February 2014 Research Highlights
Brian Wojciechowski, M.D.
March 3, 2014

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In the March 2014 Breastcancer.org podcast, Brian Wojciechowski, M.D., Breastcancer.org’s medical adviser, discusses some of the most talked about research studies that were published in February 2014. Listen to the podcast to hear Dr. Wojciechowski explain:

  • the Canadian mammogram study and why it’s flawed
  • why the FDA is warning women not to use ductal lavage in place of mammograms
  • the importance of starting chemotherapy within 30 days of surgery
  • how yoga can ease fatigue and reduce inflammation in women diagnosed with breast cancer
  • how acupuncture can ease aromatase inhibitor side effects

Running time: 23:01

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Jamie DePolo: Hello everybody, this Jamie DePolo. I’m the senior editor at Breastcancer.org. Welcome to our latest podcast. Our guest today is our medical expert here at Breastcancer.org, Dr. Brian Wojciechowski. We are very excited to have him here, and we’re going to do a roundup of some of the most interesting research studies that came out in February 2014. Hello, Brian. How are you today?

Dr. Brian Wojciechowski: I’m fine, Jamie. How are you?

Jamie DePolo: I’m doing well, and I guess we’ll just jump right into it because we had another mammogram study, this one done in Canada, and as we’ve seen lately, there was a lot of controversy around this study. And I guess I’ll just summarize what the study said, or what it purported to say, was that having mammograms didn’t reduce the number of women who died from breast cancer. Now, if you could just explain a little bit about why some experts were questioning this study, and how it seemed that the researchers arrived at those results.

Dr. Brian Wojciechowski: Well, this is a very interesting study and one that I think is an important piece of scientific data, albeit quite flawed for a number of reasons that I’m going to get into. But this is a study that was prospective, so that is the strongest type of data that we have, because the scientists are not looking back at events that have already happened in the past, but they’re actually starting before any events occur, and that is a very strong piece of data. This was also a large study and a study that was done over many years of follow-up, 25 years. So, at least conceptually, this should be a very high-quality study. Now, the issue with the study is that...so it’s looking at mammograms and comparing, basically, women who did get them and did not get them. The problem is, is that the mammograms were done between 1980 and 1985 with...

Jamie DePolo: That’s a while ago.

Dr. Brian Wojciechowski: Yeah, a long time, with what is considered to be substandard techniques and machines. It’s very hard for me to imagine that a study done in Canada from 1980 to 1985 would be applicable to our practice today.

Jamie DePolo: Yeah. I mean, we’re talking a quarter century, 25 years. I mean, in terms of technology, that’s quite a long time, isn’t it?

Dr. Brian Wojciechowski: Yeah, and that’s before digital mammography. You know, the physicians reading the mammograms did not have the same level of training that our doctors do today. So it’s not surprising to me that you didn’t see a difference in death rates in this study. We know that from conversations we’ve had about this topic before, that the absolute number of women’s lives that are actually saved with mammograms is relatively modest for women over age 60. You have to screen about a couple hundred women to save one life, and the number gets even bigger as women get younger. But what this study, and most of the other studies, do not take into consideration is, it’s not just about lives saved, but it’s about the women who would be spared more invasive treatments, like, for example, mastectomy and radiation, and the women who would be spared going through chemotherapy because their cancers were detected earlier. And those women may not have their life saved, but that’s because our treatment is so good that you can’t really even see a difference. So, I think this study is flawed for the reason that it’s ancient. You know, the mammograms were performed in 1980 to ’85, which is ancient history, and also for the fact that it underestimates the true value of mammograms by only looking at lives saved and not the other outcomes that I talked about.

Jamie DePolo: Okay. That sounds good, and I know the other thing we always say, and what Breastcancer.org always stresses, is that we know mammograms aren’t perfect, but they are the best thing we have. And if you’re a woman 40 or over, then mammograms should be part of your medical care, and this study doesn’t change that at all. Okay.

Dr. Brian Wojciechowski: I agree 100%.

Jamie DePolo: Excellent. The next study, which was pretty interesting, it was about ductal lavage, which is also known as nipple aspirate testing. And before we go into it, if you could just sort of explain a little what that is, Brian? I’m not sure everybody knows. It’s not routinely done, anywhere that I know of.

Dr. Brian Wojciechowski: Yeah. So, in ductal lavage, the surgeon will actually insert a very tiny tube into the small opening at the nipple, the milk duct, and they’ll inject some fluid into there and then basically suck that fluid out with a syringe and attempt to rinse out any cancer cells that could be sitting in there. And this has been described as a way to help detect breast cancer.

Jamie DePolo: Okay, and in the middle of February the FDA was very concerned that some women were using ductal lavage test as an alternative to mammograms, and so the FDA put out a warning saying you should not do that because it’s not a substitute for a mammogram. And my understanding is that while ductal lavage can show if there are abnormal cells there, it really doesn’t tell us where the abnormal cells came from so it’s not really giving you a complete picture, and if there is cancer in a breast, ductal lavage may not necessarily show that. Is that correct?

Dr. Brian Wojciechowski: That is correct, it’s a test that has what we would call a low sensitivity. So, in other words, it’s very possible that if a woman had a breast cancer this test may fail to pick it up. It’s a somewhat unsophisticated way of screening for breast cancer and the worst thing would be if a woman was trying to use this as a substitute for mammograms.

Jamie DePolo: Okay. Okay.

Dr. Brian Wojciechowski: The FDA doesn't do this everyday, so this is something to take very seriously.

Jamie DePolo: Right. Right. Yeah. That’s exactly what I was going to say. The FDA doesn’t issue warnings at the drop of a hat, so there must have been some very serious concern that some women were skipping mammograms and just having ductal lavage done. And again, I’ll reiterate, we know mammograms aren’t perfect, but they really are the best screening tool we have to detect breast cancer. So, again, if you’re 40 or older, then a yearly mammogram is recommended for you and there are ways to make mammograms less painful. There are also ways to get help paying for a mammogram if you don’t have insurance. So, definitely go to the Breastcancer.org website and you can find more information about both of those topics.

So, moving onto treatment, there was another study that came out that strongly suggests that women should start chemotherapy, if it’s prescribed, within 30 days of surgery. Because this study compared groups of women, one group waited to start chemotherapy until 60 or more days after surgery, and they compared the results to women who started chemotherapy within 30 days of surgery, and the women who started the chemotherapy earlier had much better survival. And I guess on the surface that makes sense, but is there more to this study, Brian, than I’m seeing?

Dr. Brian Wojciechowski: There could be. First of all, this was a retrospective study, so the investigators looked back into the past, they were looking at 1997 to 2011, and they looked at all of the patients in their one institution, this was a single institution study, which is also somewhat limiting. But they looked at all the patients from ’97 to 2011 who received chemotherapy and they went back and said, “All right, let’s make three groups.” Let’s take one group who got their chemo within 30 days, one group that got their chemo between 31 and 60, and one group that got their chemo after 61 days, and they found that women who got it later, that is after 61 days, had worse outcomes. This makes sense because the purpose of the chemotherapy is to eliminate any microscopic disease that might still be left behind that the surgeon can’t see after she does the surgery. And the more time elapses between the surgery and chemotherapy, the more time those tiny little cancer cells have to grow and spread.

So, logically, it makes sense that you want to get the chemotherapy in as soon as possible, and that’s how we practice. I mean it’s rare that we’re waiting more than 30 days to give chemotherapy. So, this doesn’t necessarily change practice because I think most physicians out there are interested in having their patients treated as soon as possible, but the thing about it is, in the rare instances, in my own practice when a woman has to wait more than 30 days for chemotherapy, it’s usually because of comorbidities and what’s a comorbidity? A comorbidity is some factor that makes life difficult for a patient, such as medical problems, high blood pressure, diabetes, if the patient has a heart condition that needs to be addressed before her surgery, if the patient is elderly. All of these things may actually be what’s causing the women to delay chemotherapy, and it may be those same factors, the same factors that cause her to delay her chemo that caused her to have a worse outcome.

So, in my mind, especially with the retrospective study design looking into the past here, it’s hard for me to say, “Well, is it because they got their chemotherapy late and their tumors were given more time to grow, or is it just because that women with a lot of other medical problems are going to get their chemotherapy later, and are going to have worse outcomes in terms of their breast cancer?” So, is it the chicken or the egg here?

Jamie DePolo: Sure. One thing I did notice in the study, it seemed especially pertinent for women who would, I guess, be diagnosed with more aggressive cancers. Cancers that were stage 3 as opposed to stage 1 or stage 2, or cancers that were HER2-positive, starting the chemo earlier seemed to make a big difference. And as you said, there could have been these other health factors that were influencing that as well, which would all take into account if they have other health factors and the cancer was more aggressive, it would make sense that you would kind of need to start that earlier as well.

Dr. Brian Wojciechowski: Right, and the more aggressive triple-negatives and HER2-postive tumors would grow faster as well. So, it does make sense again intuitively that you want to get the chemo started as soon as possible. Especially in a woman with a subtype that we know is more aggressive and more dangerous.

Jamie DePolo: Okay and one thing I would add too, especially if there are people out there who are concerned about how they’re going to pay for chemotherapy, if you’ve been prescribed perhaps a newer medicine like Herceptin, like Tykerb, like Kadcyla that is more expensive than some of the older medicines, there are ways to help. There are ways that you can get help paying for your medicine. Most of the pharmaceutical companies have care advocates and they can help you get some money to pay for your medicine. So, please, again, go to the Breastcancer.org website under the treatment section there’s paying for your care, and there’s a lot of information there. So if you’re considering delaying treatment because of your concern about cost, it’s not a good idea and there are resources that can help you.

Now, onto what I think are two more, I guess, happier studies, if any study can be happy, but these are good. They are finding that different sorts of complementary and alternative medicine treatments or therapies can help ease some of the side effects that come with breast cancer treatment. And the first one I wanted to talk about is a study, now granted these are both small studies, but they’re very promising. This study showed that yoga can ease the fatigue and inflammation that accompanies breast cancer treatment after women have been diagnosed. And in this study too, and this was interesting as well, the more yoga the women did the better their fatigue was and the lower their inflammation was. And Brian, do you have a lot of women in your practice that do yoga or do they talk to you about that? Would you ever recommend that?

Dr. Brian Wojciechowski: I would say that it’s a minority of women in my practice who actually ask about these things, but seeing studies like this really kindles my interest in the whole complementary and alternative medicine field. You know, looking at this yoga study, and are we going to talk about the acupuncture study as well?

Jamie DePolo: Yes, that’s the next one.

Dr. Brian Wojciechowski: Great. I mean, looking at these two studies, you really have to say to yourself, wow, this is clearly doing something. It seems like whether it’s yoga or acupuncture or even an exercise program, you know the women who are doing something, being proactive, as opposed to the women who are doing nothing, seem to be making out better. Especially for my patients on hormone therapy who may be having a lot of musculoskeletal side effects, I worry that because of that they’re not really taking their medicine, and therefore their chance of cure is diminishing. So, the more and more studies like this that I read, the more and more I’m thinking about incorporating this into my practice. I’ll be honest, some women I’ll talk to about yoga or acupuncture or something like it, and they’ll say, “Well, I really have no interest in that. Thanks, Doc.”

Then some women are right up front and they’re asking me about it, and they’re asking me about herbs and all sorts of different things like that, so it really depends on the person. I think it’s more common in my younger patients, and it’s definitely changing. And so people are becoming more aware of it and it’s really out there.

Jamie DePolo: Okay. And I’ll just explain a little bit about the study. They split women up into two groups, and one group did yoga with an instructor, it was Hatha yoga, and the other group was put on a waiting list for yoga, so they basically didn’t do anything differently. And the women in the yoga group took one class a week, no, excuse me, I think it was two classes a week, and then they were encouraged to do some of the postures at home. Well, again, it was a small study. It’s very encouraging to show that this kind of...sort of mindful thinking exercise can produce some helpful results, and that’s the type of yoga that Hatha is. It’s a very meditative, sort of low, I don’t want to say low energy, but it’s not very aerobic. You hold the postures for a while, and it’s a gentle yoga. And the other thing I would point out is that it’s a great idea if you are thinking about yoga definitely talk to the instructor ahead of time because some women may have some shoulder or arm mobility limitations, or some issues. Talk to the instructor ahead of time, let him or her know that you have been diagnosed with breast cancer, you’re either undergoing treatment or have had treatment, and you can work together to modify any postures to make sure that they’re safe for you.

And since Brian brought it up, we’ll jump right into the acupuncture study, and this, again, was a small study, but it found that acupuncture can ease the side effects of aromatase inhibitors. And the thing that I thought that was really fascinating about this is from what we’ve learned, especially at the San Antonio Breast Cancer Symposium and in other studies that have come out, that side effects are the number one reason why women stop taking aromatase inhibitors, and some women are very, very affected by them. Their side effects are very severe. They’ve got joint pain, they’ve got hot flashes, they’re tired all the time. And acupuncture in these women, this was in postmenopausal women who were taking an aromatase inhibitor, the study didn’t say which aromatase inhibitor, but that the acupuncture helped ease the side effects of hot flashes, depression, and it improved their quality of life. So, again, and according to this study, there were no side effects from the acupuncture. So there was really no downside.

Dr. Brian Wojciechowski: That’s the great thing about a lot of these treatments is that there’s very little prospect for doing harm with things like yoga and exercise and acupuncture, and they really do seem to work for many women. One thing I found interesting about the acupuncture study was also that there was an arm with sham acupuncture, which seemed to do something as well.

Jamie DePolo: Right, and from what my understanding was, the sham acupuncture it still used, I don’t want to say needles, but they were styluses that actually poked the women’s bodies, but they didn’t penetrate the skin. So it was almost like you were being kind of poked with a very small knitting needle or something, and it didn’t go through the skin. So just that touch was enough to stimulate a response, which as you said, was very interesting that there’s something going on there about that kind of touch that can help alleviate.

Dr. Brian Wojciechowski: Well, I don’t know if you’ve ever experienced acupuncture, but I actually have once, and I have to say it was very relaxing, it was very calming and centering. You just kind of focus and it takes your mind off of everything else. So, either there’s really something to it, the whole puncturing of the skin and the technique and the philosophy, or there really is some sort of placebo effect. It would have been interesting in this study if they had a third arm of patients who actually got nothing at all.

Jamie DePolo: Right. I thought about that, too, and I actually have had acupuncture too, and I’ve had good results. I would agree with everything that you said. It’s a very meditative procedure, and you kind of focus on what you want to focus on, and it is very relaxing. So, you know, again, the studies are small and we’re not saying that this is right for everybody, but these complementary and alternative medicine techniques really don’t have very many downsides. So, if you are having severe side effects from aromatase inhibitors, as it seems like many women are, this may be something that you want to check out. And again, on the Breastcancer.org website, we have an entire section on complementary and alternative therapies, and you can learn more about them, and you can also learn how to find a qualified practitioner. That’s probably the biggest challenge I had when I was looking to start receiving acupuncture, is I wanted to make sure I went to somebody good, and so I had to do some asking around. And we have tips on our site on how to find a qualified practitioner.

Dr. Brian Wojciechowski: Yes, and I just wanted to say, before anyone starts any of the complementary or alternative treatments or medications, please talk to your physician about it first, just to make sure that there’s nothing interfering with your treatment.

Jamie DePolo: Excellent. Excellent advice. Always good advice and that includes, as you mentioned some of your patients were talking to you about herbs. If you’re going to start taking anything different, vitamin supplements, doing some sort of exercise or alternative therapy, always, always, always talk to your doctor. You just want to make sure that nothing’s going to interfere or conflict with any of your current treatments. And I think that’s all the studies we have to talk about today, Brian, unless there’s anything else you’d like to add.

Dr. Brian Wojciechowski: No, that’s it for now.

Jamie DePolo: Great. Well, we want to thank everybody for listening. Again, I’m Jamie DePolo. I’m the Senior Editor at Breastcancer.org and our very, very intelligent guest today has been Dr. Brian Wojciechowski, Breastcancer.org medical expert, and we thank him for all his insights, and we will be back next month to do another wrap-up, and thanks to all of you for listening. We will talk to you later.

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