October 2007: Living with Metastatic Breast Cancer

More attention for metastatic patients?

Question from VanD: Often women with Stage IV breast cancer feel like outsiders. Attention and focus is given to women whose breast cancer is "curable." Are there any initiatives underway across the U.S. to bring more attention to women who are living with breast cancer day in and day out?

Answers —Larry Norton, M.D.: The comment is absolutely right. A lot of the communication and resources are focused on patients with primary breast cancer rather than recurrent breast cancer. However, there are efforts to correct that. One was started here in New York by Roz Kleban who is the social worker in our center, the Evelyn Lauder Breast Center at Memorial Sloan-Kettering. It also involves many volunteers here in New York. They established the Metastatic Breast Cancer Network. It had two meetings so far — one at Memorial Sloan-Kettering and this year at New York University. It had lectures of relevance to the audience, who were 100% metastatic breast cancer patients, as well as networking, resources, and information. One of the major changes in metastatic breast cancer over the years is conversion from an acute fatal disease to a chronic one that people can live with. I have people with metastatic breast cancer that I've cared for for 25 years. I expect that we're going to see more and more people with long survival with this disease, which is always a prelude towards disease cure. I've seen cures over the years I've been involved in cancer medicine. It's always a chronic disease before it becomes a curable one, and I suspect we're in that transition now.

Marisa Weiss, M.D., president and founder: As women who have received many different therapies in sequence or combination, you become great personal experts in how and what it's like to be treated for breast cancer and help others making their way through it. In the discussion boards at breastcancer.org, so many of you share this personal knowledge. New therapies for breast cancer are usually first introduced in clinical trials for women with metastatic disease, so you truly are pioneers for new treatments and approaches in the future.

Prognosis for liver metastases?

Question from Mariamosca: A year after chemo, double mastectomy and radiation, my breast cancer has metastasized to my liver. How viable is liver surgery for me? And what are the latest stats for a prognosis for this kind of metastasis? Everything on the Internet for metastatic cancers is pretty outdated.

Answers —Marisa Weiss, M.D., president and founder: Medicine certainly is marching forward. Every day, Breastcancer.org does report on the results of clinical trials and other study information on new therapies.

Larry Norton, M.D.: When breast cancer becomes metastatic, the liver is certainly one of the organs that can be involved. Bone is the most common site, then lung, then liver. It appears that each individual breast cancer has a tendency to go to a specific metastatic site, and one of the areas of current research involves defining the genes that become abnormal in cancer, that allow the cancer to go to specific sites (what we call “site specific” metastasis). One of the important things that has to be done for a patient who has newly diagnosed metastatic disease is define all the sites of involvement and use this to plan appropriate therapy. Initial therapy almost always involves medications, which might be chemotherapy or hormone therapy or newer drugs that attack molecules such as HER2 or cancer blood vessel formation. If it appears that there is a solitary site of involvement in the liver or occasionally two sites in the liver and the cancer in other parts of the body is totally controlled, then there indeed might be a role for local therapy such as surgery. One technique that has become rather widely used is called radiofrequency ablation, or cryoablation. These techniques involve introduction of a wire through the skin into the cancer, and an application of energy that destroys the cancer at the tip of the wire. However, in general, this technique is used only in patients who have achieved good control of their disease by the use of medications.

Stage I to Stage IV means fast-growing cancer?

Question from Sylvia: I am a 52-year-old metastatic breast cancer patient. In 2004 I was diagnosed with stage I, no lymph node involvement. I had a mastectomy, was told I was cured. June 2007 I am at stage IV. How can this be? Does this mean I have a rapid-growing cancer?

Answers —Larry Norton, M.D.: Breast cancers appear first in the breast in most situations. In that case, the therapy is focused on eradicating the cancer in the breast and the use of medications to kill cancer cells elsewhere in the body if the cancer cells have spread to other parts of the body but have not yet grown. In most cases this treatment is successful, and cancers do not grow back either in the breast or in any other part of the body. However, such treatment is not always successful and sometimes cancers do grow in what we call distant sites, which are parts of the body separate from the breast. When this occurs, we have to focus our energies on treatments that can kill these cancer cells. Which treatments we use depends on the biochemistry of the cancer cells, sites of involvement, and any prior treatment for cancer that the patient has received.

Marisa Weiss, M.D., president and founder: Even though you've experienced a recurrence, and that can feel devastating, don't give up hope. The cancer may still respond quite well to new therapeutic approaches. And new therapies are being investigated and are on the horizon. Ask your doctor about clinical trials for which you may be eligible.

New treatment schedule for Xeloda?

Question from Joan: I've been on Xeloda for a year now and it is working, but the side effects are somewhat debilitating — hand-foot syndrome. What do you consider to be a good schedule for the drug — 7 days on, 7 days off at a higher dose? I understand that this is a new protocol.

Answer —Larry Norton, M.D.: Yes, that's a treatment that we've developed at Memorial Sloan-Kettering. The conventional schedule for Xeloda (chemical name: capecitabine) is 14 days on and 7 days off. However, by analyzing lab experiments, we have determined that most of the cancer killing activity of the drug is in the first 7 days of exposure. Hence we have explored 7 days on and 7 days off instead of 14 days on and 7 days off. This allows a higher dose to be administered safely, and seems to remarkably reduce the incidence of hand-foot syndrome. Currently this regimen is being tested in various settings; however, because of the reduction in toxicity many oncologists are already using the 7 on/7 off schedule as their preferred method of administration. The important thing is to stay away from the drug until the hand-foot heals completely. You can go to other anti-cancer medications for weeks or months until the hand-foot syndrome heals, and then go back to the Xeloda with the new schedule and get anti-cancer activity with reduced side effects.

Helpful antidepressants with low side effects?

Question from Alison: Are there recommended antidepressants or anti-anxiety drugs for metastatic breast cancer patients? My mother tried Paxil, but had severe side effects (anxiety, panic attacks, nausea). Do you find that these types of drugs are helpful for cancer patients, and which ones are most common/have the least side effects that interact with other drugs such as pain medications?

Answer —Larry Norton, M.D.: Anti-depressants have to be individualized. There are many available agents, and which one is best for a patient can only be determined by working with that individual patient. Just because you have bad side effects with one does not mean you'll have them with another. So the patient must work with an expert in the use of these drugs to find the drug or combination of drugs that works best. Cautionary note — the commonly used antidepressants can stimulate increased amounts of certain enzymes in the liver that can metabolize other medications at different rates. Therefore if other drugs are used, especially anti-cancer drugs, they may have to be used at a different usage in a concurrent usage with anti-depressants. For example, any of the SSRI drugs like Paxil (chemical name: paroxetine) can change the metabolism of tamoxifen. It is somewhat specific to the individual, but in general if you're using SSRIs, you should be aware of the interference with anti-cancer drugs. You really need expert consultation in this. The antidepressant medication has to be individualized, but your doctor must be aware that they can affect the metabolism of other drugs as well.

Editor's Note: Paxil is known to reduce the effectiveness of tamoxifen. If you are taking tamoxifen, talk to your doctor about alternative antidepressants. For more information, please visit the Breastcancer.org Tamoxifen page.

How long does feeling good last?

Question from Cindy: I am Stage IV and am taking Femara. Right now I feel like I could do almost anything. I don't know how long this is going to keep up. I am keeping very busy and commit to things that will last for a few months at a time. Question: Can I plan on feeling this good for some time?

Answer —Larry Norton, M.D.: The answer is nobody can predict how well an individual patient is going to do, or for how long. However, it is certainly one of the possibilities that a drug will work for many years, in fact, and that you will feel fine for many years. I think it's important that you should do what your body is telling you to do in terms of your activity level, and not curtail your activity level just because you have Stage IV disease. Live your life fully, and let the medicines do their work, which is to allow you to live your life fully.

Risky to have radiation to spine?

Question from DeLeisa: I have metastasis in the spinal bones. How risky is it to have radiation there — I mean, having the spinal cord damaged?

Answer —Marisa Weiss, M.D., president and founder: Radiation therapy is a very effective way to get rid of cancer cells when they travel to an area of the spine. Radiation can reduce pain, and reduce the risk that the cancer could impinge upon the spinal cord, thus causing loss of neurologic function. Radiation in this setting is very safe if delivered in a modern radiation therapy department by a board-certified radiation oncologist. The benefit of this treatment far outweighs any potential side effects.

Stop Herceptin because of heart problems?

Question from MsM: My oncologist recently stopped my Herceptin treatment. My heart is only functioning at 45 percent after starting treatment and I have an artificial aortic heart valve. They knew this when I began chemo treatment. Some clots have been found in my lungs. My oncologist said he would see me in 3 months. I'm concerned and confused and I wondered what you would suggest I do?

Answer —Larry Norton, M.D.: Obviously I can't give specific advice, not knowing your case in-depth. However, there are a few points to be made here. First, valvular heart disease is not a contraindication for Herceptin (chemical name: trastuzumab), and having valvular heart disease does not increase the risk of developing heart toxicity from Herceptin. However, if there is weakening of the heart muscle from Herceptin, it is totally appropriate to stop the Herceptin. Often in that setting, doctors give medication to strengthen the heart. When those medications are successful, it is sometimes proper to restart the Herceptin. Only an expert medical oncologist could properly handle this situation. The other thing to note is that Herceptin lasts in the bloodstream for a long time after it's stopped. The reason for the 3 month period is that the Herceptin is actually still working against the cancer in that period, even though it is not being administered. The issue of blood clots in the lungs is a separate issue, probably related more to the valves than the Herceptin. Most people with blood clots are given anti-clotting medications to allow those clots to dissolve and to prevent new clots from forming. If any individual is not totally comfortable with an opinion they've received from any doctor, it is acceptable to seek other medical advice for clarification and sometimes a fresh opinion. In other words, a second opinion in this case might be in order, even if the second opinion did turn out to agree completely with the first opinion.

When to stop treatment with all organs affected?

Question from NyMo: How do you know when to stop treatments? How many organs can be treated at one time if they are all affected?

Answers —Larry Norton, M.D.: Anti-cancer medications, because they go into the bloodstream, go in the whole body and treat cancer wherever it's found. Knowing when to stop medication is part of the skill of medical oncology and can't be specified in an individual case except by a skilled doctor. But I do want to make this point: it is not always necessary to treat the cancer continually. For example, I often treat until I have control of metastatic disease and then stop the medications, offering what we call a "chemotherapy holiday." There is evidence that treating intermittently gives just as long a period of disease control as treating continuously, but of course with fewer side effects.

Marisa Weiss, M.D., president and founder: If you think you would like or need a break in your treatment, work this out with your doctor. You can take a break for holidays, for a special occasion, because you want to travel, or for other reasons.

Larry Norton, M.D.: This is an excellent point. Don’t assume your doctor knows how you feel. You have to talk about any special considerations in your life. If you don't provide that information, the doctor may not make the right decisions because such information is an important part of the total care package.

Signs of liver metastases?

Question from Zim: After stage I breast cancer, what signs indicate movement to the liver? My MRI shows two small "lesions."

Answer —Larry Norton, M.D.: If the lesions are small, they may not have symptoms at all. So you can have metastatic disease and not be aware of it in terms of how you feel. However, if the cancer is there, it should be treated. One important step is to make sure that any suspected areas of metastasis are biopsied to confirm that they are metastatic sites before therapy is instituted.

Switch from tamoxifen to aromatase inhibitors?

Question from Randirella: Hello Drs. Norton and Weiss: I was diagnosed with metastatic disease after 9 yrs of dormancy. I just had an oopherectomy. I'd gone back on tamoxifen and now my doc wants me to switch to an aromatase inhibitor. I prefer to stick with tamoxifen, since it’s keeping me stable and I remain asymptomatic. Don't want to use up my tools if I don't have to. Does my logic hold? Thanks for everything you do, I'm a fan.

Answer —Larry Norton, M.D.: I think you should ask your doctor that question, as there may be a reason for using the aromatase inhibitor that you don't know. I agree with your sentiment that you never get off a winning horse. If the medication is working and there are no side effects, then almost always the right thing to do is not switch. However, you really must discuss this with your doctor as there may be facts that are not apparent to you that would necessitate a switch at this time.

New metastatic medications coming?

Question from Endel: I was first diagnosed 16 years ago. My disease is Stage IV now. During the last 3 years, I used almost every chemo drug available. I stopped responding to hormonal therapy. I just started Navelbine as the last drug available. Please give me hope that new drugs are coming. I cannot live without this hope.

Answers —Larry Norton, M.D.: There is never a last drug available. We have dozens of effective drugs for breast cancer. Sometimes going back to drugs that have been used in the past can give someone a new response that can be long-lasting. There are many useful clinical trials that are exploring new and exciting drugs and other approaches.

Marisa Weiss, M.D., president and founder: To find out about clinical trials that you may be eligible for, go to cancer.gov, the clinical trials section at breastcancer.org, or by calling 1-800-4-CANCER to identify study groups in your particular area.

Larry Norton, M.D.: It's extremely important not to give up, to keep gathering more information about clinical trials and to remain optimistic.

Marisa Weiss, M.D., president and founder: Getting treated for metastatic breast cancer can feel like more than a full-time job. You have to keep pushing and always keep reading about new treatments on the horizon. A great place to go for support and encouragement is the community at breastcancer.org where there are specific discussion boards for women who share your concerns. You might learn about clinical trials and other new ideas from them. We monitor all the discussion boards.

Flaxseed okay with ER/PR+ metastasis?

Question from MJCS: Is flax seed or oil okay with ER/PR-positive metastasis? I figure, what have I got to lose? Currently, I have metastasis to all bones and lung fluid. Seems to be some promising research suggesting flax can stop cancer cells. I guess I am asking how much risk we should take at Stage IV. Thanks for this conference!

Answers —Larry Norton, M.D.: In terms of resources, you should know about Breastcancer.org, and also, Memorial Sloan-Kettering's site at mskcc.org has an Integrative Medicine section on medicinal plants and other alternative medicines. It's a good place to get solid information. The fundamental issue is that most plant products have not been adequately tested for us to know how safe they are. This is especially true with hormone-receptor-positive breast cancer because so many plants have estrogen-like activity. The other fact is that some of these plant products, by the way they are handled in the body, can change the metabolism of other drugs that are administered. So effective anti-cancer drugs could be made ineffective by the simultaneous administration of plant products. So the question is what do I have to lose? Potentially, a lot, and I would suggest great caution in this regard. By all means, make sure your doctor knows everything you're taking. Don’t assume that because it's not labeled a drug that it's safe.

Marisa Weiss, M.D., president and founder: The FDA does not test food products including flax seed oil, and therefore we are without rigorous study information or an accountability from companies that make these products.

Larry Norton, M.D.: We don't even know for sure if what is labeled flax seed oil is in fact flax seed oil. We don't know if the labeling is accurate.

Time to switch from forgetful doctor?

Question from Nie: My oncologist never calls me with test results — I have to call. He also forgets what chemo I've already had. But he behaved better in the beginning of my illness. Does it mean that he already "gave up" on me? Should I just find another doctor?

Answers —Larry Norton, M.D.: I'm impressed that many people don't realize that they are the consumer. The doctor is there to help you. If you're not getting what you need, it's your right to find another doctor who will give you want you need. Asking for test results on time, and a doctor who's knowledgeable about your case is a reasonable request, and you have the right to obtain those services.

Marisa Weiss, M.D., president and founder: For women with metastatic disease, your situation might change over the years. You may have moved to another city, you may have changed your philosophical approach to your care, your priorities may have shifted, your relationships may have changed as well. All along the way you may also want to reevaluate who's on your health care team and if they're meeting your needs in a way that gives you confidence and hope and optimism about the future. Our book “7 Minutes!” (the average time people have with their doctors during follow-up) is being launched next month at breastcancer.org. It's a book derived from a performance I did called "Doctor, Doctor, Lend Me Your Ear." It’s about how to get the most out of the short time you may have with your doctor. How do you address this sacred relationship that's inherently lopsided to provide the best care?

What to do when ready for a breakdown?

Question from MarshaB: I have mets to my liver and bones, and because most of the time I look great, people assume I am great when really I feel like crap and am tired. When they say, "Wow, you look so normal," it is so hard to not break down and cry and yell at them. What can I do?

Answers —Larry Norton, M.D.: Basically Marsha, you need somebody to talk to about your own individual psychological situation and relationship to this illness. I think you need some individual counseling — not because you're ill or you're doing things wrong, but you need coping skills. I hear stories about people who are trying to be nice, but say or do inappropriate things. Often, this means individual counseling so you need a friendly ear to talk to so psychologically you can do as well as you seem to be doing physically.

Marisa Weiss, M.D., president and founder: Often people will take their cue from you. So if you are looking glamorous, strong, and courageous, people will want to assume that you are everything that you seem plus more. These people probably depend on you in many different ways, particularly family members. Dealing with expectations — your own, as well as others’ — is one of the challenges of living with metastatic breast cancer. It takes a lot of work to let yourself and others know what they can expect from you and also what you may need in terms of private time, extra rest, extra nourishment, and time alone as well as time with others. You may need to let people know how you want to manage this. Ideas from a therapist, as well as others in our discussion boards can be quite helpful in this situation.

What to do for nerve pain with Abraxane?

Question from SixCats: I'm having a lot of nerve pain from Abraxane. What can I do for this besides over-the-counter meds and steroids?

Answers —Larry Norton, M.D.: Abraxane (chemical name: paclitaxel) is a medicine that's known to cause nerve pain. It's one of its major side effects, and it may be a reason why Abraxane should be discontinued. There are many treatments that have been offered to try to decrease the nerve pain. Neurontin (chemical name: gabapentin) is widely used; however, the treatment has to be individualized. The most important thing is stopping the medicine. Sometimes you can get permanent damage if it's continued. If the medicine is stopped appropriately, sometimes the nerve pain goes away.

Marisa Weiss, M.D., president and founder: One of the most important things to keep in mind as you're in treatment, especially with nerve pain or hand-foot syndrome, is safety. Be careful when you are multi-tasking. Don't try to do too much at one time. Your ability to know exactly where your feet are when you're running up the stairs is not quite as accurate as it might be when you're feeling your best. Fingers can be more sensitive to heat — watch out for burns. Don't talk on the phone and cook at the same time. Don't talk on the phone and cross the street at the same time! Keeping safe and sound is very important when you're not feeling 100 percent.

Larry Norton, M.D.: We've had real success with acupuncture as a treatment for chemotherapy induced nerve damage. That's one treatment that is often not considered. There are other alternative medicine techniques that can be useful for nerve damage. Information is available at mskcc.org in the Integrative Medicine section.

Who are clinical trials good for?

Question from Tricia: I have Stage IV mets and was thinking of entering a clinical trial. Can you think of any reason why a person should not do a clinical trial?

Answer —Larry Norton, M.D.: The answer is if you're eligible for a clinical trial, you will do better on that clinical trial than if you got the same exact medicine off the clinical trial. The only reason not to be on a clinical trial is if you don't meet eligibility requirements for that trial. There are many reasons why participation in clinical trials makes sense. One is that you stand a chance of getting a new promising therapy that is not available except in the clinical trial. Another reason is that if you're being treated on the clinical trial, many hundreds or even thousands of individuals are receiving the same treatment. Because the doctors in the trial are all networked, any information learned from one patient is transmitted to the other doctors so everyone can learn and the information so gathered can be helpful to all the patients. If you're receiving medicine not on a clinical trial, you are somewhat in isolation. By being on a clinical trial, you're part of a community.

Candidate for bone marrow transplant?

Question from Leona: I was diagnosed with breast cancer in 1997, and just was diagnosed with metastatic bone cancer last March. I’ve had radiation on my spine. My question: Is there any chance that I am a candidate for bone marrow transplant? How can I find out?

Answer —Larry Norton, M.D.: Bone marrow transplant has been shown to not be a useful way of treating breast cancer. It causes severe toxicity with no benefit, compared with other forms of treatment. The fact that it's been 10 years since you were originally diagnosed and the fact that you have primarily bone involvement indicates a good chance your cancer can be treated successfully with hormone treatment, which should be discussed with your doctor.

Update on PARP inhibitor trial?

Question from Jill: I am BRCA positive and I have heard that the PARP inhibitor (ICEBERG) trials are showing success. Do you have any additional information on the current trial or the upcoming trial at NIH where they will combine the PARP inhibitor with chemo?

Answer —Larry Norton, M.D.: The PARP inhibitors are one of the promising treatments for breast cancer and other cancers, and might make sense for people with the breast cancer that commonly arises in women who have a defect in BRCA1. That type of breast cancer is called triple-negative breast cancer because it is negative for estrogen receptor, progesterone receptor, and HER2. The best way to find out if you are eligible for any of the trials with any PARP inhibitors is to go to www.clinicaltrials.gov or call 1-800-4-CANCER.

Adriamycin and Taxotere only affect HER2+?

Question from D8: I've seen multiple news articles recently about findings that both Adriamycin and Taxotere are ineffective except for in HER2+ women. Is this just early stage breast cancer study or does it involve metastasis too? What are the implications?

Answer —Larry Norton, M.D.: The information you’re quoting is in early stage breast cancer, in the adjuvant setting. These are two separate topics. The Adriamycin (chemical name: doxorubicin) question is derived from studies that have looked at HER2 and another gene called topo II or TOP2A. In general, most experts feel that information is not complete enough to decide who should or should not get Adriamycin on the basis of available tests. This is an active area of study, and we should have more information over the next year. In particular I feel strongly that people should not be denied Adriamycin on the basis of available tests, since the tests for both HER2 and topo II are not precise enough yet to give me confidence that we can pick individuals who will benefit from treatment. But I admit this is a controversial area. The next topic involves Taxol (chemical name: paclitaxel), not Taxotere (chemical name: docetaxel). We have recently published our findings on the activity in the adjuvant setting of Taxol. Activity is found in all groups except patients with HER2-negative, ER-positive disease. In other words, Taxol helped all patients with ER-negative disease and HER2-positive disease. However, in that paper of which I was a co-author, we stated that these findings would have to be confirmed by at least one other study before we would deny a patient adjuvant Taxol.

Genetic testing for triple-negative?

Question from Maija: So if triple-negative breast cancer is related to a defect in BRCA1, should members of the family be tested when the mother has triple-negative breast cancer?

Answer —Larry Norton, M.D.: It is a clue that BRCA1 may be involved. There is no substitute for expert genetic counseling if there is any suspicion of familial breast cancer. There are tools available online to help you estimate your chances of having a breast-cancer-related gene defect. But we have recently published that these tools are not extremely accurate. Hence, anybody with any suspicion should seek expert counseling to determine if testing is right for you.

Dealing with day-to-day life during clinical trials?

Question from JW: It seems to me that women with Stage IV cancer on clinical trials face a great deal of uncertainty regarding effectiveness of their treatment. Are there particular/specific ways of helping these women cope with day-to-day living on clinical trials?

Answers —Larry Norton, M.D.: Uncertainty is part of life and if you have a serious disease, that uncertainty is heightened. Being on a clinical trial in many ways reduces that uncertainty since the schedule of testing for the status of the disease is determined by experts and adhered to carefully. Also, on a clinical trial, one has the comfort of knowing you're not alone; that many are being treated with the same treatment so knowledge of what happens to one patient can be shared with all. It is very important when one has a serious disease to do everything possible to do well with that disease, including establishing a relationship with a doctor or nurse with a great deal of trust. If one develops a trustful relationship and one is doing everything one can to do well, then you should turn your attention to living as full a life as possible. It is a mistake to become a professional patient. Your illness is only one part of your life; the other parts of your life also deserve your attention and respect. You make good decisions and you go on with your life. Enjoy the people that you love. And that's the best way to reduce fear.

Marisa Weiss, M.D., president and founder: Dr. Norton taught me a long time ago that there's only one of each of you, and each person deserves to be hopeful and believe that you can do well. As a physician in practice for 20 years, and Dr. Norton has been in practice longer, we have both learned that the patients who may seem to have the worst prognosis can beat out the odds and show us that they too have a chance of beating the statistics and living well. There are patients I took care of 15 years ago who I was sure would never make it who are still writing me Christmas cards. And there are women who appeared to have an excellent outcome who, for whatever reason, didn't do as well as we may have predicted.

Larry Norton, M.D.: This is an important point. Uncertainty often works in your favor. It can have a positive side as well as a negative side, and I have noticed over the many decades I've done this that expecting to do well often leads to doing well. Visualizing a happy future often leads to a happy future. The only way you can guarantee that you're going to do poorly is to stop fighting.

More personalized treatment in the future?

Question from D8: You have referred to the importance of understanding the biochemistry of the cancer cells. Besides ER, PR, and HER2 markers, what other tests will become available? What's the future of personalized treatment? And how important is it to re-test new metastases?

Answer —Larry Norton, M.D.: Personalized treatment is with us now. You already mentioned some of the factors we analyze. But even now there are tests that measure more factors than just ER, PR, and HER2. One of these is Oncotype DX, which measures 16 genes and has been shown to be very useful in predicting whether an individual tumor will do well with hormone therapy or chemotherapy. There's another test that measures 70 genes called MammoPrint which also provides useful information. This is a rapidly evolving area. No two cancers are exactly alike. We are indeed learning which treatments will work best with which cancers.

Okay to take vitamins during chemo?

Question from Lisab: What are your recommendations as far as taking vitamins during chemo treatment?

Answer —Larry Norton, M.D.: I actually have very strong views on this. The only vitamin supplementation I recommend is vitamin D. I am advising vitamin D-3 at 2000 units a day. It may turn out that higher doses are actually preferable, but we do know for sure that 2000 units is safe. Almost everybody in the world who does not live at the equator is vitamin D deficient. Vitamin D is made by the skin by exposure to the sun, but those of us in the far north or far south and who wear clothes do not have enough skin exposure to make enough vitamin D. I do not advise excessive sun exposure because of risk of skin aging and skin cancer. Hence vitamin D supplementation makes sense. 2000 units a day is not a very big dose. If one takes one's shirt off and goes in the sun for half an hour, your body will make 10,000 units. We do not find toxicity from vitamin D until people take hundreds of thousands of units for prolonged periods. I used to prescribe a multivitamin, but I no longer do so. This is because of evidence that multivitamins may actually have adverse affects on the growth of cancers - prostate cancer as well as breast cancer. You are much better off getting your vitamins from healthy food instead of pills, except for vitamin D. Eat a good healthy plant-based diet, lots of vegetables, some fruit. Look at the Breastcancer.org Nutrition section.

Are tumor markers reliable?

Question from Ruth: Do tumor markers in the blood always show if breast cancer has spread and/or if you have developed another separate cancer?

Answer —Larry Norton, M.D.: Tumor markers in the blood are helpful but not definitive. Some patients can have growing disease and the markers do not become elevated. Others have elevated markers but no disease. Tumor markers are often a source of anxiety that is unnecessary because they are helpful, but not absolute in terms of their meaning. For this reason, tumor marker results have to be interpreted by an expert oncologist.

Lowered AI dose still effective?

Question from Susie: I have been living with bone mets for the last 3 1/2 years. For the last year I have cut my aromatase inhibitor dose in half so that I can be in less joint and muscle pain. Have you heard of other patients doing similar treatments? And were they successful at keeping the cancer away? Thank you.

Answer —Larry Norton, M.D.: There are 3 aromatase inhibitors in common use. It is unusual that a patient develops muscle and joint pain from all three. If one aromatase inhibitor is causing muscle side effects, the patient should be advised to try another aromatase inhibitor. However, I do not advise reduction in dosage since a reduced dose may not be as effective as a full dose. Symptom management is a very important part of cancer treatment. If a drug is keeping the cancer in control, finding ways of handling the side effects of the drug and still continuing the drug may be the best course. With side effects such as aches and pains, I have found that acupuncture, yoga, and massage may be very useful in keeping people on effective therapy.

Navelbine causing intestinal neuropathy?

Question from Joette: I go in for my third Navelbine treatment on Thursday. My stomach pain has gotten out of control. What is intestinal neuropathy? I think it is what I am experiencing...it is misery.

Answer —Larry Norton, M.D.: I can't diagnose you on the basis of your question. There are many causes of abdominal pain, and these should be investigated before the medicine is discontinued if it is working. In particular, your physician would probably ask a gastroenterologist to make sure you don't have ulcer pain.

Adjust treatment to improve quality of life?

Question from Randirella: Getting PET/CT and MRI scans every 3 or 4 months was having such a negative impact on my quality of life, I asked to go on a 6-month schedule instead as long as I'm feeling great. Am I making a big mistake?

Answer —Larry Norton, M.D.: The answer is perhaps. This is a question that only the oncologist treating you can answer. However, I have some general rules. Doctors listen very carefully to the message the patient is sending about how they want to deal with their disease. A patient by their actions or words or attitudes can be saying, "Whatever you do, don't hurt me." In other words, don't do tests that make me anxious. That is often the wrong message. The right message is, "Doctor, whatever you do, make me well." If your doctor feels a patient's primary goal is to avoid tests or information, then important tests or information may be excluded and that could be a mistake. Make sure your doctor knows you're there to win.

How to talk to kids about end of life?

Question from ThomasX: My wife just stopped her treatments altogether. We are beginning hospice this week, and have children, ages 5, 8, and 14. They have been closely involved, but it is hard to say that we are stopping now. Could you offer help?

Answer —Larry Norton, M.D.: If you are not sure that you're making the right decision, it is entirely appropriate to get more input from at least one other expert. It is critically important no matter what you do that you are absolutely sure that you have done everything possible to make the best decision. Information is always helpful, and ignorance feeds fear which leads to bad decisions.

Thoughts on metastatic breast cancer?

Question from Dr. Weiss: Dr. Norton, would you like to sum up for us as our conference ends?

Answers —Larry Norton, M.D.: I want everyone out there to know that knowledge is power in breast cancer medicine, as in all of life. Staying connected to people involved in this disease, such as the community at Breastcancer.org, is essential. Being connected and optimistic is an integral part of being healthy.

Marisa Weiss, M.D., president and founder: Thank you so much for joining us tonight and sharing your encouragement and expertise.