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.

Michael Douglas, HPV, oral sex, and cancer of the oropharynx

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The Guardian newspaper recently published an interview saying that the actor Michael Douglas attributed his head and neck cancer to HPV (human papilloma virus) from oral sex. Douglas reportedly offered “without wanting to get too specific, this particular cancer is caused by HPV, which actually comes from cunnilingus.” Douglas’ spokesman later clarified the statement, offering that Douglas never said that was the cause of his cancer, but was discussing what causes oral cancer during the interview.

Epidemiology: HPV is the most commonly diagnosed sexually transmitted infection in the USA. It is associated with warts, as well as pre-cancers and cancers of the cervix, vagina, vulva, penis, and anus. Two vaccines are available to prevent infection with several types of HPV known to cause cervix cancer.

How: HPV is a virus that is spread by skin-to-skin contact, including sexual intercourse, oral sex, anal sex, or any other contact involving the genital area (for example, hand to genital contact). Condoms do not appear to provide complete protection, as the do not cover all exposed genital skin. You can’t get it, though, from the toilet seat.

To vaccinate, or not to vaccinate: In the USA, HPV vaccination with either vaccine is recommended for all girls/women between 9 and 26 years old. Gardasil vaccine is recommended for boys/men between 9 and 21, and can be given up to 26 years of age. We do not know how long the vaccine works, but it appears to work at least 5 years.

Does HPV vaccine prevent other diseases from sex? No.

So, what’s the scoop on HPV and cancer of the head and neck region? Recent studies have shown a remarkable increase in the incidence of cancer related to a common virus, HPV. In fact, it is estimated that 60% to 70% of newly diagnosed cancers in one part of the head and neck (the oropharynx) are due to this virus. The specific culprit is a particular strain of the virus, HPV type 16. And yes, it

Clinical reports indicate that patients with HPV-associated cancers have improved response to treatment and survival, as compared to HPV-negative tumors. My read is that smoking and alcohol tumors have a worse prognosis, HPV-related tumors the best, and someone who smokes and is HPV positive intermediate between the two. We do not have enough data to tell us that we can de-intensify treatment for the HPV-associated tumor, however.

I’m Dr. Michael Hunter.

The fine print: This communication should not be construed as medical advice for an individual. Check with a valued health care provider for informations specific to you.

Partners of patients with HPV-related head and neck cancer not at increased risk

Partners of patients with HPV (human papilloma virus)-related oropharyngeal cancer do not have increased levels of oral HPV infection. The risk of a partner developing HPV-related of the oropharynx (back of the mouth, including the base of tongue) is low.

– American Society of Clinical Oncology, 49th Annual Meeting (2013)

Pregnancy after a breast cancer diagnosis does not affect prognosis

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Young women who have completed treatment for invasive breast cancer often ask if a pregnancy will increase their chances of recurrence (cancer return). The question seems appropriate to me, especially given the fact that hormon receptor positive breast cancer is fueled by estrogen. It should be comforting to these women that a new study suggests that a pregnancy after treatment for early stage, estrogen receptor (ER-positive breast cancer does not affect the recurrence rate (Journal of Clinical Oncology 2013;31:73-79). Researchers in Brussels, Belgium aimed to compared the disease free survival (DFS) in pateitns with ER-positive breast cancer both with and without a subsequent pregnancy.  The authors also looked at a number of other outcomes, including disease free survival among ER-negative patients.

The retrospective review found no difference in DFS between the pregnancy and non-pregnancy groups in the ER-positive group. Perhaps surprisingly, the patients who became pregnant less than 2 years after diagnosis had a better disease free survival compared to their matched controls. This last observation may be due to selection bias, I think. The bottom line? This study provides good evidence that a woman who desires a biological child after breast cancer diagnosis will not have their prognosis adversely affected by pregnancy. The study is not without flaws however, including the fact that 80% of patients had no information about a critical marker known as HER-2.

A big question is what to do if you want to become pregnant, but have not completed a recommended course of anti-estrogen therapy such as tamoxifen. Researchers are beginning to investigate the impact of a break from tamoxifen on results. I hope you have found this blog informative, and look forward to offering an e-book on breast cancer (for IPad) within weeks. I’m Dr. Michael Hunter, and I thank you for visiting with me.

Heartburn raises cancer risk … but antacids may reduce risk

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Gastric reflux, more commonly known as heartburn, can increase the risk of cancer of the throat area (laryngopharyngeal squamous cell carcinoma). Now the good news, reported online May 23, 2013 in Cancer Epidemiology Biomarkers & Prevention. Individuals without a history of heavy tobacco or alcohol consumption who have a history of frequent heartburn have a 1.8 times greater risk. This risk remained, even when the researchers adjusted for age, sex, race, smoking, alcohol consumption, presence of human papilloma virus (HPV), educations, and body mass index. For those with a history of heartburn, the use of antacids only to relieve symptoms was associated with a big drop in the risk of larynx cancer (by two-thirds!) or laryngopharyngeal cancer (by about a third). In addition, there was the suggestion of a lower risk of cancers of the pharynx. While these findings are provocative, we still need more studies to clarify a potential role for antacids as a cancer risk reduction agent. I’m Dr. Michael Hunter.

Small print: Remember, the information provided here is for general use only. We do not provide medical advice for individuals, and recommend that you check in with a valued health care provider.

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