April 2014 Research Highlights

Jamie DePolo: Hello, everyone. Welcome to this edition of the Breastcancer.org podcast. I’m Jamie DePolo. I’m the senior editor at Breastcancer.org, and I am joined this week by Dr. Brian Wojciechowski, our medical advisor. And we’re going to talk about some of the most recent Research News stories that came out pertaining to breast cancer.

Hello, Brian. How are you today?

Dr. Brian Wojciechowski: I’m fine, Jamie. Thanks for asking. How are you?

Jamie DePolo: I’m doing well. So, we’ve got four studies that we’re going to talk about today. Actually, there are two stories on new guidelines that the American Society of Clinical Oncology has put out, known as ASCO for short.

And ASCO’s a group of experts, and they look at research and what’s being done in treatment with patients, and then they make recommendations for how cancer should be treated or how various things should be done. And a lot of people follow these guidelines, so that’s why we’re going to talk about them.

The first one is on sentinel lymph node biopsy. And Brian, if you could just explain a little bit for us what exactly that is and who might be a candidate for sentinel lymph node biopsy.

Dr. Brian Wojciechowski: Well, lymph nodes are the first place that a cancer will travel to outside of the breast. So it used to be when a woman was diagnosed with breast cancer, the surgeon would take out all the lymph nodes in the axilla, or the armpit. And this often came with a lot of bad side effects like lymphedema, pain, and dysfunction in the arm.

So, eventually, what was figured out was that you don’t have to take every lymph node. You can just check a couple lymph nodes. So, how do you know which lymph nodes to check? The surgeon, when she goes in to do the lumpectomy, will inject some dye at the site of the tumor. That dye will travel in the natural lymph node pathway to a certain couple lymph nodes in the armpit.

And we have a machine that can detect that dye in those lymph nodes. So when those lymph nodes light up with the dye, the surgeon can take out two or three lymph nodes and examine those. If the node is negative, you don’t go any further. If there’s no lymph node involvement, that’s all you have to do. If a couple of lymph nodes are positive, then you have a few options. You can take out all the nodes in the armpit or you can go and just do some radiation.

And I think what the main takeaway point from this new set of guidelines is that most women with only a couple lymph nodes positive can have radiation and don’t need all the lymph nodes removed. Radiation is associated with less side effects than the full removal of all the lymph nodes by surgery.

Jamie DePolo: Okay. That was going to be my question. It seems like this guideline is really for women who have been in what’s been called a gray area. So where they have one or two positive sentinel lymph nodes and it wasn’t ever really clear which was better, do we remove the axillary nodes, too, or is radiation okay? And it sounds like now that if the woman is going to have a lumpectomy and radiation, then you don’t need to have the axillary surgery.

Dr. Brian Wojciechowski: Yeah. And this is with small tumors where there’s only a couple lymph nodes involved, and most women in this category can safely have radiation instead of a full axillary lymph node dissection.

Jamie DePolo: Okay. Is there anybody, I’m just curious, is there anybody who should not have sentinel lymph node biopsy? Are there times when it’s just not recommended?

Dr. Brian Wojciechowski: Oh sure. Yeah. And if you look in these guidelines, there’s a few different cases where you should not have the sentinel nodes.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: One is DCIS, which is treated with lumpectomy. DCIS is considered basically a stage 0 cancer and low risk to spread to the lymph nodes, so, generally speaking, is not recommended in that case. Pregnant women cannot get the sentinel lymph node procedure because of that dye, that marker, can be potentially harmful to the baby.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: If it’s an inflammatory breast cancer, we don’t do a sentinel lymph node because inflammatory is so aggressive that you probably wouldn’t be able to get a good reading anyway, but more importantly, most women with inflammatory, because of the aggressiveness, will have to get a full dissection and radiation.

A very large or locally advanced tumor, which has spread extensively in the breast, or one of those really bad tumors, we usually don’t do a sentinel because, again, a large tumor, very aggressive, we want to get all the lymph nodes out. The studies that they did for this did not include women with large, aggressive tumors. They only really included women with low-risk, small tumors.

Jamie DePolo: Okay. Okay. That’s good to know. Thank you. Great. Anything else you want to say about that? I thought those guidelines were fairly straightforward and should be pretty helpful for women if they’re, as they used to call them, in that gray area. So now they have a choice or they can, I guess, get radiation and not have axillary dissection with good peace of mind.

Dr. Brian Wojciechowski: That’s right. I think if these guidelines are widely adopted, then many fewer women will have to get this full axillary dissection, this very burdensome surgery, so I’m happy that they put these out.

Jamie DePolo: Great. The second set of ASCO guidelines are part of a very large group of guidelines that are going to come out on issues that are faced by cancer survivors. I believe there are three that came out, and these are the first of a series of 18, because survivorship is becoming a very big issue now as more and more people are surviving long-term with cancer. Cancer is pretty much a chronic disease now. You can live for 10, 15, 20 years after being diagnosed.

So, these first three guidelines focus on three different issues, neuropathy, fatigue, and depression, all of which are fairly common side effects of cancer treatment, and they’re looking at ways to help survivors cope with these.

So, Brian, if I could ask you, let’s start with neuropathy. Could you just kind of explain to us what neuropathy is and then what the guidelines recommend?

Dr. Brian Wojciechowski: So, neuropathy refers to damage to the nerves themselves, usually from chemotherapy. And the most common manifestation of that is pain, numbness, tingling, and burning in the hands and feet. It usually starts in the feet, often involves in the hands as well.

I think most of the time it reverses, although it reverses very slowly. It might take more than a year for them to return to normal. In a very small minority of patients, the neuropathy is persistent and never really fully goes away.

Jamie DePolo: Does that happen with most chemotherapy, or are there specific chemotherapy regimens that are known to cause neuropathy more than others?

Dr. Brian Wojciechowski: Yeah. Most chemotherapy does not cause neuropathy. In breast cancer, the most frequent culprit is drugs in the taxane category, so Taxol, or paclitaxel, or Taxotere, or even Abraxane, things like that.

Jamie DePolo: Okay. And then if I’m remembering right, the guidelines say that some of the medicines that are now being used to treat neuropathy actually cause other side effects, so they don’t recommend using them.

Dr. Brian Wojciechowski: Yeah. And mostly because they’re largely ineffective.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: There’s not really a lot of good scientific evidence that a lot of the drugs out there can slow down or reverse the process of neuropathy. Now, there are drugs that can help with the symptoms and take the edge off that way, such as drugs that have been used for antidepressants and seizures, like Neurontin, for example, but ASCO really does not recommend use of any of the drugs for prevention.

Jamie DePolo: Okay. So really, there’s limited treatment options for people with neuropathy. Do you know, and we didn’t talk about this beforehand, but are there any sort of complementary/alternative medicine ideas or therapies that can help with neuropathy? Does exercise help with neuropathy, do you know, or anything like that?

Dr. Brian Wojciechowski: I’m not aware of anything complementary or alternative that can really alter the course of neuropathy. Meaning it can make it go away quicker or get better sooner. And it’s frustrating to say that because I’m constantly having these conversations with my patients.

Really all we can do that I’m aware of that helps is to kind of treat the symptoms and try to manage the pain until it goes away.

Jamie DePolo: Okay. And is it that the nerves then just have to sort of repair themselves and that’s when the pain stops?

Dr. Brian Wojciechowski: Yeah. Nerve repair is a very long process. Nerves can regenerate, but it takes a long time.

Jamie DePolo: Okay. Okay. All right. The second topic then in this guideline was fatigue. And I know that that is a very, very common side effect based on some of the messages we get on our Discussion Boards, as well as questions we get sent into the site. And all sorts of breast cancer treatments are known to cause fatigue. So what does ASCO recommend for that?

Dr. Brian Wojciechowski: Well, the first part is that we need to be more aware of the problem with fatigue, and all the patients who are under treatment should be at least screened for fatigue once a year. So that would include anyone who’s being treated and anyone who’s a survivor.

There’s other things that can contribute to fatigue, such as depression, chronic pain, lack of exercise, and those are things we need to address and try to correct as healthcare professionals, and that can actually mitigate some of the fatigue that the patients are having.

Jamie DePolo: Okay. Let me ask you this: Is there a way for me, as just an average person… I’m feeling tired all the time, can I tell the different between fatigue and just being tired, or is that something that I really need to go in and be screened for?

Dr. Brian Wojciechowski: So, I think as a lay person when they’re trying to figure this out, the best way to tell if it’s just run-of-the-mill expected kind of routine life-fatigue versus something more serious that requires intervention is ask yourself the question, does it interfere with your daily function?

Can you get the things done that you need to get done, or are things kind of falling apart, things going by the wayside? You’re not keeping up with the bills. You’re not able to do things you need to do to get through your day. That’s how you know it’s a problem, it’s really one that interferes with your function.

Jamie DePolo: Okay. Okay. That’s very helpful, thank you. And then the third is kind of a lead-in to what you said, that depression can be a factor in fatigue. The third part of the guideline was looking at anxiety and depression and making recommendations for screening, as well as how that should be treated. So if you could kind of go over that for us.

Dr. Brian Wojciechowski: Anxiety and depression are very common with cancer patients and can be so severe that it’s actually debilitating, as I said before, interfering with function, interfering with personal relationships. You may lose interest in the things that you loved to do before, that’s a red flag for depression. You may experience weight changes and that sort of thing.

Again, it’s just healthcare professionals needing to be more aware of these things and make sure we screen our patients for anxiety and depression. I’m not sure if most physicians flat out ask their patients, “Are you experiencing anxiety and depression?” at every office visit, and I think we probably should do that.

Jamie DePolo: And it sounds like, too, from the ASCO guidelines, that’s something that they would like oncologists to start doing as well as your regular doc that you would see for your physical checkup every year, so there’s kind of asking both types of doctors to do that, to keep in front of it.

Dr. Brian Wojciechowski: Right. Exactly.

Jamie DePolo: And that’s probably something, correct me if I’m wrong, that’s probably something that oncologists perhaps aren’t used to doing, because oncologists are so focused on treating the cancer.

Dr. Brian Wojciechowski: Yeah. It’s a real challenge, I’ll tell you, Jamie. It’s hard to find time to get there. You’re really focused on, “Is the patient on the right medications, is the diagnosis right, how do we manage the side effects of chemotherapy, and are the blood counts okay?” And by the time you get through all that and by the time you make your note in the electronic medical record, it’s hard to get to all those things.

So that’s where, really, physician extenders like PAs and nurse practitioners and even nurses and the people in your staff in the office can really help for screening for these sort of things. Social workers who can use an assessment tool, like a checklist a patient can fill out. So if you determine if they’re experiencing these things, then get them plugged in with the right therapy or support groups.

Jamie DePolo: Okay. That’s good to know. And I have another question, too. If you’ve treated someone, say you’ve treated a woman for breast cancer and she’s done with her treatment now and, say, has been done for a couple years, do you continue to see her or usually not, because I guess that’s what I’m wondering, too. It sounds like sometimes these guidelines may require patients to be proactive and say to whichever doctor they’re seeing, you know, I really think I need to be screened for depression or fatigue because these things are happening.

And if you may be more in tune with the cancer treatment, but if somebody’s out of treatment, do you still see that person once a year, or is it pretty much now they’re back to their general practitioner?

Dr. Brian Wojciechowski: Yeah, Jamie. When I get a breast cancer patient, I never let her go because there’s always some small risk of getting another cancer in the future. So, for example, I have a lady who was initially diagnosed in 1979 who had been following the doctor before me in the practice all that time, and now she’s my patient and she just got diagnosed with her second breast cancer.

So generally speaking, a medical oncologist is going to be following a breast cancer patient for the rest of her life. So you do have a nice relationship. It’s kind of like, almost like a primary care relationship, and in those follow-up visits where she’s not on any active treatment, that’s a really good time to screen for depression and anxiety.

Jamie DePolo: Okay. That’s good to know then. So there could be potentially two doctors that are doing this screening, and hopefully most of these issues would be caught.

Dr. Brian Wojciechowski: That’s correct.

Jamie DePolo: Okay. Now, our third study that we’re going to talk about is about healthy eating after diagnosis, and there’s a study that has found that this can improve survival. And I’ll give everybody my biases about these kinds of studies, because I’m always concerned when a study is looking at what people eat, invariably it requires people to write down and remember what they’ve eaten, sometimes for up to a year earlier.

Now, I can’t remember what I ate for dinner three days ago. I suppose I could if I actually sat down and thought really hard about it. But it always boggles my mind that they ask people, “Well, what did you eat six months ago?” And so I’m always a little skeptical of some of the results of these when they show these things. And of course, the results did show that if you eat healthy, which includes fruits and vegetables and not a lot of processed food, not a lot of sugar, that your survival is better. I guess the other question I have for you about this study, Brian, is there was no mention of whether the women were following their treatment plans. And so I guess I would ask you, you know, how important is that and how solid do we think these results are?

Dr. Brian Wojciechowski: Well, Jamie, it’s not just that your bias, it’s a legitimate concern. There’s so many different studies out there. I’ve noticed, I don’t know if you’ve noticed this, but it seems like if someone has a conclusion that they’ve already made about some health aspect, like, for example, vaccines, you could always go out and find a study that supports your personal conclusion. And the thing of it is, while that’s true, the thing of it is, is not all studies are created equal.

So I think one of the good things we do at Breastcancer.org is frequently, when we write up a study, we’re not just saying the result, but we’re also talking about the quality of that study and how reliable it is.

This particular study is good because it’s large. There’s a lot of patients, and it’s what we call prospective, so they’re not looking back in history at what women ate and answering a question now, but they actually start with two defined groups of women and say, “You’re going to change your diet and you’re not going to change your diet,” and see what happens.

So, in that sense, the study is stronger than most. But it is weaker than other studies because, as you said, it required people to remember what they ate, and that’s not always accurate. [Editor’s Note: The study is prospective, meaning the investigators started the study with two groups and followed them over time waiting for an outcome to occur; retrospective studies start with women who have already had an outcome and then they are asked to recall how they ate. During the study, as the women were followed over time, they had to recall their diets, but that is not the same as asking them about their diets after the outcome has already happened.] It’s not a very measurable thing, and it also, as you said, does not tell you how well each of the women stuck to their treatment plans. So were they compliant with their hormones? Did they finish their chemo? Etcetera, etcetera, etcetera.

So, it is somewhat limited in terms of its reliability, but I would say overall, it’s more reliable than most. And on a scale of 1 to 10, if 10 is the most reliable and 1 is the most least reliable, this is probably a 6 or a 7.

Jamie DePolo: Okay. Well that’s good. So then that, again, is more evidence that while your diet isn’t going to fix everything and it’s not going to prevent everything, it can help your overall general health, which then helps you live longer, have a better quality of life.

Dr. Brian Wojciechowski: Yeah. There’s just so much evidence out there to support healthy diet, and this seems to back that up.

Jamie DePolo: Okay. Okay. Well that’s good. And then our last study for today, it’s actually two studies that we’re going to talk about together. We’re again going back to the mammogram controversy and are screening mammograms necessary, the pluses, the minuses. And these two studies both said that what we really need for screening mammograms is an individualized approach.

I’m going to back up a little bit, too, and ask you, Brian, to explain two of the issues with people that criticize screening mammograms are overdiagnosis and false positives.

So, if you could explain for us what both of these things are and then talk about what an individualized approach might be. Dr. Brian Wojciechowski: So let’s start with overdiagnosis. Overdiagnosis sounds like a funny thing. It’s hard for some people to understand. How could you have something called overdiagnosis? You get cancer and that’s a good thing that you picked it up, right?

Jamie DePolo: Sure.

Dr. Brian Wojciechowski: Well, the natural history of cancer is not necessarily to grow and spread and to hurt you. Some cancers actually spontaneously go away and are never found. Other cancers -- say if you detect a cancer, an early-stage breast cancer in a woman who’s 95 years old whose life expectancy is a year for other reasons, maybe she has heart problems and the breast cancer would never have caused her any issue nor would she have ever opted for treatment, well, that’s overdiagnosis.

The second point, you said false positives, correct?

Jamie DePolo: Correct.

Dr. Brian Wojciechowski: So, false positive is when a mammogram reveals a suspicious spot or calcifications and it ends up being benign, not malignant, which is usually a relief in the end, but it does expose women to more tests and more biopsies. So it can be a source of a lot of stress.

Jamie DePolo: Sure. I mean anybody, this has happened to me. You get called back because there’s something on your mammogram and they say you need another one, we need to look at it, and you immediately get that, “Oh my gosh.” It is very stressful.

Dr. Brian Wojciechowski: Yeah. And the ideal screening test would identify every cancer and would not identify anything that’s not a cancer. But unfortunately, we do not live in an ideal world, and in order to get the benefit from mammograms, you have to screen a lot of women and you have to realize that there will be some false positives, and there will be some anxiety generated by those false positives and extra studies and extra tests and biopsies.

Jamie DePolo: And now, these two studies were saying that if we could have a more individualized approach, so somebody who, let’s go back to your first example. There’s a women who’s 95 years old. She’s got cardiac problems. Does she really need a yearly mammogram?

Dr. Brian Wojciechowski: So I wouldn’t. I probably would not recommend that she have a yearly mammogram, but as a physician, you have to talk to the patient about it, and I have women in their 80s who come to my office and ask me, “Do I still need a mammogram?”

Here’s how I answer that question. I say, “Well, if we found something on the mammogram, if we picked up a breast cancer, would you have surgery? Would you have radiation? Would you consider chemo or hormone therapy?” And if the answer to all those questions are no, or if I think the woman’s life expectancy is quite limited for other reasons, then the answer is no. You can stop getting your mammograms.

Jamie DePolo: But if a woman would want to be treated, then obviously she should have mammograms.

Dr. Brian Wojciechowski: Yes. That’s my feeling.

Jamie DePolo: Okay. Okay, that’s good to know and I guess, too… I know the studies say that we needed these individualized approach, but we don’t really yet have the tools to do that, unless a woman is at very high risk for breast cancer because of an abnormal BRCA1 or BRCA2 gene, family history, personal history, or other things that would put her at very high risk for breast cancer.

So we do have those individualized approaches for high-risk women, we just need to kind of develop those tools for women at average risk.

Dr. Brian Wojciechowski: Yeah, you know, we need individualized screening. Hopefully 30 years from now, not every woman will need to be screened because we know what their risk is going in, and we’ll look back and think it was kind of silly that we did mammograms on every single woman. But unfortunately, we’re not as good as picking those high-risk patients out in 2014 as we really would want to be.

Jamie DePolo: Okay. And just to reiterate, to make it very clear, the Breastcancer.org stand is that every woman should have an annual mammogram unless you’re at high-risk, then you may need more frequent screening. But right now, we just don’t have the tools to know who may be at average risk, who’s below average risk, who’s a little bit higher than average, so you really do need to get that screening.

Dr. Brian Wojciechowski: Yeah. Starting at age 40.

Jamie DePolo: Yes. Starting at age 40 no matter what other things that you may have heard about people saying no, you don’t need it. Well, you really do. And we know that mammograms aren’t perfect, but right now, they’re the best screening tool that we have, so we would urge everyone to get your annual mammogram. And there are programs if you have problems getting to a mammogram screening center, there are programs that can help you get there. If you find that mammograms are painful, you can talk to the mammogram technician and you can figure out ways to make that less painful. If you have a problem affording them, I hope no one does because they are now under the Affordable Care Act, mammograms are paid for. But if you do have an issue paying for it, if you don’t have insurance, there are programs that offer free mammogram screenings, too. So please do everything you can to get your annual mammogram.

Dr. Brian Wojciechowski: Agreed.

Jamie DePolo: Yes. Unless you have anything else to add, Brian, I think that’s our podcast for today. Does that sound good?

Dr. Brian Wojciechowski: Sounds good to me.

Jamie DePolo: All right. Thank you so much. I always appreciate your insights and again, thank you, everyone, for listening. We hope you’ve enjoyed this edition of the Breastcancer.org podcast on Research News stories.