September 2006: Open for Your Questions

Birth control after treatment?

Question from Dena: My breast cancer was diagnosed when I was 46. I was taking Lo/Ovral 28-day for birth control. What are the best options for me now that hormone therapy is over?

Answer —Beth DuPree, M.D., F.A.C.S.: The best option for birth control at 46 if you have not gone through menopause would potentially be either an IUD (intrauterine device) or possibly a combination of a diaphragm with spermicide cream or spermicidal cream condoms. If the birth control pills were being used as an estrogen replacement therapy, then a careful look at your tumor to be sure of its estrogen receptor status would be required prior to adding any hormonal therapy, including estrogen suppositories or cream.

Arimidex contributing to osteoarthritis?

Question from RTaylor: I have been taking Arimidex for five months. Is it possible that it is contributing to an increased deterioration of osteoarthritis of my knees?

Answer —Beth DuPree, M.D., F.A.C.S.: One of the side effects of Arimidex (chemical name: anastrozole) is the potential deterioration of bone that could be occurring from underlying osteopenia and osteoporosis. If the symptoms of your arthritis are increasing with the use of the medication then you should discuss these symptoms with your medical oncologist. A baseline DEXA scan can be helpful.

Aricept used for memory problems?

Question from HVC: My primary care physician has me on Aricept for some memory problems. Is this becoming standard treatment for chemo brain, which is what he thinks caused the memory problem? I also have concerns about what insurance agencies may think about people being on such a medication in the future, and how it will affect purchasing long term care insurance, etc. Thanks.

Answer —Beth DuPree, M.D., F.A.C.S.: I do not believe that Aricept (chemical name: donepezil HCI) medication that is being used for memory problems after chemotherapy is standard practice in oncology care. This may have been a medication that your physician chose to use for you at this point in time to try and counteract some of the side effects that you may have been having in your therapy. I would certainly discuss this with your physician and I do not believe that it should affect your ability to purchase long-term insurance.

Getting results of breast cancer study?

Question from MJD: If you are part of a breast cancer study, do you have a right to receive the results in writing instead of just over the phone?

Answer —Ruth Oratz, M.D., F.A.C.P.: The details of how information is disclosed are available when you sign up if you decide to participate in a clinical study. That will vary from trial to trial. In some studies patients will be notified of the results. In other trials they will hear about the results once they've become public information, either because they've been presented at a scientific meeting in abstract form or once the results are published.

Inflammatory breast cancer survival rates?

Question from Snowbird: What are survival rates for inflammatory breast cancer? I'm considering breast reconstruction (3 years after chemo) and don't know if it's "worth it."

Answer —Ruth Oratz, M.D., F.A.C.P.: Inflammatory breast cancer is a very difficult disease to predict an outcome for. The best predictor is if the patient had a good response to initial therapy. So I'm encouraged by the fact that you have remained free of recurrence for what sounds like already a few years. I think you should discuss the details of your prognosis with your own medical oncologist and then with your plastic surgeon to find out what the different options for reconstruction are. You may opt for less involved surgery and yet still be able to have a satisfactory reconstruction. I would not say you shouldn't consider it at all.

Is DCIS really cancer?

Question from Earthact: What is the latest on whether DCIS is really cancer or not?

Answer —Beth DuPree, M.D., F.A.C.S.: DCIS is a form of breast cancer that we consider a non-invasive, or not having broken through the duct wall into the breast. Ductal carcinoma in situ is a very diverse form of non-invasive cancer and depending on the specific pathology (whether the DCIS is low-grade, intermediate-grade or high-grade) combined with the extent of the disease will determine the appropriate form of treatment. A confusion often comes up between the disease we call lobular carcinoma in situ (LCIS) or lobular neoplasia and DCIS, as LCIS is considered a marker for future risk of breast cancer and DCIS is truly a form of breast cancer that is non-invasive. Their treatments are completely different.

Shadow on mammogram, not on ultrasound?

Question from MaureenT: Why would a shadow show on a mammogram and not be seen on an ultrasound? I also had a lump that I could feel not show up on ultrasound.

Answer —Beth DuPree, M.D., F.A.C.S.: A mammogram is a two-dimensional X-ray of the breast, which may show dense tissue in the breast that when an evaluation is followed up with ultrasound may fail to demonstrate a specific area of concern on the ultrasound. That does not mean that the mammographic density is less of a concern. It could mean that a biopsy of that region would require mammographically guided biopsy techniques to obtain tissue from that region that was abnormal on the mammogram. A lump that is felt or palpable in the breast can exist and still not be able to be shown as a separate area on an ultrasound. That does not mean that the mass has no clinical concern. It means that the area would potentially need to be biopsied, based solely on the fact that it is a region that is concerning on clinical exam. One of our greatest pitfalls in the diagnosis and treatment of breast disease is that no one test is able to find every cancer. Therefore, we rely on mammography, ultrasound, MRI, and physical diagnosis to help us during the time of the workup of a lesion found by any of the above means.

Lumps in breast at age 28?

Question from ArtS: I am only 28, but I have found several lumps in my breast—one toward the bottom of my breast, and one much larger on the top. Am I too young for breast cancer? What are these lumps? Thank you!

Answer —Ruth Oratz, M.D., F.A.C.P.: The incidence of breast cancer increases with age, so most breast cancers in the United States, in fact, are diagnosed in women over the age of 50. However, young women can develop breast cancer and particularly young women who are at increased risk for breast cancer because of perhaps a family history. Even in the absence of a strong family history of breast cancer, a young woman who feels lumps in her breasts should definitely seek medical attention. She should see a physician for a careful breast examination. If there's any concern at all about the nature of these lumps or palpable abnormalities, then it should be pursued with further diagnostic evaluation. In a young woman, this might start with an ultrasound of the breast because as you heard, you may see abnormalities more clearly in a young woman in a dense breast using ultrasound. But we do also use mammography in young women, and sometimes MRIs can be helpful in determining the nature of palpable abnormalities in the breast. Women in their 20s, their late 20s in particular, can develop breast cancer. It is not the most common cause of lumps in the breast in young women, but breast cancer can occur in young women so the findings should not be ignored.

How accurate is needle biopsy?

Question from Pony: If you have a needle biopsy for a suspicious mammogram, how accurate is it and does it later cause discomfort or aching in the breast?

Answer —Beth DuPree, M.D., F.A.C.S.: There are many types of needle biopsies that can be performed. The accuracy of each is dependent upon multiple factors. One type of biopsy that we term FNA, fine needle aspiration, is a tiny needle placed into a mass, extracted and evaluated under a microscope. The accuracy of this particular type of biopsy is extremely dependent upon the ability of the pathologist to read the pathology and centers that use FNA often times have a pathologist that specializes in cytopathology. The other form of needle biopsy that is used very commonly is either a core biopsy or vacuum-assisted biopsy. These biopsies obtain a true specimen of breast tissue for the pathologist to evaluate and as the size of the core increases, so does the diagnostic accuracy of the biopsy. With a needle biopsy or vacuum-assisted biopsy there is less than a 10 percent chance that a diagnosis would differ from that of an open biopsy. Breast centers will vary the type of biopsy that is the standard at that center, depending on the specialists available to interpret the specimen.

Updates on ER/PR/HER2-negative cancer?

Question from Patty: Any new updates on ER/PR/HER2-negative breast cancer?

Answer —Ruth Oratz, M.D., F.A.C.P.: We now are thinking about breast cancer as not just a single disease but as several different subsets, or several different categories of breast cancer based on the biology that is on the molecular characteristics of the tumor cell. These molecular characteristics that we're interested in are the ones that determine the behavior of the cancer cells; for instance, the likelihood that the cancer cells could spread away from the primary site. We are interested in the molecular characteristics that control the growth, the proliferation, and the invasive potential of the tumor cells. The estrogen receptor (ER) and progesterone receptor (PR) are molecular markers that tell us that the cancer cells can respond to hormonal signals, particularly from estrogen. The presence of ER and PR on the cancer cells allows us to use hormonal therapies in order to manipulate, or change, the signal to the cancer cells. In simple terms, we can target those receptors ER and PR with hormonal medication. It is quite effective in preventing the spread or recurrence of breast cancer.

Another molecular marker that we can measure (and there are many) is the HER2/neu receptor. When HER2/neu is present in large amounts on the cancer cells, it confers a more aggressive biologic behavior on the tumor cell. We have very effective targeted therapy against HER2/neu, and the name of that treatment is Herceptin (chemical name: trastuzumab). Herceptin is a biologic treatment, not a chemotherapy drug; rather an antibody that blocks the HER2/neu receptor on the cancer cells. And Herceptin shuts down the signal from HER2/neu. In the so-called triple-negative breast cancer, we do not have ER, PR, or HER2/neu as biologic targets. Therefore, we cannot use hormonal therapy or Herceptin in treating this form of breast cancer. At the present time the standard therapy for triple negative breast cancer is chemotherapy. However, there is a great deal of research on this particular subset of breast cancer to identify other biologic targets for which new treatments will be more effective. There is some indication that using drugs like Avastin (chemical name: bevacizumab) might be beneficial for triple negative breast cancer, and a number of new agents are being investigated both in the laboratory and in clinical trials. I would encourage any patient who has this form of breast cancer to pursue participation in clinical trials.

What is Reiki?

Question from Anna: Can you explain Reiki, and would it help with the side effects I am having with Femara, i.e., still joints?

Answer —Beth DuPree, M.D., F.A.C.S.: Reiki is a Japanese form of energy therapy. It is an ancient tradition passed down from generation to generation that utilizes universal energy that is channeled from the practitioner to the recipient, and may be beneficial in helping to alleviate side effects from cancer treatments. It is considered a form of complementary medicine and, as such, is meant to work in concert with standard Western medical therapy. There are some medications that have side effects that, regardless of what additional Eastern medicine modalities, may not be alleviated. Certainly Reiki or massage or potentially acupuncture are all forms of complementary medicine that could be used to help treat the side effects of the Femara (chemical name: letrozole). As the drug Femara is a very important therapy in the treatment of breast cancer, being able to tolerate the medication by utilizing Eastern medicine modalities is certainly something to be tried.

Herbal supplements and risk of recurrence?

Question from Chris: Could you tell me if any herbal supplements are helpful in lowering the risk of recurrence?

Answer —Ruth Oratz, M.D., F.A.C.P.: There is a great deal of interest in sorting out the impact of a variety of complementary therapies on breast cancer. These include herbal treatments, physical therapy as you just heard about (energy therapy, Reiki, acupuncture, yoga), as well as the effects of diet and exercise. It is very, very difficult to demonstrate the impact of these treatments on the course of breast cancer. Nonetheless, there is some preliminary data that yoga and perhaps other forms of exercise may help alleviate side effects and symptoms from breast cancer treatments and also may, in fact, have a beneficial effect on prognosis. We also know that obesity has a negative effect, particularly in post-menopausal women. So diet and exercise may be somewhat helpful in reducing the risk of recurrence in post-menopausal women with breast cancer.

The role of herbal therapies is very difficult to sort out. There are no studies to date that demonstrate either a clear-cut benefit or a clear-cut harm from the use of herbal treatments. Of concern is the fact that some herbal remedies may contain phytoestrogens. These substances are molecules derived from plants, which mimic the activity of estrogen. It is possible, although not definitively proven, that large quantities of phytoestrogens may act like estrogen, and for women who have estrogen-sensitive or ER-positive breast cancer, these agents may be contraindicators. On the other hand, there is some provocative data that perhaps phytoestrogens, and perhaps in particular soy products, may be protective against the development of breast cancer. So we're right now in the time where the information and data about herbal treatments is still somewhat unclear. My recommendation to women with breast cancer is to consult with naturopaths and practitioners who are experts in herbal therapy, as well as consulting with your medical oncologist to find herbal treatments that could be beneficial while not being harmful. I generally recommend avoiding large amounts or high doses of phytoestrogens, but many other herbal treatments can be helpful in managing the side effects of breast cancer or breast cancer treatment. We need more research in this area and I hope that we will see more support for these kinds of investigations in order to answer these questions with good, scientific evidence.

Studies of Femara at lower dosages?

Question from Susie: Are there any ongoing studies for Femara at lower doses?

Answer —Ruth Oratz, M.D., F.A.C.P.: No. We've done many clinical trials with all of the aromatase inhibitors, and the current doses that are approved and in clinical use have been carefully delineated in large clinical trials.

Radiation therapy for DCIS?

Question from Krys: I have had a diagnosis of DCIS. I have had a lumpectomy and the surgeon has suggested radiotherapy. I go to an acupuncturist and he has suggested I don't have radiotherapy. I like the idea of no radiotherapy. I would like some advice. I have been told that radiotherapy will damage some of my immune system which is the natural way to protect the body from cancer cells developing.

Answers —Beth DuPree, M.D., F.A.C.S.: Depending upon the type of DCIS, the size of the area of DCIS, and the margin of normal tissue that was excised around the DCIS, the determination for whether or not to give radiation therapy is made by the surgeon, medical oncologist, and radiation oncologist. The standard treatment for DCIS would be to give radiation therapy to the entire breast with a boost to the tumor bed in order to prevent other cells that are like-minded from beginning to divide. The time to do so is at the diagnosis of a disease after adequate surgical resection. There are times with very low grade DCIS with wide margins, depending upon the age of the patient, where radiation therapy may not be recommended. But the standard of care would be to receive radiation therapy in the treatment of DCIS. I would certainly obtain an opinion from the radiation oncologist, the medical oncologist, and the surgeon. I respect the opinion of your acupuncturist, but the physicians who are trained to treat breast cancer may have information about your specific diagnosis that will help them to help you with a game plan for appropriate treatment.

Ruth Oratz, M.D., F.A.C.P.: I agree 100 percent that the standard of practice is for radiation therapy following resection of DCIS except in very, very specific circumstances. And I would really emphasize the importance, as Dr. DuPree said, of having a conversation about this with the experts in the field with medical training.

Beth DuPree, M.D., F.A.C.S.: Look at the DCIS in your breast as though you have a beautiful Victorian porch wrapped around your house. If you had termites in the steps of your porch, you would certainly have the steps removed. And prior to placing a new set of wooden steps onto your porch you would want to exterminate the porch and have a professional do this for you before rebuilding your steps.

Risk of breast cancer with implants?

Question from ReneS: Is the risk of breast cancer any different if you have had breast implants? I had my first breast implants 37 years ago and two implant replacements over the last 20 years. I just found a lump under my left arm and a swelling above my left breast. I'm visiting the breast clinic soon. Is there likely to be any problem with treatment because of having implants? Thank you.

Answers —Beth DuPree, M.D., F.A.C.S.: There is no difference in the incidences in women who have implants. There may be issues in the diagnostic workup, depending upon whether the implants were placed above or below the muscle. A swelling in your left breast needs to be evaluated with both mammography and ultrasound, and an ultrasound evaluation of the lump under your arm should also be undertaken. The treatment, surgically, of breast cancer in women with implants can at times be challenging, as the amount of native breast tissue in women with implants (by virtue of the fact that their native breast size was likely small prior to the placement of the implants) can be challenging to the surgeon. And the treatment of breast cancer in women with implants is the same as in women without implants. I have many times used chemotherapy to shrink tumors in order to help perform breast conserving surgery in women with a small volume of native breast tissue.

Ruth Oratz, M.D., F.A.C.P.: If you make diagnosis of breast cancer in a woman who has breast implants, it is not required that the implants be removed. Depending on the size and location of the tumor, it may be possible for breast conservation therapy; that is, the surgery to permit the implants to remain in place. Certainly, in women who have a diagnosis of breast cancer who don't have implants and who undergo mastectomies, we insert implants as a type of breast reconstruction. So we are comfortable that the presence of the implant itself does not increase the risk of breast cancer. But as you heard, there may be some technical issues related to imaging and surgery that need to be considered. The presence of implants has no impact on our choice of systemic therapy, whether or not we use chemotherapy, hormonal therapy, or biologic treatments.

Hand soreness and black nails?

Question from Katrina: I have just finished my chemo and have been on Herceptin for five treatments now. I have been experiencing soreness in my hands as well as the nails blackening. Is there anything to make it more comfortable, and is this common?

Answer —Ruth Oratz, M.D., F.A.C.P.: The soreness in your hands and the blackening of your nails is more likely related to the chemotherapy that you received rather than Herceptin. You should discuss this in detail with your medical oncologist. The things that come to mind are the possibility of peripheral neuropathy—damage to the nerve endings in the fingers and toes—that can be related to the use of Taxol (chemical name: paclitaxel) chemotherapy. There are possibilities including infection of the nailbed, softening of the nails, and slowing of nail growth related to chemotherapy. Infection is very rare, but it could be treated if it's present. It is common for nails to grow more slowly or break and to be softer because of chemotherapy treatment. And just like hair loss, this is a reversible side effect and generally improves over time.

Prophylactic surgery for triple-negative?

Question from Joanne: I am BRCA1 positive, and being treated for triple negative breast cancer. I am considering bilateral mastectomy and oophorectomy, but what if a treatment for triple negatives is found? Will I have gone through a lot of surgery/disfigurement for nothing?

Answers —Ruth Oratz, M.D., F.A.C.P.: There are many issues in this question. The first and most important consideration is the treatment for the breast cancer that has already been diagnosed. The prognosis of your breast cancer, even if it is triple negative, also depends on the size of the tumor and whether or not lymph nodes were involved. You should discuss the issues with your physician in order to have a clearer understanding of the risk of recurrence of this breast cancer. The second set of issues in a patient like you who has a BRCA mutation relates to preventive measures in efforts to avoid a second breast cancer or the possibility of ovarian cancer. It is appropriate for you to question how much or how far to go with these preventive measures. There's not a simple or single answer for everyone in this situation, and decisions are very personal and very complex. You should discuss this with your medical oncologist, your gynecologist, and meet with a genetic counselor if you have not already. Sometimes speaking with other women who have faced this decision can be very helpful. There is a very good web-based group called FORCE, which is an information based website that addresses the concerns, the realities, and the medical information for women who are at increased risk of cancer because of genetic susceptibility. The URL is www.facingourrisk.org.

Beth DuPree, M.D., F.A.C.S.: Specific things to consider: we currently have no fail-safe screening tools for ovarian cancer, and many women after childbearing who are BRCA1 positive and BRCA2 positive opt for or choose prophylactic removal of the ovaries. The decision to choose mastectomy for the treatment of the cancer would also need to look very carefully at how the tumor that you currently have was detected. If the cancer was found early on mammography and if it was image detected on screening studies, the choice of mastectomy may or may not be the appropriate choice. Some women who have cancers that are not found mammographically on screening studies who are BRCA1 and 2 positive feel less comfortable in our ability to detect another cancer in the future at an early stage. These are certainly issues and questions that you should sit down and discuss with your surgeon very carefully in order to help you come up with a plan for your future that will not only appropriately treat the risk of another cancer, but help you to make decisions based upon facts and not upon fear.

New book by Dr. DuPree?

Question from Annamarie: Dr. DuPree, thank you for your new book! I'm glad others are getting a chance to learn from you, as I have as one of your patients.

Answer —Beth DuPree, M.D., F.A.C.S.: Thank you, Anna Marie, I'm glad you are enjoying The Healing Consciousness: A Doctor's Journey to Healing. It was a labor of love and I am thrilled to be sharing it with many people, particularly those like yourself who have taught me so much on my journey.

Why can't daughters get mammograms?

Question from GHB: Why can't my daughters (ages 27 and 31) get a baseline mammogram, since I've had breast cancer? Why wait until age 40, as their doctor said?

Answer —Beth DuPree, M.D., F.A.C.S.: Mammography is the best screening tool for breast cancer that we have at this point. Because breast tissue in young women, particularly under the age of 35 to 40, has a very large proportion of the tissue that is dense in fiber, the diagnostic accuracy of mammography in women of that age is questionable. There are several issues that should be addressed. The age at the diagnosis of your cancer is an important factor as well as the possibility of any genetic predisposition such as BRCA1 or 2, or a genetic link. I would suggest that you discuss with your surgeon and medical oncologist those issues and what I would suggest for your daughters is for them to be receiving a clinical breast exam, meaning by a physician, annually. I do obtain a baseline mammogram at the age of 35 and certainly one decade earlier than the cancer was diagnosed in the mother. If either of your daughters, regardless of age, has a mass that they feel in their breasts, that would require a workup of that specific finding. There are trials for using other modalities, such as MRI in screening very high risk patients, but that would be someone in a risk case such as BRCA1 and 2 positive patients who have the gene themselves, or in a specific incredibly high risk scenario, meaning multiple first degree relatives such as mother or sister that have breast cancer diagnosed under the age of 50 or in both breasts. I would ask your breast surgeon and medical oncologist to make a recommendation for what type of screening your daughters should be receiving based upon your history and your family tree cancer history.

Can PET scan replace needle biopsy?

Question from Jax1: Can the PET scan replace the need of a needle biopsy?

Answers —Beth DuPree, M.D., F.A.C.S.: No.

Ruth Oratz, M.D., F.A.C.P.: PET [positron emission tomography] scan is a relatively new form of imaging, which looks at the metabolic activity of cells. Cancer cells, in general, are more active than normal cells in the body. PET scan uses a radioactively labeled form of glucose. Cancer cells pick up this glucose very avidly with great affinity, and on PET scan, malignant cells light up more brightly than normal cells. PET scans can be helpful in identifying areas of increased metabolic activity where there might be deposits of tumor cells, whether in a primary site, in the regional lymph nodes or in another area, such as a metastatic site. However, and this is a big however, PET scan is sensitive but not necessarily specific for cancer cells. Other conditions may cause increased metabolic uptake of glucose; for example, infections or inflammation. Furthermore, the amount of uptake may vary, depending on the nature of the metabolic process. I think a PET scan as a very rough road map. The PET scan points out areas of concern, but it is not definitively diagnostic of malignancy. Other imaging modalities and ultimately pathologic correlation with a biopsy may be required to define whether or not cancer is present in a particular site.

Beth DuPree, M.D., F.A.C.S.: PEM (positron emission mammography) is an imaging study currently under investigation that has potential in defining extent of disease in the breast when determining potential treatment modalities in breast cancer. But as Dr. Oratz has pointed out, the scan can show many things that take up glucose that are not necessarily cancer. Therefore, it is one of many diagnostic studies that could be used in the workup of a breast lesion.