BREAST CANCER REFRESHER COURSE FOR PATIENT ADVOCATES

Dr. Francis Lopez

September 21, 2006
Astoria Plaza
Ortigas Center, Pasig City

(Host Intro: Dr. Francis Lopez is one of the very few bone marrow transplant specialist in the country. He is a medical oncologist at Asian Hospital, Makati Medical Center, and the head of the Victor R. Potencianco Medical Center’s Oncology Center)

Hi, good afternoon to all. It’s always a pleasure to be here and since this is a small group, I have decided to change the format of the presentation. I am not going to make a monologue up here; what we’re going to do is a question and answer type. What we’ll do is we’ll go over each question and then I will discuss the answers to the questions. Please stop me and raise your hand if you have any questions.

I divided the questions into five sections, namely:
1. Prevention
2. Screening
3. Diagnosis
4. Pathology Report
5. Treatment

The reason you are here is because you were chosen to be leaders of your own community, or if not in your organization, and inevitably, people call you and ask you questions. Perhaps these are some of the basic questions that are frequently asked by your patients or your friends, and perhaps maybe a little knowledge on how to answer these questions might help.

BREAST CANCER PREVENTION

Question # 1: Tamoxifen does not reduce the risk of developing breast cancer in women with non-malignant breast mass.

The answer is false; and when we mean by non-malignant breast mass, you’re talking of masses that are what they call atypical hyperplasia, or lobular neoplasia. We’re not talking of the fibro adenoma, because fibro adenoma is really a benign tumor, or cyst. Sometimes, when you have a breast mass, and you have it biopsied, the pathology report will read features of atypical hyperplasia, which means that they look like breast cancer cells but they are not really normal looking, in a sense, that they are showing some signs of differentiation but it’s not yet malignant.

There was a study that was done and these women were given tamoxifen; it showed benefit that tamoxifen will reduce the chances of developing invasive ductal carcinoma. You’re talking of atypical hyperplasia and preventing it from becoming invasive ductal carcinoma.

There was a subsequent trial that they used reloxifen or Evista, and I think it also showed some benefit when you take Evista as well. Now, they are moving it on to trying other medicines like Arimidex, the aromatase inhibitors.

Right now, if somebody says that this was read in my pathology, then there is that recommendation to take tamoxifen to prevent the development of invasive ductal carcinoma.

Audience: Is the benefit greater than the risk in taking the drugs considering that it can have side effects?

That’s a good question. The patient must remember that this is not breast cancer, this is atypical ductal hyperplasia and you’re only taking it to prevent the risk of developing invasive ductal carcinoma.

First of all, it will have to be discussed with the patient: What are the side effects of let’s say, tamoxifen? If the patient doesn’t have high risk features of developing blood clots, etc., etc., and they can tolerate tamoxifen, then fine. So, everything has to be discussed with the patient, but yes, the benefit outweighs the risks.

So here, we just have an illustration of what a cancer cell looks like. If this is a cancer cell and you have your what we always say ER/PR positive; which is your estrogen receptor, progesterone receptor, and if you have your receptor present, there you have your estrogen molecule, attaching to the receptor, and then your breast cancer cell, or your normal breast gets stimulated by your estrogen. So, when you read your pathology report, there’s always that ER/PR that you have to look out for.

Question # 2: There is no guarantee that surgical removal of both breasts, or prophylactic bilateral mastectomy, will prevent breast cancer in high risk patients with strong family history of breast cancer.

The answer is true. It is not a 100% guarantee; it’s only around 90%. A lot of studies have already came out from the States where they do this, but they cannot do a randomized trial because you cannot tell this group of women to have both breasts removed and the other group to have only one removed. These are studies that are just accumulation of patients and it is not a 100% guarantee. So, for example, the mother, the grandmother, etc. has breast cancer and then you checked for that genetic defect and it’s positive, even if you removed both breasts, there is still a chance of developing breast cancer. Why? Because your breast tissues goes all the way up here, and it also goes all the way up here. So, even if you remove both breasts, inevitably there’s still some breast tissue left behind. The chances are higher, it’s like 90% or so, but it’s not a 100% guarantee.

I will discuss reduction in the incidence of breast cancer in high risk patients from strong family history or presence of the BRCa1 or BRCa2 gene mutation in subsequent slides.

Audience: Do you personally know of anybody who had prophylactic breast surgery and they still had cancer?

Personally, no; but when you read the literature regarding that, they don’t quote a 100% guarantee. The lady we will be featuring in the next issue of Big C did not really fall into what we wanted as prevention because of strong family history. The patient we got to interview had breast cancer and she had a mastectomy; in addition, she opted to have her other breast removed because there is still a risk that she will develop a second breast cancer so she just opted to have it removed. In that sense, she did a prophylactic mastectomy even if she did not have any breast cancer in the other breast. But no, I do not know anybody personally.

Question # 3: Reduced caloric intake and low fat diet are not beneficial.

The answer there is false. Decreased caloric intake and low fat diet have been associated with either a decreased risk or no change in the incidence of breast cancer. Also, this intervention may have beneficial effect on cardiovascular disease.

It’s funny because you read some data, they say yes, then after that, another information comes out, and it says maybe not, and then years later, yes, and then no. But again, there’s no harm in doing or changing your diet to low fat, low calories, because you will also benefit from it for your other organs, like your heart.

Question # 4: Regular physical exercise does not reduce the risk the breast cancer recurrence.

The answer is false. There was this article I just read when I was doing this questionnaire that it does. Those who walk three to four hours per week were 50% less likely to die from breast cancer than those who exercise less than one hour per week. There is some benefit. For those couch potatoes out there, start walking; and not walking in the mall, by the way.

SCREENING FOR BREAST CANCER

Question # 1: MRI of the breast is a better screening test for breast cancer for all women.

The answer is false. MRI detects mammographically occult, when you say occult, it means a very small disease that is also undetected by physical examination. But you have a few patients that you catch the breast cancer and they will always complain that “my mammogram missed it.” Maybe it’s sad, but you get a few “my mammogram missed it” or “the ultrasound did not pick up,” then it got bigger over the years and then finally by the time they had their surgery, it’s already stage III. You get a few of those patients. Why? Mammogram is not 100%, okay? It’s only maybe what? 60? 80? 80% I would say of the chance that you will detect a breast cancer. And why do we still call that it’s the best screening? It’s the best screening because medically, when you say screening, you want to make it accessible to all, affordable to all.

An MRI is not accessible to all, and it’s definitely not affordable to all. When you start going out to the provinces, you don’t have MRI anymore. Some don’t even have a mammogram machine; and then it has to be at least sensitive so that it will be able to detect a breast mass there. So, those are the reasons why mammography or mammogram is still the best screening test, but it is never 100%.

Now in comes MRI; where does MRI come into play? Right now, MRI can be used for women who have a strong family history, either based on the family history or they already are positive for this genetic defect. If I recall, only I think St. Luke’s has this BRCa1 gene testing, but you shouldn’t all be rushing right now to St. Luke’s to have this test. If you really have a strong family history of breast cancer, ovarian cancer, or even prostate cancer, then maybe it’s something you might want to have – not for your own benefit because you already have breast cancer, but this information you will be able to pass on to your children, so that they will be aware that it runs in the family.

This BRCa1 or BRCa2 gene mutation accounts for less than 10% of all cancer cases. Again, the most common cause of breast cancer is what we call idiopathic. You just got it. There are risk factors that we all know – because you start your menses early, you menopause late, or you’re taking hormone replacement therapy, etc., etc. down the line, but again those are only risk factors. The most common cause or 90% of you got breast cancer not because of your strong family history or a genetic defect, but because of what we call idiopathic. You just got it.

What this gene does, the BRCa, it functions to suppress changes or mutations that lead to cancer. So now we are moving to the…..

END OF DISK 2 – missing minutes

… traffic policeman saying: “cannot seem to stop” the cell from dividing. So, that is what we call function to suppress changes. It loses that function, it cannot identify anymore that that cell is abnormal, so that the cell just continues to divide. From cell, it becomes two, it becomes four, it becomes sixteen, it becomes thirty two, etc. it’s exponential; then before you know it, it is already growing that abnormal cell. Those who have this gene, again, they usually get breast cancer at a very young age; it inherited lifetime risk of developing. There is an 87% chance of developing breast cancer if you have this gene; 65% of developing a second primary cancer; and a 44% of developing ovarian cancer.

You have some women who have breast and ovarian cancers, and perhaps they have this genetic defect. This genetic defect has been identified in women with the Ashkenazi Jews, and some Northern American descent. I don’t know what the data here is in our country, and I don’t know if somebody is looking into that.

This is what we call pedigree, like a family lineage – here is the paternal side, and here is the maternal side. So, you have the maternal grandfather, maternal grandmother, etc. All the yellows mean that there is no defect or there is no cancer, but as you can see here, this one has breast cancer, this one had ovarian cancer. This one had prostate cancer, and now the granddaughter has breast cancer. Take note that this came from the paternal side and did not come from the maternal side. So, even if your maternal side is clean, there is genetic defect that could be passed on through the paternal side. So, it could be either side, just take note of that. When you say strong family history, every generation, somebody gets some kind of cancer. So, in this case, prostate, ovarian, then you have breast. So, that is what we mean by strong family history.

Question #2: Mammography at age 40 to 49 remains controversial.

The answer there is true. First of all, when they did this study, it just showed benefit for women aged 50 and above. Women younger than 40 years, in whom the risk is average, showed no benefit from routine screening, which means that if you get a lot of women at the age of 40, the chances that you will get one who has breast cancer is very low, and I will show you the graph later. Maybe these studies were done by HMOs in the States, and for obvious reasons, they want to show it is not beneficial, so they won’t have to spend, or they won’t pay for it. That’s the reason why they said that it is not beneficial because of the number of women getting breast cancer at that age is very low, and therefore, it is not economically worth it to screen all women at the age of 40 for breast cancer. Again, I understand a lot of the women in this group are young women, and I personally have patients in their 30s, and we will always say “How about us? We were diagnosed at 20s or late 20s or 30s?” But you are more of the exception than the rule, and somehow, you just get these patients at a younger age. But if you think of yourself and in your office, all the women who are 35, how many of you really have breast cancer? Very low or none at all.

For women 40 to 49 years, the relative of risk of dying from breast cancer was only 13%, if you screen women at that age. So, for an HMO, that is not worth it. Is that the proper way of saying it? It is not economically beneficial to do that because it is only 13% of women that you’re going to save.

Sensitivity of mammography is lower as a result of dense breast tissues – that is also another issue. However, the average tumor size is smaller and the fraction of node‑negative disease is greater than for those unscreened control. So, what happened here when they did the study, they were saying it wasn’t beneficial to screen women from 40 to 49 years because you only save like 13%, so which is rather low. However, for those who are pro-mammogram, we’re saying: “Yeah, but still if we did mammogram on them, we would be able to catch them at an early stage.”

So, for women 50 to 74 years old, screening mammography has shown to reduce breast cancer related mortality rates by 26%. That is the reason why they say: “Okay, maybe it is worth spending money and having women at the age of 50 and above and have them do the mammography because we will be saving 26% of the women from dying of breast cancer if we did not do regular or yearly mammography.” For women older than 74 years, there is insufficient data because maybe by that time women are not having mammograms anymore. However, if in good health, continue screening. Why? Because age, one, is in itself a risk factor for developing breast cancer. If you look at this diagram, this is age and rate per 100,000 women. If you look at the age 39, or 40, somewhere here, it is very low; but as you get older, the risk of developing breast cancer increases. By age 41, out of 200, only 33 develop breast cancer, but when you get to age 80, 1 out of 9.

Question # 3: Breast self examination can replace mammography as a screening method.

The answer there is false. There are no conclusive data stating that breast self examination is or is not of value in reducing mortality in addition to mammography and physical examination by a physician. It can compliment mammography but it cannot take its place. So, mammography is still the best screening at this point.

Question # 4: Breast ultrasound can be used in the absence of mammography for screening purposes.

The answer is false. Breast ultrasonography has substantial value for evaluation of suspicious lesions found during screening mammography and for the characterization of lesions found by physical examination, but not detected by mammography. However, there is no data promoting the use of sonography in the absence of mammography in screening purposes or the use of both mammography and sonography. The only reason I know why we doctors order both ultrasound and mammography is that to reduce the screening time; because sometimes you will find something during mammography and then you will have to go back and have an ultrasound; but if you both at the same time, it is just an element of time, really, that is why I order both at the same time, but you can question me the next time you see me.

So the standard, up to today, is still mammography for screening purposes, and also for after treatment because you want to catch any tumor recurrence at the early stage in the contralateral breast.

Question # 5: Digital mammography is as accurate as standard mammography in younger women.

The answer there is false. I read an article recently saying that using the digital mammography, similar to the digital camera, seems to be better in younger women. We do not have yet, at least I haven’t heard, you know, unless anybody in this room has heard digital mammography being used already, I haven’t heard yet. I have had a patient who goes to Hong Kong to have it done there. She was a young girl whose regular mammogram did not show anything, then the following year it did not show anything until finally by the time she was diagnosed, it was already stage 3. I think part of it is that she was maybe one of the 20% I was saying that it just doesn’t show. And because of that experience, they’re just very paranoid and they are having it done in Hong Kong every year, and they use the digital. So, it is available, but not here.

DIAGNOSES AND PATHOLOGY REPORT

Question # 1: Fine needle aspiration biopsy provides more information than a core biopsy.

The answer is false. When you say core needle, you’re using a bigger needle; when you say fine needle, you’re just inserting a fine needle, a smaller needle. A core probably is 0.3 cm in size and a fine needle is just really very small. With the core needle, you can get a bigger piece. The reports that I see turn out to be 0.3 cm x 0.8 cm in size; less than a centimeter but bigger than an FNA, fine needle aspiration. There you just put the needle in and then try to aspirate any cells.

False positive diagnoses are rare in core biopsies. Fine needle aspiration biopsy requires a well-trained and experienced cytopathologist. Also, it cannot differentiate invasive and non-invasive. Why? When you do fine needle, you’re basically just getting a cluster of cells. When you do a core, you can see more of the breast architecture and you’ll be able to tell if it’s invasive or non-invasive. I think one advice you can give to somebody who has felt a lump is that, which we will tackle later, is the two-step approach. A biopsy done first and then they can decide later on what they want to do; because I still hear stories of women who are brought to the OR frozen section, next day they wake up and it’s already gone – unless that is what they want; but I don’t know if options are always explained to patients by some surgeons. Some do, some don’t. They’re told: “We have to remove it tomorrow because it might spread.” And it just doesn’t make sense. You’ve had this probably for months, so what’s more day? If it has spread, it has spread.

When you say excision biopsy, you’re practically removing the whole tumor; similar to a lumpectomy, you’re just removing the whole tumor already. So here, you have the area of the breast mass and there is an excision-incision done, and then here, you have the breast mass and the breast mass here is being surgically removed as a whole. I don’t know if it’s clear at the back but you’ll see the tumor here.

When you say needle localization, the tumor is located very deep into the breast tissue. Here is where the tumor is, but side view, if you look at the breast side view, you see the tumor is well inside or deeper that you will the aid of this needle to guide the surgeon when they go inside to look for the tumor. So that is what you call needle localization. The needle then is placed closed to the tumor and that is where the surgeon is going to go, so it is guiding the surgeon as where to go when you say needle localization. Once they have localized where the tumor is, then they go in and make the incision, and then here you have already the tumor and the tumor is removed over here.

When you say stereotactic core biopsy, you use this machine, and this is the breast, and you use the machine like a gun to direct it towards the tumor and then you get a piece of tissue. So those are some of the terms that you will encounter.

Question # 2: Frozen section of the breast tissue biopsy followed by immediate modified radical mastectomy remains a standard of care.

The answer there is false. It is still being practiced today – you’re brought to the OR, they do a frozen section, and then you wake up, you have no more breast.

So, the two-step diagnostic and therapeutic procedure is appropriate, safe, and effective, and this is preferred for making informed choices. You can do the biopsy, tell the patient “You have breast cancer, now these are your options.” Then they can also decide what they want to do. Whether a mastectomy, lumpectomy, etc. etc. Thus, a patient can have a biopsy first, followed by a lumpectomy and axillary node dissection a couple of weeks later. So, it is safe to wait for a while. Diana, maximum of – after a biopsy, maximum of five to six weeks; that long after a biopsy? Okay. Correction, five, six weeks even, after the biopsy is done. And there is no truth to that myth that when you do the biopsy, ay, kakalat yan, no?

Sometimes, when you do the biopsy, it gets bigger because of edema or swelling. It is not that the cancer has already spread and it’s getting bigger right away. I have had patients where we give the chemo before surgery and they come to me right away and I notice that the breast is a bit swollen because the patient just had a biopsy. So that happens. It doesn’t mean that the cancer cells are already growing because you touched it.

Question # 3: Breast cancer that has invaded blood vessels is a hallmark of an aggressive cancer.

This pertains to your pathology report. Sometimes, when you read your pathology report, they’re going to say lymphovascular invasion. That basically means that when they were looking at it under the microscope, and they saw the blood vessels, and inside the blood vessels, they already saw some breast cancer cells. So that’s what it basically means, lymphovascular invasion. Lymph, which is your lymph glands, and vascular, which is your blood vessels; and they already see cancer cells inside and that is an aggressive feature.

So in the pathology report, things that you want to read are the type of breast cancer; if it’s invasive ductal, and later I will answer that other features that you will see. Sometimes, they mention the grade. Grade I, II, III; and that grade I, II, II will depend how the cancer cells looked under the microscope. If they are grade I, that means it resembles somewhat close to the normal breast. When they say grade III, it looks very aggressive and doesn’t resemble very close to the normal breast tissue. Then you look also for lymphovascular invasion. Those are the things that you look out for when you’re reading the pathology report. And then, you also look out for the ER/PR, or make sure that there is already an ER/PR and now the HER2/NEU in the report.

Question # 4: Breast cancer that has developed in the ducts or invasive ductal is the only type of breast cancer.

The answer is false. The most common is invasive ductal, which means that it came from or it started from the ducts of the breast. However, breast cancer can develop in the lobes or glands of the breast as well. There are also other types of breast cancer, which are not very common, but have good prognosis; which means that if you have features like mucinous, papillary, tubular; and it’s in the pathology report, these are good characteristics of breast cancer. They’re not very common, and they can arise from any part of the breast; but if these are the features, typically, you don’t need chemotherapy unless the tumor is like 3 cm or greater. The patient can just take tamoxifen if they are ER/PR positive. So, invasive ductal is the most common but not the only histological feature.

Here, I think some of you may have seen this drawing already. You have a mammogram showing a breast mass, and here you have the lobules of the breast, and here you have the ducts, and here you have the nipple. Cross-section, looking at the duct this way, here you can see that the duct is empty and here are the normal breast cells lining the ducts. Here you already have a tumor developing inside the ducts, so this is what you call in situ; when they start getting out of the ducts, that’s what when you start calling it invasive ductal.

Here, you have the tumor, original tumor, and it has already spread to one lymph node. So here, a lymph node is removed and here you have a cluster of tumor cells inside.

Question # 5: The presence or over-expression of HER2/NEU gene occurs in 60% of breast cancer patients.

That is false. You already know HER2/NEU. Are you familiar with that term now? HER2/NEU? Okay, HER2/NEU is a gene that if it is present or mutated or it has changed, we all have HER2/NEU in all of our cells, but once it mutates, then it becomes aggressive and it has abundant or “over-expressed” is the medical term that we use. You have to have many of it present then it becomes an aggressive tumor. HER2/NEU means human epidermal growth factor receptor. It is a gene that is expressed in 20% to 30% or 1/3 of breast cancer patients. It commands the cell to divide again. Another policeman.

Now you already now the BRCA1 gene and then here you have another gene that works like a policeman, the HER2/NEU gene. If it is present, then you have abnormal growth. It is associated with increased risk of relapse and shorter survival. Over‑expression predicts response to Herceptin. So now, ER, PR, and HER2/NEU are the important things that we always request from our patients. When they come to see us, sana andun na yung report because that will help us decide and explain the treatment to the patient. So if they are HER2/NEU over-expressed, then they are a candidate for Herceptin. When they grade the HER2/NEU, there is 0, 1+, 2+, or 3+. If you are 2+ to 3+, then you are a candidate to get Herceptin, if you are a 0 or 1+, then that is not over‑expressed. So, those are the three things, ER, PR, and HER2/NEU.

Yes?

(Inaudible question from audience)

Partly so, but majority would be probably ER, PR, HER2/NEU positive. Sometimes, you also get ER/PR positive, and HER2/NEU. You can have several permutations.

Here is a diagram of a normal cell, we’re going back to our basic biology. You have the cell, and inside the cell is your nucleus, and you look inside your nucleus, you have your DNA. So, this DNA, what it does, it makes proteins and eventually these proteins become receptors on the surface of your normal cell. When you have an over‑expression, you have more of the DNA producing more proteins, forming more receptors around the surface of your breast cancer cells. So this is what you call over‑expression.

Audience: Herceptin? Is it available here?

Oh, yes, it’s been available here since 2003, I think as compassionate use. Now, you can get it. Yes please, go ahead.

Audience: I just wanted to know if those patients with ER/PR positive and HER2/NEU positive has a more aggressive kind of cancer than ER/PR positive and HER2/NEU negative.

ER/PR positive, HER2/NEU positive, triple plus versus ER/PR positive and HER2/NEU negative. Being ER/PR positive is good. Being HER2/NEU positive is bad. So, when you tell me the patient is ER/PR positive and HER2/NEU negative, so that is good. That will be probably less aggressive than somebody who is HER2/NEU positive.

Audience: You said that the mucinous is less aggressive, so the patient does not need chemotherapy. Suppose the patient is negative for ER/PR.

Yes, then that is the time you would offer…even if the patient has a tumor less than 3†cm, but ER/PR negative, then I probably would offer chemotherapy. Because there, you won’t be able to offer the patient anything more.

Audience: So if you will give chemotherapy, at least how many cycles?

I would probably go AC x 4, or CMF x 6.

Audience: Thank you.

Welcome. Yes?

Audience: As a prevention?

Yes.

Audience: So now, if you have a cyst or any growths in your breast, you should have it biopsied. So that if you find a hyperplasia to be there, then you can take tamoxifen. Would you recommend that?

I think not all masses that you see are all cysts. Cysts are just basically fluid. It is what it means. There are some breast masses that turned out to be fiberadenoma, which is benign, and then you get a few of them that will become atypical ductal hyperplasia or lobular neuroplasia. So these are the ones that you need to treat with tamoxifen. I cannot recommend that every time you feel something, go and have it biopsied. I think before you know it, your whole breast, especially for those who are lumpy, before you know it, your whole breast will have incisions. Maybe by closely monitoring these lesions, and then once they’re very suspicious, or there is some growth, then maybe that is the time you do have the biopsy done.

Diana is here in the group, and I don’t know if she’s a speaker, but maybe she’ll be the best person to comment on that because she sees the patients at the time of the biopsy, when they have breast mass. I usually get to see them when they’re ready for chemotherapy. Diana, what is your answer to that comment or that question?

Dr. Cua: Generally, if you’re 35 and over, and you feel a lump, it should be investigated, you know, by ultrasound, mammogram, just to make sure how the images would add up to the overall risk. If it is a liquid lump, of course, you could just aspirate it and it would disappear. If it were a solid lump, depending on how it looks, if it is palpable, generally we recommend a needle biopsy, the least invasive one.

Obviously, you will find that in this country, there are different levels of expertise and availability of medical care. So, that’s why, I would say especially in this group, there is a huge difference in where you’re at and what was available in your place. Ideally, a lot of what Francis is saying here are the ideal setup, but for other people who are staying out of the bigger cities, they might find it unavailable. So, yes, since we are both practicing in the metropolis, we would say fine-needle aspiration biopsy and the likes.

At least, if it’s benign, and of course, we also add up in reality the expense of treatment, some patients would just say, okay, if it’s benign, I don’t have the money for another surgery, then let it go. In the US, ideally, if the person is 35 and over, even if it’s benign, the recommendation is to have that palpable or something, the lump that you can feel, removed, even if it’s benign. But in practice here, as I have said, some surgeons would actually, you know, prefer to go for open surgery, excision immediately, because maybe in their place, there is no cytopathologist to read a fine-needle aspiration biopsy.

In our country, there is just a very wide range of treatment provided by the doctors, not because they do not know, but because a lot of times, it is not available. And it may not be like there is a really right or wrong answer to it, but what we’re discussing is more of the ideal setup.

So, the answer, I think, to your question is yes, if there is a palpable mass and it’s suspicious, then yes, have it removed. Any more questions?

Audience: Good afternoon, doktora. This is my question. I supposed the patient is told that the mass is benign and is not cancerous. She was given the option for her to decide if she wants it removed or not. If she decides that she will not undergo surgery, will there be a possibility for the years to come that that mass will turn malignant?

Dr. Cua: Well, something is really…was it…it won’t be biopsied and they just leave it there. Well, again, you’ll never know if it was malignant or not to begin with, but if something…was it biopsied? No?

(inaudible response from audience)

(Dr. Lopez): Well, if there is no capacity, as what Dr. Cua was saying, that in some areas that ideally you would want to offer a two-step approach, but if you don’t have the facility there, then you will end up also having the patient brought to the OR, the mass removed, and then or immediately mastectomy upfront, even without really being certain that this is benign or malignant because you don’t have the capacity to do biopsy.

Audience: The usual question a patient will ask is “I will not go to the city to have it removed, will that mass turn into a malignant tumor in the future?”

If it was malignant to begin with, it’s already malignant. A benign tumor cannot turn into a malignant tumor. If this was already malignant to begin with, over the years, it’s going to get bigger. You won’t be able to tell if it’s small that it is already malignant or not, so that’s the reason why it is biopsied, but over the years it gets bigger, then it was already malignant to begin with.

Audience: I have a strong point of clarity that I need. You mentioned that in the States, if there is a mass and it’s benign, that they have it removed anyway?

It was Diana.

Dr. Cua: I was the one who mentioned it, yes. In the U.S., there are litigations, so protocols are stricter. Generally, even if a person did a fine-needle aspiration biopsy, which is the least type of procedure to find out whether it’s benign or malignant; if it’s benign and it’s palpable and you can feel the lump, they generally would recommend having the lump removed through excision. Generally, because at 35 and above, with all the concerns about breast cancer, and having a lump that’s very palpable, generally, they would say “have it taken out because once you get to see another doctor, the doctor would probably just bug you about it.”

When people find that you have a lump, and you’re 35 and over. There’s a tendency to make you concerned about the presence of a lump. If the person is like 20 years old, on the other hand, if it’s benign, they would generally give that patient an option. Like, you know, it is okay not to have it removed, but then basically not to observe, because once you have diagnosed it as benign, that’s what Francis was saying, if it’s diagnosed as benign, and of course, in our country, you have to check your pathologist, because it all by interpretation; but if it is read by a reputable pathologist, then it remains as benign, even if it grows larger, it would be a benign mass that has grown larger.

Audience: Doctor, mine was benign for long. For three years, it was always benign, benign; and then it became malignant, stage IIB. In fact, I am thinking about it, I have lumps in my other breast; I really should go for a PET scan every week, or something.

Again, you are more of the exception than the rule. While you were having that MRI every so often, that tumor there was already a malignant tumor, but maybe it was just too small to be seen or recognized as such. My only comment about MRI and maybe Diana can share an opinion here is that we have a lot of, which also frightens me, is that we have a lot of these technologies already starting to come in and each hospital is trying to outrun, outbeat each other and saying “OK, we are now St. Luke’s Cancer Center” or “Cardinal Santos Cancer Center” and they are trying to bring in all of these new machines right away and technology. But again, the learning curve is still there and that sometimes frightens me because I do also hematology, blood cancer, and I have identified what hospitals I am going to send my tests to because that’s where that I know that pathology is going to read it well and I am comfortable.

Now, going back to breast cancer: How many of these radiologists have really read MRIs of the breast? And it’s a scary thought also, and I think that’s the reason why my patient said: “That’s it. I’m flying to Hong Kong and I’m going to have my mammogram there.” But again, you are more of an exception than to the rule. And again, the younger you are, it becomes more difficult, and then you hear stories like this because the younger you are, the breasts are more dense. It’s unfortunate for you, but you are more of an exception than the rule.

Scintimammogram. I think the scintimammogram has the addition of a dye that is injected. Is it more sensitive than the regular mammogram? No, it’s not.

Audience: Is it compared to…

It is not more accurate than the regular mammogram.

Audience: So, if…

We don’t really recommend it.

Audience: So, if we are going to ask you which is mas mabuti, mas mabuti na yung mammogram?

Yeah, there’s not much benefit when you do scinti versus just the regular mammogram. So regular mammogram is still considered the best screening test; as I mentioned earlier, screening test for all, but it is not a 100% guarantee that you will be able to spot it.

Audience: Ok, which is better for the screening for breast cancer?

Still mammogram.

Audience: How about ultrasound?

No; as I mentioned earlier that an ultrasound is just an adjunct to a mammogram. You don’t use ultrasound to replace, in exchange of mammogram.

Audience: Thank you.

Welcome.

The scintimammogram, they inject, Diana, do you want to explain that? They inject a dye.

Dr. Cua: Word of caution lang with scintimammography, it is not being practiced or recommended anymore because it usually…it was a hospital beside UCLA that did a lot of studies on this one. So, for a while, even mga doctors, obviously, data would come in, and we would entertain and then study it. And over the years, the conclusion came out that yes, it can detect breast cancer if it is greater than one sonometer. But with earlier or smaller breast cancers, it fails miserably. That is the reason when we talk about screening mammogram, or for screening purposes, meaning a woman does not feel anything, obviously, that woman would want a tool that can pick up the earliest, the smallest size possible na breast cancer. And scintimammography has been proven over and over, over the years in the US, that it’s not effective in detecting early breast cancer. And the whole point of screening is to catch breast cancer at its earliest.

So, right now, if you go abroad, generally, if you bring a scintimammography films to them, some doctors would not even be aware that there is such a thing because it is not being practiced anymore. Someone mentioned earlier about thermography also, thermogram. The same thing; yes, for a while, a lot of organizations wanted to provide a less painful means of screening the breast because a lot of women complains about mammogram. But apparently, the only one that was proven to be better scientifically to mammogram is MRI. But as it is, MRI in our country, generally, we do not have a dedicated breast MRI. In the US, data have shown that MRI is actually the only one that is more sensitive than a screening mammogram.

Unfortunately, as what Francis mentioned earlier, it’s prohibitive in terms of cost, that why it’s not being, even in the US, it’s not being a device as a screening modality. So, no thermography, no scintimammography. They just do not prove to be effective.

Audience: Doctor, I’m a breast cancer survivor for eight years. I was not tested for the HER2/NEU. If I still have my specimen, do I still need to have it done?

It’s been eight years, probably not. Probably I may presume you’re negative. But eight years, even if you tested positive now, we’ll have the information, it’s all academic, but will a doctor want to give you Herceptin now? I think it’s a bit too far away. The study of giving Herceptin in the adjuvant setting was like, I think, seven to nine months after the time you were diagnosed to start the Herceptin. There are three ways of doing it. What I usually do is finish the chemo, they go to radiation if they need radiation, and then I start the Herceptin. Other studies where you do the chemo, and then use a different kind of chemotherapy combination and then you can overlap the Herceptin. So, there are three ways of doing it. You can give it weekly, you can give it every three weeks. I tend to it every three weeks so that the patients don’t get sick and tired of me, so they only see me every three weeks.

I.V., initially over two hours, then an hour and a half, over an hour, and by the fourth session, it’s like 30 minutes. They come in and out, their hair won’t fall, there’s no nausea or vomiting, if at all, none. Some of you have had Herceptin. I mean, Suzette got it for over a year or 18 sessions, and usually, no problems. Again, it all depends on your weight. Everything is computed based on your weight.

It is expensive. But still the cost of Herceptin here is still cheaper than in the States because there was one patient who was vacationing here and I had to give her Herceptin here. When she found out the cost was a lot cheaper here, she bought her supplies here and brought it to the States. Some people think that the drugs in the States are cheaper or unless you go to India, but otherwise, some of the drugs are even cheaper here than in the States.

Audience: Doctor, I have a question. Either one of you can answer this. You know, all of a sudden I feel so tired because I just had my scinti the other day. One question is nagging me all these years, what is your opinion about having annual bone scan? Because some of my surgeons, they don’t want me to undergo that, but my onco insists, then another onco does not; so, there’s conflicting opinions. Is it safe to have it done annually?

Let’s talk first about the rationale, and then remind me about your question if it’s safe. Let’s talk about the rationale about this annual testings na lang in general.

The American Society of Clinical Oncology always publishes data information and a lot of these information and data is based on whether it will benefit or not. So, they get information from how many thousands upon thousands of breast cancer women do all of these tests, and is it beneficial or not. And one of the end goals of this study, when you say beneficial, is that will it prolong the patient’s life? or to improve the overall survival of a breast cancer patient by doing things annually? And so the solid recommendation that they have is very simple: annual mammogram of the lumpectomy breast or the other breast that is still remaining, both breast or other breast that is remaining. That’s number one. So I always tell me patients you need your yearly mammogram. Why? Because there is a still a risk of the breast cancer coming back. And if your breast comes back on the same breast if you have a lumpectomy, or it comes back to the other breast, it is still salvageable. It is not like may taning ang buhay, because it is still salvageable. You just have to go through the whole thing again – surgery, plus or minus chemotheraphy, radiation, etc. So that is one recommendation.

Number two recommendation, quarterly visits to your doctor. So basically, that is your solid recommendation only. I include blood test because some of the patients are taking tamoxifen, so I want to check the liver always and I also the CBC because chemotherapy can affect the bone marrow and that’s what I only add to the patients’ tests. Now, when I talk to my patients, what tests do you want? Because everybody ask what tests do I need? So there is a variety of other test and there goes your bone scan. Do I need a CT scan or can a chest x-ray be enough? Do I need a CT scan of the abdomen or an ultrasound of the liver is enough? Do I need a bone scan?

What I recommend to my patient, a lot of it depends on what they can afford. Why? It’s because it does not matter if you do a chest x-ray or a CT scan, because if your cancer comes back in your lungs, liver, bone, or brain, it does not matter whether you catch one versus two, 3 cm versus 1 cm. Once it comes back, it comes back, and everything changes from a curative intent to a prolongation of life. So there is no solid recommendation when it comes to that. It all depends what the patient wants. 90% of my breast cancer patients or maybe 98% want something done. And it’s like more of a psychological reassurance to tell them “yes, you are clean for the year.” But it can come two months later or three months later and you will never know. Only 1% would say “I will deal with it when it comes. Don’t do anything to me. I will just do a mammogram.” I only have one or two patients who think that way, but all the rest want something done. And so, does it matter when you do a CT scan and you see a lung nodule that is 1 cm versus you do a chest x-ray when you can only see it at 2 cm? It does not matter, because the goal changes from a curative intent to a prolongation of life. And it does not matter that you, because some people would think “Ay, nakuha pa natin nang maliit, baka pwede pa.” The answer there is no.

So, you do everything upfront. When you’re trying to give your adjuvant treatment, everything should be done upfront and no shortcuts. Because that is the only time, and maybe that’s an advice that you can give to future breast cancer patients, it is easier, for example I am recommending chemo to a patient, it is easier for the patient to hear me to hear me say “No, you don’t need chemo, you just need tamoxifen” rather than me really saying you really need chemotherapy. They would rather want to hear the other thing – “that I don’t need chemotherapy.” And I do have some patients that way. They would force the issue that they don’t want, they don’t want, they don’t want. And fine, we do all the tests, and if the tests really show that they don’t need it, then I don’t really offer any chemotherapy. I just put them on medications. But some people will find ways of trying to avoid chemotherapy when they really need it, like maybe a stage 2 patient who will try to haggle with the doctor because the only chance of cure is really upfront and not later on when it comes back.

So, do I do bone scans? Back to that question – bone scans, I typically don’t ask for bone scans for my patients unless they are complaining of bone pain and for the same reason, if it goes to your bones and I don’t detect it until you say “Doctor, I’m having bone pain here. Oh, come on, let’s do a bone scan.” Then it turns out to be positive. Again, it doesn’t make any difference. If I do a bone scan and I catch it before you’re having any symptoms versus when I do a bone scan when you’re having a symptom of bone pain, it does not matter. The one who did not have symptom and positive bone scan will not live any longer than somebody who was having pain in the pelvic area and we did a bone scan and it turned out to be positive. And so that’s the answer to the question what is the recommendation really of the American Society of Clinical Oncology, and the answer is that: yearly mammogram and quarterly visits to your doctor, because those two have been shown to save lives.

Audience: Good afternoon po. Ano ho ang effect ng technetium na ininject sa amin pag mag pa bone scan? Is there any effect? Kasi radiation, e. Ino-orient ka muna nyan na lalayo sa mga pregnant women and mga bata, kasi masisira yung kanilang mga cells at an early age. Paano yung sa amin, iniinject. Ano yung effect?

I have asked that question. This is not the first time I get this question in the group like this. I have asked a radiologist, “How about those patients, who get yearly CT scans, is it bad? Those who get yearly chest x-rays, is it bad?” The answer there is no, because the amount of radiation that you get when you have CT scans or chest x-rays is very, very small. It is nothing compared to the kind of radiation you get from your breast cancer treatment. Definitely nothing compared to the radiation that you get from an atomic bomb. But it is very, very negligible. Even with the cumulative effect over the years.

Why is it pregnant women? It is because when they have fetus, when they have a baby, the cells are still rapidly dividing and becomes theratogenic, it can cause birth defects because the normal cells are dividing rapidly and if you give radiation then it can damage the normal rapidly dividing cells.

Audience: Doc, you mentioned that you don’t recommend bone scan unless your patient feels something. I believe that we are into the advocacy of early detection. Getting a yearly bone scan, I think, will help in detecting, na maaga pa,malalaman mo na there is something wrong with the bones. So, it can be treated earlier.

No. The reason why I disagree with that is that once it has gone to your bones, it has gone to your bones. And the goal changes from a curative intent to palliation intent. Anybody who has breast cancer that has gone to the bone, or any organ for that matter, liver, lung; the goal changes from a curative intent to palliation intent. So, that’s the answer to that question. It’s not that, as I said earlier. Just because you caught at 1 cm, “Oy, isang bone lesion lang yan versus yung isa, tatlo, masasalvage pa natin ito.” There’s no truth to that. The only way we can prolong somebody’s life is they’re very sensitive to the chemo and further treatment you will give down the road.

Audience: So, are you trying to say that if the cancer cells have reached the bones and some organs of the body, there is no more cure?

There is no cure, there is prolongation of life, and that I’m very clear with my patients. It is a very difficult conversation I have with patients, but it is something that I have to tell them upfront, that the goal changes now.

Audience: I am concerned about taking tamoxifen. Pag basahin mo kasi ang PIMS, may mga effect yan sa liver because everything goes to the liver. Dito sa Pilipinas, there are some doctors who initiate fine-needle aspiration biopsy for the liver, kasi I have talked to a friend I met a week ago, he’s from Dubai. Hindi na daw nila ginagawa yung mga ultrasound pag liver na kasi it’s a big mass of internal organ. Pag ultrasound, hindi mo makikita yung mga period period lang, wherein pag ginawa mo yung aspiration sa needle, makikita mo talaga kung kanser o ano. So, dito sa Pilipinas yata, hindi natin ginagawa yun, puro lang ultrasound or blood test, blood chem.

No, let me clarify. Ganito po yun. The procedure there is, for example nag regular testing every year, or in general, no? If something is found in the liver whether it is via CT scan or ultrasound, so, meron nakita, for example, “oy, may mass sa liver.” Then the next step is to do biopsy. A lot of these big centers do liver biopsies po, whether it is a fine needle or whether it’s a core biopsy, a lot of these big centers do that. It’s nothing unusual. It is a regular thing to do biopsy of the liver. It all depends again on who’s doing it and who’s reading it, but it’s being done in all major centers, maybe all hospitals, tertiary hospitals for that matter.

We will proceed? It’s getting to be hot up here. (laughs) No, joke only. Feel free to ask more questions. Where are we now?

TREATMENT

Question # 1: True or false? Patients with node negative invasive ductal carcinoma that is 1 cm or smaller in size do not benefit from adjuvant systemic therapy.

When you say adjuvant, again it is the treatment given after the primary treatment, which is surgery, and the reason why you’re giving chemotherapy is because you want to decrease the chances of recurrence so that your patient will live longer and have a better overall survival. There was a paper that came out in the journals recently, a month or two months ago, that I happen to read and they were reviewing information for women who have tumors less than 1 cm. So that’s really a stage 1, with tumors less than 1 cm. The normal practice is greater than 1 cm, you offer them some form of adjuvant therapy, whether it is chemotherapy, hormonal therapy, or both.

In this paper, they tried two studies, especially those that have tumor size between 0.5†cm to 1 cm, do they benefit from giving some form of adjuvant treatment? The answer, they have identified those who are ER/PR negative and those who have lymphovascular invasion and HER2/NEU. So, these are sub groups of patients that even if the tumor is less than 1 cm, that if they have these characteristics, ER/PR negative, lymphovascular invasion, HER2/NEU, these are the patients who will benefit from some form of adjuvant treatment.

Tip of advice when you have people asking you “Ay, sinabi ng doctor ko, hindi na kelangan ng chemotherapy,” then make sure that all of those features that I have mentioned are not present. Otherwise then they have to reconsider or find out who was the one who gave the advice.

Again, all of you are familiar with this, with the different chemotherapy regimens. You have the CMF x 6, AC x 4, or EC x 4, FAC x 6, or FEC x 6, TAC, which is taxotere, adriamycin, cytoxan x 6. I personally like using the FEC x 3, followed by doxytaxel x 3, because I think a patient can easily tolerate it, we don’t need to give the injection to boost the white count, so that seems to be one of my favorites that I offer to my lymph node positive patient. The AC x 4, followed by taxol x 4, and the dose-dense is every two weeks. It gets a bit confusing to the patient if they go from one oncologist and they hop on to the next and one tells them “oh, I want to give you this regimen” and the other one…really, there hasn’t been any data comparing one over the other and saying one is better than the other because you’re going to kill a pharmaceutical company if you’re going to use a regimen that has doxytaxel by Aventis and you have paclitaxel used by Bristol-Myers Squibb. If one shows better than the other, then you kill the other company. Nobody is going to use that regimen. So there will never be a regimen comparing let’s say, TAC versus dose-dense, which is not a scientific way of extrapolating data.

My basic rule is I look at the features, and the first feature that I look at is lymph node positive or lymph node negative. If the patient has a lymph node positive, and if money is not really a problem or there’s no financial issues and they can afford a taxing, whether it’s a doxytaxel or a paclitaxel, then I offer a regimen that has a taxing, if they are lymph node positive because of the data that is out there, using doxytaxel and paclitaxel are those that are lymph node positive. There is information that will be coming out later this year or by next year, showing the study using the TAC regimen in lymph node negative. So, we don’t have yet information as of today. Depending on the characteristics, I can….

Missing minutes

Audience: On our hotline, women say they can’t afford all chemotherapy sessions but only two or three sessions, do I go for it still? Is two or three better than, say, a standard six? It’s a really confusing question…than nothing, sorry, yeah.

When you give chemotherapy in the adjuvant setting, which means that after surgery you have no more disease, you’re stage I, II, or III, you want to improve the chances of survival. So, as you can see, there are a set number of drugs and a set number of cycles, and most of it doesn’t go beyond six or eight. Dose-dense is eight; the AC x 4 is eight. Now, if you’re asking me: is two better than none? One, nobody has ever tried using two cycles only; so that’s number 1. So, the answer to that question is nobody really knows if two is better than none. For all you know, there is or there is none, but nobody has ever given chemo for two sessions only. So, that’s a difficult question, and maybe that’s the only way you can answer them: no, hindi natin alam kung may benefit or wala.

Audience: Actually, maybe one of the questions we have to ask them is: Is it palliative that, you know, that they’re going through, or is it curative because maybe it’s spread, and if it is palliative, what will two sessions do for them? I mean, maybe ruin their quality of their life of whatever time they have.

Was it clear, Crisann? When they called you, what stage they were. Maybe that’s the next thing you ask them when they call. What stage are you? Then you might be able to help them.

Next slide, please.

So, the other recommendation is, again, this also becomes confusing because you are now in the evolution of treatment, where you have tamoxifen given for five years. That has been the standard and perhaps may not be the standard anymore now. Then those aromatase inhibitors can be started off and taken for five years, but you know it is expensive; and all of these companies have their own studies to prove that it is better than tamoxifen, but they will never be compared to each other because it’s a death to one pharmaceutical company so they will never compare one against the other. But all of them show that they were all better than tamoxifen, that’s sufficed to say.

Then for those who are started on tamoxifen, two to three ways midway, again, it has shown benefit to switch to an aromatase inhibitor; and for those who have already finished or nearing completion of their five years tamoxifen, there was a study by Novartis, that if you take their Femara for another five years, it is better than not taking anything. Placebo. So, there are a lot of combinations that you can use. So, what do you suggest?

In my practice, which I got during the convention, is if you are ER/PR positive, perhaps you can start off with tamoxifen, and later on make the switch, and the rationale there is because if you’re going to relapse, you’ll probably relapse later rather than sooner.

Now, if you are ER positive, PR negative, or vice-versa, you will tend to relapse sooner rather than later, so perhaps, these are the patients that you start off with an aromatase inhibitor right away. That’s what I usually recommend in my practice.

Yes, ma’am?

Audience: Number one I noticed is bone pain.

Correct, that’s a very common complication. Patients complain of morning stiffness, like…

Audience: …I cannot get up.

You cannot get up from bed?

Audience: No, I find it very hard.

Ah, okay. Yeah, so that’s a common complaint. Joint stiffness; and they explained it to me like they are robots. It takes them a while to get started. One patient, to an extreme, who was taking Arimidex, had to get off it and shift to Femara. I told her: Why don’t you try Femara and let’s see if there’s less bone pain. That’s common. That’s a common complaint, and the other side effect that you have to watch out for when you are taking aromatase inhibitor is bone loss. So I always recommend yearly bone density, not bone scan, but bone density and then give calcium supplement, and if there are already signs of osteopenia, or softening of the bone, I start them on Fosamax.

Cholesterol? I have seen that, there is, but it is not a very common side effect. I have seen that in one patient. Her triglycerides went up. I have seen that in one patient. But it’s not a very common side effect. Yes?

Inaudible question from audience: …normal. Everything is normal, except my cholesterol.

It is a side effect but it is not very…was it already high to begin with?

Audience: Ah, no. My cholesterol was normal.

To begin with?

Audience: Yes, and I remembered that there was one doctor who went to Cebu, he conducted, I think, a…he introduced the Femara there in Waterfront, and he made mention that one of the side effects of this Femara is your cholesterol level will really go up.

Yes, I have seen that. Personally, I have seen that in, maybe a couple of patients.

Audience: So, what do you usually suggest?

Again, you’re back to the benefits and the risks of taking it; if Femara was what was given to you because of whatever reason given to you by your doctor, that he really thinks that that is the best choice for you now, then your side effect of that is your cholesterol goes up, so you can either (a) try to control it with diet and exercise, and if that fails, you’re going to end up taking again another drug to control your cholesterol. So, there seems to be a domino effect; at the end of the day, you have to discuss this with your doctor, the risks and the benefits of doing all of these things. If you’re scared that your cholesterol is going too high, and you will start developing fat or cholesterol in your arteries and then end up having, down the road, not naman maybe in one year after taking your Femara, but down the road, then, it’s something you have to discuss with your doctor. Yes, ma’am?

(Inaudible question)

Yes.

Audience: After you have taken it for five years, what happens? You have to shift to another medicine?

That’s a good question. There are ongoing studies now, believe it or not, looking at that. For those patients who have been on that Femara study, those who took tamoxifen for five years and who are now finishing their five years of Femara, there is now a study by the same company, extending it to another five years versus placebo. So, we don’t have yet that answer, but the standard recommendation after your five years of Arimidex, you stop. Unless a year from now, there will be new information saying that ten years of Arimidex is better than five years; but in the absence of any information, I always stop. I tell my patients to stop first because there no information to say that you must continue.

Audience: So you don’t take anything?

None.

Audience: Nothing?

Nothing.

Audience: Does it have any, because of the…there’s information that tamoxifen should be taken only for five years after which it has a certain kind of side effect, which is done for the patient already, so you have to be shifted to another medicine. But in the case of Arimidex and Femara, no data is available at this time.

Okay, what information do we have out there? One, the standard of treatment has always been tamoxifen for five years until three years ago, when all of these aromatase inhibitors came out in the market. Okay, so what were the studies they did?

So the one study called the ATAC trial was they compared women to take tamoxifen for five years, Arimidex for five years, tamoxifen and Arimidex for years. So, that was the study that was done. Now the study is like several years already from the time they closed the study and it is showing that women who were given Arimidex, because it was by their company, from the beginning, now starting to show benefit in terms of overall survival; decreased recurrence of breast cancer; decreased recurrence of breast cancer in situ. So, that is a choice for the patient. Do I start on tamoxifen? Or do I start off with Arimidex? Or do I start off with tamoxifen and shift later on to Arimidex midway? So there are many combinations now, but all of them have shown that they are better than tamoxifen five years. So, what do you recommend to your patients?

As I’ve said earlier, in my private practice, if the patient is ER/PR positive, and other features look okay, I tend to start them off first with tamoxifen and then midway, I make the switch because those who are ER/PR positive tend to relapse later on rather than sooner. So, if they were destined to relapse after three years, four years and you shifted them on the second year, you would have caught them, and perhaps they wouldn’t have relapsed.

Now, if they are ER positive, PR negative, or vice-versa, what I do in my practice, in the beginning, to start them right away with an aromatase inhibitor because these are the patients who tend to relapse sooner rather than later. So, you try to catch them. Give them the best drug upfront.

Now, if you are already done with your five years of tamoxifen, should I continue/move on now to Femara. I think that has to be case to case discussion with the patient. If you were a stage I, and you’re done with five years of tamoxifen, I probably would not solidly force my patients go and take Femara, because you were a stage I. What are your chances that you have already beaten your breast cancer? It’s probably 90 to 95%, and you have only a 5% chance it will come back. That’s based on data that I’m quoting.

Now, if you were a stage II, and definitely a stage III, I would probably say I think you should go on Femara. After your adjuvant treatment for a stage III, you improve your chances to 60 to 65%, and you still have this 40% chance, 35% chance that your breast cancer will come back, or you will die from your breast cancer in a span of ten years. So, these are the patients I will say “I think it is still worth taking Femara for another five years, because it will further improve your chances from dying from breast cancer.

So, it has to be a case to case basis. Now stage II, after your adjuvant treatment, your chances are what? 80%, 85%. So, is that 15%, 20% natitira, is it worth taking Femera for five years and spending what? 400,000.00 over the span of five years. So, you have to individualized the treatment; and of course also the cost and everything. Am I correct? 400,000, right? Over five years. Because each box is like…or even more…because each box is like 9,000+.

We have to move on. Okay, next question. Where are we?

The new recommendation now is Herceptin for one year if you are HER2/NEU positive.

Yes, in the adjuvant setting po.

Question # 2: In early stage breast cancer, lumpectomy alone produce…no, it just basically says that if you are going to do a lumpectomy, you need radiation.

That’s basically what the…lumpectomy, not mastectomy. Lumpectomy, where you remove only the tumor, combined with radiation in early stage breast cancer. So, always, always, always. So, if you’re giving advice to a breast cancer patient, and they’re asking you about lumpectomy, you have to warn them that lumpectomy, yes, will come with an added cost, the radiation.

Question # 3: Administering chemotherapy before breast surgery has shown to improve survival compared to post-operative chemotherapy.

The answer is false. When you give the chemotherapy first before surgery, the only thing you want to do is to shrink the tumor so that you’ll be able to remove it and especially if you want it to look good is it’s under the nipple or close to the nipple, and that’s basically it. Then, you can also see whether the cancer is responding; because you will see the tumor shrink. Diane and I, we work closely together with several patients and we have done this, no? We shrink the tumor first and then after that surgery follows. There are some patients who respond very well. We start off with 2, 3 cm tumors, and by the time Dr. Cua operates on them and we look at the pathology, they’re down to 0.7, less than a centimeter in size; and cosmetically… There was one patient who we are going to be featuring in the magazine next month, I think. Next month? Yeah, the neo-adjuvant? Is it next month? The tumor was very close to the nipple area, we were able to shrink it and the surgery was done so well that you cannot…and it’s beside the nipple area, that you cannot basically see the scar anymore; and we were able to save the nipple. So, that’s an added advantage of neo-adjuvant. You give the chemo first, shrink the tumor, and go in later.

In terms of survival, it is the same; because some people might say: Oh, let’s give the chemo first, and the probably the outcome is better. I will live longer. The answer is not true. It is the same as giving the chemo before and after. The other term that you call it is primary systemic therapy, you’re giving it first before surgery; and when it’s given after surgery, it’s called adjuvant.

Question # 4: Adding Herceptin to standard chemotherapy for early stage breast cancer that expresses HER2/NEU reduce the risk of recurrence in women by 52%.

The answer there is true. So, for those who are HER2/NEU positive, you add Herceptin for a year, that’s how much they benefit. So, not bad. It’s very good information. Very good data, especially if you are stage III. So after your chemotherapy, you’re already 60-40. Then you add yet Herceptin for one year so that 60-40 will further go down.

Question # 5: After mastectomy, all patients should undergo radiation because there’s lower…

Ah, here, I’m sorry. We have a diagram here. This is your another diagram of HER2/NEU. So, here is your cancer cell with the normal HER2/NEU. As I have said earlier, we all have HER2/NEU in our cells. Everybody. It’s a normal thing; but once it becomes abnormal because here, you have your chromosome, and there is now a mutation, and you have the presence of HER2/NEU, you have now a tumor growing and in the cancer cell, you have a lot of HER2/NEU receptors being expressed on the surface.

Here is a molecular diagram. Here is your cancer cell, in the surface of your cancer; and this is the receptor, and you have HER2; and what happens is that your Herceptin, which is an antibody, that’s why it’s a bit expensive, goes to the receptor and stimulates it, and then it sends signal down to your nucleus and tells your cell to divide. There is a new drug that is now available, not commercially yet. It’s called Tycurb. I think it is available in a clinical trial in St. Luke’s, and it is only for stage IV patients; but there have to be certain criteria that you have to follow to be able to participate in that study. That they’re giving it in combination, I think with Herceptin.

Tycurb, if it proves that it is a good drug, will eventually from metastatic over the years, finds its way to adjuvant therapy; and that’s how everything really starts. Herceptin was available in the States since 1998 for metastatic, and it has shown benefit; then it gradually made its way to the adjuvant setting. So, now, Herceptin is already considered as a standard therapy in the adjuvant setting for HER2/NEU positive patients. So, that’s something new, no? Tycurb.

Question # 5: After mastectomy, all patients should undergo radiation.

The answer there is false. All lumpectomy patients should have radiation. If you have a mastectomy, should you gave tumor size greater than 5 cm and 4 or more positive lymph nodes, you should also have radiation after your mastectomy.

So, when you advice a patient: No, you can have a lumpectomy. You have to make sure that you inform them that they will need radiation; so that is an added expense for the patient.

COMPLIMENTARY TREATMENT

Question # 1: Taking large doses of anti-oxidant supplements is safe while undergoing chemotherapy and radiation therapy.

The answer there is false. Taking large doses of anti-oxidant supplements, please don’t hurl your glasses at me for those who are taking, it may be dangerous and is not recommended while undergoing chemotherapy and radiation therapy. Why? Because several studies show evidence of potential interaction between anti-oxidant supplements and radiation and chemotherapy. Since anti‑oxidants protect cells from damage or oxidation, they may keep cancer cells safe from oxidative cancer treatments, too. So, if you have a cancer cell, and you’re taking large doses of anti-oxidants, what it can do, it might even protect your cancer cell, and when you’re given your chemotherapy and your radiation, you want your cancer cell to be in a state where it is not “oxidized,” then you may not be able to get that benefit. So, right now, the recommendation, if your patient insists on taking anti-oxidants, I would always say the usual regular dose is fine.

Yes, ma’am?

Inaudible question from audience: …oxygen in the body. Too much oxygen they die, right? They don’t survive, you know, that’s why they require us to exercise regularly so that our lungs will always be breathing in.

Well, cancer cells survive when they have blood vessels going to it, and when they have nutrients supplying it. Part of the nutrients will also be some oxygen in it. So when your tumor cell is already very big, sometimes, they die amongst themselves already. It is because they lack blood supply and they lack the oxygen going to it.

Audience: Anti-oxidant, I think, is the one that is supplying oxygen to our body.

No, anti-oxi…wait; you’re bringing me back to my biochemistry years in medical school. Let’s go first to the normal cell. Our normal cells produce waste products and these waste products, some of them are triple oxygen, or something like that, or oxide, or what have you. These waste products can damage the cell itself. So, what it does is with all of these nutrients, it will provide us an anti-oxidant. So, if you have this waste product that is going to destroy your cancer cell, your anti-oxidant is to counteract this one so it doesn’t kill your cell. So, that’s what basically anti-oxidant means. It is not that you’re taking an oxidant that is rich in oxygen.

So, vitamin E, someway or somehow, replenishes the stores in our body that helps make these anti-oxidants, so that it doesn’t affect or kill your normal cells. Now, if your cancer cell has a lot of these waste products, and then you’re taking large doses of anti‑oxidants, and it will somehow counteract it and prevent your normal cancer cell to be in a state where it is very vulnerable. Your cancer will be in a state that is very vulnerable for the chemotherapy to kill it or the radiation to kill it.

If you’re taking high doses of anti, I’m saying high doses, not normal doses, high doses of anti-oxidant, it might counter-effect that, and your cancer cell, being in a vulnerable state, will become in a less vulnerable state, and therefore your chemotherapy and your radiation may not be effective. That’s what it’s all trying to say.

Audience: That also applies to vitamins?

Now, vitamins, what happens, again, there is no really strong data…it is very confusing, no? and I understand that, is because you read. There’s a lot of things that are out there, telling you that this, and this, and this. My basic rule is this, if I don’t read anything in a reputable journal that is read by majority of the oncologists all over the world, or sanctioned by the best societies all over the world, that this is the journal. If this is not published there, or if it’s not done in a proper design, I don’t recommend. I tell my patients basically is: There is no data to support it, and I think that’s the confusing part is when you read any supplement, sunday magazine, the newspaper and they say: Drink three grams of vitamin C because it is helpful and it becomes confusing for the patient. They will read and take it. So, all of these things you have to ask your oncologist. My patients always ask me all of these questions. That’s the best answer I can tell you.

What’s wrong with taking vitamin C is that you just urinate it and I remember that very well from medical school days. Even when we were taking biochemistry, your kidneys can only take a certain amount of load, of everything. After a while, your kidneys will just have to excrete it. So, if you’re taking three grams, four grams of vitamin C, once it has reached its threshold, your kidneys are just going to excrete all of your vitamin C.

Audience: But at least, Doc, while you’re taking that chemotherapy, and at the same time you’re taking the vitamins, and some anti-oxidants, it’s keeping you, you know, energetic also, at the same time.

Agreed.

Audience: It will not make you weak.

Agreed. So, what I basically say is when they ask me: Can I take my multivitamins? My answer is: Yes, you can take your regular multivitamins. Do you take it in large doses? That’s a whole different issue. But I do allow my patients to take their multivitamins during chemotherapy and radiation, it is fine. In fact, a lot of the literature that I’m reading is “Don’t be strict on your patients.” Because your tendency is: I’m diagnosed with breast cancer, I will change my lifestyle right away. I will stop eating this. But you don’t do that when you’re getting your chemotherapy. Let’s deal with it later on, no? When you’re done with your treatment and you want to do something more, then let’s discuss about diet and everything; but not when you’re getting your chemotherapy.

Am I scaring both of you? No? Okay. (laughs) ah, nagiginaw. Okay. Next.

Question # 2: There is evidence to link alcohol intake with the risk of cancer recurrence and an effect on survival.

The answer is false. There is not much evidence to link alcohol intake with the risk of cancer recurrence and an effort on survival. I recommend limit alcohol intake to four ounces of wine, twelve ounces of beer per day, benefits of alcohol include appetite stimulant and decreased risk of heart disease.

Audience: Now you’re talking!

Question # 3: Ah, this is a more controversial. Sugar feeds cancer cells.

Okay. Sugar feeds cancer cells. I better hide when I give this answer: False. Ooops, oops, oops, okay.

Audience cheering and clapping.

Okay. Sugar does not cause cancer nor hasten the growth of cancer cells. Highly refined or highly sugared foods, which are low in nutrients, low in fiber, and high carbohydrates contribute calories to the diet but little else. The only thing that sugar does is it is not a good source of carbohydrates. Your best source of carbohydrates, again, are your grains, your wheat, etc., etc., not your sugar. But you know, I have a story, I won’t mention who this person is; but the patient was like already half sick, practically dying in the bed, a cancer patient, and he wasn’t eating at all. So, I said: “Sir, what food do you really like to eat? Do you like to eat ice cream?” Because that has a lot of calories. And he said: “That is my favorite. I love ice cream.” And the family just looked at me said: “But doctor, you are going to feed on the cancer cells.” Then I said: “But look, your husband here is dying to eat ice cream; and you know, you give him ice cream, and it is not like that all your cancer cells are jumping and Yehey! I have ice cream, and I’m gonna grow faster!”

So, there is really no truth, in theory, maybe in theory, it make sense. But whether theory translates into practice, or it really does, is a whole different issue. But as of now, there is no solid information that if you eat ice cream or cake, that your cancer cells will be jumping, jumping and very happy that they are now going to grow faster. I think you disagree.

Inaudible comment from audience.

Okay, then if you believe that, then that’s fine. I mean, there is also nothing wrong if you want limit your diet. Okay next. Yes ma’am?

Audience: Soy is a … there seems to be a grey area because some doctors say it is good.

The only literatures that I read there in women who have been diagnosed with breast cancer, and are ER/PR positive then you try to avoid soy and ginseng, because they have estrogen-like properties. There is no data saying that if you eat soy or ginseng, that will promote breast cancer. What I am saying is if you have been diagnosed already with breast cancer, then you try to avoid that, especially if you are ER/PR positive. Now, don’t ask me which soy is okay, or which ginseng is okay, because I really don’t know. But suffice to say, when I tell my patients try to avoid taking ginseng and soy because they have shown to contain estrogen-like properties, and if you are ER/PR positive, and that’s the reason why you are taking tamoxifen, to block the receptor, and here you are supplementing yourselves with…but I agree, if you don’t have breast cancer, soy is a very good source of protein. So, I’m only saying that for those who have been diagnosed with breast cancer and who are ER/PR positive.

Number two, there is no data for me to say that taking large amounts of tokwa everyday will make you have breast cancer. No, that’s true, because you all know Lydia Paredes. She is like a tokwa eater. I mean like, day in and day out, she eats tokwa and for Christmas, give her tokwa, she’s happy, and that’s what she said, no? And she developed breast cancer but there is really no information to say that tokwa will cause breast cancer. If you have, so this is a whole different thing, if you have ER/PR positive breast cancer, then avoid tokwa and ginseng.

Okay, now to maybe a less controversial question.

Question # 4: A daily cup or two of green tea is safe.

The answer is true. Okay? So, that’s okay. They have anti-oxidant effects and catechin, also an anti-oxidant, blocks the production of an enzyme needed in cancer cell growth and suppresses the formation of blood vessels supplying blood to the cancer cells. So, it is okay to take green tea. No, I don’t if you ask me black tea and all the other teas also.

Okay, last question, so you can have your cake and eat it too.

Question # 5: One kind of fruit or vegetable in large amount per day is better than several kinds in smaller quantity.

The answer is false. Eating five, and I got this from the American Cancer Society, eating five or more servings of a variety of vegetables and fruits each day will provide the vitamins and minerals you need.