Breast Cancer: Endocrine Therapy and Hair Loss

I recently blogged about male pattern baldness (Click here to learn more: Male Pattern Baldness). Today, we turn to hair loss among women. Many of my patients who have had chemotherapy for breast cancer experience hair loss. But what about endocrine therapy such as tamoxifen or aromatase inhibitor pills? There is relatively little data looking at this issue. Now comes a retrospective study from a single cancer hospital in the USA, published in JAMA Dermatol 2018 April 11.

Scope of the Problem: Alopecia (hair loss) resulted from aromatase inhibitors and tamoxifen in 67 percent and 33 percent of patients. The pattern of hair loss resembles androgenic (“male hormone”) alopecia, including increased shedding and shorter, finer, sparse hairs.

Researchers identified 112 a women with alopecia who had received endocrine therapy in the form of tamoxifen or the so-called aromatase inhibitors (anastrazole, letrozole, and exemestane are examples), but not chemotherapy for breast cancer. The investigators asked whether 5% minoxidil applied to the scalp could help with hair loss from endocrine therapy. Here are the authors’ findings:

1) Alopecia negatively affected quality of life; and 2) Topical minoxidil resulted in moderate or significant improvement in 80 percent of those who tried it.

My Take: This study confirms the emotional impact of hair loss on patients with breast cancer who received endocrine therapy. It also provides genuine hope (in the form of the topical drug minoxidil) in the management of this condition. Affected patients may wish to discuss this option with their doctor. I’m Dr. Michael Hunter, and I thank you for joining me today.


I received an undergraduate degree from Harvard, a medical degree from Yale, and completed a residency in radiation oncology at the University of Pennsylvania. I have been blessed to be named a “top doctor” in Seattle Magazine, US News & World Report, Seattle Metropolitan Magazine, 425 Magazine, and WA magazine. Readers of the Kirkland Advertiser have voted me the top doctor (in any field) in the region. I help individuals with cancer at Evergreen Hospital, outside Seattle.

Any information provided herein is not to serve as a substitute for the good judgment of your valued health care provider.

Rare Breast Implant-Associated Lymphoma

The US Food and Drug Administration (FDA) has provided an update on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). First, a bit of background: The FDA has been closely tracking the relationship between breast implants and ALCL since the agency first identified a possible association in 2011. Here’s what they have found:

As of 20 September 2017, the FDA has received a total of 414 medical device reposts of BIA-ALCL, including nine deaths.

  • Of the 414 reports, 272 included information about the surface of the implant. There were 242 reports of implants with textured surfaces, and 30 implants with smooth surfaces. Of the 413 that reported implant fill types, 234 were silicone gel, and 179 saline.
  • BIA-ALCL has been identified most often in patients undergoing implant revision operations for late-onset, persistent sermon. Half of the reported cases of BIA-ALCL were found within 7 to 8 years of implantation.
  • Based on the clinical literature, the FDA estimates that the lifetime risk of developing BIA-ALCL for patients with textured breast Jim plants ranges from 1 in 3817 to 1 in 30,000.

So what does this all mean if you already have implants? You should continue to have routine care and support. As BIA-ALCL has generally only been identified among patients with late onset of symptoms (pain, lumps, swelling, breast asymmetry), removal of the implants if you do not have signs or symptoms is generally not recommended. And be aware that most confirmed cases of BIA-ALCL have occurred in women with textured breast implants. As clinicians, we should consider the possibility of BIA-ALCL in a patient with late-onset, persistent seroma (a pocket of clear fluid) around the implant.

I’m Dr. Michael Hunter, and I encourage you to follow me on this blog, or on my wellness blog: Wellness!


I am a graduate of Harvard and Yale. I completed a radiation oncology training program at University of Pennsylvania, and practice in the Seattle area. Thank you for joining me today. (21 March 2018)

Breast Cancer: Why I Prescribe Exercise

This is increasing evidence to support the use of physical activity as a part of the management of breast cancer. Potential benefits in cancer risk reduction, less fatigue with treatments such as chemotherapy or radiation therapy, improvements in the risk of at least 15 types of cancer and in cardiovascular disease, and better psychological well-being, and improved quality and length of life all come to mind. A lot of potential benefits. But today, I want to show you the results of a study published in the Journal of Clinical Oncology this week.

A condition known as metabolic syndrome is associated with an increased risk of heart disease and stroke, diabetes, and breast cancer recurrence among survivors of the disease. Researchers conducted a randomized clinical trial, examining the effects of a 16-week combined aerobic and resistance exercise intervention on metabolic syndrome, obesity, and blood markers among ethnically diverse, sedentary, overweight, or obese survivors of breast cancer.

Here’s what the researchers discovered at the 3 month follow-up mark:

Combined resistance and aerobic exercise effectively attenuated metabolic syndrome, obesity, and relevant biomarkers (such as insulin, insulin-like growth factor-1 (IGF-1), leptin, and adiponectin) in an ethnically diverse sample of sedentary, overweight, or obese survivors of breast cancer, as compared to usual care. Our findings suggest a targeted exercise prescription for improving metabolic syndrome in survivors of breast cancer and support the incorporation of supervised clinical exercise programs into breast cancer treatment and survivorship care plans.

I’m Dr. Michael Hunter, and I invite you to follow this blog by signing up below. Explore more here: Wellness! Thank you, and I hope you have a joy-filled day.


I am a radiation oncologist who serves patients in the Seattle area, and hold degrees from Harvard, Yale, and the University of Pennsylvania.

Breast Cancer: Do We Have a New Target?

Currently, chemotherapy is the only standard drug therapy for those with “triple negative” breast cancer. By triple negative, we mean that the cancer does not have estrogen receptors (it is ER negative), progesterone receptors (PR negative), or HER2 receptors (HER2 negative). Of the major groups of breast cancer, triple negative has the worst survival overall.

However, when we interrogate triple negative breast cancer cells with molecular assays, we find that there are distinct subjects of the entity. One subset expresses a receptor for “male hormone”; cancer cells that have these androgen receptors (AR-positive) have been shown to have a modest response to drugs that block androgen receptors. Examples of these AR-inhibitors include a abiaterone acetate and bicalutamide, drugs that we sometimes use to help manage prostate cancer in men.

Now researchers have conducted a study looking at enzalutamide, another androgen receptor inhibitor (that is sometimes used for prostate cancer that has spread to distant sites). How well did the drug work for patients with metastatic (spread to distant sites) androgen receptor positive, triple negative breast cancer? Certainly not extraordinary results, but at the 16 week mark the drug led to clinical benefit for 25 percent of patients; for the subgroup with androgen receptor over 10 percent, the clinical benefit was 33 percent. The most common severe side effect was treatment-related fatigue.

My take: The study did achieve its primary endpoint. Subsets of triple negative breast cancer may benefit from strategies targeting the androgen receptor in the future.

I am Dr. Michael Hunter, and I invite you to follow me (below) and to learn more here: Wellness!

My background? I have degrees from Harvard, Yale, and the University of Pennsylvania. I help folks with cancer in the Seattle area, serving as a radiation oncologist. Thank you for joining me today.


* above is the human androgen receptor ligand binding domain

Reference: J Clinical Oncology 2018 Jan 26; or try the web by clicking here: Targeting the Androgen Receptor in Triple-Negative Breast Cancer

Cancer Management Guidelines – Bias?

As I manage patients with cancer, I frequently turn to the National Comprehensive Cancer Network guidelines. The NCCN is an alliance of 27 leading cancer centers in the USA, and regularly publishes clinical practice guidelines that help shape the course of management for cancer patients and insurance coverage. Yesterday, I read a piece that called these generally well-regarded guidelines into question.

A study found that recommendations may include using a drug for a type of cancer for which it wasn’t necessarily approved by the US Food and Drug Administration. We call this “off-label” use, and it is widely done in cancer care. So what’s the problem? Previous research has shown that 84 percent of NCCN members in developing guidelines have received personal payments from the drug/pharmaceutical industry.

Unfortunately, the recommendations of the NCCN are typically not based on high-level evidence (say, multiple prospective, randomized trials comparing a gold standard drug with a proposed replacement drug). The researchers found that the drugs in the study, as of March 2016, were FDA-approved for a total of 69 treatment approaches, but the NCCN recommended those drugs for a total of 113 approaches, which included the approaches approved by the FDA but also many others.

Among those recommendations that the NCCN made beyond the FDA approvals, only 23% were cited as being based on evidence from randomized controlled trials, the researchers found, and just 16% were based on findings from phase three trials. Both types of trials are considered the gold standard in medical research.

And the response? The NCCN Clinical Practice Guidelines for Oncology are continuously updated based on the strongest scientific evidence available, said Dr. Robert W. Carlson, Chief Executive Officer of NCCN, in a written statement on Wednesday. “NCCN’s 1,355 panel members come from 27 leading academic cancer centers in the United States. Their expertise allows them to evaluate complex circumstances based on all available data, in order to come to a consensus about what constitutes optimal care,” Carlson said in the statement. “The NCCN process is designed to make sure the most effective, life-saving therapies are accessible and available to the patients who need them,” he said. “CMS and other major providers have designated NCCN as the leading source for arbitrating oncology drug and biologic coverage because of the NCCN Guidelines’ proven track record for helping physicians to prolong their patients’ lives and reduce their suffering.”

For my patients, I always think about the level of evidence. In the NCCN guidelines, they provide an indicator of level of evidence. For example, should you get radiation therapy after a lumpectomy for early invasive breast cancer? The answer for almost all is yes: We have over a dozen prospective randomized clinical trials that randomized women to radiation therapy or not, and found the omission of radiation to be associated with a much higher risk of losing the breast in the future. In addition, combining all the trials in a so-called meta-analysis led to the conclusion that one may also suffer a potential loss of survival opportunity.

Always ask what our recommendation is based upon. Is the evidence anecdote, or is it based on higher level evidence (such as from multiple well-done prospective, randomized trials)? I am Dr. Michael Hunter, and I invite you to follow me (below) and to learn more here: Wellness!

My background? I have degrees from Harvard, Yale, and the University of Pennsylvania. I help folks with cancer in the Seattle area, serving as a radiation oncologist. Thank you for joining me today.

Breast Cancer Genes: A New Consumer Test

Have you heard of 23andMe? In the USA, it is a leading consumer genetics and research company. I have used it to learn about my ancestry and genetic predispositions. But can the test help you spot weaknesses in your genes (maybe you have a mutation that puts you at higher risk for heart disease), providing you a change to make changes in your lifestyle to improve your risk? Well, we just got some big news from the US Food and Drug Administration (FDA) regarding 23andMe’s direct-to-consumer genetic test on cancer risk.

The test can use your saliva and check for genetic variants in the breast cancer genes 1 and 2 (BRCA1 and BRCA2). When such mutations are present, the risk of developing breast, ovarian, prostate, and colon cancer can increase dramatically. For example, the risk of breast cancer for a woman with a BRCA mutation may be up to 85 percent by the age of 70. While these mutations are most common among people of Ashkenazi Jewish descent, anyone could have a BRCA mutation. Wouldn’t it be nice if individuals knew if they had the gene, such that they could consider risk-reducing maneuvers (ranging from removing the breasts and ovaries, to incorporating MRI into regular breast screening)?

The FDA approval of this consumer test for evaluating your DNA for a BRCA mutation is a big deal. No prescription needed. You are empowered. And I’m Dr. Michael Hunter. I invite you to explore more of my blog here: Wellness! Please consider following me by signing up below. Thank you in advance.

Breast Radiation Therapy: Better Than Expected

A study recently published in the journal Cancer reports that the actual experiences among patients with breast cancer who undergo radiation therapy are at odds with their fears and misconceptions. We have much data regarding the effectiveness of radiation therapy at healing women keep their breast after a lumpectomy for localized breast cancer and to improve survival as well. Still, there is a paucity of information regarding the perspectives and experiences of out patients.

For the current study, researchers surveyed 502 patients with breast cancer who underwent radiation therapy as a part of curative management. They asked these patients about their fears regarding radiation therapy, and then checked in with them about their actual short- and long-term adverse events. About 65 percent of the patients responded to the survey, at a median follow-up of 31 months.

Nearly half (47 percent) of patients had heard frightening experiences about radiation therapy, although 68 percent stated that they had little or no knowledge about radiotherapy. Here’s the amazing thing: Only 2 percent of patients agreed that the stories they had heard proved true for them. Of the patients who had had breast-conserving surgery, fully 92 percent felt that if future patients were more knowledgeable about radiation therapy, they would be less scared of treatment.

I’m Dr. Michael Hunter, and I am a radiation oncologist in the Seattle area. I have degrees from Harvard, Yale, and the University of Pennsylvania. Please follow this blog by signing up below. And explore more here at my other blog site: Wellness! Thank you.