Breast Cancer Patients: Lumpectomy is Less Risky than Mastectomy

Story first appeared on Counsel & Heal News


For women who are diagnosed with breast cancer in its early stages, lumpectomy followed by radiation offers more survival chances than mastectomy, a recent study reveals.

The research was led by E. Shelley Hwang, M.D., MPH, chief of breast surgery at Duke Cancer Institute, and the analysis was published in the journal Cancer.

Lumpectomy is a preferred surgical procedure where the lump in the breast is removed; this lump is usually a benign tumor or breast cancer. The procedure is non-invasive as it involves the removal of minimal tissues. Mastectomy, on the other hand, involves the partial or complete removal of one or both the breasts surgically. This research also justified the decision of certain patients to undergo lumpectomy to preserve their breasts.

In the research, data spanning 14 years was collected from the California Cancer Registry, which has detailed information on the result of the cancer. The researchers found that people opting for the less-invasive technique like lumpectomy have a higher survival rate than those opting for a mastectomy. This held true for patients from different age groups and also for those who were either hormone-resistant or sensitive.

For women who were 50 years or above and had been diagnosed with hormone-sensitive breast cancer, lumpectomy gave them 13 percent more survival chances from breast cancer and 19 percent more survival chances from any disease as compared to mastectomy.

"Our findings support the notion that less invasive treatment can provide superior survival to mastectomy in stage I or stage II breast cancer. Given the recent interest in mastectomy to treat early stage breast cancers, despite the research supporting lumpectomy, our study sought to further explore outcomes of breast-conserving treatments in the general population comparing outcomes between younger and older women," Hwang was quoted as saying in Medicalxpress.

"We found that lumpectomy plus radiation was an effective alternative to mastectomy for early stage disease, regardless of age or tumor type. Even patients we thought might benefit less from localized treatment, like younger patients with hormone-resistant disease, can remain confident in lumpectomy as an equivalent and possibly better treatment option," Hwang added

Survival Rate Lengthened by Drug Duo

Story first reported from seattletimes.com

Women with metastatic breast cancer treated with a combination of two estrogen-blocking drugs survived more than six months longer than those treated with just one of the drugs or one followed by the other, according to a study involving nearly 700 women.

It's the first time such improvement in overall survival has been seen in trials of first-line hormonal therapy for hormone-receptive metastatic breast cancer, the study authors said.

"We're finding a lot of other ways of treating these estrogen-receptor-positive breast cancers that don't include chemotherapy," said co-author Dr. Julie Gralow, director of breast medical oncology at Seattle Cancer Care Alliance.

Such hormone-targeting therapy is a key focus in breast-cancer research, in part because it avoids the toxic effects of chemotherapy, Gralow said. However, she cautioned, these first results need to be repeated and verified by other researchers and may only apply to a subgroup of women with this type of breast cancer.

The report, from the University of Michigan-based research group SWOG, one of five cooperative groups that comprise the National Cancer Institute's National Clinical Trials Network, was published Wednesday in the New England Journal of Medicine.

The SWOG Statistical Center is based at Fred Hutchinson Cancer Research Center; and co-authors also include Dr. William Barlow, professor of biostatistics at the University of Washington.

The two drugs, anastrozole (brand name Arimidex) and fulvestrant (brand name Faslodex), are both called endocrine therapies because they work through action on a hormone — in this case, estrogen. About three-quarters of women with breast cancer and metastatic breast cancer have tumors that are responsive to estrogen, Gralow said. Anastrozole inhibits estrogen synthesis, while fulvestrant works on estrogen receptors.

The combination therapy increased the median survival of the women in the trial by 6.4 months compared with those who took only anastrozole. The combination also lengthened by 1.5 months the time before patients' disease progressed. More than 40 percent of the women in anastrozole-only group switched to fulvestrant when their disease progressed.

Although at this point metastic breast cancer isn't cured with such endocrine therapies, Gralow said researchers are making a lot of progress in this area.

"We're trying to get away from toxic, nonspecific therapies, like chemotherapy, and better understand how we can affect the estrogen receptors and its pathways and get even better results than with chemo, with fewer side effects. That's where we're going in treating breast cancer."

About 700 women with metastatic breast cancer were enrolled in the study. Gralow said she was surprised to find that nearly 40 percent of them had received no treatment for breast cancer before coming in for evaluation of a breast lump and being informed their cancer had already spread.

"When I first saw that I didn't believe it," Gralow said. While such late diagnosis is common in the rest of the world, she said, it's troubling to see so many women from this country whose breast cancer was not caught in the early stages.

"That means there are a lot of those patients out there," she said.

For the study, having such a large percentage of previously untreated patients may mean the results would not hold for women who had received estrogen-blocking drugs in the past, Gralow said. "What the results mostly relate to is a patient who is just starting endocrine therapy for the first time," she said.

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IS NEW BREAST CANCER BILL HELPING PATIENTS OR CAUSING UNDO ANXIETY?

Story first appeared in the Traverse City Record-Eagle.

It took seven years of annual mammograms and a cancer diagnosis for Amy Colton to learn something her doctors had realized for the beginning: Her breast tissue is so dense that it could have masked tumors on earlier exams.

She requested a copy of the report send from her radiologist to her primary care physician, and every single one said, “Patient has extremely dense breast tissue.” The registered labor and delivery nurse was really outraged that she didn’t know this.


About 40 percent of women over 40 have breast tissue dense enough to mask or mimic cancers on mammograms, but many of them don’t know it. Mammogram providers in California will be required to notify those patients, and suggest that they discuss additional screening with their doctors based on their individual risk factor, if Gov. Jerry Brown signs a bill that the Legislature passed this month. Similar laws have passed in Texas and Connecticut in the past two years but no data is available yet from either state on the effect of the legislation.

Researcher studying breast density, a relatively young field, said such requirements may end up causing undo anxiety in millions of women and lead to unnecessary and expensive ultrasound or MRI screening.

The California Medical Association, which represents 35,000 doctors, recommended a public education campaign instead of individual notifications, and said there isn’t enough evidence to support the idea the extra money spent on additional screening will save more lives.

Those test could cost the state more than $1 billion, and may women wouldn’t be able to afford them, said a professor of radiology and chief of breast imaging.

Study Questions Use Of Anthracyclines By Breast-Cancer Patients

Wall Street Journal

Researchers presented new findings Saturday at a breast-cancer symposium here suggesting that the risks associated with anthracyclines, a class of chemotherapy drugs widely used to treat the disease, outweighed their benefits in some patients.

The findings renewed a debate over whether anthracyclines, which have been around since the 1960s, should remain the standard of care in treating breast cancer, or whether newer drugs should be used more frequently instead.

Anthracyclines are effective but can damage the heart, particularly when used in combination with Roche Holding AG's Herceptin, a highly effective medication used to treat women with HER2-positive cancer.

The researchers, from the Breast Cancer International Research Group, evaluated the efficacy and safety of two separate regimens to treat breast cancer, one comprised of Herceptin and anthracyclines and another comprised of Herceptin and non-anthracycline drugs. The researchers compared the two treatment regimens to a control group receiving anthracyclines, but not Herceptin.

The 10-year study, which includes 3,222 women with Her2-positive breast cancer, is sponsored by French pharmaceutical company Sanofi-Aventis SA and supported by Genentech, a subsidiary of Roche. The data presented Saturday was collected at the study's halfway point.

The data showed that, after five years, women in both Herceptin groups were significantly more likely to remain alive than those in the control group, and there wasn't a statistically significant difference in overall survival between those who received anthracyclines and those who got non-anthracyclines, according to Dennis Slamon, one of the study investigators and director of the women's cancer research program at the Jonsson Comprehensive Cancer Center at the University of California, Los Angeles.

But, women receiving the combination of Herceptin and anthracyclines had significantly more heart damage, including cases of congestive heart failure, than those getting Herceptin and non-anthracyclines. They also had more cases of leukemia, a secondary consequence of the chemotherapy. "The damage we're doing to the heart is not transient," said Dr. Slamon.

The results are consistent with an earlier analysis of less comprehensive data in 2005, which provoked considerable debate in the field. One group of oncologists, including Dr. Slamon, believes that doctors should move away from using anthracyclines as a uniform treatment for all cases of breast cancer and instead use it only in subgroups of patients, such as those who express both the Her2 gene and another one called the Topo gene.

"I don't know why we keep pushing the anthracycline agenda," said Dr. Slamon, who called these latest results a "direct assault" on these drugs.

However, other experts disagree, saying the data aren't convincing enough to change the standard of care.

"What the data show is that there's certainly no superiority" of the non-anthracycline treatment, said Eric Winer, director of the Breast Oncology Center at the Dana-Farber Cancer Institute in Boston. But because the two treatment groups aren't significantly different on efficacy, "I'm just not of the view that [non-anthracycline therapy] is the preferred regimen," said Dr. Winer. "We have to be cautious before adapting new standards."

Dr. Winer also pointed out that, even though there wasn't a statistically significant difference in survival between the two Herceptin groups, there were a greater number of deaths among the patients who got Herceptin and non-anthracyclines than among those who got Herceptin and anthracyclines. The difference was 214 deaths to 185.

Gary Lyman, a professor of medicine at Duke University's Comprehensive Cancer Center, said he didn't think the results would change much the use of anthracyclines. His patients want the best treatment for the cancer they are facing at the moment and are less concerned about the potential future safety concerns. "When I go back home, they are not going to want to compromise the most effective treatment for cancer" because of concerns over heart damage or leukemia, he said.

However, "patients should be warned; they should be informed about these issues," said Dr Lyman.

Public Health Officials Refusing New Patients

NBC Los Angeles

 

The "unprecedented fiscal challenges" claimed another victim this week as health officials decided to discontinue a cigarette tax-funded program that pays for breast cancer screenings for low-income women.

Mandatory changes were required this week by California Department of Public Health to the division, Every Woman Counts. The specialized division provides a cancer detection program for California's medically underserved women by giving them access to screening and diagnostic services for breast and cervical cancer.

The two biggest changes to the program according to a release are:

    * They will stop paying for breast cancer screening for women under 50.

    * They will stop enrolling all new patients for breast cancer screening until July 1.

The changes according to their Web site are based on the lack of state funding, and the only way to keep within their budget.

A statement released by Dr. Mark Horton, the state health officer, said "the short-term increases in state funding for the program have not been enough to keep pace with the growing demand for and cost of providing breast cancer screening services to the women in this program.

This comes on the heels of the recommendation by the U.S. Preventive Services Task Force. The task force suggested that women younger than 50 do not need regular mammograms. The Los Angeles Times printed a response by Dr. Willie Goffney to the claims of the task force.

Dr. Willie Goffney, a surgical cancer doctor who serves on the board of directors for the California division of the American Cancer Society, said he was disappointed by the state's decision to put the free screening program on hiatus and then limit who can enroll.

“We feel we are moving in the wrong direction. We know that screening for breast cancer and having access to that screening saves lives,” Goffney said. “So to take those resources from people who need that access means more people will fall through the cracks, and will lead to more deaths from breast cancer.”

Many in the industry of providing mammography services are worried that their businesses will not be able to survive, and more importantly, that these changes will deter women under 50 from being tested.

Breast-Screening Advice Upended

Wall Street Journal

For years, women have been taught to perform regular breast self-exams and those 40 and older told to undergo annual mammograms to detect breast cancer, a disease that kills about 40,000 people in the U.S. every year. Now, new guidelines released by an influential government-funded authority on screening offer this message: never mind.

The new U.S. Preventive Services Task Force guidelines, published Monday in the Annals of Internal Medicine, state that routine mammograms aren't necessary for women of average cancer risk in their 40s, and that women between 50 and 74 years old don't need to undergo mammograms more often than every other year. They also recommend that physicians abstain from teaching women how to examine their breasts for signs of cancer because of a lack of evidence that it is of any benefit.

The guidelines were based on a routine review of research published since the last set of recommendations and a new analysis of data. The guidelines were formed by weighing benefits of screening compared with the harms of false positives, such as anxiety and unnecessary additional tests and biopsies, which are expensive and time-consuming, according to Diana Petitti, vice-chairman of the task force.

The task-force recommendations only apply to women without a family risk of breast cancer and who don't have genetic mutations known to be associated with breast cancer, such as the presence of BRCA1 or BRCA2 genes.

By scrubbing the previous recommendation of annual mammograms for women 40 and older, the new guidelines are likely to be controversial and confusing. They also raise concerns that health insurers will curtail coverage and reimbursements for screenings that fall outside the guidelines, according to doctors and groups including the American Cancer Society.

Phil Evans, a professor of radiology at the University of Texas Southwestern Medical Center and president of the Society for Breast Imaging, says he was "shocked" by the changes. "There's a ton of scientific data in this country and others on screening that shows a significant benefit for women between 40 and 49 to be screened," he says.

The National Comprehensive Cancer Network, the American Cancer Society and the American Medical Association recommend annual mammograms for women starting at age 40, while the American College of Physicians recommends women in their 40s decide for themselves whether to seek annual exams.

USPSTF Breast Cancer Screening Guidelines: Then and Now

Mammography

2002: Recommended every 1 to 2 years for all women older than 40

2009: Recommends against routine screening for women 40 to 49; recommends mammograms every 2 years for women 50 to 74; insufficient evidence to conclude benefit or harm of mammograms for women 75 and older

Breast Self-Examination

2002: Insufficient evidence to conclude benefit or harm

2009: Recommends against teaching BSE

Digital and MRI Mammography

2002: Not addressed in guidelines

2009: Insufficient evidence to conclude benefit or harm 

Source: U.S. Preventive Services Task Force guidelines published in 2002 and 2009

The task force, which receives funding from the federal Agency for Healthcare Research and Quality but is independent from the government, last issued guidelines for breast cancer in 2002. "The task force isn't saying there isn't a benefit" to screening women in their 40s, but "we're saying the benefit is small," Dr. Petitti said. "The change really is a change between do it routinely and don't do it routinely." Women 40 and older who are free of any symptoms should talk with their doctors and decide with them whether to put off screening for a few years, she said.

Dr. Petitti's advice is less nuanced about the issue of breast self-examinations. "Women should know it doesn't work," she said. Two large studies published since the last guidelines, involving 200,000 women in China and more than 100,000 in Russia, showed no benefits from breast self-examinations, she said.

There is agreement among scientists that mammography saves lives but that it also gives rise to numerous false positives. It reduces cancer death by about 15% in women ages 39 to 59, according to the task force's review of published data.

There are fewer cases of cancer in younger women, which means there are fewer absolute benefits when weighed against risks for women in their 40s. For each case of cancer death prevented among younger women, 1,900 women must be screened, according to the task force's review of published data. That ratio drops to 1 for 1,300 for women 50 to 59 years old, and 1 for 377 for women 60 to 69 years old, according to the task force.

The task force's interpretation of the data overstates the downsides of mammography for women in their 40s and doesn't take into account the fact that saving a younger woman leads to more "life years saved" than for older women, Dr. Evans says.

About $3.3 billion was spent on mammograms in the last 12 months, according to the American College of Radiology.

Whether the new guidelines lead to changes in insurance reimbursement is likely to be a big concern among health providers and patients.

The Centers for Medicare and Medicaid Services, which administers government health benefits for the elderly and the poor, says the new guidelines wouldn't change how it covers mammograms for Medicare patients. But that may not be the case for private insurance. The task force guidelines tend to influence public and private insurers' coverage decisions, though they aren't the only factor, according to John Ayanian, a professor of medicine and health-care policy at Harvard Medical School who published a paper last year on the impact of cost-sharing on mammogram usage rates in the New England Journal of Medicine.

Susan Pisano, spokeswoman for America's Health Insurance Plan, an industry trade group, says she anticipates mammogram coverage will continue even for those who fall outside the new guidelines' target age range. What may change, she says, are insurers' aggressive outreach efforts to get women to get their screening, such as the reminder postcards they used to receive about getting their annual mammogram.

Eric Winer, chief scientific adviser of Susan G. Komen for the Cure, a breast-cancer advocacy foundation, and director of the Breast Oncology Center at Dana-Farber Cancer Institute in Boston, says that "at a minimum, what we can say is that women and their doctors have a right to make a decision about whether they should be screened. If they don't have financial coverage, then they don't have that right."