New Breast Cancer Guidelines

The St Gallen International Breast Cancer Guidelines were recently updated to include the Oncotype DX test for breast cancer as the only screening tool for women with early stage ER+/Her2- breast cancer to determine the benefit of chemotherapy.

On some levels this is great news but again it is not for all women. The criteria for the Oncotype DX test for breast cancer are:

"You may be a candidate for the Oncotype DX breast cancer test if you are medically eligible for chemotherapy and:

• You have been diagnosed with stage I,II or IIIa invasive breast cancer.*
• Your breast cancer is estrogen-receptor positive (ER+) and Human Epidermal growth factor Receptor -negative (HER2-) and you do not have lymph node involvement (also known as lymph-node-negative breast cancer).

        OR

• You are a post-menopausal woman recently diagnosed with node positive, hormone-receptor-positive, Human Epidermal growth factor Receptor -negative breast cancer"

The problem is that while most women have ER+, Her2- and node negative breast cancer, not all do. For example, I was not given this test because I had one tiny positive lymph node. Apparently they are starting to do some testing on women with node positive disease. The Oncotype DX test is also available for colon and prostate cancer as well.

I have digressed. I do like the fact that this test is available for some if not all. I do like the fact that it is covered by most insurance companies. I do like the fact that it helps determine if a patient will benefit from chemotherapy before they receive it. I do like the fact that it is part of standards for treatment.

I do not like the fact that it is still part of the conversation about treatment - do you remember the little analogy - an ounce of prevention is worth a pound of cure? Why can't we put that into the guidelines?

What if Chemo came the last resort instead of the first wave of treatment?

That would be awesome. Right now most cancers are automatically treated with chemo, radiation and surgery. But with the development of individualized treatment and molecular medications, chemotherapy may be going the way of the past.

This is a huge advance in cancer treatment and looks like it is not so far fetched. When I first saw this article I was very surprised but glad to see it.

It had never occurred to me that cancer could be treated with out chemotherapy. In my mind I was leaning towards chemo regimens that were not as harsh on the patient than in the past.

So optimism reigns in cancer land these days.

By the way yesterday's procedure went pretty well, some pain as a result but that should go away in a day or two. I'm taking it easy today and back to work tomorrow.

Here's a big oops!

A bunch of cancer patients in Canada received less than the specified dose of chemotherapy. Nearly 1200 patients in a group of medical centers and then 186 at another. Oopsy! They do not really say how it happened but its clearly a problem. Chemotherapy doses, I believe, are based on body weight. I think the dose you receive always starts on the higher side to see if its tolerated and then the oncologist can tweak it down.But if the oncologist does all their math and then the dose is too weak, that's a problem.

What is scary is this wasn't discovered until a pharmacy technician noticed it.

The hospitals say they have steps in place for handling chemotherapy drugs but they will work carefully to find out the source of the problem. I certainly hope they do.

While you are in chemo you assume you are getting th eright treatment. But what if the doctor is doing their best and some how your drugs were mislabeled. And what if you were overdosed the 3-20% that was the amount underdosed in this case? You might get pretty damn sick from it. At the very least your blood counts would tank.

Anyway, a big oops here. I hope someone learns a lesson and everyone is okay who got the wrong dose.

Chemo again or just semantics?

I have been emailing back and forth with a friend with whom I had lost touch. His wife had died a few years ago of pancreatic cancer.  I told him that I had RA which is why I haven't been around as much recently. He replied that he has a friend who is on methotrexate - which is a form of chemo  for their RA.

Eeek! I had not considered that Methotrexate was a form of chemo. I take it in pill form weekly so its not like I go for an infusion or anything. I looked it up on Scott Hamilton's Chemocare.com and found out its true.

The thought of being on chemo again had always freaked me out. I mean who wants a port, baldness, and nausea again? But they snuck it in on me. They said it was for RA treatment, they never mentioned chemo. So I guess its easier to cope.

My mother was on methotrexate, at a lower dose than me, for years, and we never considered it to be chemo.

Which brings up a point. If a drug is used to treat cancer, they call it chemotherapy. But if the same drug is used to treat something else, can't we just call it a medication for rheumatoid so I don't have to think I am on chemo again? Doesn't it come down to semantics here?

Further proof of chemo brain

A study (because we needed another study to keep all those researchers busy) shows that an EEG can detect chemo brain in women undergoing chemotherapy for breast cancer. So will people now really start to believe chemo brain, or cognitive deprivation, exists? For some reason, this reminds me of when doctors told women their cramps were imaginary.

If I think about the research and clinical trials put into development of chemotherapy and other drugs, when was chemobrain determined to be a 'non-issue'? It is a true side effect of chemotherapy for patients. If its temporary its one thing but for some women it really never goes away. So why was its impact determined not to be of importance?

So pretend if it it was not impact on your brain but on your heart or lungs which could be measured medically through tests quite easily and left the patient with a permanent impairment which interfered with their daily living and ability to hold a job. Would it be considered then to be a caution or warning when prescribing?

Chemotherapy drug doses are estimated based on patient weight and a few other factors so there is not really an exact dose to give everyone. It appears to me (and I am not a doctor) that the patient's first dose is a guess based on their weight and a few other factors, and then based on their reactions to it, they alter the dose for future rounds. Would lower doses still be effective but with fewer side effects such as chemo brain? I think we already know the answer - more research is needed.

The FDA isn't always the bad guy.

We like to think of all the alphabet government agencies as the bad guys. They are the big brother that is overlooking everything we do, think, eat, wear, breathe, etc. But maybe this time the FDA is not the bad guy.

There is a massive problem with shortages of oncology and anesthesiology drugs in the US. Most of them are related to manufacturing problems when they are shut down for failed FDA inspections. Others have tried to claim that the FDA doesn't concern themselves with potential shortages when they cite manufacturers but that is not the case. The FDA tries to work with the manufacturers to prevent shortages and tries to get substitute drugs that are manufactured to US specifications overseas.

So where does the problem lie? In an aging manufacturing infrastructure. Hmmm.... so the same people that charge upwards of $10K per dose cant keep their manufacturing facilities up to par? I fail to sympathize here. They are supposed to be saving lives not killing people with defective drugs.

Angiogenesis

I only learned about angiogenesis last year. Not having recently gone to medical school, I turned to my friend, Mr. Google (as opposed to Dr. Google) for a definition. Wikipedia says:

"Angiogenesis is the physiological process involving the growth of new blood vessels from pre-existing vessels."

 It goes on to add:

"Angiogenesis may be a target for combating diseases characterized by either poor vascularisation or abnormal vasculature."

Now we have gotten through a LOT of big words this morning.I have found an article explaining how contrast MRI may predict how women would respond to chemotherapy and possibly allow them to avoid mastectomies. Another (as if we needed it) research study was done and found:

"... contrast-enhanced MRIs can work as an early predictor of the body’s response to neoadjuvant chemotherapy by measuring the blood vessel formation in tumors, a process known as angiogenesis.  Angiogenesis is considered an earlier and more accurate marker of tumor response."

"... MRIs can detect tumor changes as early as the first cycle of chemotherapy.  If the tumor appears smaller and less bright on the scan, it can be interpreted as a sign that the chemotherapy may be effective and eventually lead to tumor eradication."
However this is all new and exciting but the results will be published later this year and then we need to see if this is coming soon to a hospital near you (and me). So one big word I learned last year combined with a technology I have already experienced has created progress. We may have to wait but in this case progress is progress.