Happy Thanksgiving from Susan

  Wishing everyone a very Happy Thanksgiving! I love this holiday! Always filled with family, good stories, good food and very good times. I...

Wednesday, January 30, 2013

Prescribing a New Kind of Rehab for Cancer Survivors


A new push for cancer "rehab" is helping patients avoid long-term physical disability and complications after treatment ends. WSJ's Laura Landro and Julie Silver, Harvard Medical School assistant professor, discuss on Lunch Break. Photo: Getty Images.
Patients who undergo cardiac-bypass or joint-replacement surgery routinely are given specific guidance to the exercises and therapies they will need to return to their everyday activities and to prevent complications or relapse.
For cancer patients, the story is very different.
After undergoing often harsh and debilitating treatments, there is often little help for their return to normal life.
Now, an increasing number of hospitals are offering programs to provide cancer patients with comprehensive rehabilitation services, amid mounting evidence that these can help speed recovery, shorten hospital stays and improve quality of life.
Rehabilitation services are "an absolutely essential part of cancer care," says Dan McKellar, chairman of the Commission on Cancer. Last year the nonprofit standards-setting group, overseen by the American College of Surgeons, began requiring cancer programs to offer rehabilitation services to be eligible for accreditation. Major cancer centers are taking steps to better coordinate rehabilitation after treatment. And Medicare and most insurance companies are covering such services.
Doctors who specialize in rehabilitation medicine can evaluate patients for fatigue, pain, anemia and decreased endurance that result from chemotherapy, radiation and surgery. They can then prescribe physical and occupational therapy, as well as treatment for sleep problems, depression and cognitive impairment. Dietitians help with nutrition, as cancer can change the way the body uses food and patients often lose their appetite from treatment. Some institutions offer massage and yoga.
More than a third of the nation's 12.6 million cancer survivors had physical or mental health problems that put their overall health in jeopardy and had a negative impact on their quality of life, according to a recent study of federal health data funded by the National Cancer Institute. While patients may get emotional help from friends, family and support groups, physical problems may get scant attention once they are no longer in the care of oncologists and surgeons.
"When cancer patients are diagnosed, everyone sits down to look at the case, decide what to do and convey that plan to the patient, but the same sort of process doesn't happen for survivors of the treatment," says Kathryn Weaver, lead author of the study and an assistant professor at Wake Forest Baptist Medical Center in Winston-Salem, N.C. Patients, she adds, may feel their physical problems are "the new normal" and may not ask their doctors for help. And even though most hospitals have rehabilitation services, there may not be a formal program to identify cancer-patient needs or coordinate a care plan among different therapists.
One model being adopted by hospitals, including Johns Hopkins in Baltimore, M.D. and Bon Secours St. Francis Health System in Greenville, S.C., is called STAR, for Survivorship Training and Rehab. It uses specially trained teams of caregivers, coordinated by navigators such as nurses, to help patients with physical and emotional issues, as well as any other concerns that arise.
In 2011, Dan Yarborough, a 67-year-old attorney, had two stem cell transplants within months of each other and high-dose chemotherapy to treat multiple myeloma, a form of blood cancer, at Bon Secours. The treatments left him weak and fatigued, with pain and numbness in his feet that threw off his balance and left him unable to walk steadily and unable to stop himself from falling if he tripped. Golf and travel, favorite pastimes, were out of the question, and he was worried about being able to argue his cases standing in court.
While hospitalized for his second transplant, a nurse navigator from the hospital's STAR program set him up with regular physical therapy appointments and nutrition counseling. Staffers helped him establish goals such as improving his ability to get in and out of his SUV, and worked with his doctors to change medications that were linked to his foot problems.
The program was "incredibly valuable," Mr. Yarborough says, giving him back the stamina to return to work. He is following up with a recommended exercise program at a medical fitness facility owned by the hospital where his exercise plan is overseen by a STAR-certified physiologist for a $30-per-month fee.
The Bon Secours STAR team also deals with specific issues such as helping head and neck cancer patients restore normal functions of swallowing, speech and movement after treatment. "In a lot of hospitals you will see these patients fall through the cracks after surgery, so their cancer is gone but they can't turn their neck to drive a car," says Lori McKitrick, a speech therapist who oversees the program. "We are doing a great job saving people's lives but we have to help them live their lives too."
Julie Silver, an assistant professor at Harvard Medical School and expert in rehabilitation medicine, developed STAR after her own treatment for breast cancer, which she says left her too sick to care for her family or return to work. Her oncologist suggested she rest and try to heal on her own, but "it left me thinking there has to be a better way," Dr. Silver says. "Every cancer survivor should have the opportunity to heal as well as possible and function at optimal level whether their cancer is cured, in remission or they live with cancer as a chronic disease," Dr. Silver says.
She started a company, Oncology Rehab Partners, which helps health systems and hospitals create their own STAR programs for many types of cancer. STAR certification is used by insurance companies in reimbursement decisions. The program costs a typical hospital about $25,000 to launch with an annual fee of $10,000 for continuing education and recertification, Dr. Silver says.
Michelle Houle, 45, has been participating in the STAR program at Bon Secours since she was diagnosed with breast cancer in 2010. After chemotherapy, a bilateral mastectomy and radiation, Ms. Houle, on long-term disability from her job as a food company shelf manager, says she felt "about 90 years old." Nurse navigators at the hospital set her up with a specialist to help prevent lymphedema, a painful swelling of the lymph nodes and a common side effect of breast surgery, and she began a physical therapy regimen.
Ms. Houle suffered a recurrence in 2011 and is now on another chemotherapy regimen, but keeps up her exercises at the hospital's medical fitness facility. She is slowly returning to activities like gardening and housework. The rehabilitation program provides "a base to keep you going," she says, "and there is always someone to talk to if I'm feeling side effects."
Signature Healthcare in Brockton, Mass, which includes Brockton Hospital and 150 employed doctors, treats local cancer patients and those who have had treatment at major centers in Boston, then return home for follow-up with difficult physical aftereffects. Last week, it launched its own STAR program after 23 staffers went through six months of training and received STAR certification. "These needs have been unmet for such a long period of time, and they are very excited to be able to offer this enhanced level of service" says Linda McAlear, the program's coordinator.

What Women Should Know about Breast Density


Diagnostic Radiologist Carol Lee Discusses What Women Should Know about Breast Density

By Media Staff  |  Wednesday, January 30, 2013
Pictured: MammogramA new law requires radiologists to inform women if dense breast tissue is found on a mammogram.
To help improve breast cancer detection and prevention, New York Governor Andrew Cuomo recently signed legislation that requires radiologists to inform women if dense breast tissue is found on a mammogram. The law, which went into effect this month, is raising awareness among women about this topic.
In an interview, we discussed the concept of breast density with diagnostic radiologist Carol H. Lee. Dr. Lee suggests that if you find out you have dense breasts, you should discuss potential next steps with your doctor. Each individual woman’s risk for breast cancer is different, and many factors – such as family history and lifestyle – must be taken into account when determining whether additional forms of breast cancer screening are necessary.

What are dense breasts?

Breasts are made up of different types of tissue: fatty, fibrous, and glandular. Fibrous and glandular tissues appear as white on a mammogram and fatty tissue shows up as dark. If most of the tissue on a mammogram is fibrous and/or glandular, the breasts are considered to be dense.
Because cancer cells also appear as white on a mammogram, it may be harder to identify the disease on a mammogram in women with dense breasts.

How common are dense breasts?

Breast density is classified into one of four categories, ranging from almost entirely fatty (level 1) to extremely dense (level 4). Dense breasts are completely normal. About half of all women have breasts that fall into the dense category (levels 3 and 4). Dense breasts tend to be more common in younger women and in women with smaller breasts, but anyone – regardless of age or breast size – can have dense breasts.

How does a woman know she has dense breasts?

The only way to determine whether a woman has dense breasts is with a mammogram. A breast exam cannot reliably tell whether a breast is dense.

What does having dense breasts do to a woman’s risk for breast cancer?

If you compare the 10 percent of women who have extremely dense breasts with the 10 percent of women who have very little breast density, the risk for breast cancer is higher in those with very dense breasts.
However, most women fall somewhere in between in terms of breast density, so it’s nearly impossible to determine whether a particular woman’s breast density is a risk factor for the disease.

What should women who are told they have dense breasts do?

Women found to have dense breasts should talk to their doctors about their individual risk for breast cancer and together decide whether additional screening makes sense.
Tests such as ultrasound or MRI can pick up some cancers that may be missed on a mammogram, but these methods also have disadvantages. Because they are highly sensitive, they may give a false-positive reading, resulting in the need for additional testing or biopsy that turns out to be unnecessary. There is also no evidence to show that using screening tests other than mammography in women with dense breasts decreases the risk of death from breast cancer.
Ultimately, women who have dense breasts should weigh the pros and cons of additional screening with their doctor.

Should women who do not have dense breasts make any changes to their regular screenings?

Women who do not have dense breasts may still develop breast cancer, and should continue to receive regular mammograms. Regular mammography is the only screening method that has been shown to decrease deaths from breast cancer, and all women of appropriate age should have mammograms, regardless of their breast density.

Getting Connected, Getting Support: African-Americans

 Living Beyond Breast Cancer

When:   Wednesday, February 6, 2013
Noon – 1:00 p.m. ET
Many of us are used to being the caregiver rather than receiving care ourselves. We’re strong and we’re keeping on, but after a breast cancer diagnosis we’re often surprised to learn that we need support, too. During our February teleconference, Alisha Ellis, LMSW, MA, will help you explore how to:
  • Connect to your faith, family, friends, care providers and other survivors
  • Nurture your soul and get the support and care you need as an African-American woman affected by breast cancer
  • Ask for help, keep a positive outlook and avoid common barriers in accessing support
  • To enhance your learning and gain additional support during your breast cancer journey, we encourage you to order a free copy of our culturally sensitive bookletGetting Connected: African-Americans Living Beyond Breast Cancer.
About Our Speaker
Alisha Ellis, LMSW, MA, is a licensed clinical social worker. She coordinates a mental health court diversion program at Mental Health America of Greater Indianapolis. Ms. Ellis previously worked as an oncology social worker at Winthrop University Hospital’s breast health center, where she provided therapeutic, advocacy and programmatic support to people diagnosed with breast cancer, their family members and caregivers. She has served as the clinical coordinator of the Women’s Cancer’s Program at CancerCare and the clinical coordinator of the L’Oréal Paris Ovarian Cancer Research Fund Hope Line.
Register online by January 30 or call (610) 645-4567.

Taking Tamoxifen for 10 Years Lowers Recurrence and

 Mortality

Premenopausal women with breast cancer most likely to be affected
December 20, 2012
Written By Robin Warshaw
Reviewed By Generosa Grana, MD
A major new study has shown that the well-established benefits of tamoxifen treatment for estrogen receptor-positive breast cancer are increased when the therapy is given for 10 years instead of the standard five.
Findings from the large international study were presented at the San Antonio Breast Cancer Symposium and published at the same time in The Lancet.
Background
Tamoxifen, known as a selective estrogen receptor modulator, is used to treat both metastatic and early-stage breast cancer, as well as to prevent the disease in women at high risk. It functions by binding to the estrogen receptor and blocking estrogen action.
For women who are premenopausal or perimenopausal, tamoxifen is standard treatment after primary therapies, such as surgery and chemotherapy. Postmenopausal women may be prescribed an aromatase inhibitor (AI), tamoxifen in sequence with an aromatase inhibitor or tamoxifen followed by an aromatase inhibitor. AIs are hormonal medicines used only for postmenopausal women. 
Reason for the Study
Earlier research established that five years of tamoxifen provides greater protection against cancer return, or recurrence, and death than two years or none at all. Studies of tamoxifen treatment for more than five years have been inconclusive.
The researchers of the new clinical trial, known as ATLAS (Adjuvant Tamoxifen: Longer Against Shorter), wanted to determine the effects of extending tamoxifen treatment to 10 years.
Study Structure
The multi-center research was conducted in numerous countries, from the United Kingdom to the Middle East, Asia and South America. It included 12,894 women with early breast cancer who had completed five years of tamoxifen therapy. The participants enrolled in the trial between1996 and 2005.
A computer randomly assigned the women to stop tamoxifen at five years or continue to the 10-year mark. They received yearly follow-ups to document who stayed on tamoxifen, any breast cancer recurrence, new primary cancer, hospital admission or death. Long-term follow-up is continuing.
Findings
The researchers reported on breast cancer results in the 6,846 study participants who had estrogen receptor-positive disease.
  • That group was split nearly evenly between those who stopped tamoxifen at five years (3,418 women) and those who continued for 10 years (3,428 women)
    • 18 percent of the five-year group and 19 percent of the 10-year group were younger than 45 when diagnosed
  • About 80 percent of the women assigned to continue for 10 years stayed on the medicine
Compared to the group with five years of tamoxifen treatment, women taking tamoxifen for 10 years had:
  • Fewer breast cancer recurrences (21.4 versus 25.1 percent)
  • Lower mortality from breast cancer (12.2 versus 15 percent)
  • Reduced overall mortality (639 deaths vs. 722)
  • Greatest improvements shown in second decade after diagnosis
    • 25 percent lower recurrence rate
    • 29 percent lower breast cancer mortality rate
Findings were reported after more than seven years of follow-up and looked at results from years 5 to 14 after the women were first diagnosed.  
The risk of endometrial (uterine) cancer, a rare but serious side effect of tamoxifen, rose among women age 50+ in the 10-year group, but not among premenopausal women. Endometrial cancer is very treatable, so the cumulative risk for death was 0.4 percent for the 10-year group compared to 0.2 percent for the five-year group.
The researchers concluded that women with estrogen-positive breast cancer who stay on tamoxifen for 10 years will further reduce recurrence and mortality.
What This Means for You
You may be taking tamoxifen on a five-year schedule and now wondering whether you should stay on the medicine for 10 years. Or, if your tamoxifen therapy is completed, you might want to know if you should start it again.
Every woman’s situation is different, so talk with your oncologist about whether extending treatment is right for you. Some things to think about:
  • Tamoxifen is beneficial for a long time, even when taken for only five years
    • The new study shows benefits can last longer with 10-year treatment
  • Tamoxifen may cause side effects such as hot flashes, vaginal dryness and fatigue, which may be hard to tolerate
    • Your healthcare team can offer ways to ease side effects so you will be able to stay on the medicine
    • If your risk of recurrence is low (ask your doctor) but side effects are difficult, you might decide to take it for only five years
  • Tamoxifen poses rare but serious risks such as blood clots and endometrial cancer
    • Risks for most women are far less than the reduction of breast cancer deaths achieved through longer treatment
  • Because tamoxifen can damage a fetus, you should not get pregnant while taking it. Adequate non-hormonal contraception is critical if you are premenopausal and taking tamoxifen—your doctor can help you.
    • For family planning reasons, you might decide to stop tamoxifenafter five years of treatment
  • Many breast cancer experts believe this study will change the standard length of time for tamoxifen treatment, but others consider the gains to be only modest
  • If you completed five years of tamoxifen and are now postmenopausal, your doctor may suggest you take an aromatase inhibitor for five additional years instead of tamoxifen
This study’s findings could apply to other hormonal therapies. Research is ongoing to see whether postmenopausal women would benefit from taking aromatase inhibitors for 10 years instead of the standard five. When that research is published, we will report it at lbbc.org. 
This article was supported by Cooperative Agreement Number DP11-1111 from The Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

Thursday, January 24, 2013


New Drug Target for Her-2 Related Breast Cancer

Jan. 22, 2013 — Research led by Dr. Suresh Alahari, the Fred Brazda Professor of Biochemistry and Molecular Biology at LSU Health Sciences Center New Orleans and its Stanley S. Scott Cancer Center, details exactly how the Her2 cancer gene promotes the progression and spread of breast cancer cells. The inactivation of a tumor suppression gene called Nischarin is among the mechanisms identified. The findings provide a new therapeutic target to block the function of Her2.
The research was published inCancer Research, Online First on January 21, 2013.
About 30% of breast cancers are positive for the Her2 oncogene. Although this gene is implicated in breast cancer, the exact mechanism has been unknown. In this study, the researchers showed that the Her2 oncogene activates two short microRNAs, called miR-27b and miR-23b, which in turn regulate breast cancer progression and lung metastasis. The study also shows, for the first time, that these microRNAs inactivate the function of a tumor suppressor gene called Nischarin, that Dr. Alahari's lab discovered.
Analysis to determine which of a number of cancer-related genes could be potential targets for miR-23b/27b found that only one other gene and Nischarin were directly targeted, and these microRNAs repressed its function. Nischarin is a novel protein that regulates breast cancer cell migration and movement. In a previous study, Dr. Alahari found that breast tumor growth and metastasis were reduced in the samples where they manipulated the overproduction of Nischarin.
"Our data for the first time show that these two microRNAs are highly expressed in breast cancer patients, and we were able suppress the expression of microRNAs using a novel antisense compound that led to inhibition of breast tumor growth in a mouse model," notes Dr. Alahari. "This study will be helpful in developing novel breast cancer therapeutic drugs that target mciroRNAs in breast cancer patients."
Excluding skin cancer, breast cancer is the most common type of cancer among women in the United States. The American Cancer Society estimates 232,340 new cases of invasive breast cancer among American women this year, and 2,240 among men in the US, with 39,620 deaths in women and 410 deaths in men.
Risk factors include aging, weight gain, combined hormone therapy, physical inactivity, and alcohol consumption. A family history increases risk, as does never having had children or having a first child after age 30. Mammography can often detect breast cancer at an early stage when treatment options are greatest and a cure is possible.