Cutting Your Cancer Risk through Diet

English: nitrosylheme, nitrosyl-heme, heme-NO,...
Nnitrosylheme. (Pegg & Shaidi, 2000, “The color of meat” in “Food & Nutrition, Press Inc., Trumbull, Connecticut, USA), released from NO-myoglobin by cooking cured meat (Honikel K.O., 2008, Meat Science, 78, 68-76) (Photo credit: Wikipedia)

Today, I’d like to focus on a couple of things you can do to reduce your risk of cancer. We have long known that consumption of processed meat can increase the risk of cancer.

1. Processed meats: These agents are created by nitrites used to color and preserve processed meats such as bacon, sausage, and lunch meats. These compounds have been linked to cancer in lab animals. The N-nitroso compounds are not in the meat (the food companies must add chemicals to keep it from forming), but are created in the gut in a reaction probably facilitated by bacteria. This may explain why those of us who eat processed meatus have a higher risk of colorectal, esophagus, and stomach cancer.

2. Unprocessed meats: Unprocessed red meat can also increase N-nitroso compounds in your gut. For example, the risk of colorectal cancer is higher (at least according to some studies) among individuals who consume more heme iron, a substance found in all meats, but especially in red meat). On the other hand, white meat does not appear to do so. Could it be that iron attaches to hemoglobin in the blood? The studies are insufficient to say with any degree of certainty.

3. Meat mutagens: Cooking meats to well done at high temperatures causes cancer in animal studies. For humans, the data is more mixed. In the NIH-AARP Diet and Health Study, colorectal cancer risk increased by a factor of 1.2 among those who consumed the highest levels of two key heterocyclic amines (HCA). Chicke eaters may have a lower risk, even though the levels of HCA may be high in barbecued chicken.

In our next issue, we’ll look at specific things you can do to lower risk, including improving your grilling technique. 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. And have a great day!

Breast Invasive Lobular Carcinoma: Link to HRT

Patients often wonder why they got a particular cancer. While we  cannot know with certainty why a particular individual got a cancer, we know of risk factors that increase the odds of getting it. Today, we look at the association of hormone replacement therapy (HRT) and a particular type of breast cancer, lobular carcinoma.

The observation: Post-menopausal hormone replacement therapy can significantly increase the risk of the less-common lobular form of breast cancer.

What’s lobular carcinoma? This breast cancer subtype involves the lobules, grape-like structures in the breast that contain milk-producing glands. Lobular carcinoma accounts for only about 15 percent of all invasive breast cancers, and is typically hormonally sensitive. However, lobular breast tumors also present a clinical challenge because they can be more difficult to detect both by clinical examination and by mammography (as compared to the more common ductal cancer).

English: Lobular Breast Cancer. Single file ce...
Lobular Breast Cancer. Single file cells and cell nests. (Photo credit: Wikipedia)

The data: In a study published in 2008 in Cancer Epidemiology, Biomarkers and Prevention, of more than 1,500 postmenopausal, western Washington women, my friend and colleague Christopher Li, MD found that current users of combined HRT had a 2.7-fold and 3.3-fold elevated risk of lobular and ductal-lobular cancer, respectively, regardless of tumor stage, size or number of lymph nodes involved. Only women who used combined HRT for three or more years faced an increased risk of lobular cancer. Among mixed ductal-lobular cases, hormone therapy increased the risk of tumors that were predominantly lobular but not tumors that had predominantly ductal characteristics.

Bottom Line: Postmenopausal women who take combined estrogen/progestin hormone-replacement therapy for three years or more face a fourfold increased risk of developing various forms of lobular breast cancer. 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. And have a great day!

Hernias more common after minimally invasive prostate surgery

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Did you know? Based on Medicare claims data, incisional hernias after radical prostatectomy are about three-times more common with minimally invasive surgery than with an open surgical approach. The frequency of incisional hernia requiring repair in the two groups was 5.3% and 1.9%, respectively. 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. And have a great day!

3D versus 2D mammograms

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Today, I want to briefly discuss the use of tomosynthesis (sometimes called 3D mammography) for breast cancer screening. This sophisticated imaging approach uses a moving X-ray source to acquire 3-Dl volume data than can be displayed as thin slices. While relatively new, tomosynthesis is becoming more popular, especially for evaluating women with dense breasts (as defined by mammograms), and for women at high risk for getting breast cancer. Still, we have fairly limited data on outcomes when tomosynthesis is used for routine screening.

The results of a manufacturer-sponsored study were recently reported. The investigation looked at Italian women at least 48 years old, and did screening with integrated 2D and 3D mammograms.Screening mammograms were then interpreted by radiologists, first using standard 2D images and subsequently using integrated 2D/ 3D mammography.

Among over 7000 women screened, 52 invasive cancers and 7 cases of ductal carcinoma in situ were detected. The rate of cancers detected per 1000 screens was 5.3 with 2D technology and 8.1 with integrated 2D plus 3D screening, a statistically significant increase in sensitivity. Of 395 false-positive screens (that is, the test suggested cancer, when there actually was none), 181 resulted from both screens, 141 resulted from 2D only, and 73 resulted from integrated screens.

Bottom line: The finding that integrated screening enhances sensitivity (th ability to find cancer) while reducing false-positive results (the test says there is cancer, when there is not) match results from an interim analysis of a Scandinavian trial.

Any downsides? 2D/3D screening roughly doubles the radiation exposure to the breast.

Going forward: We need more randomized trials comparing 2D with integrated 2D/3D screening mammograms. In my own institution, we prefer the tomosynthesis approach. 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. And have a great day!

Breast Cancer With Involved Sentinel Nodes: No More Surgery Needed?

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For early breast cancer, the sentinel node procedure has been a breathtaking achievement. Historically, as a part of management, many lymph nodes were removed from the axilla (underarm area). Over time, we have learned that the number of nodes involved with regional spread of cancer is the most important prognostic factor for survival. More recently, we have discovered that the removal of axillary nodes serves this important purpose, but is not as important from a treatment perspective. Not surprisingly, we have moved from taken all of the dozens of nodes in the axilla, to 10 or 20, and now just a node or two.

The sentinel lymph node procedure involves the injection of trace amounts of radioactive material (or blue dye) around the time of surgery. A small incision is made in the underarm area, and a Geiger counter-like device brought near. The surgeon listens for the ticking node and plucks it. As cancer needs to travel through this first (sentinel) node, we can determine whether there is regional spread of cancer! Voila, lower chance of pain and arm swelling, or lymphedema. So what if the sentinel node is involved? What now? Go back and take more nodes or hope the radiation therapy that follows surgery will take of any more disease that might be left behind? We have more answers this week.

Radiotherapy is a better option than surgical dissection for women with breast cancer and a positive sentinel lymph node, according to an international multicenter phase 3 trial. In fact, axillary lymph node dissection (ALND) was associated with twice the rate of lymphedema as axillary radiotherapy, with no better locoregional control and fewer adverse effects (as compared to radiation therapy), in the European Organization for Research and Treatment of Cancer (EORTC) AMAROS (After Mapping of the Axilla: Radiotherapy or Surgery?) trial. The results were presented here at the 2013 Annual Meeting of the American Society of Clinical Oncology (ASCO®).

“We shifted from mastectomy to breast conservation, and now we will shift from complete axillary dissection to axillary-conserving strategies,” study author Emiel Rutgers, MD, PhD, surgical oncologist at the Netherlands Cancer Institute in Amsterdam, said during a press conference.

Outcomes no better with additional underarm surgery: There were no significant differences between the surgery and radiotherapy groups in disease-free survival (86.9% vs 82.7%; P = .1788) or overall survival (93.3% vs 92.5%; P = .3386).

Complications worse with completion axillary dissection: 5 years after therapy, the rate of lymphedema in the surgery group was twice that of the radiotherapy group (28% vs 14%).

Questions remain: 1) Extent of radiation therapy (is less more? Should we treat only the breast (with a bit of exit dose to the lower axilla) or more comprehensively (breast and of the regional nodes, recognizing more potential side effects). 2) What if a woman is not to receive radiation therapy? Should she go back for more surgery?

Still, progress. And good news for patients who have a sentinel node involved who receive radiation therapy. Your risk of regional recurrence is remarkably low, even if you don’t have more surgery.

Coming soon: Understand Breast Cancer in 60 Minutes (an e-book for IPad)

Fine print: The material herein is not aimed at providing advice for an individual, and is only general in nature. Check with your valued healthcare provider with any questions or concerns regarding your own management.

Endocrine Treatment Toxicity in Breast cancer: A Good Thing?

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We have additional evidence that post-menopausal women who get side effects from anti-estrogen treatment for breast cancer do better than those who don’t experience toxicity! A study of nearly 10,000 women received some anti-estrogen treatment for breast cancer. Patients received either the anti-estrogen drug exemestane for 5 years, or tamoxifen for 2.5-3 years, followed by exemestane (for 2.5-2 years).

Results: Patients who reported vasomotor symptoms (for example, hot flashes) during the first year of treatment had a longer disease-free survival (DFS) and loger overall survival (OS) when compared to those who did not have such side effects. Women who had discomfort in their muscles, bones, or joints also achieved superior DFS (but not OS). These results helpd true regardless of the type of anti-estrogen therapy.

My take: The link between toxicity and treatment benefit is intriguing. Still, we need better studies, as the  available ones have mixed results. The researchers need to do a better job of controlling for symptoms at baseline, other medications used at the same time as the anti-estrogen therapy, and capturing side effects with a validated tool.

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Caveat: This material is for general use only, and should not be regarded as personal, individualized medical advice. Please check with a valued health care provider with any questions or concerns. Today’s material is based on an article in the Journal of Clinical Oncology, published 22 April 2013.

Gene test predicts prostate cancer outcomes

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A slew of information is pouring out of the American Society for Clinical Oncology (ASCO) Annual Meeting this week. Now we have results from the Prolaris test, launched in 2010. The test is designed to measure the activity of cell cycle progression (CCP) genes in prostate cancer biopsy samples, and was evaluated for its ability to predict either death from prostate cancer, or a risk in the PSA (biochemical recurrence) in 5 company-sponsored trials. The studies included a multivariate analysis (accounting for variables such as grade and PSA). Overall, the CCP score was a highly significant predictor of outcome in all studies. In other words, the test appears to discriminate who is at high risk for progression of cancer. Exactly how we will use this test is being developed, but it may be especially useful for patients with low-grade, low-risk cancers. The Prolaris test for prostate cancer is predictive of a patient’s response to therapy. Still, we don’t have firm risk cutoffs to steer decisions toward a different treatment. Other tests are emerging, too, including the just-launched Oncotype DX test (Genomics Health). I’m Dr Michael Hunter.

Caveat emptor: This information is general only, and should not be construed as medical advise for an individual. Please check with you valued health care provider to determining optimal management for you.