Ask-the-Expert Online Conference: Updates From the 2009 San Antonio Breast Cancer Symposium

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Ask-the-Expert Online Conference

The Ask-the-Expert Online Conference called Updates From the 2009 San Antonio Breast Cancer Symposium featured Kathy Miller, M.D. and Kristin Brill, M.D., F.A.C.S. answering your questions about the latest updates on breast cancer risk, screening techniques, treatment options, and more.

Editor's Note: This conference took place in December 2009.

Will denosumab be offered to early-stage breast cancer patients?

Question from RHU: With the report that denosumab is more effective than Zometa in dealing with skeletal events in advanced cancer, do you think denosumab will be offered to early-stage breast cancer patients, as Zometa is now to prevent metastasis?
Answers - Kathy D. Miller, M.D. The first thing is to review the results of the denosumab study. This is a very different agent. It inhibits the activation of a type of cell called an osteoclast. Those are the cells that are responsible for destruction of the bones. It was directly compared to Zometa (chemical name: zoledronic acid) in women with newly identified metastatic disease involving the bones. The women had not previously been treated with Zometa. The women who were treated with denosumab had fewer complications of the disease in their bones or had a longer time until those complications developed. We expect the study to result in the FDA approval of this agent for treatment of women with metastatic disease that involves the bones, but currently this drug does not yet have FDA approval. This drug has also been studied for treatment of bone loss and osteopenia and it's likely that it will be approved for use in that setting before the FDA has had time to fully review the new information about its use in bone metastasis. There is great interest in studying this drug for women with earlier stage disease to prevent recurrence, but we couldn't recommend its routine usage in that setting.

Any discussion of proposed mammography guidelines?

Question from Jewel: The new guidelines about mammograms came out around the conference — was there much discussion there among the experts? What was the general view?
Answers - Kathy D. Miller, M.D. I think many people would be surprised that there was less discussion about the guidelines than you might expect. Much of the focus is on treatment of women with both earlier stage cancer and metastatic disease, and understanding the biology of breast cancer or why some women develop breast cancer in the first place. Understanding that could lead to better options for prevention. Screening is certainly important, and there were studies focused on screening, but for women with very high risk of developing breast cancer, so the guidelines really don’t apply to that group of women.

Adjuvant Zometa beneficial in postmenopausal women?

Question from MaryA: Is there any new data indicating that Zometa shows a survival benefit when given to postmenopausal women in the adjuvant setting?
Answers - Kathy D. Miller, M.D. It's a short answer — no. We have at least three large studies comparing the addition of Zometa or not to the other standard treatments that women have received, that have finished enrolling patients, but we have not yet seen results. Those studies enrolled a much broader group of patients, so they included both premenopausal and postmenopausal women and those who received chemotherapy, but we are still awaiting the results of those studies.

New information on long disease-free interval distant metastasis?

Question from KattyC: Hi, was there any information presented to address long disease-free interval distant metastasis to a single location? I'm ER/PR+, liver tumor resected, oophorectomy. What now?
Answers - Kathy D. Miller, M.D. Your situation is very unusual so there are no studies specifically addressing patients with a long disease-free interval and metastasis that appears limited to one location. In that situation, many oncologists would recommend a treatment very similar to what you received combining local therapy, either with surgery or radiation, with systemic therapy that might treat other areas of disease that were too small to be detected. But since this is such an uncommon situation, it's difficult to collect enough patients to be able to compare different approaches.
Kristin Brill, M.D., F.A.C.S. With newer therapies, especially targeted therapies, we see this scenario more than we did in the past and it's becoming an important question of how to treat systemic disease that is localized to one site. For example, isolated liver disease or lung disease or bone disease. In general, the breast cancer community is being more proactive and aggressive in these situations.

Additional treatment for HER2-positive after Herceptin?

Question from Tigs: I was HER2+ (diagnosed in July of 06). I was wondering if there is anything out there on further treatment. I had a year of Herceptin but was hoping for some additional treatment.
Answers - Kathy D. Miller, M.D. We know that treatment with a year of Herceptin (chemical name: trastuzumab) dramatically reduces the risk of recurrence so you should be feeling very good about your prognosis. But the fear of recurrence is always an issue. There is a study ongoing currently looking at adding treatment with an oral inhibitor of the HER2 factor after women have completed a year of Herceptin in the adjuvant setting. That study is still actively enrolling patients, so we have not seen any results from that study yet.

Developments on breast cancer vaccines?

Question from Eriana: Were there any new developments regarding breast cancer vaccines and their use for metastatic disease?
Answers - Kathy D. Miller, M.D. I saw no new studies about vaccines. This was not a big focus of the meeting this year. Several of the small vaccine studies that were really looking at the safety and feasibility of this approach had updates and longer term results. But I didn't see any important new studies in this area.

Does alcohol make tumors and metastases grow faster, larger?

Question from Conner: SABCS has reported that alcohol usage increases breast cancer recurrence. What about AFTER the breast cancer has returned? Does it make subsequent tumors and/or metastases grow faster or larger?
Answers - Kathy D. Miller, M.D. The study that you mentioned looked at a large database of women who had been previously diagnosed and treated for breast cancer and compared the risk of recurrence in women based on their use of alcohol. They found a higher risk of recurrence in women who regularly drank more than seven to eight drinks a week compared to women who didn't use alcohol at all. Their study didn't include women who had already had a recurrence to see if it might alter their prognosis. The results of this study are very similar to previous studies, which had shown that consistent use of alcohol has a slight increase in the risk of developing breast cancer. For my patients with metastatic disease, I don't worry about them having an occasional glass of wine or alcoholic drink, but I do worry about regular daily use of alcohol.

Possible to receive T-DM1 outside of clinical trial?

Question from A22: Is it possible to receive T-DM1 (chemical name: ado-trastuzumab emtansine) outside of a clinical trial or on a compassionate use basis?
Answers - Kathy D. Miller, M.D. No. There are several ongoing clinical trials with this exciting new agent, but the drug is not yet approved and there is not a compassionate use program.

Clinical trials for gamma-secretase inhibitors and breast cancer stem cells?

Question from DJ: There was some exciting news about targeting breast cancer stem cells. My oncologist calls this the "holy grail." Any indication as to when trials may be open for "gamma-secretase inhibitors"?
Answers - Kathy D. Miller, M.D. The data on gamma-secretase inhibitors did look exciting, but it's important to remember this is early data in laboratory and animal models. It frequently takes several years to move those ideas into the clinic with the very first clinical trials. This is not an agent that I've had any experience with, so I don't know specifically how close they are to activating the first trial.

New tracer for sentinel lymph node biopsy?

Question from DCarre: How much better is this new sentinel lymph node biopsy tracer (Lymphoseek) than the traditional methods used today? I received the blue dye/radio in my procedure but have been reading there's a more accurate drug up and coming? Thoughts?
Answers - Kristin Brill, M.D., F.A.C.S. It seems that Lymphoseek is a new chemical similar to Lymphazurin (chemical name: isosulfan blue) blue dye which is traditionally used to map the sentinel node in staging breast cancer. Lymphoseek is a new product that has been looked at in early trials, but may be beneficial because the map time is shorter and at least in early trials, seems to map to fewer lymph nodes and may have a greater ability to identify just one or two lymph nodes more quickly.

Determination of intermediate OncotypeDX scores?

Question from WallyC: Has there been a determination for the intermediate OncotypeDX score and chemo cut-off for node-negative?
Answers - Kathy D. Miller, M.D.

No. We still struggle with the potential benefits of chemotherapy for women with ER-positive tumors that have intermediate Oncotype DX scores. In this group, there may be no benefits from chemotherapy or the benefit may be as high as 4-5%. That leaves women and their oncologists with very difficult decisions. This is essentially the difficult decision that all women faced before the Oncotype test was able to identify the low and high risk groups. This is why the current TAILORx trial, which randomizes patients with intermediate scores to hormone therapy alone or hormone therapy plus chemotherapy is so important. We suspect that many women in the intermediate group don't need chemotherapy, but the current test simply can't clearly identify them.

Editor’s note: Since this research was published, new genomic tests have come to market. For the most up-to-date information, visit the Breast Cancer Tests page.

Long-term effects of lymph-node surgery?

Question from Analog: Was there any data presented about the long-term effects of surgery (limited mobility, implant problems, etc.)? After 8 years of having no problems, I'm now having a lot less mobility in the arm where the lymph nodes were removed—maybe it's scar tissue buildup as we age?
Answers - Kristin Brill, M.D., F.A.C.S. After an axillary dissection, we know scar tissue exists and for most women it requires continual stretching. If women don't stretch, they can develop reduced range of motion. Some women over time also develop shoulder/rotator cuff/joint problems that may be responsible for limited range of motion as well.

New therapies for metastatic, ER-positive cancers?

Question from enjoyful: Are there any promising, new therapies for metastatic, ER+ cancers?
Answers - Kathy D. Miller, M.D. There was no specifically new hormonal therapy, but there was important information about fulvestrant or Faslodex. This medication has typically been given as an injection in the muscle once a month and has been effective in women with ER+ metastatic disease. We learned this year that using slightly higher doses of this drug makes it more effective, but does not increase the side effects. There was also an important study looking at combining fulvestrant with an aromatase inhibitor such as Arimidex (chemical name: anastrozole). In that study, the combination was not more effective than using the drugs by themselves. So while there wasn't a new therapy specifically for women with ER+ disease, we did learn important information about how to use these existing therapies more effectively.

Avastin for stage IIB-IIIA triple-negative breast cancer?

Question from Will: Is there any evidence that Avastin helps the survival rate for stage IIB-IIIA triple-negative breast cancer? If not, does it make sense to get out of the B-40 trial, since Avastin has negative side effects?
Answers - Kathy D. Miller, M.D. We know that in women with metastatic disease, adding Avastin (chemical name: bevacizumab) to initial chemotherapy makes the chemotherapy more effective, meaning that more women had their tumors shrink, and the benefits of the therapy lasted a much longer time. But in that setting, Avastin did not change the overall survival. The ongoing studies looking at Avastin as part of the adjuvant therapy for women with early stage disease are very important, but we don't have any results from those studies currently. They are all still enrolling patients. I don't think there was any information about Avastin at this meeting that should alter someone's decision about participating in those adjuvant trials. But as you mentioned, all of our therapies do have some side effects. So those side effects, depending on their severity, may be a reason for you to talk to your oncologist and to discuss again whether continuing in the study is right for you.

Information on taking aromatase inhibitors for longer than 5 years?

Question from Euro: When can we expect to hear results from studies on continuing aromatase inhibitors for longer than 5 years? Was there any discussion of this at the conference?
Answers - Kathy D. Miller, M.D. This is a very important question, and there are two large clinical trials comparing 5 years of an aromatase inhibitor to 10 years. Both of those trials finished enrolling the number of patients they needed within the last 9-12 months, so we have not seen any results from those studies. It's difficult to predict when we will hear results, because that partly depends on whether there is any difference between the two treatment approaches. The bigger the difference, the sooner we can see those results and have confidence in the results. When the differences between two groups are small, it takes longer for us to see those results and have confidence that there really is a difference.
Question from KayD: What recent data do you have on CT versus ACT? Are the anthracyclines still recommended for all breast cancers? Dr. Slamon said to shelve it and Dr. Jones seems to say it has problems. Please comment.
Answers - Kathy D. Miller, M.D. There was no new data presented at this meeting, so currently we have only one fairly small trial comparing the TC regimen to the AC regimen. There are rare but potentially serious side effects from the anthracyclines, but they are also one of the most effective drugs in the treatment of breast cancer and many of our most effective treatment regimens include anthracyclines or use the anthracyclines as an important part of the treatment. It's difficult in this situation to make recommendations that would be appropriate for everyone, but there are other studies going on to give us more information. Until we have the results from those studies, this will still be a long discussion between patients and their oncologists to determine what's best for them.

Benefit to surgically removing areas of metastasis?

Question from CarlaDeB: Was anything reported about surgically removing cancerous tissue in metastatic patients? Is this going to be the norm now?
Answers - Kristin Brill, M.D., F.A.C.S. For women who are diagnosed with metastatic disease, the way to treat this, particularly if it's a single site and they've had otherwise a good response, can be challenging. Some women may benefit from excision of a solitary lesion, but these cases are somewhat uncommon. In general, it's difficult to determine if there's a survival benefit from excising a solitary lesion, for example in the liver or lungs. In general, this is better treated with systemic treatment, and if the response is good, consideration is given to localized treatment for these lesions.
Kathy D. Miller, M.D. There are really two important surgical questions for women with metastatic disease. The first is whether women would benefit from removing an area of metastatic disease, such as a lung or liver nodule. That is not something we commonly recommend, but may be a reasonable option in certain situations. I didn't see any new data at this year's meeting that would help with those decisions. The other question is for women who may have metastatic disease at the time of their original diagnosis who have not had surgery to remove the primary tumor in the breast. In that setting, there is a question as to whether removing the tumor in the breast might help those women live longer. There will be a randomized trial specifically to address that situation, but that trial has not started yet.

New information about LCIS or PLCIS?

Question from NJStein: Any new news about LCIS or PLCIS? (natural history, breast cancer progression models, risk, treatment)?
Answers - Kathy D. Miller, M.D. No, at least not that I saw.
Question from Mary: How great is the link between breast cancer (DCIS) and ovarian cancer?
Answers - Kathy D. Miller, M.D. Most of the link between breast and ovary cancer comes from the breast cancer associated genes BRCA1 and BRCA2. Women who have inherited abnormal forms of those genes are at greater risk of developing both breast and ovary cancer. In women who have not inherited abnormal copies of those genes, there is very little if any increased risk in developing ovary cancer in women who have had breast cancer.

New treatments for brain metastases?

Question from sloop: Are there any new treatments for brain mets that offer up hope for long-term survival?
Answers - Kathy D. Miller, M.D. Perhaps not new therapies for patients with brain involvement, but more information that many of our new therapies are able to enter the brain and may have some effect at preventing the growth of brain metastases or decreasing the chance of brain metastases. We are also learning more about genes that alter the likelihood that the disease will travel to the brain, and that could lead to different treatment recommendations or follow-up recommendations for patients in the future.

Are lymph nodes with isolated tumor cells still considered node-negative?

Question from Geri: What is the latest on isolated tumor cells? I had one lymph node out of seven that had seven isolated tumor cells. Two years ago I was considered node negative. Due to the MIRROR study, are ITC now considered node-positive?
Answers - Kristin Brill, M.D., F.A.C.S. Lymph nodes that have small amounts of tumor cells can be challenging for the pathologist to identify, but with a special dye we can pick up very small metastatic deposits in lymph nodes. These small deposits are called isolated tumor cells. By staging these, they have their own notation and at this point we're not certain if there's clinical significance to these small deposits, meaning it's hard to know if these truly represent positive lymph nodes. So at this point they're still considered to be negative lymph nodes.

Guidelines for surgical removal of calcifications?

Question from grantly: I had calcifications show up on a mammogram a year after my lumpectomy, and my surgeon went to remove them but didn't use needle-guided surgery. He removed the wrong tissue, so now I have to have ANOTHER surgery. Aren't there guidelines in place saying surgeons should always use a needle guide in order to take out calcifications found post-lumpectomy?
Answers - Kristin Brill, M.D., F.A.C.S. For abnormalities identified only by mammogram such as calcifications, this would require needle localization to help the surgeon target and remove the appropriate area. Sometimes when the calcifications form in a lumpectomy site, it's more apparent to the surgeon because it's just under the scar and in a palpable area, so in that case the surgeon would not use needle guidance. But typically this would require needle localization.

Exercise program after breast cancer surgery?

Question from EKatz: What is the physical exercise program utilized in the University of Pittsburgh study regarding exercise, post-surgery breast cancer, and lymphedema?
Answers - Kathy D. Miller, M.D. The short answer is exercise is not bad!
Kristin Brill, M.D., F.A.C.S. Usually surgeons will evaluate patients postoperatively for range of motion and risk of lymphedema. We know women who have had a complete axillary dissection and especially women who have had radiation to the chest wall and axilla are at higher risk for developing lymphedema. Being evaluated by a physical therapist postoperatively can be good in maintaining range of motion and reducing the risk of developing chronic lymphedema.
Kathy D. Miller, M.D. There have been a couple of studies recently looking at exercise, specifically in women with lymphedema. There had always been a concern that exercise, particularly resistance training with lifting light weights, might increase the risk of lymphedema or the severity of lymphedema. In the recent studies, that was not true. The women who participated in exercise with the supervision of a physical therapist had less trouble with lymphedema and better function of their arms.

Research on metaplastic, or squamous cell, breast cancer?

Question from DFR: Metaplastic/squamous-cell type breast cancer is a rare type of breast cancer. I'm looking to find out if any research is being done on it. Right now it seems the treatment is based solely on stage. If it is truly so much more aggressive, are there other treatment recommendations? Any data on response to chemo?
Answers - Kathy D. Miller, M.D. You are correct that we have much less information about metaplastic breast cancer because it is so much less common. Metaplastic breast cancer starts in the cells that support the breast tissue, rather than in the glandular breast tissue itself, and it behaves very differently. The treatment recommendations are based primarily on stage, because there haven't been any clinical trials specifically in women with metaplastic disease. Metaplastic disease is sometimes less sensitive to commonly used breast cancer therapies, but may be more sensitive to chemotherapies that are more commonly used for lung cancer or other cancers that have a similar squamous cell appearance. Unfortunately with more rare tumors, it's always difficult to do focused studies to be able to provide patients with clear information to guide their decisions.

News on concurrent chemotherapy and radiation?

Question from Jaqui: Was there any news about concurrent chemo and radiation?
Answers - Kathy D. Miller, M.D. I didn't see anything new, but I did follow one small study that looked at that. This was a study done by investigators at Johns Hopkins who looked at concurrent radiation with dose-dense adjuvant chemotherapy. This was a small study of only about 20 patients, but they found no increase in toxicity from the radiation, and that approach did allow patients to complete all of their treatments sooner. With such a small experience at only one institution, this isn't something that we could recommend to women right now, but I know the investigators hope to study this further in more patients and with other participating institutions. I would add because the study was so small and there was no comparison group, there is no way for this study to tell us if the combined approach was more effective.

Advances for triple-negative breast cancer, preventing recurrence?

Question from KathyW: Are there any advances for triple-negative breast cancer, and what can we do to prevent a recurrence?
Answers - Kathy D. Miller, M.D. The good news for women with triple-negative disease is that they are the group that gets the biggest improvement in prognosis with chemotherapy in the adjuvant setting, but we know many of those women still have a high risk of recurrence. The most exciting development in the treatment of women with triple-negative disease in the past year has been the development of a new class of drugs called the PARP inhibitors. Those drugs take advantage of an inherent defect in repairing damage that is unique to the cancer cells, so they have had much less toxicity to normal tissues and in combination with chemotherapy in the metastatic setting, they made the chemotherapy much more effective. As you would expect, we are very excited about the potential of the PARP inhibitors as part of the early treatment of women with newly diagnosed triple-negative disease, but in that setting the potential side effects become even more important. So there are plans for a pilot study in the adjuvant setting specifically to look at the safety of that approach. That first step should start enrolling patients within the next 6 months.

Research on biomarkers to indicate if cancer cells are in the body?

Question from BrenUKI: I have completed treatment (lumpectomy, chemo, and radiation). What current research is likely to end up with useful biomarkers to address whether malignant cells have escaped and/or are proliferating in the body? The tumor is gone. How can biomarkers tell us about circulating cells?
Answers - Kathy D. Miller, M.D. Your question is a very good one. At this point, they don't. We all hoped that biomarkers would identify recurrence of breast cancer sooner, and that would allow those women to initiate therapy sooner, and therefore the treatment of metastatic disease would be more effective. Unfortunately our current biomarkers simply haven't allowed us to do that. This is still a very active area of research, and as biomarkers get more sensitive [they can identify smaller and smaller amounts of disease] and as our treatments become more effective, that answer may change.

Effectiveness of metronomic chemotherapy on metastatic breast cancer?

Question from RebeccaJ-2: Were there any updates on the effectiveness of metronomic chemotherapy on metastatic breast cancer, both with and without bevacizumab? Thanks.
Answers - Kathy D. Miller, M.D. Metronomic therapy is an approach that uses much lower doses of chemotherapy administered more frequently as a way of inhibiting the growth of blood vessels that may help the tumor grow. This has been most commonly studied using chemotherapy medicines called Cytoxan (chemical name: cyclophosphamide) and methotrexate (brand names: Amethopterin, Mexate, Folex). Those drugs are often given in higher doses as an IV infusion, but they can also be given in lower doses in pill form that would allow women to take the therapy more frequently. In previous studies, that combination has been effective in some women with metastatic disease and was more likely to be effective when combined with Avastin. But I didn't see any new studies of this approach reported at this year's meeting.

Is IV Zometa beneficial for someone who has taken Fosamax?

Question from otic: With the report that women on Fosamax may have protection against breast cancer, is there any information about whether IV Zometa would be advantageous to someone who has already been taking Fosamax?
Answers - Kathy D. Miller, M.D. Yes, potentially. The Zometa is a much more potent form of bisphosphonates so it may be more effective than Fosamax (chemical name: alendronate sodium). We are also learning that Zometa has other effects that may influence how tumors grow that is not related to its effects on the bones. Specifically Zometa can also decrease the blood supply to the tumors in other areas of the body, and that is not an effect that we have seen with all of the bisphosphonates. Whether it makes sense for you to change your treatment is something you need to discuss with your oncologist because there may be other considerations as well.

Will Sutent be used for triple-negative breast cancer?

Question from Caryn: Pfizer was announcing something about Sutent being used for triple-negative breast cancer. What did they announce, and will the FDA approve its use for that purpose?
Answers - Kathy D. Miller, M.D. Unless the announcement was just today I didn't see any new announcements about Sutent (chemical name: sunitinib) and triple-negative breast cancer. We did see the results of a phase III trial of Sutent as treatment for women with metastatic disease. That study required patients to have had previous chemotherapy with an anthracycline and a taxane, but it was not limited to patients with triple-negative disease. In that study, patients were treated either with Sutent or with an oral chemotherapy medicine called capcetabine, otherwise known as Xeloda. In that study, Xeloda was more effective, and because of that, the study was stopped early. We do know that Sutent can be effective for some women with breast cancer but in this study it was less effective than the other option. There are still other studies of Sutent that are going on, and one of those studies is focused on women with triple-negative disease, but that study is still going on, and we have not seen any results.

Medicare coverage for more than one mammogram per year?

Question from Ocho: My concern is that I recently joined the Medicare coverage and I noted they only cover one mammogram each year. What about us already with cancer and surgery who have the need for at least two a year?
Answers - Kathy D. Miller, M.D. The Medicare guidelines are focused on primarily on screening mammograms: those done to detect disease in women who have never had breast cancer and have no symptoms. The coverage for diagnostic mammograms, those done to investigate a previous problem, might be different. This sometimes requires discussing your concerns both with your insurance carrier and your oncologist or surgeon to determine the options and the best approach for you.

What is the best or newest treatment for brain metastases?

Question from JBick: What is the latest/best treatment for brain metastasis that involves multiple lesions?
Answers - Kathy D. Miller, M.D. Patients with multiple brain lesions are best treated with radiation to the entire brain. If one or two of the areas are particularly large, they may add focused or stereotactic radiation to that area.

Does Reclast protect against breast cancer?

Question from BCar: Does Reclast have the same possible protection from breast cancer as Fosamax and Actonel?
Answers - Kathy D. Miller, M.D. Both Reclast (chemical name: zoledronic acid) and Actonel (chemical name: risedronate) are in the same class of drugs called bisphosphonates, but they have not been directly compared, so there is no data to allow us to answer your question.

Is any amount of soy safe for people with breast cancer?

Question from rev002: Is any amount of soy safe to use if you have breast cancer?
Answers - Kathy D. Miller, M.D. There is information from some new studies suggesting that soy is safe to eat and that women who had a diet higher in soy had a lower risk of recurrence. It's important to remember that there may have been many other differences besides the amount of soy they ate, and this study did not look at soy supplements that you might find in a health food store.

Information on PARP-inhibitor study for triple-negative breast cancer?

Question from DianneLi: What phase was the PARP inhibitor study in triple-negative women? How long will it be until PARP inhibitors are available to us?
Answers - Kathy D. Miller, M.D. That's the question we would all like to know! The PARP inhibitor study that was reported earlier this year at ASCO was a randomized Phase II study that enrolled about 120 women. The FDA has required that those results be verified in a larger randomized Phase III trial. That Phase III trial is ongoing and will likely finish enrolling patients early next year, but it's difficult to predict how quickly we will have the results and perhaps more importantly how quickly the FDA will act once the results are available.

Studies on getting chemotherapy but no hormonal therapy?

Question from Tammy: Are there any studies on women who choose to do chemotherapy, but not hormonal therapy?
Answers - Kathy D. Miller, M.D. None that I have seen in women with ER+ disease. We know from our previous studies that there is a bigger benefit from the hormonal therapy than from chemotherapy in those women with ER+ disease. It's also important to remember that for some pre-menopausal women, chemotherapy may function both as chemotherapy and hormonal therapy if it results in decreasing function of the ovaries, and pushing that woman into menopause.

Vitamin D for joint pain from Arimidex?

Question from RochaM: I heard about the new findings on vitamin D helping joint pain from Arimidex. This is great. How much vitamin D do you need to take, and when? My joints are killing me.
Answers - Kathy D. Miller, M.D. The study results in this area are a bit contradictory. Several small studies found that women with lower levels of vitamin D were more likely to have joint pain with Arimidex or other aromatase inhibitors. But studies that looked at replacing vitamin D as a way of decreasing joint pain I found disappointing. The largest study gave women high doses of vitamin D weekly, until their levels were back to normal, and then decreased them to a maintenance dose through the rest of the 6 months. In that study, they found an early improvement in joint symptoms, but at 6 months the levels of joint symptoms were the same. It's certainly important for women to have their vitamin D levels checked. Many Caucasian women are vitamin D deficient and that vitamin is necessary to help prevent osteoporosis, but it's not clear that replacing vitamin D or taking extra vitamin D will improve the joint symptoms.

Are researchers looking for other breast cancer genes?

Question from Lynna: Every woman in my immediate family except my mother has had breast cancer, including me. None of us have the BRCA1 or 2 gene. You would think that all kinds of studies would be trying to get us involved, but apparently there is no interest! Don't researchers want to know about other genes that are clearly causing breast cancer?
Answers - Kathy D. Miller, M.D. Of course we do. There are several large groups actively looking for extra breast cancer genes because we know there are many women, such as yourself, who have a strong family history that is not explained by the genes we have currently identified. Those studies are typically conducted in a few specialized centers. Because breast cancer is such a common disease, they particularly look for large families.

Nerve block as treatment for hot flashes?

Question from Portianna: Can you talk about the nerve block that was studied in the treatment of hot flashes? What is it and how does it work? Thanks.
Answers - Kathy D. Miller, M.D. I saw the study but I hate to admit I don't know a lot of the details. The study looked at a particular nerve block that had to be administered by an anesthesiologist. There were very few complications. Many of the women did report a decrease in hot flashes. But I don't know how widely available that procedure might be, and at this point we have only seen one small study to know how effective this might be.

Information on a shortened course of radiation?

Question from MollyS: Any news on shortening the course of radiation therapy?
Answers - Kathy D. Miller, M.D. Nothing big. We have had the results for several years of a study looking at a 3-week course of radiation compared to the standard 6-week treatment course. That study now has very long-term follow-up, and found no difference in the risk of recurrence or the cosmetic outcome of women treated with the shorter duration. Several newer techniques decreased the duration of treatment even more, to just 1 week. But those techniques also don't treat the entire breast; they only treat the region where the tumor was. We don't yet have results from randomized studies comparing that approach to the more standard approaches. The studies doing those comparisons are going on but we don't have the results yet.

Long-term effects of anthracycline chemotherapy on the heart?

Question from ElsieBruin: Was there anything reported about the long-term effects of chemotherapy on the heart? If we had an anthracycline in the past, what precautions should we take to ensure heart health?
Answers - Kathy D. Miller, M.D. No new long-term studies of women treated with anthracyclines were reported. We do know that in women who received an anthracycline after the age of 50, there is an increase in the likelihood of developing heart problems, although the increase was small. We don't have as much information about women who were treated with anthracyclines when they were younger. I think women should know that age is a factor in side effects from anthracyclines, and it is important for them to reduce factors that are in their control, like reducing fat in the diet, maintaining a healthy body weight, aggressively treating diabetes and high blood pressure, and avoiding smoking.

Safety of Estring to treat vaginal dryness?

Question from ELK: I'm using Estring for estrogen supplementation because of the dryness from Arimidex; is there any new information about the safety of doing this?
Answers - Kathy D. Miller, M.D. Nothing new. But our previous studies would raise concern that this might not be a safe approach. The Estring (estradiol vaginal ring) or other topical forms of estrogen like Premarin (chemical name: conjugated estrogens tablets, USP) cream have very little estrogen that is absorbed and circulates through the body, but they do have some estrogen that is absorbed. And since the aromatase inhibitors like Arimidex function by decreasing the estrogen level, that makes us concerned that the estrogen that is absorbed from the Estring could interfere with the results of Arimidex. Arimidex reduces estrogen levels, and you are giving some of that estrogen back with the Estring, so we would not recommend that combination.

Possible side effects of doubled dose of Faslodex for metastatic breast cancer?

Question from metamama: I'm on Faslodex. Do you think there will be any major side effects if doctors are now doubling the dose of Faslodex for metastatic patients?
Answers - Kathy D. Miller, M.D. No. In the randomized trial that compared the lower dose (which was the standard dose that we had typically used, with the higher dose being two times the dose), there was no difference in side effects with one exception. The higher dose is given as two shots instead of one shot, so there were slightly more reports of pain at the site of the injection.

Will Tykerb and Herceptin be prescribed together in the future?

Question from PEN: Do doctors typically prescribe Tykerb at the same time as Herceptin, or is this the wave of the future?
Answers - Kathy D. Miller, M.D. It is potentially the wave of the future. The combination of Herceptin and Tykerb (chemical name: lapatinib) has been studied in one trial in ladies with metastatic disease, and in that study the combination was more effective than Tykerb alone. That study was in women with very advanced metastatic disease and did not include chemotherapy. That study helped support the ongoing ALTTO trial, which includes the combination of Herceptin and Tykerb with chemotherapy as one of the treatment options for women with early-stage disease.

Most encouraging news from the conference?

Question from rebecca: What was the most encouraging news you heard at the San Antonio conference this year?
Answers - Kathy D. Miller, M.D. I think it was the Phase III trial comparing denosumab to Zometa in women with metastatic disease involving the bones. This is an important and common problem for women with metastatic disease. Denosumab was more effective and had fewer side effects, and I think will be a big advance for our patients.

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