Expert Review And References
- Bursein HJ, Harris JR, Morrow M. Malignant tumors of the breast. Devita, V. T., Jr., Lawrence, T. S., & Rosenberg, S. A. Cancer: Principles & Practice of Oncology. 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins 2008: 43.2: pp. 1606-54.
- Foxson SB, Lattimer JG & Felder B. Breast cancer. Yarbro, CH, Wujcki D, & Holmes Gobel B. . Cancer Nursing: Principles and Practice. 7th ed. Sudbury, MA: Jones and Bartlett 2011: 48: pp. 1091-1145.
- National Cancer Institute. Breast Cancer Treatment Health Professional Version. Bethesda, MD: National Cancer Institute 2010.
- Breast cancer. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. National Comprehensive Cancer Network 2010.
- Tripathy D, Eskenazi LB, Goodson, WH, et al. Breast. Ko, A. H., Dollinger, M., & Rosenbaum, E. Everyone’s Guide to Cancer Therapy: How Cancer is Diagnosed, Treated and Managed Day to Day. 5th ed. Kansas City: Andrews McMeel Publishing 2008: pp. 473-514.
Is Radiation Therapy Necessary If The Margins Of The Removed Tissue Are Clear
Many studies have reviewed this approach for patients with invasive cancers. Nearly all show that the risk of relapse in the breast is much higher when radiation is not used than when it is . When breast cancer re-occurs locally after breast conservation surgery, patients may then need to have a mastectomy to be cured. Because having breast cancer reappear in this way is a very traumatic psychological event, and because not everyone who has a recurrence in the breast can be cured, radiation therapy after lumpectomy has become a standard part of breast-conserving therapy.
There are several recent studies in which older patients with small, favorable invasive cancers have had a low risk of local relapse when treated with lumpectomy and hormonal therapy without radiation therapy. There is still uncertainty about the long-term results with this approach or about which individuals will do best without radiation therapy. This issue should be discussed in detail with your doctor.
Healthbrca Mutations Don’t Hurt Breast Cancer Survival
The new study followed 9,717 women with early-stage disease, ages 18 to 75, with estrogen-receptor-positive, HER2-negative cancers that had not spread to the lymph nodes cases where doctors have been unsure whether chemo would be helpful.
Of the 9,717 women, 6,711, or 67 percent, had test scores indicating an intermediate risk of recurrence their score was 11 to 25. After surgery and radiation, those women were randomly assigned to receive chemotherapy with an estrogen-blocking medication or just the estrogen hormone blocker.
Prior to the study, doctors knew women with a low score on the test, less than 11, were told they could skip chemo with no ill effects. Women at high risk, or scores of 26 or higher, were advised to have chemo.
The new study showed that women with intermediate risk, it made no difference in terms of recurrence whether a woman was treated with chemotherapy or not.
We didnt know if chemotherapy benefited women in this range,” said Dr. Sara Hurvitz, an associate professor at the University of California, Los Angeles, and director of breast medical oncology at the UCLA/Jonsson Comprehensive Cancer Center. “The study showed that if you take the group as a whole, there is no difference in the risk of recurrence when you compare chemotherapy to no chemotherapy.
Some cancer specialists have been postponing the decision to treat their newer patients with chemotherapy until the study findings were released.
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Survival Rates Are Tripling For Lung Patients
When Dr. Roy Herbst of Yale started in oncology about 25 years ago, nearly every lung cancer patient with advanced disease got chemotherapy.
With chemotherapy, he said, patients would be sure to have one thing: side effects. Yet despite treatment, most tumors continued to grow and spread. Less than half his patients would be alive a year later. The five-year survival rate was just 5 to 10 percent.
Those dismal statistics barely budged until 2010, when targeted therapies began to emerge. There are now nine such drugs for lung cancer patients, three of which were approved since May of this year. About a quarter of lung cancer patients can be treated with these drugs alone, and more than half who began treatment with a targeted drug five years ago are still alive. The five-year survival rate for patients with advanced lung cancer is now approaching 30 percent.
But the drugs eventually stop working for most, said Dr. Bruce Johnson, a lung cancer specialist at Dana-Farber. At that point many start on chemotherapy, the only option left.
Another type of lung cancer treatment was developed about five years ago immunotherapy, which uses drugs to help the immune system attack cancer. Two-thirds of patients from an unpublished study at Dana-Farber were not eligible for targeted therapies but half of them were eligible for immunotherapy alone, and others get it along with chemotherapy.
Myth #: People With Metastatic Breast Cancer Look Sick And Lose Their Hair
You dont look sick. You look so well. Why do you still have your hair? Are you sure you have cancer? These are comments that people with MBC report hearing. But there are many treatment options besides chemotherapy, and people often appear well while taking them.
As NancyHB comments: Id much rather be a poster child for how sometimes we can live with, rather than die from, MBC at least for a while. Instead, I find myself defending against people who are increasingly becoming impatient with my lack of cancer-patient appearance. Im grateful for this time of feeling good, and theyre harshing my buzz.
Some people with MBC report that they actually look better than they feel while in treatment. So they sometimes have to let family and friends know that even though they appear fine, they dont feel well.
Shetland Pony notes: If she looks good, she is good. Nope. Many of us suffer from the invisible disability of fatigue. I would venture to say every available treatment causes us some level of fatigue. We struggle to keep up. It may look like we are doing the bare minimum when we are really giving it our all.
JoE777 of Texas adds: The new normals advertised about therapies on TV are deceiving about the side effects. They talk about side effects while women are skipping through life. not looking to show the harsh side effects but think there is something wrong with me that my life is not like that.
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Advances In Conventional Breast Cancer Treatment
Early-stage, localized breast cancer is highly treatable, but not everyone is aware that cancer treatment in general has evolved and improved in the last few years. Advances in breast cancer treatment have improved patient outcomes while also reducing side effects patients may experience during treatment. Below are a few of the most promising developments.
A Disease No One Gets
Sadly, people donât âgetâ mets. In fact, a recent survey sponsored by Pfizer Oncology shows just how misunderstood it is. Sixty percent of the 2,000 people surveyed knew little to nothing about MBC while 72 percent believed advanced breast cancer was curable as long as it was diagnosed early. Even more disheartening, a full 50 percent thought breast cancer progressed because patients either didnât take the right treatment or the right preventive measures.
âTheyâve built an industry built on four words â early detection equals cure â and that doesnât even begin to define breast cancer,â said Schoger, who helped found Breast Cancer Social Media, a virtual community for breast cancer patients, caregivers, surgeons, oncologists and others. âWomen are blamed for the fate of bad biology.â
The MBC Alliance, a consortium of 29 cancer organizations including the biggest names in breast cancer , addressed this lack of understanding and support as well as what many patient advocates term the underfunding of MBC research in a recently published landmark report.
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Buddy Check : Living With Metastatic Breast Cancer
KNOXVILLE, Tenn. Deborah Scaperoth and Chris Betts are two women at different points in their lives, but they share a terminal commonality. They both have stage four metastatic breast cancer and know without a cure, the disease will kill them.
According to komen.org, more than 160,000 people in the U.S. are living with stage four metastatic breast cancer. One in three breast cancer patients will develop the incurable disease through no fault of their own.
A diagnosis means treatment for the rest of your life.
People want to know, Oh, when do you finish treatment? When I die. Thats when treatment finishes, Betts admitted.
They are considered metastatic thrivers because they live each day facing a battle they wont win without a cure.
Im a person who doesnt give up, so when people talk about how they won over cancer and Im very happy for them but we all do what we were told to do and Ive had like 105 radiations and 66 chemos, Scaperoth said.
They are exhausted physically and emotionally from treatments, pain and everyday life. The hard part is, they dont know how long the treatments will keep their cancer sleeping.
You know, I know the statistics, Betts nodded. The statistics do not look good. Five years would be fantastic. I see people making it 15 and 20 years, but it all depends on finding a treatment that will give me some longevity.
Everolimus And Hormone Therapy
Everolimus is an mTOR inhibitor. mTOR inhibitors are a class of drugs that may increase the benefit of hormone therapy.
Everolimus is FDA-approved for the treatment of hormone receptor-positive, HER2-negative metastatic breast cancers in postmenopausal women. The combination of everolimus and the aromatase inhibitor exemestane can slow the growth of such cancers better than exemestane alone .
Everolimus is a pill.
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Abemaciclib Palbociclib And Ribociclib And Hormone Therapy
The CDK4/6 inhibitors FDA-approved for metastatic breast cancer treatment are:
CDK4 and CDK6 are enzymes important in cell division. CDK4/6 inhibitors are a class of drugs designed to interrupt the growth of cancer cells.
Although the CDK4/6 inhibitors abemaciclib, palbociclib and ribociclib have not been compared directly to one another, studies show similar results with each drug .
A CDK4/6 inhibitor in combination with hormone therapy can be used to treat hormone receptor-positive, HER2-negative metastatic breast cancers. Compared to treatment with hormone therapy alone, this combination can give people more time before the cancer spreads and increase overall survival .
The CDK4/6 inhibitor abemaciclib may also be used alone to treat hormone receptor-positive, HER2-negative cancers that have progressed during past hormone therapy and chemotherapy .
Abemaciclib, palbociclib and ribociclib are pills.
The table below lists some possible side effects for CDK4/6 inhibitors.
For a summary of research studies on the use of CDK4/6 inhibitors in treating metastatic breast cancer, visit the Breast Cancer Research Studies section.
Progression During Hormone Therapy
For hormone receptor-positive cancers that were being treated with hormone therapy, switching to another type of hormone therapy sometimes helps. For example, if either letrozole or anastrozole were given, using exemestane, possibly with everolimus , may be an option. Another option might be using fulvestrant or a different aromatase inhibitor, along with a CDK inhibitor. If the cancer has a PIK3CA mutation and has grown while being treated with an aromatase inhibitor, fulvestrant with alpelisib might be considered. If the cancer is no longer responding to any hormone drugs, chemotherapy immunotherapy, or PARP inhibitors might be options depending on specific features of the cancer or any gene changes that might be present.
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Myth #: Metastatic Breast Cancer Is Curable
Whether metastatic breast cancer is someones first diagnosis or a recurrence after treatment for earlier-stage breast cancer, it cant be cured. However, treatments can keep it under control, often for months at a time. People with MBC report fielding questions from family and friends such as, When will you finish your treatments? or Wont you be glad when youre done with all of this? The reality is they will be in treatment for the rest of their lives.
A typical pattern is to take a treatment regimen as long as it keeps the cancer under control and the side effects are tolerable. If it stops working, a patient can switch to another option. There may be periods of time when the cancer is well-controlled and a person can take a break. But people with MBC need to be in treatment for the rest of their lives.
As Breastcancer.org Community member Vlnprh of Wisconsin comments: The vast majority of people have no idea what MBC treatment involves. They somehow think that you will undergo something similar to early-stage patients surgery, radiation, chemo, whatever and then be done. They want to see you as a pink-tutu-wearing cheerleader jumping up and down declaring that you have beaten this disease
Amarantha of France writes: The one I get over and over is, How long will you be on this chemo? I mean doesn’t it end sometime? Yes, it ends when it stops working and then we go on to another treatment lather, rinse, repeat I guess until we run out of options.
What Is The Prognosis After Recurrence
Many patients with a recurrence of breast cancer can be successfully treated, often with methods other than radiation if radiation was used in the initial treatment. For patients treated initially for invasive breast cancer, five percent to 10 percent will be found to have distant metastases at the time of discovery of the breast recurrence. The same proportion will have recurrences that are too extensive to be operated on. While in these cases the patient’s disease can often be managed over a period of years, the goals of treatment change from obtaining a cure to preventing further progression or managing symptoms. Five-year cure rates for patients with relapse after breast conservation therapy are approximately 60 percent to 75 percent if the relapse is confined to the breast and a mastectomy is then performed.
For patients treated initially for DCIS, about one-half of recurrences are invasive and one-half noninvasive DCIS. Long-term control rates following recurrence after initial breast conservation therapy have been high, often over 90 percent.
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How Can I Prevent Breast Cancer Recurrence
Healthcare providers dont know why some people experience breast cancer recurrence. A recurrence isnt your fault. You didnt do anything wrong to cause it or fail to do something more to prevent it.
Certain medications may reduce the risk of breast cancer recurrence in people who have early stage breast cancer. For estrogen-receptive breast cancer, hormonal therapies including tamoxifen or aromatase inhibitors block either the activity of estrogen or the bodys production of estrogen. Chemotherapy may also be recommended to reduce risk of breast cancer recurrence.
Early diagnosis may make it easier to treat a recurrence. Follow your healthcare providers recommendations for mammograms and other screenings. You should also perform regular breast self-exams. Get familiar with how your breasts look and feel so you can see your provider quickly if you notice changes. And remember that most breast changes occur for reasons other than cancer.
Combining Integrative Therapies With Conventional Cancer Treatment
Supportive care modalities, including nutritional and naturopathic support, may help prevent and manage potential side effects of cancer and its treatment. These evidence-informed services may improve your quality of life during treatment and help prepare you for survivorship. If youre interested in both natural and conventional cancer treatment, consider this combination of care.
Access to integrative care is part of every patients care at CTCA. We treat the whole person by incorporating integrative care modalities with a wide range of diagnostic tools and comprehensive treatment options, all under one roof. Its all part of treating our patients like wed treat our own family members, a principle we call the Mother Standard® of care.
Supportive care services we offer to our patients include:
Nutritional support helps patients understand the importance of nutrition during cancer treatment, with the goal of helping patients stay strong and nourished throughout treatment and of supporting the immune system. Patients have the option of meeting with a registered dietitian to address their specific needs and challenges.
Naturopathic support from our naturopathic team may help you determine which dietary supplements, herbal and botanical preparations and other naturopathic approaches may help you. They can also help you avoid those that are known to be harmful when taken with certain medications and in certain conditions.
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Will I Need More Than One Treatment For Metastatic Breast Cancer
Medications are important for metastatic breast cancer to help control its spread. Resistance to therapies may develop, which can lead your care team to recommend a change in treatment.
When you start a treatment regimen, you and your care team will see how:
- The cancer responds to the therapy.
- The side effects impact you.
If the treatment isnt working or the side effects are unbearable, your care team can discuss switching the treatment method. They may recommend a different drug, dosage or schedule.
There are many treatments available. If one therapy isnt working for you for whatever reason, there is usually another one you can try.
Outcome Analysis Of Breast Cancer Patients Who Declined Evidence
Here is the recent paper I referred to above, which studied women with breast cancer in Northern Alberta who refused standard treatments. It was also a chart review with a matched pair analysis that compared survival with those that received conventional cancer care. Between 1980 and 2006 they identified 185 women that refused cancer care following diagnosis by biopsy. Women older than 75 were excluded from the analysis because this population is generally not included in clinical trials and active treatment regimens. In addition, women that accepted surgery, but rejected chemotherapy/radiation were excluded from the analysis. To qualify, women had to have rejected all conventional care. The final population studied was 87 women, most of whom presented with early disease. Most were married, over the age of 50, and urban residents. In this group, the primary treatment was CAM in 58%, and was unknown in the remainder. Some women in this group eventually accepted cancer care, and the average delay was 20-30 weeks due to CAM use.
The results were grim. The 5 year overall survival was 43% for women that declined cancer care, and 86% for women that received conventional cancer care. For cancer-specific survival survival was 46% vs. 85% in those that took cancer care. The survival curves are ugly:
All causes of deaths and deaths due to breast cancer only
The authors compared the CAM group to those where treatment plan was not known:
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