By Melvin J. Silverstein, FACS

Q. What exactly is a breast biopsy, and what is the pathologist looking for?
A. Women usually undergo a breast biopsy to have a suspicious area of breast tissue examined. Such suspicious areas are typically discovered during a clinical breast examination or via breast imaging (such as a mammogram). During a breast biopsy, a small tissue sample from the abnormal area is removed and examined by a pathologist using a microscope to check for breast cancer.

Q. What is the difference between an open surgical breast biopsy and a needle breast biopsy?
A. An open biopsy is a surgical procedure that requires local or general anesthesia and an incision in the breast to remove the abnormal area. A minimally invasive breast biopsy—also called a needle biopsy—is a simpler procedure in which the patient is given local anesthesia before a small, hollow needle is carefully guided into the suspected region, using the same imaging modality on which the abnormality was best visualized. A minimally invasive biopsy removes a core needle sample, resulting in no more than a 3-millimeter scar, whereas an open biopsy can leave scarring and indentation. With a needle biopsy, there is no need for general anesthesia, so it does not come with the risks associated with surgery.

Q. What are the risks and costs associated with each type of breast biopsy?
A. An open surgical biopsy carries the risk of infection, blood loss, and scarring, as an incision is made during the procedure that then has to be stitched closed. An open biopsy costs three to four times more on average than a needle biopsy.

Only about 15 to 20 percent of abnormalities detected by mammography turn out to be cancerous. Given that 80 to 85 percent of lesions are benign, a definitive diagnosis of cancer should be made using a needle biopsy as the first diagnostic step for all breast abnormalities. This allows for optimal preoperative workup and planning if cancer is found. It also gives a woman time to talk about various treatment options with her doctor to decide what’s best for her.

The American College of Surgeons published guidelines sanctioning the minimally invasive breast biopsy as the recommended procedure for diagnosing image-detected lesions, and the American Society of Breast Surgeons issued a statement in accordance with these guidelines. It is a quality standard that is advocated and embraced by most breast cancer organizations.

Q. Given that a needle biopsy is considered the gold standard, under what circumstances would an open biopsy be necessary?
A. There are relatively few women for whom an open surgical biopsy is medically necessary as the initial diagnostic procedure, but there are of course rare exceptions. In fewer than 5 percent of cases, it might not be possible to biopsy a lump with a needle due to positioning.

Q. What can I expect during and after a needle biopsy?
A. During a needle biopsy, you will remain awake, and your breast will be numbed with a local anesthetic. The lump will be located with image guidance, or by touch, and a core needle will be inserted through your skin into the lump to remove the sample tissue. Three to six samples are usually taken to ensure accuracy. Women should expect to feel some pressure but not any significant pain. After the procedure, you may experience slight bruising at the needle sites, but you will be able to carry on with your regular routine. A pathologist will examine the tissue samples, and a written report will be sent to your doctor with the results.

Q. Who performs a needle biopsy, and how can I locate the most qualified specialist in my area?
A. A surgeon or radiologist can perform a minimally invasive breast biopsy. Radiologists should be certified by the American Board of Radiology, and surgeons should be certified by the American Board of Surgery.

At Hoag Breast Care Center, where I serve as medical director, the minimally invasive breast biopsy is the standard of care for the initial tissue acquisition in both palpable and image-detected abnormalities—a policy that should be prevalent in more hospitals and centers across the country. At Hoag fewer than 5 percent of all breast biopsy cases require an open procedure.

If an open breast biopsy has been recommended for you, it’s important to seek a second opinion. Ask the surgeon or breast center you’ve been referred to about their rates for an open surgical biopsy versus a minimally invasive biopsy and ask if they take a specific position on breast biopsy techniques.

• Approximately 1.6 million women undergo breast biopsies annually.
• The American College of Surgeons and the American Society of Breast Surgeons both concur that a minimally invasive breast biopsy is the procedure of choice for image-detected abnormalities.
• Despite the fact that a needle biopsy is considered the gold standard in breast biopsy, a recent study showed that 40 percent of women are undergoing unnecessary open surgical breast biopsies.
• Only about 15 to 20 percent of abnormalities detected by mammography turn out to be cancerous.
• The accuracy rates for needle breast biopsies are equal to those for open surgical biopsies but with lower cost and less pain, scarring, and risk.

Radiation therapy and breast cancer

By Manjeet Chadha, MD

In 2008 approximately 240,000 women will be diagnosed with breast cancer. As a result of routine mammographic screening, a high proportion of these patients will have early-stage disease. Radiation therapy is an important component of the multidisciplinary care of early-stage breast cancer. Recent technological advances and an improved understanding of the biology of breast cancer have identified new and effective radiation treatment alternatives in the management of the disease. To receive individualized care, women need to understand their treatment options, and in consultation with their doctors participate in the process of making shared medical decisions.

Q. Why would I need radiation therapy?
A. Radiation therapy is the recommended local treatment for breast cancer after limited breast surgery that only removes the tumor (lumpectomy) with sampling of the axillary lymph nodes. Radiation therapy prevents local recurrence and contributes to improved long-term overall survival. In addition, the significant benefit of the combination of lumpectomy and radiation therapy is that women are given the option of keeping their breasts, while realizing the same survival outcomes as a mastectomy would provide.
Patients undergoing a mastectomy do not routinely require radiation therapy. However, in select circumstances (large tumors, many involved lymph nodes, or cancer noted at the edges of the mastectomy specimen) additional treatment with radiation following mastectomy can improve the outcome. Women should discuss their individual circumstances with their physician to determine whether radiation therapy after a mastectomy is indicated.

Q. What is a radiation oncologist?
A. Radiation oncologists are highly trained cancer physicians who directly oversee the care of patients undergoing radiation therapy. Radiation oncologists consult with patients and are responsible for making appropriate medical recommendations, and prescribing personalized radiation therapy plans for treatment. Radiation oncologists work alongside the medical and surgical oncologists as part of the multidisciplinary team.

Q. How is radiation therapy delivered?
A. Radiation therapy uses high-energy radiation waves or particles to kill cancer cells by blocking their ability to divide and increase in number. There are three different ways in which radiation therapy can be delivered:
External beam therapy is the most common technique. It is delivered with a highly sophisticated machine called a linear accelerator, often referred to as a “linac.”
Brachytherapy, also known as internal radiation therapy, is delivered via radioactive seeds or pellets that are temporarily placed in proximity to the original cancer inside the breast at the time of surgery.
Intraoperative radiation therapy (IORT) is the delivery of radiation therapy in the operating room at the time of surgery. Radiation oncologists can use external beam therapy or brachytherapy for this treatment. There are only a few select centers in the US that have the expertise to deliver IORT.

Q. Is radiation therapy safe?
A. Radiation therapy is carefully planned to ensure that accurate dose is delivered to the tumor site while sparing or minimizing radiation exposure of surrounding normal tissues. The medical application of radiation has made significant advances, ensuring quality, accuracy, and safety for use as a cancer treatment.

Q. What are the recent improvements in delivering breast radiation therapy?
A. Key advances in the past several years—including biological advances identifying the genetic make up of cancers and other important prognostic factors, improved understanding of how cancers grow, and where there is the highest risk of the disease coming back—have provided us with improved understanding of breast cancer. Clinical trials have shown that a shorter course of radiation therapy, completed in three weeks, may be just as effective as the standard, six- to seven-week schedule. As a result, we now have an opportunity to select patients for shorter schedules of radiation therapy.
Another ongoing clinical trial is comparing whole-breast radiation therapy to treating only the area of the breast from where the tumor was removed. This is referred to as partial-breast irradiation (PBI) and is delivered over one week duration. The efficacy of PBI is under study, and should be considered investigational requiring special treatment consent. Patients should discuss with their physician the treatment course that best suits their individual case and confers the best outcome.

Technological advances such as three-dimensional conformal radiation therapy and intensity-modulated radiation therapy—external beam techniques using computerized axial tomography (CAT) imaging that shows the size, shape, and location of tumors—are also making a difference in how we deliver radiation therapy. These techniques give a precise map of the tumor area and the surrounding normal structures and allow radiation oncologists to customize the radiation dose to targeted regions while sparing nearby normal tissues.

Q. What are the side effects of radiation therapy?
A. Radiation therapy is usually well tolerated, and patients are encouraged to continue their regular day-to-day activities. Most side effects reported are temporary in nature and individual variation in the intensity of the side effects is observed. The most common side effects are noted in the treated area. Some patients report mild to moderate fatigue.
The radiation oncologist and the radiation oncology nurse are the best professionals to consult for advice on how to cope with the side effects of radiation therapy.

Q. What key things can women do to help get through radiation therapy?
A. It is important that a woman understand her individual risks and have a direct dialogue with her physician so that ongoing symptoms are addressed responsibly. Managing expectations is also an important aspect of overall care. Maintaining nutrition and getting plenty of rest are advised to cope with the associated fatigue. Even though most patients generally feel well during radiation therapy, dealing with the diagnosis and the treatment can cause emotional and physical strain. It is helpful to seek support from family, close friends, a social worker, or a group of other breast cancer patients.

Psycho-oncology treats the nonphysical impact of cancer.

By Lynda Mandell, MD, PhD, FACR

The cancer journey is an uncharted, unwelcome, and unanticipated course. As such, it potentially has a powerful emotional impact on survivors and loved ones—from those very first words, “You have cancer,” through all the stages of living with the diagnosis.

Part of that emotional impact, for some, can be what is clinically referred to as “cancer-associated emotional distress.” This very real and difficult condition does exist, and it has only recently begun to receive the attention it deserves in the healthcare community. Common feelings and emotions associated with the condition include anxiety, fear, depression, low self-esteem, anger, shame, and guilt, which often result in disturbances that affect one’s memory, ability to concentrate, overall sense of well-being, and coping mechanisms with regard to decision-making, therapy tolerance, sleep and eating habits, partnership intimacy, and work and school performance.^1,2,3

Though the emotional impact of a cancer diagnosis is by no means a new phenomenon, the training of oncologists has historically focused solely on the physical aspects of the disease process. Because cancer patients tend to rely on their treating oncologists for overall management, the nonphysical aspects, including emotional distress and psychosocial issues and conflicts, are frequently ignored.^4,5,6,7,8 And, significantly, this neglect may ultimately have a negative influence on treatment compliance^9,10 overall outcome, and quality of life.^11,12

It goes without saying that there are many excellent, empathetic oncologists who do not ignore their patients’ emotional response to a cancer diagnosis and many who recognize the important fact that empathy and good communication skills are important in dealing with cancer patients.¹³ The fact is, however, that empathy does not automatically translate into an ability to recognize and deal effectively with psychological distress. Without the requisite tools and knowledge, even the most empathetic oncologists may remain unprepared to manage the emotionally afflicted cancer patient.

Psycho-oncology has emerged over the past two decades as a subspecialty of oncology in response to a growing recognition of the need to deal with the nonphysical, psychological aspects of cancer throughout a survivor’s journey.^14,15 Clinically, psycho-oncology addresses and scientifically studies two psychological dimensions of cancer: first, the psychological reaction of patients and the stresses on their loved ones, caretakers, and clinical treatment staff throughout the cancer journey—from the time of initial diagnosis or recurrence, throughout treatment, and during survivorship or end-of-life care (the psychosocial dimension); and, second, the psychological, behavioral/lifestyle, and social factors that influence cancer cause and risk, detection, and survival (the psychobiologic dimension).

Psycho-oncologists are multidisciplinary in background and training and include, but are not limited to, psychiatrists, psychologists, social workers, nurses, and clergy. As psycho-oncology becomes integrated into more treatment settings, oncologists are becoming increasingly aware of the need to call on their psycho-oncology colleagues and are better able to identify emotional distress and when and to whom to refer their patients for treatment beyond their own expertise.

As the healthcare community becomes more aware of the role of psycho-oncology, it is important that survivors and caregivers realize the benefits that this specialty can provide. Survivors may be surprised to read some of the following questions and hear pieces of their own stories.

Q. After a lot of testing to determine the extent of spread of my cancer, my team of doctors recommended that I receive chemotherapy and radiation. I’ve come to terms with that recommendation—and I begin my treatment next week—but I’m scared and worried about so many things: my prognosis, the side effects, how my family will cope with all this, and how it will affect my ability to go back to work and to function in other areas of my life after treatment is over. I thought maybe one of my doctors or nurses, during one of my many consultation visits, would have recognized how scared I was or asked me how I was coping, but nobody has.

I feel uncomfortable bringing up these emotional issues myself because everyone always seems so busy and focused on the details of the treatment. I still want to get help to deal with all these issues, but I don’t know where to turn. I’ve searched the Internet and read a lot of brochures I’ve picked up at the treatment center, but nothing seems to really address my worries. Are there professionals who offer individualized support and guidance? Who are they, and how do I find them?

A. Many cancer centers and oncology divisions now have psycho-oncology units. The professional discipline present within any given unit varies, but most include representation from psychology, nursing, social work, and the chaplaincy. If your treatment center does not have such a unit, you can find local professional help by contacting the American Psychosocial Oncology Society directly (www.apos-society.org; [866] 276-7443). You can also ask your oncologist or primary care physician to refer you to a behavioral health specialist (a psychiatrist, psychologist, or social worker) in your community who has the expertise to do an initial assessment and make the appropriate referral, if necessary, to a professional more specialized in dealing with cancer patients.

Q. I have just been diagnosed with cancer, and I’m having trouble focusing on what to do next. I feel like I’m going crazy, and I don’t know where to turn for help or guidance. I am rapidly falling apart at the seams—I can’t sleep, I’m not hungry, and I’m crying all day. I feel like I’m caught up in the middle of a dark tornado with no safe way out. I’ve always had a supportive family and group of close friends, but I feel very alone right now and nothing anyone says or does seems to change that feeling of doom. Am I going crazy? Is this a normal response to receiving a cancer diagnosis?

A. What you are feeling are normal psychological reactions to receiving a diagnosis of cancer. Experiencing unpleasant emotions such as sadness and anxiety when faced with cancer is usual and expected. These are all normal and typical responses to a major crisis. Feeling this way does not mean you are mentally ill or lacking emotional stamina.

The initial response is one of disbelief, denial, or despair, and this usually progresses to the second phase of responses, which can include anxiety, a depressed mood, anorexia, insomnia, poor concentration, and a basic inability to function. This second phase usually lasts for one to two weeks and is followed by an adaptation phase. In this phase, one, begins to accept the validity of the information given—the diagnosis—and starts focusing on the treatment options and the treatment process.¹⁴

How one adapts to the illness over time, however, varies from patient to patient and moment to moment. It depends on several variables, which include one’s individual personality and coping mechanisms to deal with daily stresses and emotional upheavals, prior life experience, available support systems, and the magnitude of the experienced stressors, including financial distress. Some individuals may travel through the cancer journey without suffering unbearable psychological distress. Sometimes, however, the feelings and the emotions become so overwhelming, difficult, and painful that they interfere with one’s ability to cope with the illness and its treatment and carry on with life. It is important to understand the range of normal reactions as well as when the feelings and emotions become so overwhelming and painful that professional help is needed.

Q. I was diagnosed with ductal carcinoma in situ (DCIS) three years ago and received radiotherapy after my lumpectomy. I thought I was doing well. I went back to work, and I was getting back into the social scene. Recently, I found out a close friend of mine with breast cancer was told she had a recurrence in one of her pelvic bones. Looking for some kind of solace and emotional support, I went to a breast cancer survivors’ group at one of our local hospitals. I was shocked to learn that the group did not view me as a true survivor. They even questioned why I had participated in one of the survivor walks the month before. Their reaction hit me like a ton of bricks and left me feeling very much alone in my struggle to come to terms with my diagnosis.

I continue to be confused about what DCIS is, and I can’t seem to find answers that clarify the issue. I was devastated by the diagnosis, I was frightened while going through the radiation treatments, and I still live with the fear of a recurrence that I can’t shake. So where do I go for help if I don’t even have a breast support group to turn to? Where do I belong? Am I a cancer survivor? I am feeling more and more alone and depressed, and I think I might need some professional help.

A. What you are experiencing is not at all uncommon for patients with DCIS. Recent literature supports the finding of a feeling of isolation as well as anxiety and fear among patients with your diagnosis.¹⁶ DCIS is a relatively new diagnosis since mammography has become a routine part of medical care. Because of its more indolent nature and lack of invasiveness, the prognosis for many patients is excellent, with the long-term survival rate of nearly 100 percent. It can recur, but when and if it does, it is not generally life-threatening.

Because the prognosis is so favorable, it may be difficult for those with invasive disease to relate to your situation, their rejection of you signifying their own anger and envy at your good fortune and the unfairness of it all. For this reason, support groups for DCIS have sprung up, as they have for metastatic patients, because support is always better when people can relate to one another. If you’d like to be part of one of these groups, contact your hospital or clinic; most hospitals have a breast center or social work department. There are also many organizations with information about DCIS risk, detection, treatment, counseling, and support services:

• Cancer Information Service: www.cancer.gov; (800) 4-CANCER [226237]
• American Cancer Society: www.cancer.org; (800) ACS- 2345 [227-2345]
• Living Beyond Breast Cancer: www.lbbc.org; (610) 645-4567 breastcancer.org: www.breastcancer.org
• Cancer Care, Inc.: www.cancercare.org; (800) 813- HOPE [4673]

Q. I have lung cancer and am in the middle of my radiation treatments. I am tired most of the day, am feeling the pain of a bad skin reaction, and am suffering from nicotine withdrawal. I have tried to talk about this with my doctors, but I get the feeling that they are annoyed with me. My normally kind, even-tempered husband is now always angry with me, and he says that he feels that I betrayed him by continuing to smoke and then getting this cancer.

I feel overwhelmed by my physical pain and, on top of that, all this emotional distress and guilt brought on by everyone’s assumption that I brought this on myself. It seems, in their eyes, I have no right to expect alleviation or mercy. Part of me also feels that maybe I deserve to have gotten this cancer and should suffer the consequences. I need someone to talk to who really understands and is prepared to listen and help me professionally. Does this type of help exist for cigarette smokers like me with lung cancer?

A. Recent studies have shown that patients with lung cancer often feel stigmatized by their medical care providers as well as by society at large because of the association between cigarette smoking and lung cancer.¹⁷ Whether or not the stigma is real is not the main concern here. The fact that you feel it exists and are so affected by these feelings is important. You have cancer—whether or not you contributed to its development. You have the right to get appropriate therapy for the cancer as well as for your emotional distress.

You cannot control the attitudes of others, but you can control your reactions to how other people act or what they say. You can also control your own actions. You do not need to suffer in pain alone. I believe that you would benefit the most from a support group of other lung cancer patients. It is important for you to see that you are not alone in your experience and to gain a sense of inner strength from that support to allow you to move forward with an improved sense of well-being. An excellent resource is the Lung Cancer Alliance, which offers support groups and a phone buddy program with peer-to-peer support. The information hotline (available Monday through Friday from 9 a.m. to 5 p.m. eastern time) is (800) 298-2436; the Web site is www.lungcanceralliance.org.

Q. I am 28 years old and was married six months ago. A few months after the wedding, I developed a lump in my neck that turned out to be a non-Hodgkin’s lymphoma. I am receiving my chemotherapy now and will later get some local radiotherapy to my neck. My husband and I were planning to have children right away, but now those dreams have to be put on hold while I get chemotherapy.

After I was tested to make sure I was not pregnant, my gynecologist put me on birth control pills. My oncologist has informed us that my prognosis is excellent and that with the type of chemotherapy I am getting I should be able to conceive later with minimal chance of any risk to my baby. Just to be safe, however, we saw a fertility specialist and had some of my eggs frozen.

Initially, I thought I had been dealing with the whole cancer thing quite well, but I started feeling pretty depressed after the diagnosis. I didn’t want to admit this to my husband because he’s feeling stressed about our finances now that I’m on short-term disability. I knew I needed some help, but was not sure if I really needed to see a psychiatrist and add more bills to the pile. Then a friend who had also recently gone through depression told me about St. John’s wort and described how it helped her.

I decided to give the St. John’s wort a try, and I did start feeling better. The problem is that I just found out I am five weeks pregnant! I had been nauseated for a while, but everyone thought it might have been due to my chemotherapy. Now the fact is that this baby growing in me has been exposed to the chemo chemicals that they say could be harmful, and I’m being told I should terminate the pregnancy. How could this have happened? I haven’t missed a day on my birth control pills. My husband has not talked with me since we found out.¹⁸

A. This is a classic case of an adverse interaction between two drugs. The St. John’s wort sped up the metabolism of the birth control pill in your body, leaving you with an ineffective dose for pregnancy prevention. This emphasizes the importance of telling treating doctors about anything you are taking, even over-the-counter supplements, to check for safety and contraindications. Here the St. John’s wort worked against the effects of the birth control pill, making pregnancy more likely. I suggest that you seek some short-term psychodynamic therapy at this point to help you deal with the impending personal loss associated with terminating a pregnancy. The type of therapy I would recommend is called interpersonal psychotherapy. As well, I believe that you and your husband might benefit from some couples’ therapy to work out the loss and the issues of grief and trust.

Q. My breast cancer recurred in the irradiated involved breast. I had a mastectomy, and my workup studies revealed that the disease had not spread past the breast. My doctors once again gave me an excellent prognosis for cure. I was placed on hormone therapy, am feeling physically well now, and am back at work. My problem is that I cannot shake the fear of the disease coming back again. It happened to me once, even though the odds were very small, so I can’t feel secure in its not happening again. Each time I feel any slight ache or pain, the fear becomes overwhelming. Is there any type of help for me to deal with this never-ending fear and anxiety?

A. Yes, there is. What you are experiencing is a natural response to the distrust that this disease engenders in all who have been affected by it. Living with anxiety—and fear of recurrence even in this scenario, where the likelihood of another recurrence may be low—is unacceptable. There are many medications available to alleviate the intensity of the fear and the anxiety. Besides medication stabilization, I would recommend a course of psychotherapy. Cognitive behavioral therapy (CBT) may help you reconstruct your instinctive negative thoughts and responses to more-positive conclusions with more functionally adaptive responses.¹⁹ You are entitled to have an ache or pain as a human being without always fearing that it is something much worse. Also, spiritual counseling has been shown to be quite effective in coping with the fear of living with cancer’s potential recurrence.^20,21

Conclusion
The management of psychological symptoms associated with the cancer journey is complex. Several treatments currently exist to deal with emotional distress, including—but not limited to—psychotherapy and drug therapy. Each case requires individualized attention and therapy designed to address the issues at hand. For patient safety, the administration of psychiatric medications requires knowledge of risks, contraindications, side effects, and potentially harmful drug interactions with chemotherapy, hormonal therapy, and other prescription or over-the-counter medications. Without the right tools to adequately identify emotional distress that might require professional attention, and if lacking familiarity with and in-depth knowledge of the different available therapies to deal with psychological issues, even the most empathetic and communicative physicians may remain unprepared to effectively manage the emotionally afflicted cancer patient.

Dealing with the nonphysical side of cancer—the “human side of cancer”²² —is becoming a vital component of cancer care. It is clear that untreated psychosocial and emotional conflicts impair quality of life and may have a negative impact on treatment compliance and overall survival outcome.^9,23,24 It is important that cancer patients, their loved ones, and caretakers know the following:

• Emotional distress is a normal response to receiving a diagnosis of cancer and is not shameful or a sign of psychological weakness.
• The level of emotional distress may vary during the cancer journey and at times may be significant enough to warrant professional intervention to help cope and function more effectively.
• There are trained and dedicated professionals available to treat the emotional and psychosocial aspects of cancer.
• Open communication with the cancer treatment team about feelings, emotions, and social conflicts may facilitate getting the appropriate care and resolution.

References
1. Massie MJ. Prevalence of depression in patients with cancer. Journal of the National Cancer Institute. Monographs. 2004:(32) 57-71.
2. Portnoy RK, Thaler HT, Kornblith AB, et al. Symptom prevalence, characteristics and distress in a cancer population. Quality of Life Research. 1994:3(3):183-89.
3. Roth A, Nelson CJ, Rosenfeld B, et al. Assessing anxiety in men with prostate cancer: Further data on the reliability and validity of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). Psychosomatics. 2006:47(4):340-47.
4. Söllner W, DeVries A, Steixner E, et al. How successful are oncologists in identifying patient distress, perceived social support, and need for psychosocial counselling? British Journal of Cancer. 2001:84(2):179-85.
5. Fallowfield L, Ratcliffe D, Jenkins V, Saul J. Psychiatric morbidity and its recognition by doctors in patients with cancer. British Journal of Cancer. 2001:84(8):1011-15.
6. Maguire P. Improving the detection of psychiatric problems in cancer patients. Social Science and Medicine. 1985:20(8):819-23.
7. Newell S, Sanson-Fisher RW, Girgis A, Bonaventura A. How well do medical oncologists’ perceptions reflect their patients’ reported physical and psychosocial problems? Data from a survey of five oncologists. Cancer. 1998:83(8):1640-51.
8. Passik SD, Dugan W, McDonald MV, Rosenfeld B, Theobald DE, Edgerton S. Oncologists’ recognition of depression in their patients with cancer. Journal of Clinical Oncology. 1998:16(4):1594-600.
9. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effects of anxiety and depression on patient adherence. Archives of Internal Medicine. 2000:160(14):2101-7.
10. Stein M, Miller AH, Trestman RL. Depression, the immune system, and health and illness. Findings in search of meanings. Archives of General Psychiatry. 1991:48(2):171-77.
11. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet. 1989:2(8668):888-91.
12. Butow P, Cockburn J, Girgis A, et al. Increasing oncologists’ skills in eliciting and responding to emotional cues: Evaluation of a communication skills training program. Psycho-oncology. 2008:17(3):209-18.
13. Neumann M, Wirtz M, Bollschweiler E, et al. Determinants and patient-reported long-term outcomes of physician empathy in oncology: A structural equation modelling approach. Patient Education and Counseling. 2007:69(1-3):63-75.
14. Holland JC. Principles of Psycho-oncology. In: Holland JF, Bast AC, Morton DL, et al, eds. Cancer Medicine, 4th ed. Baltimore: Williams & Wilkins; 1997:1327-43.
15. Levin T, Kissane DW. Psycho-oncology: The state of its development in 2006. European Journal of Psychiatry. 2006:20(3):1-17.

Could You Have an Early Female Pelvic Cancer? Symptoms to Note and Report to Your Doctor.

By Daniel Donato, MD

Female cancers generally produce symptoms that are recognizable as abnormal. The most important message, however, is do not dismiss the symptoms: bring them to your doctor’s attention as soon as possible. Once you describe the symptoms to your doctor, you should expect a thorough exam and possible further diagnostic testing.

Uterine Cancer
The most common female pelvic cancer is uterine cancer. Though there are exceptions, uterine cancer generally occurs in women who have gone through menopause. The major risk factor for uterine cancer is obesity. Fatty tissue converts hormones produced by the adrenal glands into estrogen-like compounds that can stimulate the uterine lining to become abnormally thickened, which eventually leads to cancer. The hormone tamoxifen (Nolvadex®), which is used to treat breast cancer, has also been associated with the development of endometrial cancer in some patients.

Signs and Symptoms
The good news about uterine cancer is that most cases are found early and are cured with surgery. But it is important to let your doctor know the early warning signs:

• If you have not gone through menopause, a change in your menstrual cycle (irregular or heavy bleeding) could be the earliest sign of uterine cancer.
• If you have stopped having a period for more than 12 months (postmenopausal), any bleeding, spotting, or even brownish vaginal discharge is considered abnormal. Remember, generally women progress through menopause by bleeding less frequently. Your bleeding should not be getting heavier or more frequent as you age.
• If you are on tamoxifen and you experience any type of vaginal bleeding, tell your physician immediately.

Diagnosis
The first step toward the diagnosis of a uterine abnormality is a thorough pelvic exam and a pap test. The doctor will then talk with you about an endometrial biopsy, a simple procedure that is normally performed in the office setting. It is very accurate in diagnosing uterine cancer. Some physicians also perform a pelvic ultrasound to see how thick the uterine lining appears. As a general rule, a uterine thickness of less than 5 millimeters is a good sign. The most accurate way to be sure of the diagnosis, however, is to do a uterine biopsy. Sometimes the physician cannot perform the biopsy in the office because the cervical opening is too small. In that case a dilatation and curettage (D&C) procedure—which involves dilating the cervix under anesthesia and scraping the inside of the uterine lining—would be the next step. This is an outpatient procedure, and the patient can return to normal activity by the next day.

Treatment
Of all the pelvic tumors, uterine cancer consistently produces symptoms early in the course of its development, and many patients are even diagnosed in the precancerous stage. Most of these cancers are easily cured by removing the uterus. The standard surgery for uterine cancer is to remove the uterus, the cervix, both fallopian tubes, the ovaries, and the lymph nodes. In young women the doctor may be able to save one or both ovaries.

Cervical Cancer
Cervical cancers generally occur in premenopausal patients but can also be seen in women in their seventies. Most cervical cancers appear to be closely associated with infection by the human papillomavirus (HPV). These tumors usually start out precancerous and can be easily detected with Pap tests. The truth about these cancers is that we shouldn’t see them anymore. In well-screened populations, cervical cancer should be almost nonexistent. The most common patient to develop cervical cancer is one who has not had a Pap test in many years. All screening tests can miss cancers, but repeated and consistent Pap tests are very unlikely to miss a cervical cancer. The actual goal of the Pap test is to detect these abnormalities at a time when the cells are in the precancerous stage and are more easily treated.

Signs and Symptoms
Most patients with cervical cancer have irregular bleeding after intercourse and between cycles and heavy bleeding during each cycle. Any of these symptoms should prompt a visit to the doctor for a pelvic exam.

Diagnosis
If the doctor sees a lesion on the cervix, the next step is a cervical biopsy. If no visible lesion is noted, the doctor will probably do a Pap test and possibly a colposcopic exam (examining at the cervix through a microscope). Any abnormal areas are typically biopsied. Depending on the biopsy results, a deeper (cone) biopsy may be necessary. When detected early, cervical cancer is curable in more than 90 percent of cases.

Treatment
The treatment for early cervical cancer is removal of the uterus, cervix, and lymph nodes, referred to as a radical hysterectomy.

Vulvar Cancer
Vulvar cancers are not very common but can cause significant problems if left untreated. The take-home message here is know your body. Any new lesion, regardless of how it looks, should be carefully evaluated. Vulvar cancers usually start out as a precancerous phase. These lesions can be flat or raised, ulcerative or not, painful or not, red, brown, black, or white. As you can see, there is no one lesion to look for. Any new lesions should be examined by your doctor and probably biopsied.

Signs and Symptoms
Symptoms of vulvar tumors include itching, irritation, a bleeding sore, or a nonpainful mass. The problem with vulvar tumors is that there is often a delay in diagnosis because a new lesion was not biopsied or was ignored until it started to spread. The first area of spread for vulvar tumors is to the lymph nodes in the groin area.

Diagnosis
Any signs, as described above, or new enlargement of the lymph nodes in the groin area will be examined by your doctor. The examination will generally be followed by a biopsy.

Treatment
Vulvar cancers tend to be slow-growing tumors. If detected early, they are almost always cured by surgical excision.

Ovarian Cancer
The most common types of ovarian cancer occur in postmenopausal patients. The rare patient with early-onset ovarian cancer is often part of a family in which multiple members have been diagnosed with breast or ovarian cancer. Ovarian cancer is by far the most difficult cancer to diagnose in the early stages. There is currently no screening test to detect early ovarian cancer. The CA-125 blood test has been available for many years, but it has so many false-positive and false-negative results that it is not a good screening test.

Signs and Symptoms
Ovarian tumors grow inside the abdominal cavity and can quickly spread to other organs with seemingly few symptoms. Most patients will have symptoms, however, so the key is recognizing them. Signs include bloating, distention, a change in bowel habits, new onset diarrhea, constipation, urinary frequency, or abdominal pain or discomfort. If these symptoms persist for more than several days, see your doctor.

Diagnosis
When you visit your doctor and describe your symptoms, the doctor should perform a pelvic exam and/or a sonogram of the pelvis with a transvaginal ultrasound. Early ovarian cancer is highly curable, but once it spreads beyond the ovary the cure rate drops dramatically.

We encourage all women to stay in tune with their bodies. Tell your doctor about anything that does not seem right. If the doctor doesn’t take you seriously, seek another opinion, preferably from a gynecologic oncologist. The following table is a summary of the signs, symptoms, and diagnostic tests for the various pelvic tumor sites.

Common Skin Cancer and Sun Protection Questions Answered

By Robert D. Bibb, MD

Q: How does sunlight affect the skin?

A: Sunlight deposits energy onto and into our skin. This energy comes to our skin’s surface through both visible and ultraviolet light (which is invisible). Scientists divide this light into three wavelength categories: UVA, UVB, and UVC. For the purpose of our discussion, our focus will center on UVA and UVB rays.

UVB rays are the shorter wavelengths (290 nanometers [nm] to 320 nm), and they don’t penetrate deeply into the skin. While they are the major cause of squamous cell carcinomas, they are effectively blocked by most sunscreens.

The longer and more dangerous wavelengths are the UVA rays (320 nm to 400 nm), which penetrate deeply into the skin. It takes a thousand times as much UVA exposure to cause a burn as UVB exposure, and UVA rays are sometimes referred to as the “tanning rays” because they generally don’t cause a sunburn like the UVB rays. My colleagues and I believe that the UVA rays, which are not properly blocked by existing sunscreens, are the primary cause of basal cell carcinomas and malicious melanoma.

Q: Is sun exposure the cause of skin damage and skin cancer?

A: As a practicing environmental dermatologist, I see firsthand how sunlight—the most obvious source of environmental damage to our bodies—not only causes collagen breakdown, premature aging of the skin, wrinkling, and brown spots, but is also the primary cause of skin cancer and its most deadly form—melanoma. Sadly, I’m also seeing a frightening increase in melanomas among teens and even preteens. Recently, two teens in particular actually developed lentigo maligna melanoma, a type of cancer that is normally only seen in individuals in their 40s and older who have had long-term exposure to the sun.

Q: What is the SPF, and how is it determined?

A: SPF stands for Sun Protection Factor, which describes the ratio of the time it takes a sunburn to develop with the respective sunscreen on, compared to how long it takes sunburn to develop without the sunscreen on. Since SPF only addresses UVB rays, however, the SPF ratings have created a dangerous misconception of sun protection in the minds of consumers. While the United States government is aware of this fatal flaw, no effective system of rating UVA coverage currently exists, and skin cancer statistics continue to climb.

Q: Is there such a thing as a “healthy tan?”

A: To me the term “healthy tan” is the deadliest of oxymorons. There is no such thing as a “healthy tan.” In addition, consumers are not aware that there is still no clear evidence that sunscreens block the malignant UVA rays, which leads to a misconception about their safety while using those products.

Q: Does sunscreen really protect against skin cancer?

A: A few years ago, the Australian government initiated a massive public service educational campaign called “Slip, Slop, Slap” to encourage the use of sunscreens. The campaign was a big success and boosted the per capita use of sunscreens there to record levels. On the heels of this campaign, researchers at the Queensland Institute for Medical Research in Brisbane followed 1,383 adults for five years and reported in 1999 that, while sunscreen use reduces the risk of developing squamous cell carcinoma, the use of sunscreens did not reduce the risk of developing melanomas or basal cell carcinomas.

Q: Since even the best sunscreens offer incomplete protection from the sun’s deadliest (UVA) rays, should we stop using them?

A: Absolutely not! Sunscreens should be used whenever one is outside, regardless of the season or temperature, and should always be applied on cloudy days as well as on sunny ones. Granted, these products are inadequate, but they do protect against UVB rays that cause sunburns and increase the risk of some skin cancers. The bottom line is that while sunscreens have disabled the body’s early-warning system—namely, sunburns—and have created a false, and dangerous, sense of security in the minds of consumers, they’re all we have for now. Therefore, we need to continue using them until science perfects a successful UVA sun-blocking solution, which I believe is near at hand.

Q: What are some practical tips to best protect myself and my family from sun damage and skin cancer?

A: Limit sun exposure and cover up as much as possible when you are outside. Always wear a hat, Polarized, UV-certified sunglasses, and sun-protective clothing whenever possible. Before applying a sunscreen, apply a topical antioxidant cream, such as vitamin E or vitamin C, to absorb or diffuse energy not blocked by the imperfect sunscreens. My own research, and patient feedback, has convinced me that antioxidant creams containing ellagitannins (found in raspberries, and other fruits) offer the greatest benefits when used in conjunction with a sunscreen. The ellagitannins not only have the ability to absorb excess energy but also may directly protect DNA.

Always use a waterproof sunscreen with a SPF of at least 30. Look for sunscreens containing the recently FDA-approved, UVA-blocking chemical Mexoryl, which, while also flawed, offers the best protection currently available. Apply the first application in a cool environment, as this decreases the chance of perspiration, thereby allowing the sunscreen to properly coat and adhere to the skin. Reapply the sunscreen at least every 90 minutes while outside. If you don’t want to use a chemical-based sunscreen, you can opt for invisible zinc oxide.

Andrew W. Menzin, MD, FACOG, FACS

Q. Is heredity an important factor in ovarian cancer?

A. Only 5 to 10 percent of ovarian cancers are thought to occur due to a hereditary predisposition. Despite this fact, knowledge of family history is important information for both a patient and her physician because of the potential preventive and treatment options available. Hereditary predisposition is assessed through genetic counseling and, if appropriate, genetic testing.

Based on 2006 American Cancer Society estimates, more than 20,000 ovarian cancers will be diagnosed in American women.¹ Although it is not the most common gynecologic malignancy, it is the most lethal, causing more than 15,000 deaths—more than all other cancers of the female reproductive tract combined. The overwhelming majority of these cases occur on a sporadic or random basis.

Q. How many women have a hereditary predisposition to ovarian cancer?

A. Much of the early research in this area focused on the importance of family history as a predictor of the risk of developing cancer. Over the past two decades, an enormous amount of work has refined our knowledge and has led to the discovery of mutations, or alterations, in certain genes that are responsible for the predisposition to a variety of cancers.

With regard to ovarian cancer, two syndromes account for most of the hereditary cases: the breast-ovarian syndrome, associated with mutations in the BRCA1 and BRCA2 genes, and the hereditary nonpolyposis colon cancer (HNPCC) syndrome, associated with different mutations in what are called mismatch repair genes.

• BRCA gene mutations occur at a rate of about 1 in every 800 to 1,000 individuals in the general population. Certain groups have a greater incidence of BRCA mutations. Most notable among these are people of Ashkenazi Jewish descent. In this population the rate is about 1 in 50, or 2 percent—a marked increase over the baseline. Although a family in which many members have been affected by ovarian or breast cancer may point to the presence of a BRCA mutation and a hereditary link, there are cases in which an individual has no family history of cancer but a significant personal history that places her at considerable risk. For instance, the development of early (premenopausal) breast cancer may be the only indication of the presence of a BRCA mutation even in the absence of other family members with breast or ovarian cancer.

Q. What are the risks associated with having one of these mutations?

A. When a woman is found to have a BRCA mutation, her risk of developing ovarian cancer is far greater than that of a woman in the general population.

• BRCA1 and BRCA2 mutations carry a risk of ovarian cancer of up to 45 percent compared with a risk of 1.4 percent in the general population. With regard to breast cancer risk, the rates are also significant, with almost 85 percent of women with a BRCA mutation developing cancer.²
• HNPCC is primarily a colon cancer syndrome, although the presence of mutations in the mismatch repair genes lead to the development of a broad spectrum of other malignancies, including cancers of the uterus, ovaries, small bowel, stomach, biliary tract, renal pelvis and ureter, and brain. Among women with the HNPCC syndrome, endometrial cancer occurs in up to 71 percent and ovarian cancer in about 12 percent.

Q. What are the options for women with mutations?

A. A woman has several options when faced with the news that she has a mutation that predisposes her to cancer.

• Surveillance, or close observation, may be undertaken, usually on an every-six-months basis. At this interval a pelvic examination, a transvaginal ultrasound, and a CA125 blood test are performed. Ongoing research is seeking to develop new strategies to enhance success with early detection.
• Chemoprevention focuses on the use of medications to reduce cancer risk. The birth control pill may be considered for these women, particularly when contraception is desired. Ovarian cancer risk is cut by half when the pill has been used for at least five to six years, and the protective effects last for many years after the drug has been discontinued.
• Prophylactic or risk-reducing surgery (RRS), the removal of both ovaries and fallopian tubes, may be an option for some women. Risk-reducing surgery may often be accomplished through minimally invasive (laparoscopic) techniques and decreases the risk by about 95 percent—limited mainly by the occurrence of primary peritoneal cancer, which originates from the lining of the abdominal cavity and develops from the same tissue that gives rise to the surface of the ovary, where
  most cancers occur. Because of the significant incidence of uterine cancer associated with HNPCC, RRS procedures in these women must include a hysterectomy as well as the removal of the ovaries and the tubes.

references
1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2006. CA: A Cancer Journal for Clinicians. 2006;56:106-130.
2. Understanding Inherited Breast and Ovarian Cancer. Myriad Genetic Laboratories Web site. Available at: http://www.myriadtests.com/brac.htm. Accessed November 16, 2006.

Q: I know that my time with my doctor is limited during each appointment and that I need to make the most of each visit. How can I make sure that I get the most from my physician?

A: It’s true, your time in the office with your doctor is limited. You may wait days or weeks for an appointment. You may travel significant distances for a specialist, only to actually see your doctor for 15 minutes. To complicate matters, the treatment of cancer requires a multidisciplinary medical team approach, which means that you need to make the most of not just one office visit, but many. Being able to effectively talk and listen to each doctor in your medical team will facilitate the step-by-step approach essential for optimal cancer treatment.

Understand the Importance of a Medical Team and Treatment Coordinator

Unlike some diseases or medical conditions, most cancer treatment is multifaceted, involving diagnosis and staging, gathering information, exploring treatment options, getting second opinions, undergoing treatment and receiving follow-up care. Each step of cancer treatment may involve several doctors and nurses that make up a medical team. A member of the medical team should be the designated treatment coordinator to oversee your treatment and facilitate interaction with other members of the medical team.

Educate Yourself

Use many resources to investigate your disease and treatment options and to define specific questions that only your doctor can answer. Resources should include your medical team, second opinions, books, the Internet and other patients with your disease. As you investigate, make an ongoing list of questions and organize your questions before your appointment.

Doctor-Patient Relationship

Most importantly, don’t be intimidated! Most cancer patients would advise that to receive optimal care, it is best to view each doctor in your medical team as a partner in your treatment. Don’t worry about asking questions or being an inconvenience; your doctor is working for you.

Preparing for the Appointment

Before you visit the doctor for the first time, do your homework. Understand your doctor’s role in your medical team and educate yourself about your disease and its treatment before your appointment. Contact the doctor’s office before your visit to determine the medical records or paperwork that your doctor will require before your appointment. This will help the doctor be prepared for you.

Invariably, you may forget to ask a question or a new question or concern may arise after your appointment. Consequently, before you leave your doctor’s office, establish a way to contact your doctor with subsequent questions. Although it may not be practical for your doctor to directly receive calls, your doctor’s nurse may be available via messaging, voice mail or email.

As you prepare for your appointment, arrange for a family member or friend to accompany you to the office visit if possible. This will not only lend you support, but will be invaluable in helping you keep record of the doctor’s comments and recommendations. In fact, studies have shown that bringing a companion to your appointments, requesting written recommendations and tape recording the appointment (with your physician’s consent) facilitate information recall and patient satisfaction. In one study, the addition of an audiocassette recording to written recommendations significantly improved a patient’s recall after the consultation.¹

At the Appointment

At the appointment, use your list of questions as a guideline to issues you want to discuss with your doctor. Remember, while a doctor will do their best to provide information, they cannot read minds. It is up to you to ensure that all of your concerns and questions are addressed. If your doctor says something you do not understand, stop and have them clarify. For example, your doctor may order CT scans daily for patients and you may have never heard of a CT scan. Find out what the scan is looking for and why one has been ordered for you.

Absorbing the Information

To appropriately absorb the information your doctor has given you, it is important to understand your doctor’s perspective and consider the source. Your doctor is giving you information that they think you need and want to hear. For example, some patients do not want to hear all of the information and only want to be told what to do. On the other hand, patients who want all of the information and treatment options may have to be more persistent. Also, consider the varying degrees of experience in your medical team, which result in different perspectives and specialties that permeate the advice your doctors will provide.

For example, a specialist dealing with a particular disease daily will have a different perspective than a general practitioner dealing with a particular disease a few times a year. Similarly, a surgeon may not be the best source of information on other treatments like chemotherapy or radiation. Furthermore, a doctor or facility that only offers standard treatment may not be the best source for information on experimental treatment.

Ultimately, it’s up to you to make the most of each appointment with each doctor on your team. Remember to take full advantage of the time you are given, go to each visit fully prepared and don’t allow yourself to feel intimidated. Remember that you should leave the appointment feeling as though your questions have been answered and that your time has been valued. And, as with any resource, remember that you always have the option of researching a second opinion.

Reference:
1. Bruera E, Pituskin E, Calder K, et al. The addition of an audiocassette recording of a consultation to written recommendations for patients with advanced cancer: A randomized, controlled trial. Cancer . 1999;86:2420-2425.

Amy Lang, MD
Fall 2006

Q: I am worried that I am going to get breast cancer. How can I know if I’m at increased risk, and what can I do about it?
A: Sometimes it seems that every time you turn around, someone else you know has been diagnosed with breast cancer. Many women feel that it is only a matter of time before they too will be diagnosed. If you have felt this way yourself, it is important to understand that the first step you can take is to accurately assess your risk and then understand that you can do something about that risk, however great or small.

The average American woman with no risk factors has a lifetime risk of breast cancer of 11 to 12 percent. A family history of breast cancer, particularly in a first-degree relative (a mother, sister, or daughter), may increase a woman’s risk up to 20 percent or more, particularly in the case of multiple relatives or an age at diagnosis of under 50 years old.1 Women known to be carriers of the BRCA1 or BRCA2 mutation (breast cancer susceptibility genes) have a lifetime breast cancer risk as high as 87 percent.2

Other recognized risk factors include: a prior diagnosis of certain pre-malignant breast conditions, a prolonged menstrual history such as early age of first menstrual period (age less than 12 years), late menopause (age over 55 years), absence of or delayed full-term pregnancy beyond age 30, use of hormone replacement therapy, and age greater than 60 years.3

Q: What are the surveillance options for women at an increased risk for breast cancer?
A: All women should perform monthly breast self-exams beginning by age 18. This exam can be learned from an OB/GYN, a family doctor, or a volunteer from a reputable breast cancer organization. The exam is best performed in the shower with soapy hands or with a body lotion to decrease surface tension on the skin. An examination by a physician, such as a family practitioner or gynecologist, should be performed annually.

Annual mammography remains the backbone of breast cancer early detection. Ultrasound or sonography can be used to better define a questionable area or to evaluate cysts.

Magnetic resonance imaging (MRI) has recently emerged as an important tool in the evaluation of a known breast cancer. At this point, however, it’s not an appropriate screening tool for the general population because the cost would be prohibitive; also, although MRI is a highly sensitive tool for detecting breast cancer, it is relatively nonspecific and could show a number of entities that are actually benign, leading to many unnecessary biopsies.4

Q: What can I do to decrease my breast cancer risk?
A: If you are at a high risk of developing breast cancer, there are several options that may help decrease your risk. You should discuss each of these options with your physician to see which may be appropriate for your particular situation.

Exogenous Estrogens
Few topics in medicine have been as hotly debated as the role of exogenous (external) estrogen therapies in the development of breast cancer. Most experts agree that hormone replacement therapy does increase the risk of breast cancer by as much as two and a half times the baseline risk, although it is still unclear whether the risk comes from progesterone or estrogen alone or from the combination. More recently, “natural” hormones, or phytoestrogens (derived from plants), have been touted as safe; but until more studies have been completed, exogenous estrogens and progesterones cannot be recommended for a woman at an increased risk for breast cancer.5

The use of oral contraceptives, or the birth control pill, is similarly controversial. Older studies using higher-dose pills did show an increased breast cancer risk, but more-recent studies indicate that lower-dose pills appear to be safe. For now, until convincing corroborating studies are done, women at a high risk for breast cancer are recommended to avoid the birth control pill.6

Lifestyle Changes
Alcohol increases a woman’s risk of breast cancer. Several studies found that two or more alcoholic drinks per day increase a woman’s breast cancer risk by up to 40 percent; and the Nurse’s Health Study showed that half a drink per day could increase a woman’s risk by 30 percent. There is evidence that folic acid appears to neutralize the risk of alcohol on breast tissue. The Nurse’s Health Study showed that 600 micrograms of folic acid per day appeared protective for women who drank more than one alcoholic beverage daily.7

There is no definitive evidence that any one food can lower a women’s risk of breast cancer, but it has been observed that women with lower body mass have a lower risk of breast cancer and that high consumption of red meat and high-fat dairy products are associated with increased breast cancer risk.8 Therefore women at a high risk are recommended to follow a diet that includes many fresh fruits and vegetables (especially broccoli, cauliflower, radishes, berries, citrus fruits, and dark leafy greens). Whenever possible, buying organic fruits and vegetables to reduce exposure to pesticides is also a good choice. Also try to eat meats and dairy that are “hormone-free” and that lack recombinant bovine growth hormone and insulin-like growth factor I, both of which have raised concern for increasing breast cancer risk.9

Exercise has long been suspected of being protective against breast cancer, and several new studies have shown that even moderate exercise (as little as four hours per week) decreases recurrence and improves survival among breast cancer patients.10 A good regimen includes a combination of cardiovascular aerobic exercise (walking and biking) with strength training (weights, resistance exercises, and sit-ups).

Chemoprevention
Prior to 1998 there were few options for women with an increased breast cancer risk. Then the NSABP P-1 trial was published, showing that the oral estrogen-blocking drug tamoxifen (Nolvadex®) reduced the incidence of breast cancer in high-risk women by about 50 percent regardless of their reason for being at high risk. (Even women whose only risk factor was being over 60 years old benefited.) Since that time tamoxifen has been the mainstay for risk reduction through drug therapy.11

This year brought us the second drug shown to reduce breast cancer among high-risk women. Evista® (raloxifene), an osteoporosis treatment, was tested against tamoxifen in the STAR trial and showed a similar 50 percent reduction in the development of breast cancer in high-risk women.12 Both drugs have an increased risk for hot flashes and vaginal dryness and a small risk for blood clots and stroke, although there were fewer deep vein clots in the Evista group. Tamoxifen can cause uterine cancer in rare cases, whereas Evista appears to have little, if any, effect on the uterus.

Role of Surgery
Finally, women at a very high risk for breast cancer, either because of a BRCA mutation or a very strong family history of breast and ovarian cancer, may wish to go further than chemoprevention to lower their risk of breast cancer as much as possible. For these women the prophylactic removal of both breasts (bilateral prophylactic mastectomy) can lower the risk of developing breast cancer by as much as 90 percent.13 Similarly, the prophylactic removal of the ovaries (oophorectomy) lowers the risk of developing ovarian cancer by up to 96 percent and reduces the development of breast cancer by 50 percent in women with BRCA mutations.14

These extreme treatments are best approached in consultation with a genetic counselor, a surgical oncologist, a gynecologic oncologist, a medical oncologist, and a plastic surgeon.

As we learn more about the factors that influence how and why women get breast cancer, we are becoming smarter about what we can do to help prevent the disease. No longer do women have to sit back and accept their breast cancer risk. If you are concerned about your risk, talk to a knowledgeable physician about what your risk actually is and then outline the best plan to help protect yourself.

references
1. Harris J, Lippman M, Morrow M, Hellman S, eds. Diseases of the Breast. Philadelphia, PA; New York: Lippincott-Raven; 1996:328-329.
2. Hereditary Breast and Ovarian Cancer Risks. Available at: http://www.myriadtests.com/provider/hboc-cancer-risk.htm. Accessed August 21, 2006.
3. Brown Z, Leffall LD, Platt E. 100 Questions & Answers About Breast Cancer. Sudbury, MA: Jones and Bartlett; 2003:17-23.
4. Hereditary Breast and Ovarian Cancer Medical Management. Available at http://www.myriadtests.com/provider/hboc-medical-management.htm.
Accessed July 23, 2006. [FILE NOT FOUND—evr]
5. Harris J, Lippman M, Morrow M, Hellman S, eds. Diseases of the Breast. Philadelphia, PA; New York: Lippincott-Raven; 1996:195-199.
6. Harris J, Lippman M, Morrow M, Hellman S, eds. Diseases of the Breast. Philadelphia, PA; New York: Lippincott-Raven; 1996:331.
7. Kaelin C, Coltrera F. Living Through Breast Cancer. New York: McGraw-Hill; 2005:286.
8. Kaelin C, Coltrera F. Living Through Breast Cancer. New York: McGraw-Hill; 2005:283.
9. Epstein S, Steinman S. The Breast Cancer Prevention Program. New York: Macmillan; 1997:197-198.
10. Brown Z, Leffall LD, Platt E. 100 Questions & Answers About Breast Cancer. Sudbury, MA: Jones and Bartlett; 2003. Epstein S, Steinman S. The Breast Cancer Prevention Program. New York: Macmillan; 1997:22. [OK that two sources are cited in this reference?]
11. Fisher B, Costantino JP, Wicherham DL, et al. Tamoxifen for prevention of breast cancer: Report of the National Surgical Breast and Bowel Project P-1 Study. Journal of the National Cancer Institute. 1998;90:1371-1388.
12. Chustecka Z. Raloxifene “Preferable” to Tamoxifen for Breast Cancer Prevention. Available at Medscape Hematology-Oncology from WebMD.
13. Hereditary Breast and Ovarian Cancer Medical Management. Available at http://www.myriadtests.com/provider/hboc-medical-management.htm. Accessed July 23, 2006.
14. Hereditary Breast and Ovarian Cancer Medical Management. Available at http://www.myriadtests.com/provider/hboc-medical-management.htm. Accessed July 23, 2006.

by Chandra P. Belani, MD, and Suresh Ramalingam, MD
Summer 2006

Q. Is lung cancer a common problem in women?

A. Lung cancer is the most common cause of cancer-related deaths in women. More than 70,000 women die from lung cancer each year in the United States. In fact, lung cancer kills more women than breast cancer. The incidence of lung cancer in women has increased rapidly and has outpaced the incidence in men over the past three decades. This change is likely related to the change in smoking practices among women because more women began smoking during this period.

Q. Are women affected by lung cancer differently than men?

A. The differences in lung cancer between men and women are being increasingly recognized in recent years, and some interesting information is beginning to emerge.

Women appear to be more susceptible to the carcinogenic effects of cigarette smoking. Compared with men, women who develop lung cancer tend to be younger and have smoked fewer cigarettes than men who develop the disease. The reasons behind the increased carcinogenic effect are not entirely clear. Studies have suggested that women are more prone to DNA damage caused by the carcinogens in tobacco.

There are also inherent differences in the biological behavior of lung cancer in women. Women with lung cancer have an overall better outcome than men do. They are generally more likely to experience tumor shrinkage when treated with standard therapies, and they survive longer than men.

In addition, there are differences between men and women in the overall side-effect profile of chemotherapy. Women have decreased DNA repair capacity, which may account not only for their increased susceptibility to lung cancer but also for the increased toxicity and the improved survival found when they are treated with platinum-based chemotherapy.

Q. What factors are responsible for the different behaviors of lung cancer in women?

A. It is not entirely clear why lung cancer behaves differently in women than men, but the answers to this question are beginning to emerge. The role of estrogen hormones is an important factor that has been studied only over the past few years.

Estrogen appears to promote the growth of lung cancer cells in the experimental setting. It also appears that tumors that overexpress estrogen receptors tend to have more aggressive behavior and are associated with overall inferior survival. Based on these observations, clinical trials are evaluating the utility of blocking the estrogen receptor to treat lung cancer in women.

A small study conducted in postmenopausal women demonstrated the feasibility of this approach, with promising preliminary results, prompting a larger trial by the University of California at Los Angeles and at the University of Pittsburgh Cancer Institute to evaluate it further. If these studies validate the observed clinical and preclinical benefits with total estrogen blockade with or without other proven systemic therapies, individualized therapy for lung cancer based on gender would be the next step.

Q. Are there differences in the way lung cancer is treated in women compared with men?

A. Until recently, women with lung cancer were treated along similar lines as men. With the development of newer drugs, it appears that gender-related differences can be exploited to improve the outcome for women with lung cancer. For example, the epidermal growth factor receptor (EGFR) pathway is a proven therapeutic target for lung cancer. Women with lung cancer are more likely to harbor mutations in the EGFR tyrosine-kinase domain, which increases the likelihood of responding to drugs that block the EGFR pathway—such as Tarceva® (erlotinib) and Iressa® (gefitinib). Female gender and adenocarcinoma histology are the two important clinical characteristics that have clearly demonstrated a correlation with EGFR tyrosine-kinase inhibitor efficacy.

Another drug that appears to be suited for gender-specific therapy is polyglutamated paclitaxel (PPX). This novel formulation of paclitaxel is given intravenously and is metabolized to its active form, a step that is mediated by an enzyme called cathepsin B. It appears that estrogen hormone induces the expression of cathepsin B. Based on this, women would be more likely to have higher intracellular concentrations of the active paclitaxel when treated with PPX. Retrospective analysis of three large clinical trials that were completed recently suggests better outcomes in women treated with PPX when compared with men.

This exciting phenomenon is now being tested in a large randomized clinical trial for women with lung cancer. In this trial women with lung cancer are treated with PPX or paclitaxel. The study is open to both premenopausal and postmenopausal women who have a performance status of 2 (limited functional status). If proven effective, this will be the first test of gender-specific therapy for advanced non–small cell lung cancer.

Clearly, the cause and the biology of lung cancer are multifaceted and require an improved understanding of the interplay among gender, genetics, and environmental factors. With increased awareness of how all of these factors are related, researchers are continuing to examine how the application of targeted and individualized therapies can help patients today and what treatments will bring hope for the future.

Chandra P. Belani, MD, is Professor of Medicine in the Division of Hematology/Oncology of the Department of Medicine at the University of Pittsburgh School of Medicine. He serves as Co-Program Leader of the UPCI Lung and Thoracic Malignancies Program and also directs the Clinical Core for the Lung Cancer SPORE. He has been recognized as one of America’s Top Doctors and Best Doctors year after year.

Dr. Belani is internationally renowned for his accomplishments in the area of lung cancer therapeutics and new drug development, and has received multiple awards for his work. His research efforts have led to changes in treatment paradigms for lung cancer. Dr. Belani has chaired several national and international trials testing novel prevention, drug development, and treatment strategies for lung cancer. He plays a key strategic role in moving promising new discoveries from the laboratory to the clinic and serves as a leader for early-phase clinical trials program at the UPCI. Dr. Belani interacts closely with other lung cancer experts across the world to develop and identify new therapeutic strategies to improve efficacy of interventions for the prevention and treatment of lung and thoracic malignancies. He is also the editor-in-chief of the journal Clinical Lung Cancer, and has extensively contributed to the literature on lung cancer and new drug development.

Suresh Ramalingam, MD, is an Assistant Professor of Medicine at the University of Pittsburgh School of Medicine. Dr. Ramalingam specializes in the treatment of lung cancer, esophageal cancer, and other thoracic cancers. He is also actively involved in the development of new drugs for the treatment of cancer. Dr. Ramalingam has published several papers on lung cancer and is currently involved in developing and conducting innovative clinical trials intended to improve the outcome for patients with lung cancer. He has received several awards including the prestigious Paul H. Ruble award presented to the “Teacher of the Year” at Wayne State University. Dr. Ramalingam serves on the Institutional Review Board (IRB) of the University of Pittsburgh and also in the Scientific Review Committee at the UPCI.

by Charles H. Weaver, MD
Spring 2006

Q: I am almost through with my treatment and am looking forward to “normal” life. What do I need to think about as I enter this post-treatment phase?

A: Completing treatment for cancer is an accomplishment. You may feel a great sense of relief as some of the anxiety and discomfort subside and the inconvenience is over. After thinking about cancer every waking moment during treatment, there are a few issues to resolve as you begin to recover physically and move on with your life. First and foremost, establish your treatment follow-up strategy and make sure that you feel comfortable with the management of any long-term side effects. Then, find resources to help you cope with financial and emotional issues.

Follow-Up Strategy 
Follow-up care is necessary to manage treatment complications and to detect cancer recurrence early, when it is most treatable. Discuss your post-treatment strategy in detail with your medical team to develop your follow-up schedule and choose a follow-up doctor. For example, if your treatment has required travel, it may be more practical for your follow-up doctor to be in your hometown. Also, find out if your post-treatment strategy includes periodic tests. For example, your follow-up care may require periodic CT scans, MRIs or X-rays to monitor and note any suspicious changes. Similarly, if your disease is associated with a blood marker, you may have periodic blood tests to monitor blood marker levels. In addition to periodic tests, you may want to discuss your prognosis as well as symptoms of recurrence that are cause for concern and further follow-up. Also, make sure that you have established a way to contact your doctor or nurse as additional questions and concerns arise.

Long-Term Side Effects 
Long-term side effects from treatment may be minor or imposing. Understanding what side effects may occur and determining the best way to manage these side effects on a permanent basis is important. Your treating doctor may not be a specialist in the management of long-term side effects so you may request a referral. For example, if the surgical treatment of your disease has left you physically challenged, your follow-up care may require a physical therapist. Or, if you have had a lymph node dissection, the management or prevention of lymphedema may best be handled by someone other than your surgeon.

Post Treatment Financial Issues
Cost of treatment may cause an ongoing financial stress and burden. Post-treatment financial issues may include disputes with your insurance, as well as debt incurred from out-of-pocket expenses or an inability to work during treatment. Patient advocate organizations offer valuable information to help patients with these issues. For more information about insurance issues, job discrimination or patient assistance programs, go to www.patientadvocate.org or other patient advocate organizations.

Support 
After completing cancer treatment, you may feel elated and relieved as you recover and side effects diminish. Although your life may return to normal, the unknown and the statistics may still weigh on your mind from time to time. To cope with emotional issues, you may wish to seek professional support, family support, as well as support from other patients with your disease. Patients recommend reading other patient stories, telling your story and researching breaking news concerning your disease. These processes have been made easier by the growth of the Internet’s disease-specific sites, bulletin boards and chat rooms. Patients also report that community support groups are a valuable resource for emotional support. Acknowledging your experience through these outlets may provide some sense of relief and validation.

Defining your post-treatment strategy, understanding management of long-term side effects, seeking support for financial issues and coping with emotional issues are all important components of your post-treatment plan. Since thinking about cancer may consume you as you go through treatment, letting go and moving on may be difficult. However, an effective post-treatment strategy may help you cope with emotional and physical side effects, as well as increase the likelihood that a cancer recurrence will be found early when it is most treatable.