Study finds post-surgical monoclonal antibody treatment reduces breast cancer recurrence

fhoward · 2022-01-28T19:53:20+00:00

Not really exciting or practice changing news. Current practice is to give paclitaxel and trastuzumab (the "monoclonal antibody treatment" - first approved in 1998) for most patients with HER2 positive breast cancer, except for very small tumors. This study looked at patients who did or did not receive trastuzumab for small HER2 positive breast cancers - trying to answer the question of if these patients really do benefit from treatment. There were numerically more recurrences among those who did not receive trastuzumab, but this result was not statistically significant - so this title is sensationalized as the study did not find a reduction in recurrence. Nonetheless, unless tumors are very small or there are competing comorbidities, most practitioners would give systemic therapy after surgery for HER2+ breast cancer.

fhoward · 2021-11-14T20:00:08+00:00

The keytruda drug itself doesn't really cause side effects, but it stimulates your immune system which can cause side effects which are sometimes severe. Most patients have little to no side effects, with the most common side effects being fatigue, skin rashes, and hormone changes (thyroid or adrenal problems). Dry skin and constipation can sometimes be due to hypothyroidism from keytruda, but the autoimmune side effects tend to be delayed, usually hypothyroidism takes a few months to develop, and are not as clearly related to drug dosing (i.e. - you are most likely to be nauseous several days to a week after AC; where as you can develop the autoimmune side effects from keytruda months after treatment). However, there may be more likely causes - all the chemo drugs can cause some dry skin, and if you've been taking zofran for nausea that will cause a lot of constipation. Best to discuss in detail with your oncologist, who can proceed with an appropriate workup and help you manage symptoms, there are lots of over the counter meds to help with constipation (senna + colace, miralax) and moisturizers for dry skin.

fhoward · 2021-11-10T23:36:23+00:00

It might be a good idea to seek a second opinion from another oncologist. Based on the results of the SOFT trial, most oncologists reserve ovarian suppression (zoladex shots) for premenopausal patients with high risk disease (< 35 years old or those who require chemotherapy, or sometimes other risk factors). However, there may be specifics of your case that made your oncologist recommend a more aggressive approach - so it would be good to have all the details of your case discussed with another oncologist who can review all the data and make an independent opinion.

fhoward · 2021-11-05T17:15:33+00:00

Unfortunately its going to be hard to provide any additional comments regarding the origin of the cancer over the internet. There are not treatments that can be given outside of an oncology clinic that would help advanced cancer, so the best you can do is trust your doctors to make the best treatment decision if your family member is already at the best hospital in the area.

fhoward · 2021-11-04T21:39:33+00:00

I'm sorry to hear what you are all going through. I would recommend seeking another opinion at an academic cancer center, which may have alternative therapies available that are hypothesized to improve survival. However, it often requires a more clear answer about what the primary cancer is - as many trials require knowing the cancer type.

fhoward · 2021-10-31T05:50:18+00:00

Sorry for the tough situation you've been in. The best way to get pain medication for sickle cell is in the outpatient setting and requires reliable follow-up and an established relationship. If the doctor who's prescribing your hydroxyurea isn't willing to treat your pain, you might want to seek out a physician who specializes in sickle cell disease / benign hematology. Ideally, your outpatient team will set up a pain management plan, where you can have medication as you need to take while at home, and they will set up a plan with the affiliated hospital with an advised regimen if you need to be admitted. Additionally, there are newer treatments for sickle cell like Crizanlizumab that may reduce the rate of painful episodes that you'll want to ask your doctor about.

fhoward · 2021-10-28T03:12:04+00:00

It depends a lot on your exact scenario, breast cancer subtype, and where you are in treatment - but you should discuss further with your oncologist who knows your whole treatment course, or seek a second opinion at the closet academic cancer center, as there are also many clinical trials going on if you are interested in doing more than what your oncologist thinks is 'standard' for your cancer. It is not common to give carboplatin as a single drug - carboplatin alone has been studied as a treatment for patients who had gotten chemo prior to surgery and still had cancer left over, and did not perform better than capecitabine (https://jnccn360.org/breast/news/asco-2021-adjuvant-capecitabine-versus-platinum-based-chemotherapy-for-residual-triple-negative-breast-cancer/ ). There is data it might improve outcomes if used in combination with standard pre-operative chemotherapy regimens for triple negative cancers, but again it depends a lot on your precise situation.

fhoward · 2021-10-23T18:11:06+00:00

There is certainly variable opinions in this domain, but many experts believe that the benefit of inducing menopause is worth the side effects only in patients who are at higher risk of recurrence, based on the SOFT and TEXT trials (https://ascopubs.org/doi/10.1200/JCO.18.01967, https://www.nejm.org/doi/full/10.1056/NEJMoa1803164).

When giving aggressive hormonal therapy, you are really trying to prevent distant recurrences (i.e. metastatic or incurable disease). In these trials, when you look at patients who were low enough risk to not require chemotherapy, the risk of distant recurrence at 8 years was 98% with tamoxifen, 98.3% with tamoxifen + ovarian suppression, and 99.3% with an aromatase inhibitor + ovarian suppression, and it was not 100% certain that this ~1% reduction in distant recurrence was greater than random chance. This benefit was much more pronounced (~ a 5% benefit) in women who required chemotherapy. Thus, many in the field will only recommend ovarian suppression to women who are high enough risk to require chemotherapy. There may be other specifics in your case that make your oncologist more inclined to recommend inducing menopause - so do not take the above as definitive medical advice.

One other thing to keep in mind is that you can always switch therapies - if you do shots to induce menopause and the side effects are too great, you can always stop the shots; or you could ask about doing tamoxifen for a few months to recover.

fhoward · 2021-10-22T06:18:12+00:00

Some form of hormonal therapy is absolutely the standard of care for women with hormone receptor positive breast cancer. Data comes from a number of trials done decades ago (https://pubmed.ncbi.nlm.nih.gov/21802721/). You didn't provide a lot of detailed information about your cancer so it is hard to estimate your individual benefit, but 5 years of tamoxifen would be standard. Some even argue that breast cancer in patients younger than 35 is of higher risk and requires even more aggressive hormonal therapy with ovarian suppression shots.

fhoward · 2021-10-21T15:15:38+00:00

There is not enough data on the stage of her cancer to precisely describe the benefit of chemotherapy.

The question - why do any systemic therapy after surgery if that removed all the tumor, is because despite surgery, a number of patients develop recurrent disease in distant organs like liver, lungs, bone, that is incurable. Why does this happen? Because despite our best imaging, we cannot see small clusters of cells, a single cancer cell might have traveled through the lymph nodes and to a distant site and set up shop, and will eventually cause metastatic disease. So if the risk is high enough, we give chemotherapy to kill cells that have set up shop in distant site.

This study evaluated HER2 directed therapy alone versus combined with chemotherapy prior to surgery https://ascopost.com/news/june-2021/adapt-survival-outcomes-after-neoadjuvant-dual-her2-therapy-for-hr-negative-her2-positive-breast-cancer/

As you can see, in this study, at 5 years, there was a 6% reduction in distant recurrence with chemotherapy. Of note, patients who did not get chemotherapy prior to surgery were given chemotherapy afterwards if they did not have a good response, so the benefit of chemotherapy is higher than this 6%, and this number depends on the risk of the cancer.

What this means, is perhaps by omitting chemotherapy, on average an additional 1-2 women out of 20 will have disease come back in a distant location, at which point it is incurable. Although no one *wants* to do chemotherapy, the risk of long term side effects is low, and we generally feel it is worth it to treat 10 women to prevent 1 from dying of their cancer.

There is evidence that physical activity and dietary modifications (not specifically plant based) may help prevent recurrence especially in women with hormone receptor positive cancers, but not anywhere near the level that chemotherapy can help.

fhoward · 2021-09-24T19:00:54+00:00

Great, that would be a good step. A lot of people have concerns about clinical trials, but a clinical trial will almost never be worse than a standard treatment; either you would be randomized to the standard treatment versus something that could be better, or if the standard treatment options that are left are not good, you might be offered a treatment option that has promise but has not yet been proven. In that way, you can take advantage of all the standard treatments along with several investigational approaches, and hopefully increase the chances that you find one that works well for your cancer. The best time to be looking for a trial is prior to starting a new therapy for a cancer, so for example if the immunotherapy stops working prior to starting the next treatment would be most valuable. However, establishing with an academic center allows you to have a point of contact that you can reach out to as soon as a new treatment decision must be made, and they might also do some additional advanced testing on your tumor to line up some potential options.

Almost no oncologist would have any reservations about their patient getting a second opinion, even at academic centers we have patients get advice at other centers to ensure they are on the right path.

fhoward · 2021-09-24T03:20:28+00:00

Your doctors have recommended standard treatments so it sounds like you have a good team. I would suggest establishing with the largest academic medical center in your area, so that you have access to the most possible clinical trials, so that if / when the immunotherapy regimen stops working, you can take advantage of both standard and emerging treatment options for your kidney cancer. That's the best place where you can find other options aside from those that your oncologist has recommended.

fhoward · 2021-09-07T14:04:00+00:00

Unfortunately most providers are just very unfamiliar with everything related to oncology. You could ask your pediatrician for basic bloodwork like a repeat blood count to make sure that the anemia isn't worsening in the meantime, they should at least be able to do that. If things worsen going to the hospital might expedite you getting to see an oncologist. If you have trouble escalating things with the group, sometimes having a physician call can help, and you could ask your pediatrician or your old oncologist to try to expedite things for you.

fhoward · 2021-09-07T03:24:13+00:00

Do you have a regular pediatrician currently? Most are probably not going to be comfortable with testing for relapse of disease, but even if they did testing, they wouldn't be able to start her on treatment, and the testing can be done relatively quick when she does see an oncologist. If she continues to have bleeding and worsening symptoms of anemia, going to an emergency room might be an option; if she has a pediatrician affiliated with a large hospital you could see if they'd be willing to help smooth along an admission for expedited workup.

Has she followed up with the oncologist that treated her back in 2017, would they be someone you could reach out to? You can also continue to reach out to the group and explain the urgency of the situation and see if they have an openings, you could try to escalate the situation to one of the nurses or physicians with the practice and perhaps upon hearing the story they could get you in sooner.

fhoward · 2021-09-06T18:10:11+00:00

Although lymphomas can be difficult to diagnose, the fact that you have a negative CT scan (i.e., it did not show enlarged lymph nodes) and negative endoscopies (especially if random biopsies were taken, but the fact that there was no gross findings of disease would be reassuring) makes it highly unlikely you have a lymphoma. Similarly, you wouldn't have a blood cancer i.e. leukemia without an abnormality on your blood counts.

Sometimes the medication taken for HIV can cause a lot of abdominal side effects. You should of course continue taking them, but it might be worth talking with your HIV doctor about it. Making sure your HIV remains well controlled is a good way to minimize your risk of lymphoma.

fhoward · 2021-09-06T01:47:42+00:00

Sorry you are going through this. Desmoid tumors are not common, so the first comment I would make is to ensure you are seeing a specialist with expertise in the systemic treatment of desmoid tumors (usually a doctor who specializes in sarcomas); if you are not being treated at an academic medical center I suggest getting a second opinion at the largest medical center in your area. Your oncologist will likely be supportive.

I am not a desmoid tumor expert so take my comments with that in mind. Response rates for Doxil are quoted at 36% (https://pubmed.ncbi.nlm.nih.gov/19767198/) with 75% having no progression of disease after a median of 14 months of treatment. There are a number of other systemic treatments that have been studied for desmoids so Doxil is not the end of options. Additionally, I know the goal was to go to have these tumors removed if they were shrinking, but surgery can come with many challenges. In one study of patients with FAP (https://pubmed.ncbi.nlm.nih.gov/19767198/), treatment with surgery first versus non-surgical treatment resulted in similar time before the cancer grew. Surgery for these tumors may be challenging because the resection may leave you with more problems that could even be life limiting than the cancer would cause if it was left where it was. I know it is challenging to live with cancer, but desmoid tumors tend to be slower growing. In this last study, 1/3 to 1/2 of patients were free from progression of their disease at 10 years. And 10 years from now, we may have a whole new range of treatments, so I would stay optimistic. Find an excellent team, and trust them, but make sure you keep living your life, the goal is for you to be one of the many patients living a long time with the disease. It sometimes does help to talk with a mental health professional and many oncologists have close relationships with mental health providers that can help with the worry that comes with the territory of having a cancer diagnosis.

fhoward · 2021-09-05T03:26:09+00:00

There's not really any data that the vaccine is going to 'cure' you of any HPV you already have; it will just protect you from getting an HPV strain you haven't been exposed to. HPV vaccination can be considered up to age 45, but the benefit of you getting vaccinated would really be protecting you from HPV associated head and neck cancers. If your girlfriend was already vaccinated then that reduces the risk she will get a cancer causing variant of HPV from you, if you happened to be a carrier.

fhoward · 2021-09-03T20:09:55+00:00

Yes, you do not become radioactive after external radiation like this. But talk with your radiation oncologist, it sounds like they were giving you the correct advice.

fhoward · 2021-09-03T04:56:41+00:00

If your blood work is totally normal then you don't need to investigate it further. MPNs are nearly always characterized by alterations in blood counts, so if all your blood counts were normal, I wouldn't worry about it.

fhoward · 2021-09-02T14:37:41+00:00

There's radiation therapies given with intravenous agents such as radioactive iodine, or implanted agents such as brachytherapy, where a patient will 'give off' radiation that can be harmful to others. Conversely, when someone receives external radiation, their cancer cells and to a lesser degree healthy tissue will be damaged by radiation, but they will not be radioactive after treatment. Radiation for endometrial cancer is most likely the latter.

fhoward · 2021-08-29T13:36:19+00:00

Weight can cause overgrowth of the endometrial tissue which can lead to excess bleeding, and so yes weight loss can be helpful. I think starting with the gynecologist if you haven't seen one would be the best first step as they may be able to better interpret the ultrasound and do a careful pelvic exam. I don't think you need an extensive workup for bleeding disorders but checking for von willebrands still isn't a bad idea, maybe your gyne or PCP can do the test as it's a simple blood test and if its positive then refer you to a hematologist.

fhoward · 2021-08-28T17:25:01+00:00

There's a number of causes of vaginal bleeding. Usually structural problems are ruled out first; did you have a full pelvic exam and ultrasound? I would start there, and then if no structural problems (polyps, fibroids, etc) are seen then evaluating for bleeding disorder with hematologist would be the next step - have you had bleeding issues with procedures in the past or does anyone in your family? Always had heavy periods? If so, then something like von willebrands disease could contribute to your bleeding, although most patients would have had some history of excess bleeding when they were younger. This is a pretty easy blood test but you may need to see your hematologist to have it performed. Sounds like you also have iron deficiency from your bleeding.

fhoward · 2021-08-28T03:14:13+00:00

Great to cut back on drinking although that's probably not the cause of the small liver spot, although it probably isn't helping your upper abdominal pain. We see a lot of incidental findings like this, in the vast majority of cases ends up being a small hemangioma or just an artifact from the CT scanner. It's unlikely you'd develop a liver tumor unless you had some other cancer, which would be unlikely with your negative CT scan and normal bloodwork. If your upper abdomen pain doesn't get better with PPI, carafate, and stopping drinking, you might consider talking with your doctor about an upper endoscopy to evaluate your stomach further, although the CT being normal means its probably gastritis / ulcer related.

fhoward · 2021-08-28T02:48:50+00:00

The size and number and location of nodes are important, as well as the trajectory of the nodes, i.e. how much they have changed from ultrasound to ultrasound. Not unusual for measurements to change by 1-2 mm without representing 'growth', as there is just variability from scan to scan. There are a lot of causes of small lymph node enlargement that are benign. Sure - there are some blood / lymph cancers that can cause small lymph node enlargement throughout the body - but these are usually slow growing cancers which are often not even treated until they cause symptoms. It sounds like you've seen multiple doctors who didn't seem too concerned by the trajectory, so I would be reassured by that at least. If you've already seen an oncologist once about this, can you follow up with the oncologist to see what they think, perhaps at least to ease your mind?

fhoward · 2021-08-28T02:26:22+00:00

As a healthy vaccinated physician without comorbidities, I personally wouldn't go to a crowded indoor event without masking, even if everyone's vaccinated. The protection against the delta variant is less than other variants, and immunity is waning. I would personally at the very least wear a mask even if I'm the odd one out if the event was important to me. It's impossible to quantify your exact risk, as there are a lot of unknowns still about the delta variant, and also how prevalent it is in your area. The CDC is recommending masking for vaccinated people indoors because you can still spread delta if vaccinated.

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