Living with Breast Cancer
11/20/2009 (7:24:57am)Tags: noneComments: (0)
Some women, after breast surgery, report pain or discomfort that persists for a very long time. Interestingly, a new study in the Journal of the American Medical Association reports that women who underwent a wide excision/lumpectomy were most likely to experience lasting pain. Here are a few quotes from the study and then a link to read more:
Almost half of women who have breast cancer surgery still have pain or numbness two to three years later, according to a new study. Women younger than 40 who receive lumpectomies are at the greatest risk. In general, women are most likely to have pain or a loss of sensation in the breast region, followed by the armpit, the arm, and their sides. However, 40 percent of women with lingering symptoms have pain in parts of the body not affected by treatment, according to a report in the Journal of the American Medical Association.
In the study of 3,754 breast cancer survivors ages 18 to 70, 47 percent had pain in one or more area, and 58 percent reported problems in the treated breast, including burning and a loss of sensation for one to three years after their surgery. Overall, 13 percent of women with lingering problems said their pain was severe, 39 percent said it was moderate, and 48 percent reported light pain. And 76 percent of patients with severe pain said they ached every day.
Women at the greatest risk for chronic pain were ages 18 to 39 and had undergone breast-conserving surgery, or lumpectomy, in which doctors remove only the tumor and some surrounding tissue. Other risk factors for persistent pain included radiation therapy, which is directed at the breast area to destroy any remaining cancer cells after surgery.
There are several reasons that breast cancer survivors experience pain such as nerve damage or injury from the surgery or radiation, but in the future, nerve-sparing surgery may help take the sting out of this persistent pain, according to study authors led by Dr. Rune Gärtner, of the University of Copenhagen in Denmark.
http://tinyurl.com/yk8sz8p
11/19/2009 (7:38:03am)Tags: noneComments: (0)
You have to sleep. We all know what a difference a good night's rest means. We also all know how hard that can be to achieve. When the normal troubles with sleep are joined by cancer-related factors, it can be even harder. All of our worries seem worse at 2 AM, and many of us have spent sleepless hours thinking about every possible dire possibility. Some of the drugs we take may make it harder to sleep. When our bodies are "chemically altered" (meaning, when we are on chemotherapy), it can seem that nothing works smoothly and normally, and that may include sleeping.
A recent article by Sonia Anooli, MD at the University of California San Diego, published in the Journal of Clinical Oncology, addresses these issues nicely. Here is the introduction and then a link to read more:
Fatigue is recognized by oncologists as one of the most frequent complaints of patients with cancer. More importantly, fatigue is among the symptoms about which patients express the most concern. What is less recognized is that there are many components of fatigue, including physiologic factors (such as pain, anemia or menopause), psychological factors (such as depression or anxiety), and chronobiologic factors (such as circadian rhythms disorders and sleep). In particular, the relationship between fatigue and sleep is becoming more clear, with data suggesting that sleep problems are significantly correlated with increased fatigue. Yet, patients with cancer are not always asked about their sleep nor treated appropriately for their sleep problems.
http://tinyurl.com/yjsxyxr
11/18/2009 (1:13:35pm)Tags: noneComments: (0)
There has hardly been another topic in my life over the past 24 hours since the new mammography guidelines were released. I have talked with a number of women, and it was a big conversation in my GYN cancer support group this morning. Last night, I gave a talk at a hospital near Hartford, and, during the Q and A, this was the focus.
The following summary from the Susan G. Komen Foundation is helpful. For all of us, the best advice remains to speak with your own doctors about your particular situation.
Making Sense of New Mammography Recommendations
The U.S. Preventive Services Tasks Force (USPSTF) has reversed its position on screening< mammography for women in their 40s: the group no longer recommends routine screening mammography for average-risk women in this age group.
The American Cancer Society, however, has stated that it will continue to recommend annual mammograms starting at the age of 40.
How should women respond to this news? Calmly.
There has always been debate about whether or not to recommend routine screening mammography for women in their 40s. The focus of the debate is the balance of risks and benefits. The most important potential benefit of screening mammography is a< modest reduction in breast cancer mortality. Potential risks of mammography include false-positive test results (which lead to stress and additional testing), false-negative test results (a missed cancer), and overdiagnosis. Overdiagnosis refers to the diagnosis of a cancer that will never cause health problems during the life of a patient. Overdiagnosis leads to unnecessary cancer treatment.
For young women, the balance of risks and benefits is different than for older women, and may not clearly favor screening (although this point continues to be debated). Young women are more likely than older women to experience some of the downsides of mammographic screening, and are also less likely to have breast cancer.
That fact that the USPSTF and the American Cancer Society now have different screening recommendations for women in their 40s simply reinforces the importance of educating yourself about< the potential risks and benefits of screening, talking with your physician, and making the decision that’s right for you. This point is highlighted by the USPSTF, which notes “The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.”
The USPSTF statement is an update of its 2002 recommendations and is based on a review of the available data. Since 2002, new data have become available about mammography in younger women.
Other highlights of the new USPSTF recommendations include the following:
For women between the ages of 50 and 74 years, the USPSTF recommends mammography every two years (rather than every year).
The USPSTF notes that there is insufficient evidence to assess the benefit and harms of screening in women over the age of 74.
The USPSTF recommends against teaching breast self-exam.
Although the USPSTF’s position on breast self exams may also be perceived as controversial, there has never been clear evidence that breast self-exams reduce breast cancer mortality.
It should be noted that the recent discussion regarding mammography recommendations is focused on women at average risk of breast cancer. Women at increased risk as a result of family or personal history may need to begin screening at a younger age, and may benefit from screening with breast magnetic resonance imaging (MRI) in addition to mammography.
Women who have questions about the screening schedule and approach that’s right for them are advised to talk with their physician.
References:
[1]
U.S. Preventive Services Task Force. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement.
Annals of Internal Medicine. 2009;151:716-726.
[2]
American Cancer Society. American Cancer Society responds to changes to USPSTF mammography guidelines. Available at:
http://www.cancer.org
Source:
http://ww5.komen.org/ExternalNewsArticle.aspx?newsID=44299
11/17/2009 (6:35:20am)Tags: noneComments: (2)
An announcement yesterday from the US Preventive Services Task force revising longstanding guidelines re mammograms has caused an uproar. Here is a brief summary from Dr. Susan Love's Blog (http://blog.dslrf.org/?p=113) :
The U.S. Preventive Services Task Force issued new guidelines on breast cancer screening today that do away with the “every woman should have an annual mammogram starting at age 40” recommendation women have long heard from their doctors.
The new recommendations are:
- Screening mammography should not be done routinely for all women age 40 to 49 years.
- Women and their doctors should base the decision to start mammography before age 50 on a woman’s individual breast cancer risk and her understanding of the benefits and harms.
- Women age 50 to 74 years should have mammography every 2 years.
- More evidence is needed for the USPSTF to recommend for or against screening mammography after age 74 years.
This is clearly very different from what we have all been told for years. It is, however, not so different from what doctors have known and what the evidence has demonstrated. Mammograms are not as good a screening test in younger women as they are for post-menopausal women. The reason for this is the difference in breast tissue; dense tissue makes it more difficult to read the scans.
Personally, a mammogram never showed my first breast cancer when I was 44--even though there was a palpable lump. A mammogram twelve years later did find a new, small breast cancer. This experience is a good example of what can happen with mammograms--as in, sometimes they work and are really helpful, and sometimes they have no value.
Additionally, many European countries have long recommended that women receive mammograms every two years, not annually. Most breast cancer grow slowly, and this extra time is not likely to make a difference in survival.
Additional comments were:
- The USPSTF recommends against teaching patients breast self-examination.
- Available studies do not provide enough information to know whether breast examination by a trained medical professional adds bene?t beyond mammography.
- There is not enough information to know whether newer types of mammography (digital mammography) or magnetic resonance imaging are any better than regular ?lm mammography results.
Where does this leave us? (Other than confused and maybe upset). First, women who have had breast cancer are in a different group. The recommendations apply to screening tests for the general, healthy population. Our doctors will prefer that we continue with annual mammograms and, perhaps, breast MRIs.
These recommendations are in line with the evidence that exists. It is horribly distressing to be told that we really don't have very good screening exams for all women, that self-breast exams have not proven their value in reducing mortality. If we already felt out of control regarding this disease, this news probably makes us feel more so.
Take a deep breath and remember that nothing has changed for you. Talk to your doctors when next you see them about their recommendations for your annual tests. This is not a crisis, and there is no need to make phone calls. If you have an appointment for a mammogram scheduled before you see your doctor, go ahead and keep it.
And stay tuned. There is certain to be a lot of conversation about this and maybe, just maybe, this dialogue will eventually result in research that leads to better screening tests. That is the hope.
11/16/2009 (5:08:29pm)Tags: noneComments: (0)
I rarely do two postings in one day, but it is really important that you all know about the GINA (Genetic Information Nondiscrimination Act) law that is about to take effect. Here is a brief quote from an article in the New York Times and a link if you want to read more:
A landmark antidiscrimination law — the Genetic Information Nondiscrimination Act — will take effect in the nation’s workplaces next weekend, prohibiting employers from requesting genetic testing or considering someone’s genetic background in hiring, firing or promotions.
The act also prohibits health insurers and group plans from requiring such testing or using genetic information — like a family history of heart disease — to deny coverage or set premiums or deductibles.
“It doesn’t matter who’s asking for genetic information, if it’s the employer or the insurer, the point is you can’t ask for it,” said John C. Stivarius Jr., a trial lawyer based in Atlanta who advises businesses about the new law.
The biggest change resulting from the law is that it will — except in a few circumstances — prohibit employers and health insurers from asking employees to give their family medical histories. The law also bars group health plans from the common practice of rewarding workers, often with lower premiums or one-time payments, if they give their family medical histories when completing health risk questionnaires.
http://www.genome.gov/24519851
11/16/2009 (3:36:42pm)Tags: noneComments: (0)
This is an interesting study from Australia that suggests that women who live alone and/or are more highly educated may experience the highest emotional distress from breast cancer. I can't say that my own clinical experience supports this observation, but I find it interesting. Would be curious for your comments.
Emotional Toll of Breast Cancer on Well-Educated Women and Those Who Live Alone
Well-educated women and those who live alone are emotionally the hardest hit by breast cancer, according to the findings of a new Australian study.
The MBF Foundation Health and Wellbeing after Breast Cancer Study, undertaken by Monash University Medical School's Women's Health Program in Australia, found that older women tended to experience lower levels of overall wellbeing compared to women of similar age in the community two years after their diagnosis.
"Up until now, there has been uncertainty about exactly what the impact of being diagnosed with breast cancer is in terms of mood and wellbeing over time. In our study, we found that two years post diagnosis women with breast cancer were not more likely to be depressed but were more likely to experience a lowered sense of control over their life, and lower general health, with lessened vitality being limited to older women," explains Dr. Susan R Davis, Professor of Women's Health, Monash University Medical School, who was involved in the study.
"The experience of having breast cancer is a personal one and is often accompanied by very complex emotions due to the fact that it strikes at a woman's very sense of self, purpose and sexuality." Co-chief investigator of the study, Associate Professor Robin Bell, added: "That women living alone were more likely to have a lower wellbeing is a novel and important finding and would suggest that such women may benefit by targeted provision of social support."
More educated women are likely to be the best informed about their breast cancer and treatment, and their lower wellbeing results may reflect greater anxiety over decision making and their difficulty coping with a sense loss of control< over their health and wellbeing.
"We would encourage health care providers to be sensitive to the fact that more highly educated women may deal less well with psychological aspects of their disease than others," said Davis. "As survival prospects for women with breast cancer continue to improve, we shouldn't lose sight of the fact that each woman's journey and coping mechanisms are different. We know from listening to the women in the study, that it is common for breast cancer survivors to experience a range of emotions and concerns once treatment ends. Indeed, some women, report experiencing feelings of isolation and abandonment once their regular appointments with their medical team stop," added Dr. Christine Bennett, Bupa Australia Chief Medical Officer and Chair of the MBF Foundation steering committee.
On a positive note, the study found that women's wellbeing two years out from being treated for the disease was overall only modestly lower than for Australian women in general.
SOURCE:
MBF Foundation
http://www.mbf.com.au/foundation
This website is supported in part by an unrestricted educational grant provided by Avon
11/15/2009 (9:37:36am)Tags: noneComments: (0)
Like many of you, I have an intense and ambivalent relationship with the gym. I get there almost every day, forcing myself out of bed at an alarmingly early (and now, dark) hour. I have been convinced that regular exercise may reduce recurrence risk, and it certainly helps tone my aging body and maintain my weight. I never, however, like it much. I used to be a regular runner and even ran a marathon in my 30s. I never experienced the lauded "runners' high" and pretty much forced myself through those miles with will power and stubborn determination. Those same traits keep me exercising now.
A new study from Kathryn Schmitz and her colleagues at the University of Pennsylvania has interesting and surprising conclusions about the benefits of weight training. Here is an excerpt and then the link if you want to read more:
In addition to building muscle, weightlifting is also a prescription for self-esteem among breast cancer survivors, according to new University of Pennsylvania School of Medicine research. Breast cancer
survivors who lift weights regularly feel better about bodies and their appearance and are more satisfied with their intimate relationships compared with survivors who do not lift weights, according to a new study published in the journal Breast Cancer Research and Treatment.
Survivors' self-perceptions improved with weight lifting regardless of how much strength they gained during the year-long study, or whether they suffered from lymphedema, an incurable and sometimes debilitating side effect of breast surgery.
http://tinyurl.com/yhpelux
11/14/2009 (7:47:54am)Tags: noneComments: (0)
Many of you know that the San Antonio Breast Cancer Conference is the largest annual meeting devoted to breast cancer. Although there are not major scientific breakthroughs announced every year, there sometimes are. And, most years, there are important research presentations that at least tweak the thinking about treating this disease. If you have an appointment with your doctor anytime in the late fall, you may hear something like: "It will be interesting to see if anything new comes up in San Antonio this year."
Cancer Care is offering a free teleconference about the event on December 16th. Sign up and mark your calendars now:
The Latest Developments Reported at the 32nd Annual San Antonio Breast Cancer Symposium
Sign up for this Telephone Education Workshop now.
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Topic:
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Cancer Type
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Cancer Type:
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Breast Cancer
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Date:
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December 16, 2009
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Time:
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1:30 p.m. - 2:30 p.m. ET
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Presented By:
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Julie R. Gralow
MD, Associate Professor, Medical Oncology, University of Washington School of Medicine, Seattle Cancer Care Alliance, Associate Member, Clinical Research Division, Fred Hutchinson Cancer Research Center, Oncology Specialist
Hope S. Rugo
MD, Clinical Professor of Medicine, Director, Breast Oncology Clinical Trials Program, UCSF Comprehensive Cancer Center
Eric P. Winer
MD, Director, Breast Oncology Center, Associate Professor of Medicine, Harvard Medical School, Chief Scientific Advisor, Susan G. Komen for the Cure
Patricia Spicer
MSW, Breast Cancer Program Coordinator, CancerCare
Register at:
http://tinyurl.com/yflwk8b
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11/13/2009 (7:23:14am)Tags: noneComments: (0)
Choosing and Interacting with Your Doctors and Health Care Team
Breast cancer is a complicated disease that is almost always treated by a multidisciplinary team of physicians, nurses, oncology social workers, techs, and other allied health professionals. In the beginning, it can be difficult to make the best choices of providers, and, as time goes on, the focus changes to how best to work with your team.
Let’s begin with those first choices. Appreciating that there may be restrictions placed by your insurance coverage, there are almost always decisions still to be made about which doctors and which institutions seem right for you. In large cities, there are numerous fine hospitals, and the question will be where you feel the most comfortable and best cared for. In more rural areas, there likely will be fewer possibilities, but you then may want to consider the possibility of traveling at least for initial consultations, surgery, and/or treatment planning. At BIDMC, we often take care of newly diagnosed women who have breast surgery here, meet with radiation and medical oncologists to decide on the best treatment plan, and then receive needed radiation or chemotherapy closer to home.
How do you find the best doctors for you? Your GYN or PCP may make suggestions and referrals, but you are not bound to those ideas. Ask around. If you can, talk with other women who have been treated for breast cancer and ask if they were happy with their care. Once you meet with a doctor, if you are wondering if a second opinion would be wise, it likely would be. My own rule of thumb is this: “If you are considering a second opinion, you should get it. You don’t want to look back later and wish that you had done so.” You will know when you have found the right doctors. You must trust, respect, and like them. The human connection is very important, and you deserve the best possible care and relationships. Generally speaking, your choice of doctors will dictate most of your other caregivers. Obviously, individual radiation techs or chemotherapy nurses work in particular medical institutions or practices, so they will be assigned based on your physician’s affiliation. One exception may be an oncology social worker. I certainly see, both individually and in support groups, many women who receive their medical care at other Boston hospitals. If you are interested in psychological support (as I think you should be!), and if the oncology social worker who generally works with your doctors does not seem to be the right match for you, feel free to explore support resources elsewhere.
Once you have begun treatment, you will discover how closely you work with your medical team. For the next months, you will see more of them than you do of most of your friends, and you will come to rely upon them for much of your support and sense of well-being. It is smart to ask in the very beginning how best to contact them. Who is available 24/7? How quickly will someone call you back if you have a problem during the workday or in the middle of the night? Do your providers like to communicate via email? What is their coverage if they are away or unavailable? Different providers have different systems, but your priority must be quick and reliable access. Ask specifically if, during your active treatment, they want to hear from you about any medical concerns or whether some things (and, in that case, which things) should go first to your PCP.
Most of the time, relationships and care proceed smoothly. You can maximize this likelihood by remembering the old Golden Rule: Do unto others as you would have them do unto you. This translates to being on time for your appointments, organizing your questions, being clear with your concerns, expressing your needs, and expecting that your health care team will do the same. If you are not feeling heard or well cared-for, speak up. Remember that doctors are human, too, and describing your feelings in a non-angry way will reduce the changes of their becoming defensive and making things worse. If, for example, you feel that you are not being given time to ask all your questions, say something like: “I understand that you have many patients and are very busy. However, when I am with you, I need to feel that all of your attention is with me. I need you to answer all my questions and listen to my fears. Is there something I could do differently to make this work better for us both?” The bottom line is that you are hiring these specialists to provide your cancer care, and they should be giving you their very best professional and human effort. You deserve and need nothing less.
11/12/2009 (9:21:53am)Tags: noneComments: (0)
A group of researchers from the Fred Hutchinson Cancer Center has just published an interesting article in the Journal of Clinical Oncology regarding lifestyle changes (smoking, alcohol use, obesity) possibly reducing the risk of developing contralateral breast cancers. Here is a summary:
www.medscape.com
September 9, 2009 — Breast cancer survivors might be able to reduce their risk for contralateral breast cancer by making lifestyle modifications. A new study published online September 8 in the Journal of Clinical Oncology has found that obesity, alcohol use, and smoking all significantly increase the risk for second primary invasive contralateral breast cancer among breast cancer survivors.
Researchers from the Fred Hutchinson Cancer Research Center in Seattle, Washington, found that obese women had a 50% increased risk for contralateral breast cancer, and those who consumed 7 or more alcoholic drinks per week had a 90% increased risk. Survivors who currently smoked had a 120% increased risk of developing a second breast cancer. The risk was particularly high in women who were current smokers and who consumed at least 1 alcoholic beverage a day. The authors found that this subgroup of women had a 7.2-fold (95% confidence interval [CI], 1.9 to 26.5) elevated risk for contralateral breast cancer.
Limited Data on Role of Lifestyle in Preventing Second Cancer
There is substantial evidence that modifiable lifestyle factors play a significant role in the risk for primary breast cancer. As recently reported Medscape Oncology, an updated version of the American Institute for Cancer Research/World Cancer Research Fund's report, Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective reaffirmed that factors such as maintaining a healthy weight, exercising regularly, and limiting consumption of alcoholic beverages can reduce the risk of developing breast cancer. However, information on lifestyle factors and their role in preventing contralateral disease in survivors is more limited.
The authors point out that although adjuvant hormone therapy can lower the risk by 47%, little is known about other factors that are within the patient's control. Reducing the risk for a second cancer is of considerable concern, they note, because breast cancer survivors have a risk of developing a contralateral breast cancer that is 2 to 6 times greater than that of women in the general population developing a first breast cancer. Therefore, identifying potentially modifiable risk factors is of public-health relevance and of individual importance to breast cancer survivors, the authors note.
"But 1 issue in our study was that while some of the smokers stopped smoking, few of the drinkers changed their drinking habits, and few of the obese women lost weight, so we could not directly assess the impact that changing these habits had on reducing risk of a second breast cancer," lead author Christopher I. Li, MD, PhD, associate member of the Public Health Sciences Division at the Hutchinson Center, told Medscape Oncology. "That said, the evidence regarding obesity and alcohol use and risk of a first breast cancer does suggest that reducing body weight and reducing alcohol consumption does lower risk of first breast cancer, so I would expect that changing these things could also reduce the risk of second breast cancer," he added.
Obesity, Alcohol Use, and Smoking Increase Risk
In this study, Dr. Li and colleagues evaluated the effect of obesity, alcohol consumption, and smoking on risk for second primary invasive contralateral breast cancer among breast cancer survivors. The cohort consisted of 365 women who were diagnosed with an estrogen-receptor (ER)-positive first primary invasive breast cancer and a second primary contralateral invasive breast cancer, and 726 matched controls who were< diagnosed with only an ER-positive first primary invasive breast cancer.
Information regarding obesity, alcohol use, and smoking was acquired from medical-record reviews and from interviews with the participants. The researchers then used conditional logistic regression to assess the association of these with the participants. The researchers then used conditional logistic regression to assess the association of these factors and the risk for a second cancer.
They found that compared with women who had a body mass index (BMI) lower than 25.0 kg/m, those with a BMI of 30.0 kg/m or above had a higher risk for contralateral breast cancer (odds ratio [OR], 1.4; 95% CI, 1.0 to 2.1). The consumption of alcohol was also positively related to an increased risk for a second cancer (OR, 1.9; 95% CI, 1.1 to 3.2) when evaluated at both the first diagnosis of breast cancer and during the interval between first breast cancer diagnosis and reference date.
In similar fashion, current smokers had an elevated risk for contralateral breast cancer (OR, 2.2; 95% CI, 1.2 to 4.0) at first breast cancer diagnosis and at reference date, compared with women who had never smoked. The association between smoking and cancer risk did not vary by pack-years, the authors note. A small number of women were smokers at the time of their first diagnosis but quit by their reference date (14 patients and 29 control subjects), and this did not seem to influence the risk of developing a second breast cancer. This observation suggests that recent smoking is the most relevant to risk, the authors note. "There were also too few women who were exsmokers and who started smoking again after their first breast cancer diagnosis for us to be able to assess this aspect," said Dr. Li.
Impact of Hormone Therapy Unclear
Despite having ER-positive primary cancers, 30% of the control women and 39.5% of the patients with contralateral disease were not treated with adjuvant hormone therapy. However, the researchers explain that this cohort included patients who received their first breast cancer diagnosis nearly 2 decades ago. At that time, the use of hormone therapy differed from what it is now, and as a result, fewer women received this type of treatment or for the amount of time needed for it to confer maximal clinical benefit. But given the low rates of hormonal therapy use in this cohort, "it is reasonable to ask whether the relationship between weight and alcohol use seen in this study would be maintained in women with ER-positive tumors treated according to current adjuvant therapy guidelines," writes Jennifer A. Ligibel, MD, from the Dana-Farber Cancer Institute, Harvard Medical School, in Boston, Massachusetts, in an editorial. "Thus, further work is needed to define the impact of modifiable factors on the risk of second primary breast cancers from modern observational data sets including women treated with modern hormonal therapy regimens," she notes.
The study was funded by a grant from the National Cancer Institute. The study authors and editorialist have disclosed no relevant financial relationships.
J Clin Oncol
Published online before print September 8, 2009.
Medscape Medical News © 2009 Medscape, LLC
Send press releases and comments to news@medscape.net
Authors and Disclosures
Journalist
Roxanne Nelson
Roxanne Nelson is a staff journalist for Medscape Oncology.
