Tuesday, April 14, 2015
Wednesday, September 18, 2013
Friday, August 23, 2013
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...
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...
Sunday, June 23, 2013
Saturday, May 25, 2013
Exercise And The Benefits For Cancer Patients
The following article describes in detail the benefits of exercise.
http://www.onclive.com/#
Read and deploy.
http://www.onclive.com/#
Read and deploy.
Monday, May 20, 2013
International Clinical Trial Day-May 20
Ask questions. know your rights, know your responsibilities but participate to improve health care, improve science.
Thursday, May 16, 2013
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.
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.
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