Sheryl Crow for Senate

Began today reading the news. Ouch. Bad idea. Can it really be that bad out there? Seems that way. Hope Obama can make as much of a difference as Sheryl Crow.

Sheryl Crow Sheryl Crow. Besides looking cool in print Sheryl is a hero to many women and most don't even know it.

So many woman who begin this journey thru surgery, chemo, radiation wonder how they will make it. It can be a long journey - a year or more- and may feel like three. But like most journeys it will end.

And here is where Sheryl (and Lance-but this ain't about Lance) shines on like a crazy diamond. Sheryl used the experience to focus on herself when need be, to get better, and then focused on everyone else. She became and remains the perfect role model for breast cancer patients.

Sheryl allowed herself to become the image of strength and hope and courage for woman. She went thru treatment without a public wimper and then went about her business. But now her business is helping in the fight. And she helps in so many different ways. Google her.

If you do google her you will find a ton of stuff about her helping and helping. City of Hope? She's with em. Changed her music after her experience. She basically let it shape her and she used it for the good - for herself and others.

I usually don't expound like this on this blog. Usually I offer advice. The only advice I can offer here is to think of Sheryl if you have breast cancer and I think it will help you get thru it and help you think of others at the same time.

Oh, and if I have to offer advice today it would be to go see "The Boy in the Striped Pajamas" and "Slumdog Millionaire".

Don't delay

Delay is usually not good. We all do it however. I"m a renown procrastinator. But some things we ought not delay.

Breast cancer treatment is one of those things we ought not delay. We kinda know that --I mean it makes common sense. And we have evidence in some other cancers that delay does make a difference. We know delay makes a difference in cervical cancer and head/neck cancer.

Well, a new study shows that delay or incomplete radiation treatment makes a difference to woman in terms of how they will ultimately do.

An analysis of the National Cancer Institute's cancer registry has found that delaying radiation therapy for women with breast cancer can lead to increased recurrence of the cancer.

The findings revealed that as many as one in five older women experience delayed or incomplete radiation treatment following breast-conserving surgery, and that this suboptimal care can lead to worse outcomes.

Delaying treatment by eight weeks or more significantly increased the odds for recurrence.

Patients whose radiotherapy was delayed by 12 weeks or longer were four times more likely to have a recurrence

Women who had incomplete radiation treatment - those who underwent fewer than three weeks of the typical five-to-seven-week regimen - had a higher rate of overall mortality.

As Ben Franklin used to say, "God heals and the doctor takes the fee". Wait a minute, wrong quote.
Ben also used to say, "You may delay, but time will not."

To be sure I know that some people have delays that are beyond control.

But if at all possible let us make a promise to eliminate all the kinda urgent but not really, I have a trip planned, but we bought plane tickets, I've never seen Mongolia, it's cold out there kind of excuses.

Breast cancer in the news

Once again we report some of the more interesting tidbits found in the news in the last 2 weeks.

Here is a rather alarming and well done study. Researchers at Univ of Southern California found that eating 1/4 of a grapefruit or more per day was associated with a 30 percent increase in breast cancer risk in certain postmenopausal women. The increased risk from eating 1/4 or more of a grapefruit per day was seen in women who never took hormone therapy to treat menopausal symptoms as well as in women who were taking estrogen alone or combined estrogen and progesterone. Breast cancer risk was also higher in the thin women who ate grapefruit than it was in the overweight women who did. The probable mechanism is that grapefruit increases estrogen levels - increased estrogen is a known risk factor for breast cancer.

Even Dr. Susan Love says the study is well done. She does not recommend abandoning grapefruit but cautions it may be wise to cut down intake. This is a rather strong recommendation from a very well respected authority. Most readers know I'm generally wary of the multitude of reports of this type. There are just so many. But the grapefruit report has gotten my attention. Be careful of the well known grapefruit diet!


US scientists have now said that women should think twice before taking the herbal therapy black cohosh. The report indicates the herb can increase the chance of breast cancer cells migrating from the breast to the lung.


In a report on their findings, published in the journal Cancer Research, they said: "These results suggest caution for black cohosh use in women with and without breast cancer."
Black cohash has been popular as a natural treatment of menopausal symptoms. I think the popularity is about to go down!

And now for some good news!

As reported in the journal Breast Cancer Research.

Researchers followed 32,269 post-menopausal women for eleven years and found that vigorous exercise was protective against breast cancer - independent of body weight.

Vigorous activity was defined as anything from strenuous sports such as running, biking up hills, and aerobics to taxing housework such as scrubbing floors, chopping wood or heavy yard work.
Fascinatingly, non-vigorous activity was not protective (non-vigorous activity included walking, light housework, leisure biking).

One of the takeaways of this article is woman may want to think about increasing the intensity level of their exercise. But I make this comment with hesitation. The increase in injuries, accidents, heart attacks etc may negate the positive effects for some woman. That said, if a woman is in good general health and has a doctors OK then the increased intensity should be good for women on many levels. Just do it!

That's it for this week in the news. I find the above particularly interesting because all three of the above are popular foods or activities. But more importantly they are things women can do right now - today - to lower the risk of breast cancer.

Mammosite and you

So many things we have to decide when it comes to treating breast cancer with radiation therapy. It used to be so simple. After lumpectomy a woman underwent 6 weeks of daily radiation and that was that.

Oh, things have changed. And mostly for the better. But like everything else there is always more to the story. So, here is the story on partial breast radiation and mammosite.

Firstly, it is in widespread use and remains controversial. For select women it is an excellent option - but only if the patient understands the controversy, risks, and benefits and then decides it is for her.

What is the controversy? Read the New York Times recent article which does a great job of explaining. Read it here.

Basically, the track record is not long. It is based on data from few women compared to the standard treatment. And the device was "fast tracked" by the FDA which means it was not determined if it is actually effective at treating breast cancer. The fast track approval means the Mammosite was actually approved because it performed as advertised - it delivered radiation to the resection cavity. It was not approved because it was proven to be better or equal to the standard 6 week course of radiation.

Secondly, it is not for everyone. It should be offered to the selection of women who meet the strict criteria. This prevents placing women at increased risk of local failure, skin damage, lung/rib damage when a safer alternative is available.

Partial breast techniques include mammosite, other implant techniques/devices, external beam with 3D or IMRT and all should only be delivered in an institution with expertise and perhaps in a study setting. The informed consent should make sure the patient clearly understands the procedure is controversial, not tested in the long term, and the side effects may be differnet than the standard 6 week course of radiation.

On the other hand, for the women who are good candidates for mammosite it can be a great idea. I've used the mammosite personally with many women and generally it is well tolerated and side effects minimal.

The leaders in partial breast techniques in the country are doing a great service to women who may need or want this approach. But like anything else in this world - there is more to the story than meets the eye. Please read the NY Times article for more info - here.

Turning Heads - the book to give away

I"m a doctor and photographer. It is just what I am. Rarely do the two meet in any artistic way. Oh sure, there is the occasional moment or two if I bring my camera to work and see something cool. Click on that cool link and you'll see a cool work photo. But few and far between.

Then one day about 5-6 years ago I got a call from Jackson Hunsicker. Jackson is just one of those people you want to know. She is funny, bright as can be, very cool, fun to be with, well, you get the idea.
Jackson's idea was to gather 2 waves of people to do something remarkable. One wave was bald women of every size, color, ethnicity, and strength. These women were all breast cancer patients who lost their hair from chemotherapy. The second wave of people were photographers. And I mean great photographers - famously great photographers.

Jackson set out to publish (on her own) a remarkable book about bald woman.
Here is the official link to this remarkable book. Check it out right here.


The purpose of Turning Heads is to show the world that life does not stop with a cancer diagnosis. That bald women can be strong, vital, and beautiful people with full lives.

The book succeeds wildly. Firstly, because it is a brilliant idea - a creative force.

Secondly, the photos are works of art taken from 59 different world class, I wish I could shoot like them, photographers. You've heard of a lot of them. You may own or collect some of their other works. You should collect and own this book. The photos are that good. Who are these photographers?

How about Stephen Wilkes, Annie Wells (Pulitzer winner), Joyce Tenneson, Greg Gorman, and Lauren Greenfield to name a few. What more do I really need to say with names like these gracing the pages.

I could say the book only cost $21.86 at Amazon and please tell everyone women to buy one for a friend. Or tell your oncology friends to stack them for giveaway in the waiting room.

Actually, every medical oncologist, breast surgeon, radiation oncologist, psychologist, should keep a stack in the waiting room to GIVE to patients. It would not really make a dent in their yearly marketing budget and be far more effective than, say, a bad holiday gift basket that is gone in a day.

Bald patients see this book and smile. They understand the message is meant for them and it is a positive, loving, beautiful message. Click on those links above, please.

Dr. Susan Love and research

While I was writing the post on the robot MRI (see below) I noted that Dr. Susan Love has several research projects within her foundation. I thought I would post on some of these because of their importance.

While the robot MRI might be years in the future these studies are open now to qualifying women. Here is one that is quite intriguing in that a small amount of chemotherapy is injected into the tumor area after diagnosis. Read on and please visit Dr. Love's blog and main page.
http://www.dslrf.org/endingbc/content.asp?L2=1&L3=7&L4=4&SID=292


Effect of Intraductal Therapy of DCIS with Pegylated Liposomal Doxorubicin (PLD) on Pathology and Biomarkers: A Presurgery Study
(Currently Recruiting)
The Dr. Susan Love Research Foundation is looking for 30 women recently diagnosed with ductal carcinoma in situ (DCIS) to take part in a groundbreaking new research project. Study volunteers will need to have been diagnosed with a core needle biopsy or with ultrasound and not yet have had surgery. The study involves having a small amount of a chemotherapy drug injected through the nipple into the affected milk duct. The volunteer will be observed for a couple of hours, and then go home, with a surgery date set in the next four to six weeks. Prior to surgery, ductal fluid will be aspirated and an MRI will be performed. The tissue removed during the surgery will be examined to see what effect the drug had on the DCIS. It is hoped that the findings from study will provide the data necessary to support the launch of a nationwide clinical trial of intraductal therapy for the treatment of DCIS.

This research is being conducted in collaboration with Ellen Mahoney, MD, St. Joseph's Hospital in Eureka, Calif., and the Humboldt Community Breast Health Project. Research participants will need to travel to Eureka, Calif., for the treatment and the surgery. This study was funded by the California Breast Cancer Research Program (CBCRP). Please call Ashley Casano at (310) 828-0060 Ext. 32 or send her an email for more information.

Future Breast cancer treatment

I agree with Dr. Susan Love. The ideal way to cure breast cancer is to prevent it. And thru her pioneering efforts we will do just that. In the meantime we still have to take care of the thousands of women who are diagnosed each year.

One area where we have made great strides is in reduction of side effects and amount of breast tissue treated. For instance, mastectomy used to be the only option for most women. Now, mastectomy is reserved for those who cannot (or will not) undergo lumpectomy and radiation. We have also learned that a sampling of lymph nodes is just as good as a full lymph node surgery for most women. And that partial breast radiation is perfectly suited for some women instead of whole breast radiation. That is a lot of improvement over a short period of time.

I do not usually comment on the "latest and greatest" news item--but this one caught my attention. It is about a robot within an MRI that can detect and destroy breast cancer cells. The only catch. Not ready for prime time until some time in the future. But it is intriguing.

Here is the link
http://gizmodo.com/5062325/robot-prototype-finds-attacks-and-kills-breast-cancer-cells

It is intriguing because this kind of thinking and technology is what leads to further reductions in side effects for women. And in lessening the trauma of breast cancer treatment.

I don't know if a robot can do everything the article says it can. But I do know that just a few years ago the words partial breast radiation, lumpectomy, sentinel lymph node were unknown to most of the world.

So until Dr. Love's vision of prevention of breast cancer is realized we still have to advance our ability to treat women with more finesse and less side effects. We are very good at this.

Breast Cancer in the news

It's amazing how often a report appears in the news about preventing or causing breast cancer.
I decided to post on this topic today. So many woman (and doctors) are confused by very common questions about the cause of breast cancer. And no wonder. The mountains of conflicting news stories and research IS confusing. One day you read not to drink coffee the next you should drink coffee and so on.

Below is a sample of stories to appear in the news during October --breast cancer awareness month.

A woman's risk of breast cancer is not increased by consuming caffeine, concludes a report published in the October 13 issue of Archives of Internal Medicine.

A study published in Cancer Research, a journal of the American Association for Cancer Research, suggests a possible role for nicotine in breast tumor development and metastases.


researchers at the University of British Columbia, Vancouver Coastal Health Research Institute, and the University of Santiago de Compostela reveals that regular use of Non Steroidal Anti-Inflammatory Drugs (NSAIDs) is associated with a 12 per cent relative risk reduction in breast cancer compared to non-users.

A separate analysis for Aspirin showed a 13 per cent relative risk reduction in breast cancer and an analysis for Advil showed a 21 per cent relative risk reduction.

So for this month anyway let's all meet at Starbucks for coffee and Advil because caffeine is not bad and NSAIDs are good. And of course, let's stay away from smoking and smokers.

Until next month, that is, when the story may be different.
Stay tuned.

Don't be fooled

by the advertising of radiation oncology centers (or other medical specialties)

In the LA Times today there is an ad for Tomotherapy offered at City of Hope. The ad promises a couple of things worth pointing out.

The ad states there are no incisions with Tomotherapy. This is correct-but there are no incisions with any other type of external beam radiation therapy either. The ad is technically correct but is very misleading by suggesting Tomo is better for this reason. This is folly.

The ad also mentions correcting the radiation position by using 3D imaging and implies it is the only and the best way to do this. This is blatently incorrect. There are other machines that use imaging to correct alignment. Tomotherapy has never been proven to be superior to these other machines. The ad is just not telling the truth.

The ad says that side effects will be reduced. Reduced compared to what? There have been no comparisons between Tomotherapy and IGRT (Trilogy), Elektas machines, or others to suggest Tomo is better. And side effects are lowered with all these machines compared to traditional external beam techniques. This is just an attempt to use misleading statements to convince patients that City of Hope is better and Tomotherapy is superior. Neither are.


City of Hope is tooting the horn of Tomotherapy in the wrong way and it is unfair to desperate patients looking for answers.

These ads are misleading and an example of taking advantage of the publics trust. The ads intention is to gather business and it is a shame that City of Hope allows these ads without proper review to make sure they are completely truthful or not misleading in any way.

I have seen many patients who believe such advertising. They want so badly to believe the hype and will drive an extra 90 minutes each day for 8 weeks to go to City of Hope or other places that use ads in this way --and they will not get any better treatment than if they stayed near their own home.

To be fair there are some instances where tomotherapy, or IMRT, or IGRT, or proton therapy will be very useful. But this should be decided by your radiation oncologist and surgeon--not by some misleading advertisement in the LA Times.

City of Hope is an exellent institution and deserves its wonderful reputation. But I think they should carefully review ads promoting themselves to make sure they are not misleading in any way.

What is radiation therapy?

Radiation therapy is simply the use of x-rays to kill cancer cells.

We use the same type of x-rays that you would receive in getting a mammogram, dental x-ray, or CT scan.

The x-rays used in radiation therapy are given in a higher dose and use a higher energy. But, generally, they are the same x-rays as getting a regular x-ray.

Because radiation is just x-rays--a patient will not feel the treatment any more than when getting a chest x-ray. Basically, the treatment is painless.

However, there can be eventual side effects. And side effects come in two types. Short term and long term.

Side effects will generally only be in the area treated. X-rays do not affect parts of the body not in the treatment beam.

Short term side effects are those you may experience during the 3-8 weeks of therapy. They are due to irritation and inflamation from the x-rays. Sore throat or red skin are examples.

Long term side effects are due to actual tissue changes from the radiation and not inflamation. These can appear 6 months onward up to many years. Each tissue/organ in the body has a certain tolerance to radiation and if exceeded can cause a long term effect in that organ.

So be sure to ask your radiation oncologist to fully explain all short and long term side effects. No sense in being surprised.

5 questions for your radiation oncologist

1. Are you board certified?  Ask this question!  You would be surprised who is not.  I think you should be treated by a board certified physician--or a younger physician who is in process of taking the boards.
2. Have  you looked at my pathology personally?  See previous post for reasons why.
3. What are my radiation options?  Whole breast? Partial breast? Mammosite? IMRT? There are many techniques available and you will only be offered what is available at that particular institution.  But what if you needed (or wanted) a treatment not offered? 
4. What other radiation facilities are close by that you can recommend? A good doctor will always happily provide names and places for a second opinion.  If your doctor balks at this question---RUN.
5. Is there an expert in the area for my particular condition?  If there is--see that person for a second opinion.

More questions next time.

Radiation Therapy and pathology

To ensure you get the best, most high quality radiation therapy one has to do a little homework.

1) Insist your radiation oncologist looks at your pathology slides personally.  Just reading the report (which is what happens most of the time) may not be good enough (unless you are being treated at a very high quality institution.

There is often valuable information (not in the report) and looking at the slides personally can sometimes change the radiation treatment.  For instance, the margin status (or nearness of the cancer cells to normal tissue) can be better appreciated by looking.  Sometimes the report only comments on the closest positive margin--when there may have been several close margins.  This can impact therapy.

See what your doctor says when you ask if he or she has seen the slides (or spoken to the pathologist)!

You have a choice

You have a choice when it comes to the radiation facility for your treatment.

Most woman go to the facility  they are referred to or one that is closest to their home.

But radiation therapy departments are all different.  And choosing a good one is very important.

Some have part time doctors.  Some have outdated equipment.  Some have no nurses.  Some are excellent and some are just plain bad.

But your referring doctor will generally not know the difference--sometimes not even care to know the difference. 

It is up to you to ask the right questions.

More on this important topic --next time.

Keep it at home

The Problem

Medical records will get lost if you mail them.

Doctors offices will lose your records.

When you go for a second opinion the office will not have a complete set of your records.

So much precious time is lost if you don't have a backup medical folder at your home.

It should include:

1. all consultations
2. lab reports
3. x-ray reports
4. copies of x-rays
5. office visit notes
6. medical history
7. prescription history
8. radiation and chemotherapy records
9. operative reports

If you have this you will never have to worry or have an appointment canceled because of lack of records.  It is worth its weight in gold.

Remember, you entitled to all of your medical records.  Ask for a copy every time you have a test, consult, x-ray, anything.

Obtain a second opinion

When faced with surgery, chemotherapy, and radiation obtain second opinions if you have any doubts or questions.

There are many types of surgery-lumpectomy, mastectomy, skin sparing mastectomy, lumpectomy with mammomsite, etc.  

Each patient may require different expertise.  Some surgeons are experts in breast conserving therapy and others lean more towards mastectomy.  Often, it is just a belief or preference.

It is imperative to know that different surgeons will recommend different procedures based on their preferences----5 different surgeons may give you 5 different recommendations.  It depends heavily on what procedures they are experienced in and what they believe.  

I have seen surgeons recommend mastectomy when lumpectomy would have been appropriate and preferred by most other surgeons. And it is a shame to do a mastectomy when lumpectomy is appropriate.  There is no reason for a woman to lose a breast if there is no benefit.  This is common and very unfortunate.  

FACT:  For early stage breast cancer, if a woman is an appropriate candidate for lumpectomy, there is no advantage to mastectomy.  A woman will not sacrifice her life if she chooses to preserve her breast.  Lumpectomy is equal to mastectomy except with lumpectomy she gets to keep her breast.

See this link for information regarding mastectomy vs lumpectomy in the USA.  Prepared to be surprised.

See this link for an excellent commentary by Dr. Susan Love on  double mastectomy and breast conserving therapy. Dr. Love is a pioneer in breast conserving therapy and superior woman's advocate.

Only one thing is important

And that one important, critical really, piece of information is:

You have to get to the right (best) doctor.  

The right doctor simply makes the right choices.  It is that simple.

Most of the hard work is in the decision making.

If you get to the right surgeon

1. You will be offered the correct choices. Mastectomy or lumpectomy? Reconstruction?
2. You will not have to wonder if the decision is based on money or lack of knowledge.

If you get to the wrong surgeon

1. He/she may not be up on the latest advances in breast surgery.
2. You may be told to have a mastectomy when a lumpectomy would be more appropriate.
3. You may regret not looking harder for a better decision maker/surgeon.

14 steps every breast cancer patient should take before treatment

This site is dedicated to the patients I have cared for over the last 15 years. I've spent my career promoting breast conserving therapy to make sure woman get the best care possible.  As a board certified radiation oncologist I specialize in breast cancer treatment. 

This blog will make sure all woman with breast cancer are given the correct information to make the best decisions possible.  I will comment later on each of these points.

So many problems can be avoided if proper steps are taken before treatment.  

14 steps every breast cancer patient should take before treatment

  1. Obtain a second opinion--this is a must.  And get one for surgery, chemo, and radiation.

2. Keep a folder with all of your medical records at your home. This will save time and heartache.

3. Have the surgeon explain and write out the options. Most times there are quite a few options.

 4. Obtain a copy of the surgeons consultation and take to your second opinion.

5. Understand how referrals are made. Sometimes to friends. Not always to the best.

6. If you feel a lump and have a negative mammogram-demand to see a breast surgeon.
  
7. Make sure you see a dedicated breast surgeon-preferably a surgical oncologist. Check!

8. Get a list of surgeons and ask friends and past patients who is the best. Why is he/she best?

9. Check credentials of anyone you  see.  What type of surgeon or doctor is he/she?  Lawsuits?

10. Read Dr. Susan Love's Breast Book. It is the bible and amazingly helpful. Get it here.

11. There are many different chemotherapy options.  Each medical oncologist has his favorite.   Your second opinion may be very different than your first opinion.  This is good.

12. Ask for a written list of all short term and long term side effects at each consultation.  

13. Obtain a copy of all consultations and put in your folder at home.  

14. Take charge!  You must be in control and do what is right for your best medical care.

More on each of these real soon.