In this Breastcancer.org podcast, Brian Wojciechowski, M.D., Breastcancer.org medical adviser, discusses some of the research that was published in May 2014 or presented at the American Society of Clinical Oncology Annual Meeting in June 2014. Listen to the podcast to hear Dr. Wojciechowski explain:
- why using Aromasin on top of ovarian suppression medicine is better at reducing risk in premenopausal women than tamoxifen on top of ovarian suppression medicine
- why some research studies on any links between vitamin D and breast cancer outcomes seem to have mixed results
- the American Society of Clinical Oncology special series of articles on pain in people diagnosed with cancer
- why childhood cancer survivors have a higher risk of breast cancer, even if they didn’t have radiation to the chest area
Running time: 21:44
Show Full Transcript
Jamie DePolo: Welcome to the latest edition of our podcast. This time we’re going to talk about some Research News stories that have come out in the last few weeks. Our guest today is Dr. Brian Wojciechowski, Breastcancer.org’s medical adviser.
So welcome, Dr. Brian, how are you today?
Dr. Brian Wojciechowski: I’m fine, how are you?
Jamie DePolo: I’m doing very well. We had some very interesting studies that were presented at the American Society of Clinical Oncology Annual Meeting, which was at the beginning of June. And some of them were also published in journals at the same time, but one of the big ones that came out, I know there was a lot of media coverage of it, was a study that showed Aromasin, which is an aromatase inhibitor, which is normally used only in postmenopausal women. So, this time it found that giving Aromasin along with medicines to suppress the ovaries reduced risk more in premenopausal women than tamoxifen along with medicine to suppress the ovaries. And so this is pretty interesting to me anyway because it gives premenopausal women another option if they’re willing to do the ovarian suppression. And so what, in terms of treatment, Brian, what does this all mean?
Dr. Brian Wojciechowski: Well, I think it’s important to realize one very important thing about this study, and that is in this study the women were having their ovaries turned off. They were getting the medical ovarian suppression, which is something that is done quite often in Europe for premenopausal women with breast cancer. But it’s not something we routinely do here in the United States.
Jamie DePolo: And why is that? Is there just different research? Different opinions?
Dr. Brian Wojciechowski: I think the research has not been conclusive enough to the satisfaction of most of the thought leaders in the United States to really recommend that on a widespread basis. There’s also major issues from quality of life when you turn off a young woman’s ovaries -- you essentially make her menopausal and that can really be miserable.
Jamie DePolo: Right, because then of course we have hot flashes and perhaps vaginal dryness, I’m trying to think of all the other menopausal symptoms.
Dr. Brian Wojciechowski: Vasomotor symptoms, trouble sleeping.
Jamie DePolo: Trouble sleeping, yes.
Dr. Brian Wojciechowski: Sweats at night.
Jamie DePolo: Right, okay, okay.
So what’s the rush now behind doing this? Is it just to give women another option if they can’t tolerate tamoxifen? Or is there some sort of protection that the ovarian suppression, in this case the medicine used was Zoladex, is that offering some sort of protection to the ovaries because they’re turned off?
Dr. Brian Wojciechowski: Yeah. It turns off the woman’s natural production of estrogen, and we know that estrogen tends to feed and promote the growth of breast cancers that have hormone receptors on them.
Jamie DePolo: And there was one interesting thing, too, about this study. I know that the results when they were presented, they were looking at Aromasin plus Zoladex for ovarian suppression versus tamoxifen with Zoladex for ovarian suppression. But then there was also another group of women who were in the study but they didn’t have the results yet. They were just taking tamoxifen. So I guess ultimately the idea is they would compare the results of Aromasin and ovarian suppression, tamoxifen and ovarian suppression, and just tamoxifen. And if Aromasin plus ovarian suppression comes out to be better than just tamoxifen, is that, do you think that’s practice-changing?
Dr. Brian Wojciechowski: That would be practice-changing because tamoxifen alone is currently the standard of care in the United States for premenopausal women. And if you can show that Aromasin plus turning off the ovaries is more effective in terms of overall survival, then that would be practice-changing. And while it’s a very exciting study right now, and a lot of us are very hopeful about this, I don’t see a lot of doctors changing their practice right now based on not having the overall survival benefit.
Jamie DePolo: Okay. Because right now it’s just showing that it reduced the risk of recurrence but there wasn’t a better overall survival yet.
Dr. Brian Wojciechowski: Right, and it’s probably because the study is still pretty young.
Jamie DePolo: Right. It was only 5 years, right?
Dr. Brian Wojciechowski: Yes. Five years. And you’re not really going to see a survival difference in that time, necessarily. So it may be another 5 years before we really know if there’s a major difference. So, like I said, it’s a very exciting study but I don’t see us changing our practice based on the results so far.
Jamie DePolo: Okay. And one other question about that: With ovarian suppression, since we’re talking about premenopausal women, is there any concern or risk if a woman wanted to get pregnant after treatment? Does that ovarian suppression, could that hinder that in any way or is it no big deal?
Dr. Brian Wojciechowski: No, the fertility should come back after the ovarian suppression is turned off.
Jamie DePolo: Okay. So once the Zoladex is stopped, after a period of time then the ovaries start working again and everything should be fine.
Dr. Brian Wojciechowski: Yeah. Assuming the tamoxifen is stopped as well.
Jamie DePolo: Okay. Great. So, our second study was also presented at the ASCO Annual Meeting, and this one looked at vitamin D and whether women that had low vitamin D levels had a higher risk of recurrence or worse outcomes with breast cancer. And this is kind of another in a series of studies looking at a relationship between vitamin D and breast cancer outcomes. And the results have been very mixed. Some studies have shown that there’s a benefit, women with higher vitamin D levels have better outcomes, and other studies have shown that there’s no effect. And this study happened to show that there was no effect.
One question I have, and I think everybody has, is the levels of vitamin D that the women had in the study were, I believe, around 27 nanograms per milliliter, which is a standard vitamin D level, and a lot of people would say that’s low. A lot of people would say that they should be in the 40 to 60 range, and so, you know, Brian, what do we make of all this?
Dr. Brian Wojciechowski: Well, I don’t think it’s clearly established in the medical community what the right vitamin D level is and what level you should strive for when you treat women with low vitamin D. You will find a lot of disagreement out there, and I know that at my institution, we do check vitamin D and the cut-off is 20. So there are some doctors who would say that 27 is high. So you can see how disjointed opinion is right now on this subject.
Jamie DePolo: Right. And that’s probably, I’m assuming anyway, contributing to the mixed results of the studies. Because if one group is saying well, these women have low levels and maybe they’re really low and other groups are saying these women have high levels and maybe they’re not so high. So the results are kind of all over the map.
Dr. Brian Wojciechowski: Right. And clearly we need to do more research to define what exactly should be considered a normal or a low level.
Jamie DePolo: Okay. And I know one of the risks that we always talk about with taking vitamin D supplements is hypercalcemia, which is too much calcium in the blood. And I know it’s a risk, but I also have never heard of anybody being diagnosed with that or having a problem with it. How much of a concern is that risk? Say a woman does have a level of 20 nanograms per milliliter and maybe she’s going to a doctor who thinks it should be at 40. Is there any risk there if she’s supplementing?
Dr. Brian Wojciechowski: I don’t think there’s any major risk at all. You’re only going to see that sort of thing in someone who is taking it by the bottle. I mean, that would be a major operation.
Jamie DePolo: Okay, and I guess I feel like I should also point out, too, that I know a lot of us work inside now, we don’t get outside as much. But going outside and being in the sun -- within limits, because obviously the sun can also cause skin cancer -- but that’s a great way to get vitamin D, and you really can’t get too much vitamin D from the sun. You can be out there and get as much as you can get, and you won’t get hypercalcemia from it, correct?
Dr. Brian Wojciechowski: That’s right. And there are other risk factors to excessive sun exposure as well.
Jamie DePolo: Right, right. So that’s, we’re still waiting, I guess, to find out exactly what good vitamin D levels are. I know in this study they referenced, the Institute of Medicine put out a report in 2011 that established this 20 nanogram per milliliter level, but then right away people were complaining that that was too low. So I guess we have to wait until more research is done and we can figure out what a good vitamin D level is for everyone.
Dr. Brian Wojciechowski: Yeah, I think so. And, like I said, at my institution, we’re checking every woman with vitamin D and trying to get them above that 20 cut-off range. I’m not sure if it’s really making a difference or not but it is hard to see the downside to it.
Jamie DePolo: Okay. And now we also had a series of articles, I don’t even remember how many, I think there were 17 or 18, that was put out by the Journal of Clinical Oncology, and it was a whole special series of articles on pain in people with cancer. And I’m going to let Dr. Brian explain a lot of it. But my take-away from it, in a layperson’s terms, was that what everybody really needs if someone’s been diagnosed with cancer -- any type of cancer, these studies weren’t just specific to breast cancer. But what everybody needs is really a personalized pain-control plan, because people’s perceptions of pain are different, the way the pain actually physically manifests itself can be different, and what works in one person may not work in another. And they went through all sorts of different treatments. So, Dr. Brian if you wouldn’t mind just going over some of the various treatments that are available.
Dr. Brian Wojciechowski: Yeah, the first thing I want to say is that pain is one of the most difficult aspects of treating people with cancer. And the reason is because there isn’t just one kind of pain. There’s many different kinds of pain. There’s visceral pain, there’s neuropathic pain.
Jamie DePolo: I don’t mean to interrupt, but what is visceral pain? What does that mean?
Dr. Brian Wojciechowski: So, visceral pain is like the pain you experience deep in your organs that can be very dull. As opposed to other types of pain, which can be more sharp. You know, there’s neuropathic pain, which results from nerve damage.
Jamie DePolo: Right.
Dr. Brian Wojciechowski: There’s also mental pain, okay. Pain doesn’t necessarily have to be physical. And mental pain and suffering often dovetails with physical pain such that, for example, a drug like morphine may not be always the best answer for someone’s individualized pain. For some people, aspirin or Aleve or Motrin may be better. For some people it may be an antidepressant that helps control their pain. So, very complex issue, very tough to deal with.
Jamie DePolo: Yeah, I think that’s why I guess my takeaway was that it needs to be very individualized, because if somebody is depressed, that can make their pain more intense when compared to somebody who, say, isn’t depressed. They may be able to tolerate pain and not think that their pain is a problem if they’re not depressed. So there’s kind of this whole physical/mental entwining, which there is with everything pretty much, but I guess in pain it makes it very difficult then to tease out and figure out exactly what needs to be treated and the best way to treat it.
Dr. Brian Wojciechowski: Yeah, pain, an individual’s experience of pain, has something to with not just their physical makeup but their prior experience of pain, what they’ve been through in life, their mental status, their tolerance to whatever pain medication they’re already on.
Jamie DePolo: Okay. And I know they talked a little bit about, in here, some sort of alternative treatments that weren’t medicine. I believe they talked about acupuncture, and I think they talked about meditation… what else, exercises, some laser therapy. Now, have you seen those be effective? I’ve not as familiar with all of those things. I am with some of them, but is that something that you’ve seen women diagnosed with breast cancer use successfully? And I guess I ask that because I can see, okay, if you sprained your ankle, yes, rehab exercises might be great to help your ankle feel better. But I wasn’t sure in people with cancer how that might be helpful.
Dr. Brian Wojciechowski: Yeah, I’ve seen women have success with electrical stimulation, the TENS machine -- transcutaneous electrical nerve stimulator, I’ve seen that be helpful. Rehabilitation like physical therapy, for example, can go a long way to help a lot of musculoskeletal pain, especially that which is associated with hormonal therapies. Acupuncture I’ve seen help, but again, I think that patients and doctors have to be open to these things and think out of the box a little bit about pain. And that’s part of the reason why they published these guidelines.
Jamie DePolo: Okay, okay. And I guess, too, one thing we do always stress here at Breastcancer.org is that if you are in pain, definitely talk to your doctor about it, because there may be a whole host of treatment options that you’re not aware of. And if your doctor doesn’t know how much pain you’re in, he or she can’t help you. So always, always, always talk to your doctor. I know one of the things they mention, too, is if people start to keep a pain diary, which is where they write down exactly what they were doing, where they were, what time it was, how long the pain lasted, what kind of pain it was -- was it sharp and stabbing, was it dull and aching? What did you do to make it feel better if anything? And that also can be very helpful to a doctor who is trying to decide what’s the best treatment for you.
Dr. Brian Wojciechowski: Yeah, and the other thing that you might want to consider is seeing a pain specialist. There’s now sub-specialties of physicians that do nothing but pain management.
Jamie DePolo: Oh, wow.
Dr. Brian Wojciechowski: Some of the physicians do procedures like injections, some of them manage medications and that sort of thing, but that can be useful as an adjunct to your medical oncologist or your surgeon.
Jamie DePolo: And I’m assuming like if somebody came to you and said, “I’m having this pain, it’s not helpful,” your oncologist could refer you to a pain specialist?
Dr. Brian Wojciechowski: Yeah, if she felt that was necessary.
Jamie DePolo: Okay, okay, great. And then our final series of articles were also, were they, I’m trying to remember if they were presented as ASCO as well. I believe they were, yes. There was a series of articles on childhood cancer survivors. And we know that women who were diagnosed with cancer as children and then had radiation to the chest to treat that cancer, like Hodgkin lymphoma, have a higher risk of breast cancer. But there was a study that was presented that said that women who had childhood cancer but didn’t get chest radiation also had about that same higher risk, I believe it’s about 4 times higher than average.
And that was very surprising to me because I did not realize that, and I’m not sure that all childhood cancer survivors realize that. What that really brought home to me was something that we say on this site, is that if you are a childhood cancer survivor, you really need to have a very, very specific tailored plan with your doctor to screen for all sorts of complications that may hit you in adulthood from that childhood cancer treatment.
Dr. Brian Wojciechowski: Right, this was a pretty surprising study for me because I, like everyone else, attributed the increase in breast cancer risk to that radiation that you got to your chest wall in your younger years, knowing that radiation damages DNA in the breast and that DNA damage leads to the development of cancer. But this study surprised me because it turns out that even a childhood cancer survivor who did not get radiation, they were still at a higher risk of cancer later in life.
And I thought about this a lot. And I thought about this lecture that I do every year for physician assistant students at Philadelphia. It’s called the Biology of Cancer, and it basically explains how a normal cell becomes a cancer cell. And the main idea of this whole lecture is that that process, the process we call carcinogenesis, is a stepwise process. It has to do with your environmental exposures and your genetic makeup, how you are born, how you are made.
And I think the reason we see that even women who did not get radiation as a child but still had cancer has a lot to do with the fact that the same risk factors that lead to that woman getting childhood cancer can also lead them to get cancer anywhere else in the body at any other time in life. Does that make sense? It’s kind of the milieu that you’re in.
Jamie DePolo: Right. Right. So if your genetics are such that something happened and you developed cancer as a child, and you’re treated successfully, obviously you’re an adult now, you’re a cancer survivor. But your genetics don’t really change so much that that risk would go away.
Dr. Brian Wojciechowski: That’s right. The same reason you got cancer as a child probably has something to do with the reason you’re getting it as an adult.
Jamie DePolo: Yeah, I thought that was very interesting. And I don’t know that the research could ever be done, but it would be interesting to know is the radiation to the chest, exactly how much does that itself raise the risk, or is it mostly genetics and the environmental milieu that someone’s in?
Dr. Brian Wojciechowski: Yeah, that’s hard to know for sure.
Jamie DePolo: Okay, and again, to emphasize in that what’s really important is that you be seeing a doctor who is very familiar with your situation and your medical history, and you develop a tailored screening plan for breast cancer. It’s also a really good idea to have a tailored screening plan for heart disease or lung disease, because you may be at higher risk of developing some of those issues because of any treatments for the childhood cancer. So we try and emphasize that on the site. And I think that’s all of our studies, Brian. Unless there’s anything else that you wanted to add to that?
Dr. Brian Wojciechowski: No, I think that’s all I can think of right now.
Jamie DePolo: All right. Well, thanks, everyone, for listening. We’re really happy you joined us this week for our Research News podcast. Make sure you stay tuned for the upcoming one, it’ll probably be in about a month. So, thanks everyone for listening, and thank you, Dr. Brian Wojciechowski, for joining us today.
Dr. Brian Wojciechowski: Thanks, Jamie, my pleasure.
Jamie DePolo: All right, take care, bye bye.