Ask-the-Expert Online Conference: Updates From the 2010 San Antonio Breast Cancer Symposium

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Ask-the-Expert Online Conference

The Ask-the-Expert Online Conference called Updates From the 2010 San Antonio Breast Cancer Symposium featured Eric Winer, M.D. and Marisa Weiss, M.D. answering your questions about the latest updates on breast cancer risk, screening, and treatment in early and metastatic breast cancer.

Editor's Note: This conference took place in December 2010.

Length of time to take Herceptin?

Question from girliebiker: Any news on length of time to take Herceptin?
Answers - Eric Winer, M.D. For any woman who has anything other than metastatic breast cancer, to prevent a recurrence, Herceptin (chemical name: trastuzumab) is often used in conjunction with chemotherapy and the standard time is 1 year. We don't know if less than 1 year is as good as a year, and we don't know if more than a year is better than 1 year. One study looked at 2 years versus 1 year and we have no information on that study yet. So the right amount of time is 1 year.

Latest on ER+ metastatic treatments?

Question from hawks: What are the latest treatments for metastatic breast cancer that is estrogen-receptor-positive?
Answers - Eric Winer, M.D. In general for women with estrogen-receptor-positive metastatic breast cancer, the therapy is hormonal therapy and the decision as to which hormonal therapy to select depends on what prior treatment the woman has had. We use hormonal therapy as long as possible because it tends to have fewer side effects and can be very effective. When hormonal therapy is no longer effective, we typically move to chemotherapy. Unfortunately, we are still in search of new targeted therapy to administer with hormonal therapy. But apart from drugs like Herceptin and lapatinib (brand name: Tykerb) for patients with estrogen-receptor-positive and HER2-positive breast cancer, we don't have others that are ready for prime time. There are many new therapies for estrogen-receptor-positive breast cancer that are under investigation.

Dairy products and breast cancer?

Question from Sandy: Are there any issues with dairy products and breast cancer and if so, is any research being done?
Answers - Eric Winer, M.D. I personally do not think there are any issues with dairy products and breast cancer.
Marisa Weiss There are some concerns about dairy products from animals that are treated with hormones to increase their milk production. We don't yet have research on this important concern. In the meantime, you can choose organic sources of dairy products in order to avoid this potential exposure.

Significance of high levels of tumor markers in metastatic?

Question from DorothyB: What is the significance of high levels of tumor markers like CEA and CA in metastatic breast cancer, and whether they increase in these patients?
Answers - Eric Winer, M.D. The absolute level, i.e., the specific number, is not terribly important; what is important is how these change over time. For many but not all women, tumor markers like CA2729 and CEA will increase when the cancer gets worse, and decrease as the cancer is responding to therapy. However, when we talk about decreases and increases, we're talking about decreases or increases of 50-100% of the value, so very minor fluctuations should be ignored. And early on, when one is starting a treatment, tumor marker levels can go up even when a patient is responding to treatment, so this is not something that should be looked at closely when a woman is starting treatment. There's always a temptation to pay too much attention to numbers and not enough attention to how a woman feels.

Advances in HER2+ metastatic treatment?

Question from Andra: Apart from TDM1, Xeloda, and Tykerb (none of these worked for my wife), are there any significant advances in the treatment of HER2-positive stage IV metastatic breast cancer?
Answers - Eric Winer, M.D. Just for background, TDM1 is what is called an antibody drug conjugate. What that means is that it is Herceptin that is chemically linked to a small amount of the chemotherapy drug. It is a treatment that has been investigated for HER2-positive estrogen-receptor-positive disease, and for many but not all women it can be very effective. There are a number of new treatments for estrogen-receptor-positive HER2-positive disease but they are only in clinical trials. These drugs include pertuzumab, neratinib, and a host of other agents.

Updates on bone-only metastasis?

Question from Marium: What was the most important information discussed for bone metastasis-only metastatic patients?
Answers - Eric Winer, M.D. I don't know that there was anything terribly new about metastasis. The news has been development of the drug denosumab (brand name: Prolia), which like the drug Zometa (chemical name: zoledronic acid) can decrease complications from bone metastasis in women with advanced breast cancer.

Zometa twice a year helpful or harmful?

Question from Arnette: What is the current opinion on taking Zometa twice a year to prevent a recurrence and increase bone density? Is it harmful?
Answers - Eric Winer, M.D. There was a large study reported at San Antonio using the drug Zometa, albeit more frequently than twice a year, to prevent bone metastasis. That study, unlike previous studies, did not suggest that Zometa helps prevent bone metastasis or other metastasis. At the moment, other than in very specific situations, most medical oncologists would not recommend the use of Zometa to prevent metastatic disease. It is a drug that can be used to prevent bone loss related to osteoporosis, but that would only involve a once-a-year dose.

New information on multiple brain metastases treatment?

Question from Ele: Is there anything new in the treatment of multiple brain metastases from breast cancer and if so, what? Also, is Temodar recommended in this case?
Answers - Eric Winer, M.D. The treatment of multiple brain metastases typically involves radiation. We continue to search for new medical therapies for brain metastases and while some can be effective, there is no single treatment that can be routinely recommended in this situation apart from radiation. Particularly for women who have problems with recurrent brain metastases, management by a multidisciplinary team that includes a medical oncologist, a radiation oncologist, and sometimes a neurosurgeon is very important.

Recommendations for aspirin and vitamin D?

Question from Beth_Popadynetz: What is the latest recommendation for aspirin and vitamin D?
Answers - Eric Winer, M.D. Aspirin has been shown in epidemiologic study to lower the risk of breast cancer recurrence, but this needs to be confirmed in a clinical trial. I would not recommend a woman take aspirin to prevent recurrence, nor would I recommend that she use vitamin D to prevent a recurrence, although vitamin D is commonly given to help with calcium absorption for women who have low bone density.
Marisa Weiss It's important to have your vitamin D level checked by your doctor to make sure the level is normal and not too low. Since many of us spend most of our time inside and are without significant direct sun exposure, it's not uncommon for women to have low levels of vitamin D. Talk to your doctor about checking it, and if it's low bring it back up into the normal range.

Soy and flax in relation to ER+ breast cancer?

Question from julie: What is the thought now on soy/flax intake in estrogen-receptor-positive breast cancers?
Answers - Eric Winer, M.D. I always tell patients the same thing about this: they should eat foods that they enjoy, and that provide good nourishment. I do not believe that women need to either increase or decrease their consumption of either soy or flax to prevent a recurrence of cancer since we do not have data to support such a recommendation. I think concentrated soy products are foods, so I don't think people should eat them as a medicine. If someone wants to drink soymilk, that's OK with me.
Marisa Weiss Soy foods such as soy milk, tofu, edamame, etc. can be a healthy part of your diet if you enjoy them, but I have concerns about people using pharmaceutically concentrated soy products beyond what they're taking for nutritional needs. We just don't know the safety when you load up on these items.

HT options for post-menopausal women with heart-related side effects?

Question from JanetC: Given the growing evidence of serious heart risks taking aromatase inhibitors and tamoxifen, what other options are available for that small percent of post-menopausal women who have experienced heart-related side effects?
Answers - Eric Winer, M.D. These drugs are not taken together; they're taken separately. There is no evidence that tamoxifen increases risk of any type of heart disease. In fact, in some studies tamoxifen decreases the risk of heart disease. The data with the aromatase inhibitors are mixed. One study at San Antonio suggested the aromatase inhibitors increased the risk of heart problems to a small extent, and another study suggested they decreased the risk. In general, the benefits of the aromatase inhibitors far outweigh the risk, and I think we can be reassured that there are not substantially higher risks of heart disease in women on aromatase inhibitors than in women on other treatments. As always, an individual woman has to weigh the benefits of treatment versus the risks in her personal situation.

Extended hair loss with Taxotere?

Question from Skipper: It has been 3 years since I finished chemo and my hair has still not grown back. A worldwide contingency of post-chemo women all have the same problem and the ONLY commonality is that we all were given Taxotere. Docs need to be aware of this and warn their patients. Why isn't this happening?
Answers - Eric Winer, M.D. This is something that people do occasionally complain of. I personally hardly ever give Taxotere (chemical name: docetaxel), so I do not have a great deal of experience with this myself. I think the possibility of persistent hair loss is something that should be discussed and perhaps this is more of an issue with Taxotere than with other agents.

CYP2D6 test available?

Question from Maher: Do you think the CYP2D6 test will ever become protocol before women are prescribed tamoxifen?
Answers - Eric Winer, M.D. There were two studies at San Antonio, both of which very strongly indicated that the CYP2D6 test was not of value. While there are additional studies that will be reported, in my mind, these two large studies that were just reported should put an end to testing for CYP2D6 unless truly compelling data become available. I fear that testing has the potential to lead to far more harm than good. In particular in premenopausal women where tamoxifen is the standard, there are women who have come off tamoxifen because of testing and I worry that substituting other agents for tamoxifen in premenopausal women could result in real harm.

Recent results on Zometa and recurrence?

Question from Lise: Please comment on the results of the most recent study of Zometa and recurrence and how the results differ from previous studies of the same. Thank you!
Answers - Eric Winer, M.D. The results of the most recent study indicate that Zometa does not prevent a recurrence of breast cancer. There is one large study that was reported approximately 2 years ago that said that Zometa might prevent recurrences in young women who are placed on medications that put them into menopause. The most recent study does not appear to support that finding, and as a result, doctors should be very thoughtful and very selective about the use of Zometa to prevent recurrence. Many doctors will decide not to use it whatsoever in this situation, which is certainly reasonable. All drugs have side effects, and drugs like Zometa, while reasonably well tolerated, can in and of themselves cause problems.

Hope for a cure?

Question from Foxes: Is anyone working on a potential cure and not just one more drug that gives us only a few more weeks? Is there any hope out there?
Answers - Eric Winer, M.D. I think there is tremendous hope out there. There are a whole range of new therapies that are being developed, most of which are targeted towards particular abnormalities in cancer cells. Whether or not any of these drugs will be able to result in a cure for women who have metastatic breast cancer is unknown. If these drugs prove to be beneficial, they could certainly help increase the number of women who have early stage breast cancer who are ultimately cured. It's always worth keeping in mind that there are occasional individuals who do far better than anyone would ever expect and even women with metastatic breast cancer who remain well for many many years, and that is even more the case today than it was 5-10 years ago.

Update on the SOFT trial?

Question from Benita: Did the conference include an update on the SOFT trial? I am 46 years old, premenopausal, and have completed almost 2 years of tamoxifen treatment. I wonder if I should complete 5 years of tamoxifen, or consider ovarian suppression and a switch to an AI. Thank you.
Answers - Eric Winer, M.D. There was no update of SOFT and there is no evidence that a premenopausal woman should switch to an aromatase inhibitor during the first 5 years. Stay on your tamoxifen. If a woman who is premenopausal at diagnosis is postmenopausal after 5 years of tamoxifen, she can consider going on an aromatase inhibitor at that point in time.

Avastin with Abraxane for Stage IV treatment?

Question from NancyH: I was wondering what the latest is with using Avastin (along with Abraxane) for first line defense in Stage IV treatment. I'm concerned about the FDA decision and am wondering what the experts are saying. Thank you!
Answers - Eric Winer, M.D. We don't know that Abraxane (chemical name: albumin-bound or nab-paclitaxel) plus Avastin (chemical name: bevacizumab) is better than Taxol (chemical name: paclitaxel) plus Avastin. There are studies underway to see if it is the same, better, or worse. The FDA will make a ruling on Avastin later this week. At present we know that Avastin is a drug that can help control cancer for a longer period of time when it is combined with chemotherapy, compared to chemotherapy alone. However, Avastin is not a drug that appears to extend the lives of women with metastatic breast cancer.

Cons of treating with Taxotere?

Question from Julie: You said in response to an earlier question that you hardly ever give Taxotere. Is there a reason why?
Answers - Eric Winer, M.D. I rarely give Taxotere because it has more side effects than Taxol and has not been shown in appropriate trials to be superior.

Can Cozaar cause cancer?

Question from bellem: I read recently that Cozaar could cause certain cancers including breast cancer by causing blood vessels to feed tumors. Research was done at Northwestern University. Is this research valid? I have stopped using Cozaar.
Answers - Eric Winer, M.D. I'm not aware of studies that suggest a link between Cozaar (chemical name: losartan) and breast cancers.
Question from edna_dominguez: Has a link between DES exposure in utero and higher incidence of breast cancer been established?
Answers - Eric Winer, M.D. I am not aware that there is a convincing link between DES exposure and breast cancer.

New options for triple-negative breast cancer?

Question from MasonG: Any new options for triple-negative breast cancer that have shown real promise?
Answers - Eric Winer, M.D. The option that is the most encouraging is the PARP inhibitor Iniparib. In a preliminary study, it enhanced the effectiveness of chemotherapy and seemed to prolong survival. A more definitive study has been completed and we are waiting for the results.

Treatment for isolated tumor cells in sentinel node biopsy?

Question from SharonT: What are the latest treatment recommendations for isolated tumor cells found in a sentinel node biopsy? Will this finding be reclassified as node-positive cancer?
Answers - Eric Winer, M.D. I doubt that it will be reclassified; at present it is classified as node-negative cancer and it is treated as a node-negative breast cancer. We simply don't know the significance of isolated tumor cells, and in the largest and best study that has been done, there was no difference in outcome between women who had isolated tumor cells in a sentinel node and those who had a negative sentinel node.
Question from Elyse: Is it possible that the late Elizabeth Edwards exposed herself to a much higher risk of contracting cancer when she took hormones to boost her child-bearing efforts (for two children she later had) at age 47 and age 50? Are there any statistics that show a link between women taking fertility drugs and higher breast cancer rates? Thanks.
Answers - Eric Winer, M.D. I am not aware of convincing data that would indicate that fertility drugs increase a woman's risk of breast cancer.

News on Femara past 5-year point?

Question from JKatz: Thank you for keeping us up to date. I am wondering about Femara past the 5-year point; any news on that subject? Thank you.
Answers - Eric Winer, M.D. At the present time there are no data to indicate that more than 5 years of Femara (chemical name: letrozole) or any other aromatase inhibitor is more effective than taking 5 years alone. We have no data as to the safety of more prolonged exposure to drugs like Femara. Outside of a trial, I recommend to my patients that they stop aromatase inhibitors after 5 years. There are studies that are looking at longer durations of aromatase inhibitors, but we don't have any results to date.

Androgel linked to breast cancer?

Question from KimLee: Is there any known link with women who have breast cancer and been exposed to Androgel by spouse/significant other?
Answers - Eric Winer, M.D. I'm not aware of any link.

Availability of pertuzumab and TDM1?

Question from NinaV: When would you anticipate pertuzumab and TDM1 might become available?
Answers - Eric Winer, M.D. I personally had hoped that TDM1 (chemical name: ado-trastuzumab emtansine) might be available in the next few months, but that will not be the case based on decisions by the FDA. I hope it will be available in the next 1-2 years, but cannot say for certain. In terms of pertuzumab (brand name: Omnitarg), we are waiting for definitive trials. I think it is conceivable that pertuzumab could also be available in the next 1-2 years. There are a limited number of trials with TDM1 and some patients can receive the drug as part of a clinical trial.

Treatments that are easier on bones?

Question from Hawaiian: Are there any new "inhibitors" or treatments like tamoxifen that are easy on the bones and offer better protection against recurrence? I'm on tamoxifen and may switch to an aromatase inhibitor. I'm 53 and have bad osteoporosis. I take Boniva, calcium, and D supplements.
Answers - Eric Winer, M.D. Tamoxifen is easy on the bones in a postmenopausal woman and the decision to switch if you already have osteoporosis and are on a bisphosphonate needs to be considered carefully. At the present, there are no drugs that will be available in the next 2-3 years for women with hormone-receptor-positive cancer looking to prevent a recurrence.

Increase of other cancers with anastrozole?

Question from DBryant: The ATAC 10-year update stated that there were more cases of colorectal (66 vs. 44) and lung cancer (51 vs. 34) among women taking anastrozole. Why is this so?
Answers - Eric Winer, M.D. I don't think there is any biologic reason, and results like this can result from chance alone. I can't say for sure it is just the result of chance, but that is quite possibly the case. Any woman with or without breast cancer needs to have a relationship with a primary care doctor and receive good medical care which does include screening for colon cancer after the age of 50.

Benefits of Arimidex after 5 years?

Question from LucyP: I have been on Arimidex for 5 years after my diagnosis of breast cancer. How long do I need to keep taking it? Are there any studies that show it is beneficial to take it longer than 5 years? Thank you.
Answers - Eric Winer, M.D. There are no studies that show taking Arimidex (chemical name: anastrozole) for more than 5 years improves a patient's prognosis. I advise my patients to stop Arimidex after 5 years.

Circulating tumor cell blood test controversial?

Question from DSD: My oncologist orders the circulating tumor cell blood test every 3 months. She utilizes the results, coupled with other indicators (such as scans), to evaluate treatment efficacy and plan future treatment. Are these uses controversial? What are the positive benefits and potentially negative consequences of this test and of using its results?
Answers - Eric Winer, M.D. The use of circulating tumor cells as a means to follow women with metastatic breast cancer is somewhat controversial. The concerns you have are probably best addressed in a one-on-one conversation with you and your medical oncologist.

Results of lymphedema and exercise study?

Question from Charlie: I lost 20 lymph nodes during a modified radical mastectomy (male breast cancer, left breast) 8 years ago. In January I will resume an exercise program involving repetitive motion. How careful do I need to be, and what were the results of the lymphedema/exercise study?
Answers - Eric Winer, M.D. The results of the lymphedema/exercise study indicated that exercise, if anything, helps prevent lymphedema. If there are changes in your arm swelling or if you experience arm swelling as a result of exercise, I would tend to back off and seek appropriate medical care. But I think it is reasonable for you to pursue an exercise program, albeit with caution as is the case for anyone with or without a history of breast cancer.

Reliability of HER2 testing?

Question from Portia: How scared should we be about this new study saying HER2 testing isn't accurate? I thought I was HER2-negative, but who knows for sure? Is it the test itself that's the problem, or the pathologists' reading ability?
Answers - Eric Winer, M.D. Your question is an extremely good one. All tests are imperfect; some are a little better than others. In the case of HER2 testing, the single most important variable is to make sure the testing is done by an experienced laboratory. If you have concerns about your own particular situation and your own test results, I suggest you discuss them with your physician. If a test result at the time of diagnosis is equivocal, then it needs further evaluation and should be repeated. I wish HER2 testing and all testing were perfect. In spite of the recent controversies about HER2 testing, most patients should feel comfortable with the knowledge that the vast majority of testing performed is accurate.

Prevention of hair loss with chemo?

Question from Giselle: Are there any studies going on concerning prevention of hair loss during chemotherapy?
Answers - Eric Winer, M.D. There is interest once again in looking at an ice cap to prevent hair loss with chemotherapy; perhaps even more importantly there is more and more interest in drugs that do not cause hair loss. We all hope that hair loss as a result of cancer treatment will at some point in the future be a problem of the past.

Most significant news at the San Antonio Breast Cancer Symposium?

Question from beth_Popadynetz: What was the most significant news at the San Antonio Breast Cancer Symposium?
Answers - Eric Winer, M.D. I think the most exciting news was about the potential for some new anti-HER2 therapies, although none of these was ready for routine clinical use. I think the two most clinically relevant pieces of information were that (1) we should not be doing CYP2D6 tests to select hormonal therapies as a matter of practice, and (2) the bisphosphonates in the most recent study do not seem to prevent breast cancer recurrence.

When will PARP inhibitors be available?

Question from Maura: When will PARP inhibitors be available and will they be allowed for use following adjuvant therapy for triple-negative breast cancer?
Answers - Eric Winer, M.D. Good question. The availability of the PARP inhibitors will depend upon a study which has been completed but from which we have no data yet. If that study shows a benefit for the PARP inhibitor, it could be available before the end of 2011. It is not going to be recommended for use as part of adjuvant therapy since that will require additional clinical trials over the next few years. If the PARP inhibitors become commercially available, there will be clinical trials in the adjuvant setting but these will be studies where some women get the PARP inhibitors and some don't. There are serious side effects associated with PARP inhibitors, which is why we have to be very careful in evaluating these agents before we apply them to routine clinical use in patients with early-stage breast cancer.

Studies on Herceptin without chemo?

Question from MarianJ: I had HER-2/neu positive breast cancer. Had bi-lateral mastectomy. Don’t want the chemo that is apparently required in order to be treated w/Herceptin. Are there any studies going on administering Herceptin without chemo? I’d like the Herceptin, as it is a targeted medication just for my cancer...but without the chemo. Thank you.
Answers - Eric Winer, M.D. We do not know that Herceptin will help prevent a recurrence without chemotherapy and I am not aware of studies that use Herceptin without chemotherapy. I understand how you feel and why you may feel that way, but particularly if a woman is at moderate to high risk of recurrence and has HER2-positive breast cancer, she should very seriously consider taking a course of chemotherapy plus Herceptin.

News on neratinib?

Question from SPW: What's the news on neratinib?
Answers - Eric Winer, M.D. Neratinib is an agent like lapatinib, but it may be more effective. That said, it also probably has more side effects. There are ongoing trials with neratinib looking at it in women receiving their initial treatment for metastatic breast cancer and for women in the adjuvant setting. Neratinib is what's called a small molecule, and it gets into the HER2-positive cancer cells and prevents HER2 from stimulating the growth of the cancer cell.

Does eribulin mesylate provide benefits for HER2+?

Question from LAN: Does eribulin mesylate (brand name: Halaven) provide any special benefits to patients with HER2-positive breast cancer?
Answers - Eric Winer, M.D. We don't know if eribulin is any more or less effective in HER2-positive breast cancer than in other types of breast cancer. To date we have no data on the combination of eribulin and Herceptin.

National shortage of Adriamycin?

Question from Wells: Is it true that there is a national shortage of Adriamycin and if true, how does this happen?
Answers - Eric Winer, M.D. There are some centers having trouble obtaining Adriamycin (chemical name: doxorubicin), but there is another drug, epirubicin, that can be substituted for it. It is not a problem we have had at our center, so it is quite variable around the country.
Marisa Weiss The Adriamycin shortage is a national problem at many cancer centers right now. According to the FDA, shortages are due to increased demand and manufacturing delays.

Factors that determine docetaxel's efficacy?

Question from LisaK: I've been reading that docetaxel is not effective in most women with estrogen-receptor-positive, HER2-negative breast cancer. Can you please discuss the factors that determine docetaxel's efficacy with this type of cancer? Are there any tests to determine the drug's effect on a patient's cancer?
Answers - Eric Winer, M.D. This is a very large question, and the potential answer is long and complicated. That said, docetaxel (brand name: Taxotere) is probably no different from Taxol and may not be different from chemotherapy in general. In women with breast cancer that is estrogen-receptor-positive, as a general rule, chemotherapy is less effective in preventing a recurrence than in women who have estrogen-receptor-negative breast cancer. However, there are women who clearly benefit from chemotherapy including drugs like docetaxel, and the risks and benefits of therapy should be discussed between a woman and her doctor. As doctors we look at a range of factors to decide what treatments may be most effective in minimizing a woman's chance of having recurrent breast cancer. In patients with metastatic estrogen-receptor-positive breast cancer the situation is somewhat different, and it is less clear that there is a difference in the benefits associated with chemotherapy compared to women with estrogen-receptor-negative breast cancer.

Progress on reconstruction with implant on radiation site?

Question from MHeube: Has there been any progress on doing reconstruction using an implant on radiated chest wall site of a mastectomy? I had a mastectomy followed by radiation to the site 5 years ago. Would love to do reconstruction, but would rather do an implant than much more complicated DIEP or flap surgery.
Answers - Marisa Weiss After radiation following mastectomy, the tissue where the breast used to be can develop scar tissue and become stiffer than tissue if radiation were not given. Therefore, it's more difficult to stretch out stiff tissue. Most plastic surgeons prefer to use tissue reconstruction after radiation in order to bring in fresh tissue that is without scar tissue and which has a full blood supply. If you are not a candidate for tissue reconstruction, an experienced breast reconstruction surgeon can usually accomplish reconstruction using a tissue expander followed by an implant with some extra techniques. A product that many plastic surgeons like to use is called AlloDerm. This can be sewn in to enlarge the pouch that will eventually accommodate an implant. Some doctors like to use a latissimus dorsi flap from the edge of the back, together with an implant. Again, this brings in fresh tissue that is softer and more stretchy, along with a fresh blood supply. It is particularly important to go to a plastic surgeon who is very experienced in breast reconstruction if you have had prior radiation.

New products for reconstructed nipples?

Question from BrookesN: Besides using Gore-Tex or AlloDerm, is there a new product to use in the reconstructed nipple to not make it TOO firm, nor go flat?
Answers - Marisa Weiss After mastectomy, the first step in reconstruction is aimed at recreating the breast mound. After that project has been finished, many women choose to have nipple reconstruction. There are various ways of accomplishing this. You can do the simplest solution, which is to have only a tattoo done. There is a fabulous 3D tattoo artist that I would highly recommend. You can check him out at He is located in the Baltimore area and has an excellent reputation. If you want to have a nipple with some projection, then some surgical intervention is usually required. Some plastic surgeons rearrange the skin of the mound using an origami technique. Other surgeons may borrow skin from another area -- usually in or around the crotch area -- and use that to build a nipple and areola. It is not always easy to create a projection that is equal on both side and stays up. That is, many women say their nipples flatten out. This can also happen unevenly. Getting the perfect set of nipples is a challenge. You are most likely to get the best result from someone who is an expert in this field. There are some products that are under investigation that can be inserted under the skin to create a little bump, but they're not ready for prime time.

News on lifestyle changes to reduce risk?

Question from hogue: Is there anything new in terms of lifestyle to reduce risk of breast cancer and recurrences that we should know?
Answers - Marisa Weiss There are basic everyday steps that you can take that may help keep you healthy and reduce your risk of breast cancer. Getting to and sticking to a healthy weight is important for breast health as well as for your overall health. I'm not talking skinny. Ask your doctor or your nurse practitioner what your healthy weight would be. Keep in mind that effective weight loss does require both modifying your diet as well as increasing physical activity, but most of the effort is in reducing what you eat. I believe it's an 80-20 proposition: it will take a few hours of walking on the treadmill to get rid of one piece of cheesecake. It's also important to limit your use of alcohol to five or fewer drinks per week. Two to three drinks per week is better, and none or only occasional use is best. It’s important to stay physically active, shooting for 3-4 hours of exercise per week. If you can get to 5, that's even better. I highly recommend Zumba -- it's the only form of exercise that gets me out of my house and that I look forward to. It combines music and dance, two things I love. It also helps get your "sexy" back, something that many of us after breast cancer have to work to make happen. I believe it's important to follow a diet that's mostly vegetarian, so 2/3 of your plate should be fruits, vegetables, grains, nuts, legumes, etc. and 1/3 of your plate a protein source like fish, chicken, turkey, lamb, pork, or beef. I think it's important to buy hormone-free dairy products. My favorite is Stonyfield. I also think it's important to minimize your use of red meat -- and if you eat beef, buy meat that is raised without hormones. I recommend you buy organic fruits and vegetables that are least likely to be treated with pesticides, like apples, bell peppers, and berries. You can buy many vegetables from nonorganic sources like cabbage, broccoli, and cauliflower. Go to for a list of the "Dirty Dozen" as well as the "Clean 15." I also think it's important to cook, store, freeze, and heat your food in stainless steel, glass, ceramic, or enamel-coated metal pans. Do not cook in plastic. I suggest you carry your water around in a glass or stainless steel water bottle. My favorite is a glass water bottle with a silicone outer sleeve available at These are changes you can make over time. Don't expect too much of yourself. It's hard to make all these changes all at once.

More recurrence with hormone-positive breast cancer?

Question from Lynn: You answered a previous question that confused me! Does hormone-positive breast cancer with chemotherapy have more of an incidence of recurrence than hormone-negative? Thank you!!
Answers - Marisa Weiss The specific characteristics of a cancer help you and your doctor design the best-tailored treatment plan possible. For women with hormone-receptor-positive breast cancer, usually their greatest benefit will come from hormonal therapy that blocks or decreases the amount of estrogen in your body. If the cancer is hormone-receptor-negative, the medicine treatment that's likely to offer the greatest benefit is chemotherapy. Hormonal therapy has no role. Some women with hormone-receptor-positive cancer may get benefit from chemotherapy in addition to hormonal therapy. There is a test called the Oncotype DX test that analyzes about 21 genes in a cancer. The result can help tell you if you may get additional benefit from adding chemotherapy on top of hormonal therapy. Of course, all of these choices are very individualized so it's important to discuss these issues carefully with your doctor. You may even choose to get a second opinion when you are making a treatment choice as important as chemotherapy.

Exposure to toxins during breast development?

Question from Debbie: Please tell me more about breast development and exposure to toxins as I heard on NPR. I work as a breast sonographer and mammographer.
Answers - Marisa Weiss During the time of breast development, when the organ is being formed, the newly developing breast cells are very sensitive to any kind of insult. So it is particularly important during pregnancy for the mother to avoid exposures that might affect the health of the breast. But only a little bit of breast tissue is made while the baby is developing in utero. Most breast development occurs between the ages of 8-18, and even into your early 20s. So what you're eating, drinking, breathing, and the products you're using become the building blocks. Girls are laying down the foundation of their future breast health. I believe it's important to avoid extra hormones from medication or food during this time. For example, use organic sources of beef and dairy products. It’s also important for girls to avoid exposures to synthetic hormones such as bisphenol-A which can be present in our everyday products. Avoid buying food in cans because the can lining contains BPA. Instead, buy your food fresh or dried or in jars. Give your daughter a stainless steel or Lifefactory glass water bottle. It's very important for girls to stay athletic because that will improve their health overall and may help them delay earlier-than-normal onset of puberty. Girls and women should avoid unnecessary radiation. The first test that should be considered should be an ultrasound that does not involve radiation. Everyday products like moisturizers and fragrances should first be checked out at Our girls should not be drinking alcohol, and when they go off to college or their first job it's important to encourage them to limit their alcohol consumption. You can also refer to my book, Taking Care of Your “Girls," which is available at Amazon (including many used copies for cheap).

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