Friday, May 21, 2010

Breast cancer update: What to expect if you've got it

For years now, my face has been disfigured by an old skin cancer scar. Yuck! Don't you just hate getting cancer? Most people do. But instead of just sitting around hatin' on cancer, my local hospital is taking action against the disease. Not only have they developed a super-duper traditional cancer-fighting program of the first order, but they also utilize almost every other kind of cancer-fighting technique they can get their hands on. I'm impressed.

At my local hospital's comprehensive cancer center they also offer acupuncture, massage, Jin Shin Jyutsu, guided imagery, yoga, chi gong and mindfulness programs along the lines of Jonathan Kabot-Zinn. They want the best for their patients and they want their patients to get well. And surprisingly enough, a goodly majority of them do get well. The number of funerals here seems to be way down.

The other day, my hospital also sponsored something called a "Mock Tumor Board". That's when various cancer specialists demonstrate how they usually get together as a board and consult each other on how a particular patient should best be served by all of his or her doctors working together to help the patient get well.

This is my report on a "mock" breast cancer tumor board. This is how a breast cancer tumor is treated these days -- from beginning to end. And since something like one in eight women in the United States will be diagnosed with breast cancer sooner or later, this is stuff you should know.

At this particular demonstration, the board only discussed traditional Western medical approaches to cancer. If you want info about the use of yoga, chi gong guided imagery, etc., that will be another report altogether. This is only a report on the mammogram/radiology/chemotherapy type of stuff.

There were no refreshments served at this board.

"Today we have a medical oncologist, a breast surgeon, a radiologist, a pathologist and a radiation oncologist," announced the moderator. "They would like to give a demonstration of what an actual breast cancer tumor board is like -- when, once a week, these experts come together to decide on a treatment plan for each new breast cancer patient case we have here."

The case under discussion today was a 64-year-old woman with a history of hypertension, kidney stones and use of hormone replacement therapy. "She has three children, works as an administrative assistant, used to smoke but quit, weighs 220 pounds and had a 4 x4 centimeter mass in her right breast."

The radiologist spoke first. "Our facility uses digital mammograms now, which are as good or better than screen mammograms. However, sometimes we don't see lesions on a mammogram even if there are lumps, so if this is the case we then do a sonogram to make sure." He then showed us a PowerPoint presentation of various sonogram photos of an actual cancerous breast tumor.

"We look for a mass that has architectural distortion," and some other things which I missed because I was too busy taking notes. "We look for irregular margins." Yep. The mass looked more like an amoeba than like a cyst.

"Notice that the mass is shaped irregularly -- whereas a cyst has a more regular shape." The next step, after a suspicious mass has been isolated, is to have the mass biopsied. "It used to be that surgical biopsies were the only accurate forms for obtaining accurate specimens but needle biopsies are very accurate now. Surgical biopsies are no longer necessary." Whew.

I had a surgical biopsy back in 1976 and it was large and hurtful and scar-producing and nasty. Fortunately, however, my biopsy turned out to be negative.

If the biopsy proves to be positive, then they do an MRI next -- to see how large the tumor actually is. "MRIs can define tumors even more clearly." Then the surgeon will know what to expect when he or she operates.

The patient (hopefully not you or me) is next seen by a surgeon. "From this MRI photo, you can see that there is a solitary lesion here. Then several questions immediately arise. Where is it located? Can it be removed cosmetically? Can it be gotten out with a clear margin around the lesion? Will it lend itself to a lumpectomy instead of a complete breast removal?"

Also doctors now can do a sentinel lymph node surgery so they don't have to remove all underarm lymph nodes. The surgeon also works with a plastic surgeon to get good cosmetic results as well as stopping the cancer.

"After the surgery, the pathologist receives the tumor for analysis. Are we sure that the tumor has been taken out completely? Are the margins clean? The pathologist makes slides from a cross-section of the tumor."

Then the pathologist showed us a photo of a tumor. Yuck! You don't even want to know. Chicken intestines come to mind.

The specimen is then processed to look for stuff. What kind of stuff? "The presence of overstimulated estrogen and progesterone, cancer cells, etc."

We are then shown a slide of a normal breast's cells, milk-producing glands, fatty areas and ducts. "Note that the cells and the architecture are regular and round and well-differentiated."

Then we saw photos of cancerous breast cells. "Here's a slide from our patient. I'm going to show you now what an invasive carcinoma looks like." The cell structure has broken down -- bigtime! "They are very disorganized." Fascinating. It's like the breakdown of civilization.

"The patient had a lumpectomy but it was a complex situation."

There are three factors that a pathologist looks for in a tumor: "Its architecture, the nuclei and..." something else. That cancer surely has taken over and fouled things up. You don't have to go to med school to see the difference between normal and cancerous cells in these photos. The pathologist's presentation made it clear that cancer is pretty violent stuff. "Sometimes tumors become more aggressive as time passes." Yeah duh.

After the pathologist, the patient is taken to the medical oncologist, who looks at various pathological aspects of the tumor. "If a person has a lot of estrogen and progesterone receptors, a patient tends to do much better." They also look at the age of a patient and the presence of other health risk factors -- co-morbidities.

This is the point when the doctors decide whether or not to give chemotherapy. "This patient may not need chemotherapy but will definitely need hormone therapy. With only a lumpectomy and radiation, she would have an 18% chance of relapse." And that's not good enough. The doc also looks at the patient's various genes via Mamoprint and Oncotype DX tests to see what her genetic disposition toward cancer is. "A low-risk patient has less than 10% risk."

"What is hormone therapy?" someone asked.

"It blocks estrogen production." Did I hear that right? Estrogen production is a bad thing? Or only a certain type of estrogen production? Remind me to Google that later. "Hormone therapies block the production of estrogen..."

"In this case, the patient's oncologist decided not to use chemotherapy which is toxic, but it is more art than science to make this call at this point." And apparently they keep an eye on breast cancer patients for the next 30 years -- just to make sure that the various specialists did make the right call.

Next came the radiation oncologist. "This patient opted to conserve her breast. If there is a clean margin -- of at least one millimeter -- around the tumor, then radiation is an option over a mastectomy."

Radiation therapy takes place five days a week for about seven weeks. Studies are showing that a radiation course may be shortened, but there is only about five to ten years of follow-up available on the long-term results of decreased radiation."

When getting radiation treatments, a patient, by holding her breath, can apparently push her lungs and heart out of the way of the radiation and thus lower its effects on those organs. But even so, radiation is still a rather fierce treatment. "Radiation can cause scarring and changes to ligaments and skin."

Next, the surgeon spoke again about the benefits of holding tumor boards. "When we all meet to consult, we discuss each case carefully. And sometimes we don't always agree on treatment. But we do combine our knowledge to the patient's best advantage."

"What is the success rate of surviving breast cancer these days?" I asked.

"There is a declining morbidity rate now, based on early diagnosis, hormone markers, targeted therapy, etc. Most women these days do NOT die of breast cancer."