With Early Breast Cancer, Targeted Radiation Shows Promise

With Early Breast Cancer, Targeted Radiation Shows Promise

Especially for women with early stage breast cancer, targeted doses of radiation therapy may be as effective as standard radiation treatment of the entire breast, a new British study suggests. The research only tracked women for five years, so it isn’t definitive. Still, “this contributes to a growing body of evidence that a large proportion of women over 50 years old with small breast cancers can avoid whole breast radiotherapy,” said study co-author Dr. John Yarnold. He is a professor of clinical oncology with the Institute of Cancer Research in London.

At issue: What is the best treatment for low-risk early breast cancer? Many studies have shown that surgery to remove the cancerous lump — but not the entire breast — followed by radiation of the whole breast reduces the chance of breast cancer returning, said Dr. Reshma Jagsi, who was not involved with the new study. Jagsi is an associate professor in the department of radiation oncology at the University of Michigan Health System.

Research also suggests that women who undergo this more intensive treatment survive somewhat longer, Jagsi added. But side effects can include breast shrinkage, firmness and tenderness, Yarnold said. That raises the question of whether partial radiation could be a better option. 

The researchers behind the new study randomly assigned just over 2,000 women with breast cancer in the United Kingdom to undergo one of three radiation therapy approaches after having small cancerous tumors surgically removed. Two of the approaches focused the radiation around the tumor, exposing the rest of the breast to little or no radiation. 

According to Yarnold, the study revealed that three weeks of partial breast radiation therapy produced fewer side effects but seemed just as effective as whole breast radiation over five years. Besides very low rates of relapse among all three groups, the rate of side effects from the target therapy was minimal, the study authors said.

On the other hand, Yarnold and Jagsi disagree over whether doctors should embrace the more limited form of radiation treatment now. He predicted that partial breast radiation treatment will become standard for large numbers of women with breast cancer over the next five years.

But he cautioned that the treatment isn’t appropriate for all patients. Physician opinions vary, he said, but in general, the treatment seems best for women over 50 with low- to medium-grade tumors who’ve had the entire primary tumor removed and didn’t show signs of the cancer spreading to axillary nodes (lymph nodes in the armpit region). The findings are promising, said Jagsi, who added that the technology to deliver partial breast radiation is available in the United States.

However, the study isn’t strong enough to warrant changing the traditional approach, at least for women with longer life expectancies, Jagsi said. More follow-up is needed to determine whether less radiation is effective over the long term, she added. 

Moreover, in the case of this ongoing study, additional results will be reported in another five years. For now, “physicians and patients should have detailed discussions about the expected risks and benefits of radiotherapy in each particular case,” Jagsi said. “Many approaches to radiation treatment are now available, and informed deliberation and discussion of this and many other relevant studies is necessary to ensure that each patient can select the approach that is right for her.”

Breast Cancer Survivors Could Have Increased Risk of Thyroid Cancer

Breast Cancer Survivors Could Have Increased Risk of Thyroid Cancer

Women who survive breast or thyroid cancer are linked to an increased risk for the other, according to a new analysis. University of Chicago researchers who reviewed 37 published studies found breast cancer survivors were 1.55 times more likely to develop thyroid cancer than women who hadn’t had breast cancer. And, female thyroid cancer survivors were 1.18 times more likely to get breast cancer than women who hadn’t had thyroid cancer, researchers said.
The study lead author Dr. Raymon Grogan, director of the university’s endocrine surgery research program said that this is a real risk. People who have had one of these cancers need to be aware that they are at higher risk for developing the other cancer.
Thyroid cancer cases have nearly tripled in the United States over the past 30 years, and breast cancer is the most common cancer among women, according to background notes with the study. Thanks to medical advances, more women are surviving each cancer, Grogan said. Moreover, Doctors need to be more aware of the link between the two cancers, he said.
“It should just become one of the common discussions between a patient and her doctor,” he said. “It doesn’t change the recommendations for screening, but people need to be aware and be screened at the appropriate time.”
The report was published Feb. 5 in the journal Cancer Epidemiology, Biomarkers and Prevention. Carol DeSantis, director of breast and gynecological cancer surveillance at the American Cancer Society, said the connection between thyroid and breast cancer is known.
She said her concern with this new report is that by lumping together so many studies that differ in their methods and findings, it’s impossible to come up with a single number that accurately reflects the risk of having one cancer after having had the other.
“The review of different studies is helpful to see that there is that link, but combining them all together, I am not sure who that would be applicable to,” DeSantis said.
Grogan said the research team tried to control for those differences as best they could. Nineteen of the studies analyzed breast cancer patients and their risk of thyroid cancer. Another 18 looked at thyroid cancer cases and their incidence of breast cancer. The researchers then combined these data and calculated the odds of a women having thyroid cancer after breast cancer and vice versa.
In addition, the researchers combed through the studies to find reasons why these cancers seemed related. One explanation was that women who survive either cancer were more likely to be screened and examined so that other cancers were found early.
Another possible connection was that breast and thyroid cancers share hormonal risk factors. There is some evidence that exposure to estrogens and to thyroid-stimulating hormones may contribute to both cancers, Grogan said.
A third theory points to radiation therapy, which has been shown to increase the risk for lung, esophageal, and blood cancers, and sarcomas. Also, earlier research found that radioactive iodine, used to treat thyroid cancer, may play a small role in the development of other cancers, including breast cancer, but that is not clear, Grogan said.
Finally, it is possible that a genetic mutation might be responsible for the connection, Grogan said. DeSantis said that cancer survivors should be aware of the increased risk of developing other cancers.
She said that generally, cancer survivors are at risk for developing a second cancer and breast cancer survivors are at risk for blood cancers, uterine cancer, ovarian cancer and other cancers. Likewise, thyroid cancer survivors are at risk for a number of other cancers, including breast cancer.

Preventive Mastectomy May Not Boost Sense of Well-Being

Preventive Mastectomy May Not Boost Sense of Well-Being

Women with breast cancer who choose to have their unaffected breast removed to potentially prevent a new cancer may not be giving themselves as much peace of mind as they expected, a new study finds. An increasing number of women are having what’s known as prophylactic mastectomy — a procedure chosen by actress Angelina Jolie when she found out she had a substantially increased risk of developing cancer due to her genes.

The percentage of breast cancer patients in the general U.S. population opting to have a double mastectomy at the time of their initial cancer treatment rose from about 2 percent in 1998 to more than 11 percent in 2011, the researchers said. Women often choose the procedure to reduce their anxiety about a new cancer developing.
However, the decision doesn’t seem to affect overall quality of life, the new research suggests Dr. Shelley Hwang, a breast surgeon and chief of breast surgery at Duke Cancer Institute at Duke University in Durham, N.C said that they found that the quality of life for women who chose to remove their healthy breast in addition to the other breast that had cancer was not that different from those who didn’t.

While those who had a prophylactic mastectomy and reconstruction surgery reported slightly higher satisfaction in how their breasts looked and felt, and somewhat higher measures of psychosocial well-being (such as feeling confident), the differences between the groups were small, Hwang said.
Hwang’s team surveyed nearly 4,000 women who had a mastectomy, including about 1,600 who had a prophylactic mastectomy. Those who had a prophylactic mastectomy tended to be slightly younger than those who didn’t, the study showed. 

Researchers asked the women about sexual well-being, physical well-being, expectations about the surgery and satisfaction with care. Sixty percent of the prophylactic mastectomy group said they were satisfied with their breasts. And 58 percent of those who didn’t have a prophylactic mastectomy were satisfied, the study found.

Physical well-being was slightly lower in the prophylactic mastectomy group. When the researchers took into account factors such as age and disease stages, they found the prophylactic mastectomy group still reported higher satisfaction with their breasts. And they had slightly higher psychosocial well-being, but no difference in other measures of quality of life.

However, having breast reconstruction had a greater impact on quality-of-life scores than prophylactic mastectomy alone, Hwang found. About 80 percent of those who had prophylactic mastectomy had breast reconstruction surgery — either immediate or delayed, the researchers said.

Women who had breast reconstruction reported greater sexual well-being. They also had higher psychosocial well-being and higher satisfaction with their breasts’ appearance than prophylactic mastectomy alone provided, the study found. 

Over time, the differences between the two groups diminished even more, Hwang found. Both groups had increases in the psychosocial well-being measures, even 10 years or more after treatment, the research showed.

For years, experts have known that having prophylactic mastectomy has little impact on reducing deaths among women diagnosed with cancer in only one breast, Hwang said. However, little research has focused on how the prophylactic mastectomy decision improves quality of life, or if it does.

In addition, the findings don’t surprise Dr. Veronica Jones. She’s a clinical assistant professor of surgery and a breast surgical oncologist at the City of Hope Cancer Center in Duarte, Calif. She wasn’t involved in the study but reviewed the findings. Jones said in her experience, women who decide on prophylactic mastectomy are generally more worried about a new cancer occurring. Both groups of patients, she said, are making the decision based on what they perceive as their risk of a future cancer.

On the other hand, the risk is low. For the general population, Hwang said, the risk of getting cancer in the opposite breast is less than 5 percent. The general population excludes those with genetic mutations that significantly increase their breast cancer risk, such as the BRCA 1 or 2 mutations, Hwang explained.

What You Need to Know About Breast Self-Exams

What You Need to Know About Breast Self-Exams

You know the drill: The breast self-exam (BSE) illustrations on those pamphlets usually show a woman with one arm up over her head, pushing the fingers of her other hand across her breast—in search of a lump or some other sort of change. Your ob-gyn may have talked to you about doing this every month at home, ideally at a time when your breasts don't feel tender or swollen. 

The truth is, even doing regular BSEs (without regular mammograms) may not protect you. A large study conducted in China by researchers from the Fred Hutchinson Cancer Research Center in Seattle made headlines in 2002 by suggesting that women who were taught to do regular BSEs didn't fare any better—or live any longer—than women who were not taught to do them. On average, they didn't find cancer any earlier. Still, many medical experts believe women should familiarize themselves with how their breasts feel.

However, BSEs can be tricky for women with dense breast tissue—which is common for younger women. "Mostly they don't know what they're feeling or are not confident," says Janet Wolter, MD, a medical oncologist and the Brian Piccolo Chair of Breast Cancer Research at Rush University Medical Center in Chicago. "The breast is constructed like an orange or a grapefruit; you'll feel segments, and that's scary, but it's normal."

For premenopausal women, "the easiest day to remember to do a BSE is the first day of your cycle, when you get your period," suggests Julia A. Smith, MD, director of the NYU Cancer Institute's breast cancer screening and prevention program and director of the Lynne Cohen breast cancer preventive care program at NYU in New York City. If you feel something, wait two weeks and then do another BSE. The odds are it'll be gone—breast tissue often changes throughout the menstrual cycle, says Dr. Smith. But if the abnormality persists, you should see your doctor. Furthermore, older women generally have easier BSEs, because after menopause the tissue gets much softer: "If you put a Ping-Pong ball in there, you'd feel it right away," as Dr. Wolter puts it.

Diabetes Treatment May Affect Breast Density

Diabetes Treatment May Affect Breast Density

Women with diabetes who take insulin appear to have a higher risk of dense breasts, a known risk factor for breast cancer, new research suggests. Women with diabetes who take insulin “have considerably increased breast density (compared to) women without diabetes,” said study lead researcher Zorana Andersen. She’s an associate professor of epidemiology at the University of Southern Denmark in Esjberg.

Conversely, women taking the oral medication metformin instead of insulin to treat their diabetes seem less likely to have dense breasts, Andersen said. Women with breasts that were more than 75 percent dense had a four to six times higher risk of breast cancer than women whose breasts were fattier, with a density of less than 25 percent, the researchers said.

Andersen and her team emphasized that, while insulin treatment was linked with greater chances of higher breast density, that doesn’t prove insulin increases breast cancer risk. The study wasn’t designed to prove a cause-and-effect relationship. Andersen was to present the findings Wednesday at the European Breast Cancer Conference in Amsterdam, the Netherlands. Research from meetings is generally viewed as preliminary until published in a peer-reviewed journal.

For the study, Andersen evaluated more than 5,600 women. They all had mammograms between 1993 and 2001. The average age was 56. Most of the women were past menopause. More than half had breasts classified as mixed or dense. Slightly more than 2 percent of the women had diabetes.

Overall, women with diabetes were less likely to have mixed or dense breasts, the study found. However, women taking insulin injections were more than twice as likely to have dense or mixed (dense and fatty) breasts, the study found. This was true regardless of their body mass index, or whether they had gone through menopause — when breasts may become less dense, the researchers said.

Meanwhile, women with diabetes who managed their condition with diet or with non-insulin medications were less likely to have dense breasts, the study found. Diabetes has previously been linked with a higher risk of breast cancer, Andersen said. But, exactly why there has been an association hasn’t been clear. It’s also not clear how insulin may be increasing the odds of denser breasts.

Moreover, cancer cells grow rapidly and uncontrollably, and growth factors are crucial for cancer to progress, Andersen said. “Insulin is a growth promoting factor of all body tissues,” she said, “and thus it is plausible that it can increase the amount of epithelial or stromal tissue in the breast, thus increasing overall breast density.”

For now, Andersen said, women should be aware that different types of diabetes treatments seem to affect breast density differently. Women on insulin should consider asking their doctor about whether they need extra screening with mammograms and other tests, she added. Andersen wants to look further at the effect of different diabetes treatments on breast cancer risk, including the finding that the non-insulin medications were linked with less breast density.

A Breast Cancer Diagnosis Checklist

A Breast Cancer Diagnosis Checklist

It is true that it is helpful to carry around a checklist of all the information you want to gather about your breast cancer diagnosis, because you’ll be seeing results from the various tests at different times. Although you may have already had a biopsy, for instance, your doctor might still need to remove lymph nodes to determine whether the cancer has spread. 

Mary McHugh, MD, a pathologist at Mount Carmel St. Ann's hospital in Westerville, Ohio, and a member of the College of American Pathologists, recommends finding out the following. What type of cancer is it? The most common form is IDC. Other common types include DCIS, ILC, and LCIS. Click here for a detailed explanation of each type. Is it invasive? Says Dr. McHugh: "If the cancer breaks through the wall of the breast duct, it's considered invasive. If it hasn't broken through, though, it's called in situ or noninvasive cancer." Invasive cancer is more serious.

What size is the tumor? This is measured in centimeters. What stage is it? Ductal carcinoma in situ (DCIS) is stage 0, the most curable; cancer that has spread to other parts of the body is stage IV. What is the histopathologic grade? This is a total score combining three different characteristics of the tumor as it appears under the microscope. Scores range from 3 to 9; a higher score indicates more aggressive cancer. Your report will include a histopathologic grade of 1 if your combined score is 3 to 5; 2 if your score is 6 to 7; and 3 if the score is 8 to 9.

After surgery: Are the margins clear (aka negative) or positive? The surgeon removing the tumor tries to take a rim of cancer-free tissue around the tumor. "We're trying to confirm that the surgeon got it all out," explains Dr. McHugh. If the margins are positive, that may mean scheduling more surgery to get the rest out.

Do the lymph nodes or blood vessels show cancer? Is the cancer hormone receptive? "Some cancer cells have a higher number of hormone receptors in the nucleus and that can promote the growth of the cells," Dr. McHugh says. Your report will say you're ER-positive, or estrogen receptor-positive, and/or PR-positive, progesterone receptor-positive, or negative for one or both. This helps doctors determine if you're a candidate for hormone therapy, such as tamoxifen, which blocks these receptors and can slow down or stop the growth of tumors.

And finally, what is the cancer's HER2/neu status? "If tumor cells are HER2-positive, it means they're associated with a more aggressive tumor," says Dr. McHugh. Your HER2/neu status tells your oncologist whether the drug Herceptin (trastuzumab), which targets the HER2 protein, should be part of your treatment plan.

Is Fat From Another Area of Body Safe for Breast Reconstruction?

Is Fat From Another Area of Body Safe for Breast Reconstruction?

Using women’s own fat cells to enhance breast reconstruction following cancer surgery doesn’t increase the risk they will experience a recurrence of their disease or develop a new cancer, research suggests.

The procedure is known as lipofilling. Fat is taken from the belly or another part of the body and injected into the breast to enhance appearance, the researchers explained. According to the report in the February issue of Plastic and Reconstructive Surgery, this technique can be safely used during breast reconstruction following a partial or total mastectomy.

The study’s lead author, Dr. Steven Kronowitz, of Kronowitz Plastic Surgery in Houston, said in a journal news release that their controlled study shows that, used as part of breast reconstruction, lipofilling is a safe procedure that does not increase the risk of recurrent or new breast cancers.
The study included more than 1,000 women who had lipofilling after cancer-related breast surgery. About one-third of these women had a high genetic risk for breast cancer and underwent a risk-reducing mastectomy.

Rates of new or recurrent breast cancers in these women were compared against a similar group of women who had cancer-related breast reconstructions without lipofilling. Women who’d had lipofilling after a mastectomy due to cancer were followed for about five years, the study said.

Overall, cancer recurrence rates were similar among the women who had lipofilling and those who didn’t. This was true for cancers that recurred in the breast or surrounding tissue as well as recurring systemic cancers that affect other parts of the body, the study authors said.

None of the women who had a preventive mastectomy developed breast cancer, the findings showed.  There was a slightly higher risk of cancer recurrence for women on hormone therapy who had lipofilling during breast reconstruction, the investigators found.

In addition, plastic surgeons are increasingly using lipofilling as part of breast reconstruction surgery. But the researchers said many doctors remain concerned that the procedure may affect women’s risk for new or recurring breast cancer.