Another Story-Breast Cancer

Few days back did a second opinion consultation. The husband and son had come with some reports.

The history started from May 2009. The lady had a lump in the right breast which was confirmed as malignant by Fine Needle Aspiration cytology (FNAC). The next report they had was a discharge summary from (HCG) Health Care Global Hospital, Bangalore which was dated October 2009. The discharge summary indicated a metastatic disease with metastasis in mediastinal lymph nodes, hilar lymph nodes and lung.

They did not mention what they did from May to October! My guess is that they would have taken either ayurvedic or homeopathic medicine and are now shy to tell about it.

She received 6 cycles of docetaxel+adriamycin+cyclophosphamide at HCG with partial response. Her ejection fraction had also dropped to 40. Possible a side effect of adriamycin. During the work up, they mention that, HCG missed getting estrogen, progesterone and Her 2 marker. After few chemotherapy the tests were done and she was found to be Her 2 positive and negative for hormonal receptors. But they did not add any trastuzumab or lapatinib.

As she had lump in her breast they consulted Dr.Raghavan. He started her on Lapatinib (Tykerb), Letrozole and Zoledronic acid (Zometa). Zometa was added prophylactically as she did not have bone metastases at that time, February 2010. According to their narration, Dr.Raghavan wanted them to take medicines directly from him and also get admitted for zoledronic acid administration. Zoledronic acid can be administered on an OPD (out patient) basis.

The good part was that PET scan done in September 2010 showed complete resolution of disease. There was no evidence of disease anywhere in the body.

The story gets murkier here. They did not have any reports post this and did not divulge any information regarding what medical decision was taken at that time. They mentioned that they took Tykerb for one more year but did not have any prescription for that period. It would have been a challenge to advice on the appropriate course of action in September 2010.

Fast forward to August 2013.

She has visited HCG again. She has local recurrence and now the disease has also spread to hilar lymph node, mediastinal lypmh node, lung, brain (right parietal and left temporal region), and also metastases in dorsal and lumbar spine. She is symptomatic for spinal metastases (she has pain). She is asymptomatic for brain metastases.

A new set of doctors have advised her gemcitabine+paclitaxel chemotherapy with pegfilgrastim support! They have mentioned that, if required, they will treat the brain metastases with Cyberknife!!

What did i counsel or suggest them?


Priority wise

1. Whole Brain Radiation 30Gy in ten fractions and RT to spine (involved areas)
2. Restart Tykerb, as it was taken 2 years back.
3. Consider Capectiabine oral chemotherapy.

I referred them to Dr.Vadiraj at Manipal or to Dr.Siddanna at Kidwai.

I am yet to hear from them...

Dumb Stuff People Say To People With Metastatic Breast Cancer

Breast Cancer Risk-BRCA and Angelina Jolie

Thanks to Angelina Jolie, the awareness about Breast Cancer has hit the roof. Any kind of publicity is good! Those interested in reading her op-ed and comments can click here, here, here.

You can read some interesting views and points worth considering here and here.

If you are a person with BRCA 1 or 2 mutation what should you do?

What are the questions you should be asking?

Here the list goes.....

1. What is the sensitivity and specificity of BRCA testing? To put it more crudely how many times does the testing give a positive report when the person does not have BRCA and how many times does it miss the positive ones!
Will not complicate it with introduction of positive predictive value.

2. What do you mean by 60-80% risk of developing breast cancer when i am BRCA positive?

Normal woman have 2-10% risk. That is out of 100 woman 2 to 10 women can develop cancer. But at what age?

Ok. In BRCA positive ladies, the chance of developing cancer is more. That is out of 100 ladies with BRCA positivity 56 to 84 of them will develop breast cancer. They are also at increased risk for ovarian cancer.

3.Important question to ask, at what age does my risk peak? If at all i have to get mastectomy done, what is the optimum age?

In one study the mean age of people who underwent surgery and showed to have benefit had median age of 40 years.

4. What other modalities are there? Tamoxifen, oophorectomy? that is removal of ovary. How good are these options?

5. What are the risks of various treatments?

When you visit your doctor or genetic counselor, please ask these and any other question which you want to.

Beta Blocker-Old Drug, New Uses-Ask Your Oncologist

Recent retrospective study published in Annals Of Oncology made me sit up and notice beta blockers closely.
Beta blockers are predominantly used as anti-hypertensive and anti-arrhythmic drug. They are also used to control tremors in Parkinson's disease. But here i am talking about its role in improving survival of lung cancer and breast cancer patients.

The article in Annals of Oncology from M D Anderson Cancer Center estimates a 22% improvement in median overall survival for those who took beta blockers.This was in a cohort of patients who had received definitive radiotherapy. The molecular mechanism being hypothesized for the benefit from beta blocker should improve survival for all kinds of lung cancer patients. There is a need to do a prospective study but practitioners and patients should explore the use of beta blockers considering the data available for its safety.
Improvement in overall survival is not a small thing when most new costly agents struggle to show meaningful difference in progression free survival!

Reach out today to your doctor and if you are a doctor read more and start thinking!!

The benefit of beta blocker is also there for patients having breast cancer and melanoma.

References:
1. http://www.medscape.com/viewarticle/777342
2. http://annonc.oxfordjournals.org/content/early/2013/01/01/annonc.mds616.full
3. http://jco.ascopubs.org/content/29/19/2635.abstract?ijkey=dc966043b03d255244605330d386a363baad8d7a&keytype2=tf_ipsecsha
4. http://www.nature.com/nrclinonc/journal/v8/n9/full/nrclinonc.2011.123.html


Conflict of Interest None.

There may be publication bias but asking questions and searching available data can help us in using old weapons against new targets. Academic institutes can do this kind of study.

Breast Cancer

In the previous post mentioned about the story of a lady suffering from breast cancer. For those who want to delve deep into scientific understanding the following resources should help.

For latest treatment options and any other questions who can mail me.

Breast Cancer from fondas vak

Hormonal treatment of breast cancer from Santam Chakraborty


Tata Memorial Hospital treatment algorithm for metastatic breast cancer https://tmc.gov.in/cancerinfo/breast/Popup/clinical%20staging%20algorithms-MBC.pdf

A Sad Story Of A Doctor's Wife With Breast Cancer

In month of February I met a doctor, a surgeon, who is working for government insurance hospital. As i needed by certificates to be attested, i had approached this hospital and had bumped into him. As he came to know that i am an oncologist he started asking about breast cancer. His questioning made me realize that someone known to him is suffering from breast cancer and has also developed metastases. He mentioned that the lady is post menopausal and has hormone positive breast cancer. I drew the algorithm of breast cancer treatment and recommended him to start letrozole 2.5 mg and a bisphosphanate. I mentioned that letrozole may cause osteoporosis.

The surgeon intermittently kept calling me. Also i had to help him get letrozole as it was not available easily in local pharmacy shops. This non availability was also a result of restriction on its supply because it was being rampantly misused in treatment of infertility. Pharmaceutical companies used to sell letrozole for more than 35 Rs when marketed for infertility but same for breast cancer patients was available for around 2 Rs!!

Yesterday made a house call to the surgeon's home. The patient was none else than his wife. She was using a walker to help her walk and appeared tired. She had pain in thoracic and lumbar spine. It was tender on palpation. From what she mentioned made the clinical judgement that the left ischium, left side of pelvis are also involved. Went through her reports.

She was diagnosed of breast cancer in December 2010. She had undergone surgery in early 2011. Was advised adjuvant chemotherapy and radiation. She had declined to take them both. This fear of chemotherapy and radiotherapy was from what she had read and seen. Her mother had suffered from carcinoma cervix and had some side effects from radiation therapy.
This lady is well read, runs a trust and a school. Takes pride in social activities and is respected and consulted in local area. She surfs the internet for answers.
What she had gathered she has refused to take main stream medicine. She takes HOMEOPATHIC medicines. She is reluctant to stop taking homeopathic medicine.

When i asked the surgeon whether she is taking letrozole for last 3 months, he sheepishly mentioned that he had brought the tablets but she has not taken them because i had mentioned that it may cause osteoporosis. Ah! I regretted!

I gave them assurance, explained about observational bias. Somebody else had recommended MRI but since she is claustrophobic they did not want to get it done.

I strongly recommended that they should get 8 gray single fraction radiation to the painful bone areas. It should hardly take 60-90 minutes inside the hospital-from registration, X-ray to getting radiation done.   Start letrozole immediately.

I did feel sorry for the doctor. Being a relative and a doctor is never an easy task. His decision making was hampered because of his emotions.He was concerned and also feeling guilty. But he was not making the right decisions.

I am hurt and angry. This is because there is no need for the lady to suffer in pain. She deserves a good palliative treatment.

What do we learn?

1. The scientific community fails to educate its own members about the risks and benefits of present and emerging evidence based treatment.

2. Fear handicaps and paralyses us. It also makes us take wrong decision.

3. Allowing homeopathic treatment to be available, accepted and taken by patients? Why do we not demand the same scientific rigor from homeopaths? The scientific community by being quite about it, is also equally responsible for nurturing unscientific treatments. I would love to be proved wrong about homeopathic medicine by good scientific research. See the reference section to what i could assess.

4. Anecdotal experience can wrongly influence doctors and patients decisions.

I know it is not easy to take decisions. I do not suggest that you should blindly accept experts. But please make an informed decision. Consult different doctors, take second opinion, speak to survivors.

This is only one of the stories which i have narrated. I have had multiple patients, educated and uneducated who have taken ayurvedic, herbal, homeopathic only to come back for palliative treatment.

References:

1. Bannerji protocol-Homeopathy http://www.homeopathyeurope.org/media/news/beneficial-effect-of-homeopathic-medicines-on-breast-cancer-cells

2.Homeopathy in general: http://rationalwiki.org/wiki/Evidence_for_homeopathy, http://www.guardian.co.uk/notesandqueries/query/0,,-9542,00.html

3. Treatment of metastatic breast cancer: http://www.cancer.gov/cancertopics/pdq/treatment/breast/healthprofessional/page7

4. Treatment algorithm: https://tmc.gov.in/cancerinfo/breast/Popup/clinical%20staging%20algorithms-MBC.pdf

Tamoxifen 5 years or 10 years?

There is a recent trial result published in Lancet

Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61963-1/fulltext?_eventId=login

If you were a patient diagnosed of early breast cancer and had oestrogen positivity, in all likelihood you were/are taking tamoxifen(some of you may be on letrozole or anastrozole!). Your doctor would have suggested that you need to take this for 5 years. With the results of the above mentioned trial, now you will be recommended to take it for 10 years. Because the results suggest that 10 years of tamoxifen treatment can approximately halve breast cancer mortality during the second decade after diagnosis.