 ounces per day, or cranberry juice 15 mL twice daily by mouth.
  • Urinary odor: Preliminary research shows there may be a reduction in urinary odor in patients receiving oral cranberry.
  • Diabetes: Clinical studies show NO improvement in fasting blood glucose (sugar), HbA1c, fructosamine, triglyceride, HDL cholesterol, or LDL cholesterol levels in patients with type 2 diabetes.

A Counter View: A meta-analysis (collection of studies, combined) showed that compared with placebo, water, or no treatment, cranberry products were not associated with significant reductions in the occurrence of symptomatic UTI overall (RR, 0.86; 95% confidence interval [CI], 0.71 – 1.04). Cranberry products also had no apparent protective effect in any subgroups, including women with recurrent UTIs, older people, pregnant women, children with recurrent UTI, patients with cancer, and patients with neuropathic bladder or spinal injury.

Compared with antibiotics, cranberry was not significantly different in efficacy for women or for children, based on 3 small studies. Gastrointestinal adverse effects were similar for cranberry products and for placebo or no treatment (RR, 0.83; 95% CI, 0.31 – 2.27).

But… Compliance was low and dropout rate high in many studies, which may have resulted from poor acceptability of cranberry juice and of other cranberry products to a lesser extent. Also, doses were not consistently provided in the studies.

Careful: Cranberries may interact with warfarin, so check with you valued healthcare provider. They can also cause gastrointestinal upset, diarrhea, or even kidney (or other urinary tract site) stones at higher doses.

Did You Know? Cranberries are native to North America and are farmed on approximately 40,000 acres across the northern United States and Canada. Fresh cranberries are harvested in September and October, so fall is the best time to get them in season. They can be refrigerated for up to two months before using and can also be frozen for later use. Choose cranberries that are firm to the touch and unwrinkled.

Cranberries can also be enjoyed dried or in a can, but watch out for added sugars. Check the ingredient label and make sure that the product contains cranberries only. If you choose to drink cranberry juice, it is often mixed with other fruits and added sweeteners. Look for juice with cranberries as the first ingredient.

I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

References: http://www.medicalnewstoday.com/articles/269142.php; http://reference.medscape.com/drug/american-cranberry-black-cranberry-cranberry-344568; Cochrane Database Syst Rev. Published online October 16, 2012.

Bone Density: Repeat Testing May Not Be Helpful

hip bone osteoporosis broken

A second measure of bone mineral density (BMD) within 4 years of a first measure did not meaningfully improve prediction of hip or major osteoporotic fracture in a cohort of men and women, who were not being treated for osteoporosis, according to astudy published in the September 25 issue of JAMA.

The Study: Sarah D. Berry, MD, MPH, from the Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, and colleagues conducted a population-based cohort study of 310 men and 492 women from the Framingham Osteoporosis Study who had 2 measures of femoral neck BMD taken from 1987 through 1999. Participants had a mean age of 74.8 years.

A total of 1766 participants in the Framingham Osteoporosis Study were alive in January 1992, when second-round BMD testing began. The researchers excluded 931 (52.7%) participants who lacked a second test, and 33 (1.9%) who had hip fractures that occurred before the second test.

Results: After a median follow-up of 9.6 years after the second BMD test, 113 people (14.1%) had 1 or more major osteoporotic fracture. They were more likely to be women, to report a prior fracture, and to have a lower body mass index and lower baseline BMD than participants who did not experience an osteoporotic event. The researchers found that the second BMD measurement increased the proportion of participants reclassified after the second test as high risk for hip fracture by 3.9%  and decreased the proportion reclassified as low risk.

Medicare (USA) reimburses for BMD screening every 2 years, and the average time between tests is 2.2 years, the researchers write. According to Healthcare Blue Book, the price can be $111. Other sources put prices ranging from $150 to $250 without insurance to a copay with insurance.

“The second BMD measure resulted in a small proportion of individuals reclassified as high risk of hip or major osteoporotic fracture, and it is unclear whether this reclassification justifies the current US practice of performing serial BMD tests at 2.2-year intervals,” the researchers write.

My Take: Patients receiving osteoporosis treatments sometimes do not gain mass and may actually lose mass. Dr. Recker, a critic of the authors’ conclusions offers: “There are a lot of situations where you need a bone mass measurement that is less than 2 years or 4 years. In other situations, you don’t. As a practitioner, I need to have the ability to make those decisions without excessive cost and hassle. I point out that all you have to do is prevent one hip fracture and you’ve saved between $40,000 and $60,000.” While I think there is a role for individualization, this study provides some evidence suggesting that average-risk patients may be able to reduce the frequency of their bone mineral density testing. Ask your valued healthcare provider about the optimal interval for you. And don’t forget your weight-bearing exercise! I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

References: JAMA. 2013;310:1256-1262; http://www.medscape.com/viewarticle/811604.

Herceptin Plus Taxol Effective for “Low-Risk” HER-2 Positive Breast Cancer

Breast cancer (Infiltrating ductal carcinoma o...
Breast cancer (Infiltrating ductal carcinoma of the breast) assayed with anti HER-2 (ErbB2) antibody. (Photo credit: Wikipedia)

Summary: A remarkable 98.7 percent of certain lower-risk breast cancer patients were cancer-free at least 3 years after taking a combination of Taxol (paclitaxel) chemotherapy and the targeted agent Herceptin (trastazumbab), according to a study presented yesterday at the 2013 San Antonio Breast Cancer Symposium.

This study is the first major trial to examine Herceptin-Taxol for patients with cancers that are HER2 positive, but very small and with no nodal involvement. About 1 in 4 patients with breast cancer have tumors that are the more aggressive HER2-overexpressing type: The cancer cells have too many antennae-like receptor proteins (HER2, Human Epidermal Growth Factor Receptor 2) on their surface. Herceptin is part of standard treatment for higher0risk HER2 positive patients. But we really did not know of an optimal approach for lower risk patients with HER=2 overexpressing tumors.

This new study identifies an in-between approach: Herceptin plus a single chemotherapy drug (Taxol) is highly effective, with few side effects. Only 3.2 percent experienced severe neuropathy, and 0.5 percent had symptoms of congestive heart failure (CHF; this resolved after the patients stopped the Herceptin). I’m Dr. Michael Hunter, and that’s your breast cancer news of the day.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: Loyola University Health System (2013, December 11). Herceptin plus taxol highly effective in low-risk breast cancer. ScienceDaily. Retrieved December 12, 2013, from http://www.sciencedaily.com/releases/2013/131211131223.htm

Are High Levels of Immune Cells in Breast Tumors A Good Thing?

Electron microscopic image of a single human l...
Electron microscopic image of a single human lymphocyte. Type: Black & White Print. (Photo credit: Wikipedia)

Women with HER2-positive breast cancer who had the highest levels of immune cells in their tumors gained the most benefit from presurgery treatment with chemotherapy and trastuzumab, according to results presented here at the 2013 San Antonio Breast Cancer Symposium, held Dec. 10-14.

“We have previously shown that high levels of tumor-infiltrating lymphocytes [immune cells in a tumor] are predictive of response to trastuzumab and chemotherapy administered after surgery for early-stage, HER2-positive breast cancer using samples from patients enrolled on the randomized, adjuvant phase III clinical trial called the FinHER study,” said Sherene Loi, M.D., Ph.D., medical oncologist and head of the Translational Breast Cancer Genomics Lab at the Peter MacCallum Cancer Centre in Melbourne, Australia. “Our new data further support the positive relationship between tumor-infiltrating lymphocytes and better outcomes with trastuzumab therapy, this time in a cohort of patients with newly diagnosed HER2-positive breast cancer who received the therapy before surgery.

Loi and colleagues evaluated breast tumor samples from 156 patients with operable or locally advanced HER2-positive breast cancer enrolled in the GeparQuattro trial. All these participants received chemotherapy and trastuzumab prior to surgery as part of the trial, which showed that women who received the combination were more likely to have a pathologic complete response; that is, they were more likely to have no residual invasive cancer detectable in the breast tissue and lymph nodes removed during surgery. Loi and colleagues found that for every 10 percent increase in the levels of tumor-infiltrating lymphocytes there was a 16 percent increase in the number of patients who had a pathologic complete response.

“These data indicate that a patient’s immune system influences outcome and trastuzumab response,” said Loi. “What we don’t know is why some patients have tumor-infiltrating lymphocytes in their breast tumor at diagnosis and others do not. Currently, we are actively investigating this and trying to understand why there is a positive relationship between tumor-infiltrating lymphocytes and better outcomes with trastuzumab therapy.”

I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: American Association for Cancer Research (2013, December 11). High levels of immune cells in breast tumors may help ID patients who benefit from trastuzumab. ScienceDaily. Retrieved December 12, 2013, from http://www.sciencedaily.com­/releases/2013/12/131211093822.htm