Oncologist is Optimistic


Our meeting on Thursday (1/30/03) with Dr. Douglas Merkel, Ann's medical oncologist was very informative. Baring any surprises in oncology and pathology second opinions, we expect Ann to begin her chemotherapy on Friday, 2/14/03.

TYPES OF THERAPY

There are different ways to classify breast cancer therapies. Knowing how therapies are classified helps to explain the role of a medical oncologist.

By one approach, a therapy can be either "local" or "systemic." Local therapies are directed at the location of the cancer, the breast itself. Surgery and radiation are examples of local therapies. Systemic therapies are directed to the the body as a whole. Chemotherapy and hormonal therapy are examples of systemic therapies because they are administered through the bloodstream and thus reach every part of the body.

Another approach is to classify therapies into either "primary" or "adjuvant" therapies. (Sometimes the term "additional" is used instead of "adjuvant.") Primary therapy for breast cancer is surgery. Chemotherapy, hormonal therapy, and radiation therapy are adjuvant therapies that work in conjunction with surgery to improve the result, e.g, survivorship and quality of life.

Medical oncologists specialize in chemotherapy and hormone therapy. Thus, they administer systemic, adjuvant treatments that improve the effectiveness of surgery.



HOW CHEMOTHERAPY WORKS

When cells reproduce they go through several steps in a process called cell division or mitosis. Chemotherapy interferes with mitosis so that cells can not divide and consequently the cells die instead of reproducing. Unfortunately, both normal cells and cancer cells go through mitosis and chemotherapy is not selective in the type of cells it targets; it affects all dividing cells. And since chemotherapy is systemic, it kills both normal and cancer cells throughout the entire body.

Chemotherapy's effect is greatest on the cells that are reproducing the most quickly, namely hair, bone marrow, and--most importantly--cancer cells. The effect on bone marrow is potentially dangerous because bone marrow is where red cells, white cells and blood platelets are made. Chemotherapy also kills dividing cells in the ovaries and may result in a chemically-induced menopause complete with all the symptoms experienced in normal menopause including: hot flashes, mood swings, and loss of menstruation.

One reason that chemotherapy is given in cycles is to give the bone marrow a chance to recover between doses so that it doesn't shut down altogether. Nevertheless, chemotherapy does kill enough normal cells to cause: loss of hair, lower energy levels due to lower red blood cell counts, less resistance to infection due to lower levels of white cells, and slower clotting of blood due to the reduced number of platelets. Blood tests are done each cycle and chemotherapy dosages are adjusted to make sure that counts don't drop too far.

Another reason for giving chemotherapy in cycles is that not all cancer cells are dividing at the same time. The first cycle will kill the cancer cells dividing at that time. Each following treatment will kill cancer cells dividing at that time. After several cycles, the number of cancer cells that are still left is hopefully so small that a strong immune system can finish them off.



CONSULTATION WITH DR. MERKEL

Dr. Merkel started his evaluation of Ann's case with a simple statement: Ann's breast cancer should be talked about in the past tense. It was cut out. The pathology reports confirm that the tumor was removed. The breast cancer is gone. His role is to administer treatments that reduce the chance of the breast cancer coming back.

There are two ways that breast cancer can come back.

One way, called recurrence, would be for a breast cancer tumor to appear in either breast. Recurrence could be treated with surgery again and potentially cured.

Another way for cancer to come back, called metastasis, would be for a tumor to appear in another part of the body. Cancer tumors, like all tissue, shed some cells and these cells can travel through the lymphatic system and bloodstream to other places in the body. Normal cells will eventually die after they are shed. Unfortunately, tumor cells sometimes continue to live in their new location and start to grow there. There are treatments for metastasis but currently there is no cure.

The purpose of the oncological treatment plan is to prevent breast cancer from coming back in any part of the body by preventing any stray breast cancer cells from reproducing.

As you recall, a very small amount of cancer was found in two of Ann's lymph nodes. Tumor cells may have moved to other places too but there is no way to surgically remove them because there is no way to detect them this early. The only way to kill these additional cells, if any, is with a systemic treatment.



PATHOLOGY AND OTHER FACTORS ARE FAVORABLE

Dr. Merkel highlighted three factors in Ann's case that are very favorable.

1. Ann's tumor is very receptive to estrogen. Normal breast tissue is stimulated to grow by exposure to the female hormone estrogen. In Ann's case, her breast tumor retained this response; it will also be stimulated to grow in the presence of estrogen. This means that depriving the tumor of estrogen will lessen its growth and hasten its death. It turns out that depriving her tumor of estrogen is the most important thing that an oncologist can do to improve Ann's chances of survival. In fact, hormonal therapy reduces the chance of cancer coming back by half!

2. Ann's tumor tested negatively for HER-2/neu which means that it is not as aggressive as it could be...which is good news!

3. Ann's case falls in the category of a pre-menopausal woman with 1-3 positive lymph nodes. Generally chemotherapy reduces the chance of cancer coming back by only about a third. The good news is that for Ann's category, chemotherapy can reduce the chance of cancer coming back by forty percent.



EXPECTED 5-YEAR DISEASE FREE SURVIVAL RATES

Dr. Merkel indicated that based on what has happened to other women like Ann, there is a 40% chance that cancer will come back within 5 years if she does not have systemic treatments to mop up stray tumor cells that may be still in her body. She cuts that in half (40% goes down to 20%) if she has hormone therapy to avoid stimulating her tumor cells with estrogen. If she has chemotherapy in addition to hormone therapy she reduces the risk by another 40% (20% goes down to 12%). So, the bottom line is that if she does both hormone and chemotherapy she has an expected disease-free survival (DFS) rate of 88% for five years.

Obviously, these number represent averages and Ann's case is individual. We don't want to focus on the exact numbers; you may find other sources with somewhat different numbers for a variety of reasons. What we want to focus on is the good news that Ann has two separate, additive weapons with which to fight this cancer, namely both hormone therapy and chemotherapy.


RECOMMENDED TREATMENT PLANS

Chemotherapy comes before hormone therapy (and radiation therapy).

Dr. Merkel offered two alternative chemotherapy plans.

1. FEC, a combination of

    fluorouracil (also know as: 5-fluorouracil, 5FU; brand: Adrucil),
    epirubicin (brand: Ellence), and
    cyclophosphamide (brand: Cytoxan)


2. TAC, a combination of

    Taxotere (generic: docetaxel),
    Adriamycin (generic: doxorubicin), and
    cyclophosphamide (brand: Cytoxan)

The second option (TAC) is more aggressive and slightly more effective than the first (FEC). Dr. Merkel indicated that TAC will make Ann more vulnerable to infections and so she would need frequent injections at home to stimulate the production of white blood cells. The benefit of TAC is that it would raise her 5-year DFS two percentage points from 88% to 90%. Ann is currently leaning towards the first option, FEC.

Additional information about these drugs is available online.

  Overview of breast cancer chemotherapy and classes of drugs

    http://imaginis.com/breasthealth/chemo.asp
    http://imaginis.com/breasthealth/drugs.asp
    http://www.susanlovemd.com/decision/c_4_2_1_1.htm


  FEC Studies

    http://www.cancerconsultants.com/syndication/veContent.jsp?ArticleID=breast_jan03_3&ArticleTypeID=News
    http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12525522&dopt=Abstract
    http://imaginis.com/breasthealth/news/news9.16.99.asp
    http://www.pslgroup.com/dg/12c24e.htm

  TAC Studies

    http://www.cancerconsultants.com/syndication/veContent.jsp?ArticleID=breast_may02_7m&ArticleTypeID=PRON
    http://www.asco.org/ac/1,1003,_12-002388-00_18-0019080-00_19-0019081-00_20-001,00.asp
    http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12170449&dopt=Abstract


  Specific information for individual drugs

  fluorouacil
    http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202245.html
    http://www.cancerbacup.org.uk/info/fluorouracil.htm

  epirubicin
    http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/500038.html
    http://imaginis.com/breasthealth/bc_drugs.asp#Ellence
    http://www.ellence.com/patient/content.asp?ptype=4&sid=2a
    http://www.fda.gov/bbs/topics/ANSWERS/ANS00975.html

  Taxotere
    http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202920.html
    http://imaginis.com/breasthealth/bc_drugs.asp#Taxotere

  Adriamycin
    http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202209.html
    http://imaginis.com/breasthealth/bc_drugs.asp#Adriamycin
    http://www.pharmacia.com/products/pdf/Adriamyc.pdf

  cyclophosphamide
    http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202174.html
    http://imaginis.com/breasthealth/bc_drugs.asp#Cytoxan

Regardless of which drugs she chooses, Dr. Merkel is recommending that they be administered in six, three-week cycles starting some time in the next one to three weeks. We had been expecting only four (three-week) cycles but Dr. Merkel says that six cycles are required for patients with cancer that has spread to the lymph nodes, as in Ann's case.

The drugs are given intravenously taking about 1-2 hours to administer. The veins in Ann's right arm appear to be strong enough to handle the expected treatment. (The left arm must not be used in order to reduce the chance of lymphedema, a condition she is susceptible to since the axillary lymph nodes on her left side were removed as part of her surgical treatment.) A fuller description of the process of administering the drugs is available online.

  http://www.susanlovemd.com/decision/c_4_2_1_2.htm



CHEMOTHERAPY SIDE EFFECTS

Dr. Merkel indicated that each woman may experience chemotherapy somewhat differently. The only thing that he could guarantee was that Ann would loose the hair on her head and that it would grow back. He estimated that she would wear a wig (or hat, scarf, etc.) for a total of eight months before her hair had grown in sufficiently. Trying to look on the bright side, we joke that she will save lots of time getting ready for work in the morning since she won't have to fuss with her hair!

Thanks to referrals from friends, Ann has scheduled a consultation at Salon 475 in Highland Park on Friday, 2/7/03 to discuss wig options. Salon 475 specializes in wigs for cancer patients and more information is available on their website.

  http://chicago-alopecia-cancer-wigs.com/index.html

Dr. Merkel said that he expects that Ann will feel most of her side effects during the two days following each dose and they will include a loss of energy and simply not feeling herself. Some people have described these feelings as flu-like. Nausea is also likely but Dr. Merkel assures us that it can be controlled very effectively with additional medication. He recommended that Ann have her treatments on a Friday so that these side effects are confined to a weekend and the impact on her work schedule is minimized.

Dr. Merkel outlined other likely side effects:

- High Risk of Infection. It is very important that Ann avoid cuts, scratches, etc. (This may be a challenge with our cat, Limpopo!). However, there will be no restriction on social interaction beyond the usual avoiding contact with people who are ill.

- Easy Bruising and Bleeding. Among other things, use an electric razor to avoid cuts from shaving.

- Mouth Sores. Since these sores can be a source of infection it is important to prevent them by brushing teeth with a soft toothbrush, using a mouth rinse several times a day and avoiding spicy, crunchy, or acidic foods or very hot or cold foods.

- Menopause. Chemotherapy may push Ann into menopause and if so she may or may not regain her fertility several months after chemotherapy ends. Even if chemotherapy does not cause menopause, pregnancy during treatment must be avoided since chemotherapy may be harmful to the fetus.

Other possible side effects include (in no particular order): taste changes; decreased appetite; diarrhea or constipation; tingling or burning sensations; numbness in hands and/or feet; skin irritations (redness, itching, peeling, or acne); dark, brittle, or cracked fingernails or toenails; kidney/bladder infections; heart problems; fluid retention; and muscle or joint pain.

Needless to day, both of us feel a lot of anxiety about what is in store for Ann. Dr. Merkel says that patients almost always imagine that chemotherapy will be much worse than it turns out to be. We hope this will be the case with Ann.



HORMONE THERAPY

Dr. Merkel did not discuss the details of hormone therapy with us other than to say that it would commence several weeks after chemotherapy ends.

Based solely on our reading, we assume that hormone therapy would consist of taking tamoxifen (brand: Nolvadex) for five years. (We do not know whether hormone therapy must be postponed until radiation therapy is complete.)

More information about hormone therapy with tamoxifen is available online.

  http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202545.html
  http://imaginis.com/breasthealth/tamoxifen.asp
  http://www.ucdmc.ucdavis.edu/ucdhs/health/a-z/06BreastCancer/doc06hormone.html
  http://www.cancerbacup.org.uk/info/tamoxifen.htm
  http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Hormone_Therapy_5.asp
  http://www.umm.edu/breast/tamox.htm



NEXT STEPS

As you know, we still have a second-opinion oncology consultation scheduled with with Dr. William Gradishar at Northwestern Memorial Hospital (NMH) in Chicago on Monday, 2/10/03. We are also awaiting the NMH second-opinion pathology report on Ann's surgical specimens, i.e., breast tissue and lymph nodes removed during her surgery on Friday, 1/17/03.

If there are no surprises in either of these second opinions, we expect that Ann will begin her chemotherapy with Dr. Merkel at Evanston Hospital on Friday, 2/14/03.

We plan to celebrate Valentine's Day a week early.

Love

Ann and Nello











Posted: Sun - February 2, 2003 at 12:00 AM        


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