Transcript

Disclaimer: All information provided during this chat is intended for your general knowledge and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for any specific health issues and consult your physician before starting a new fitness regimen.

Thank you very much for joining us today for our online chat with breast surgeon Dr. Barbara Ward and oncologist Dr. Dickerman Hollister.

The chat will begin at noon. We will try to answer as many questions as possible during this one-hour chat session.

Here is our first question:

Question: What is your recommendation if I test positive for the BRCA1 gene or the BRCA2 gene?

Dr. Ward: That is a good question. You are referring to the blood test that states that a person is a carrier for the BRCA1 or BRCA2 genes. These patients have about an 85% chance of developing breast cancer in their lifetime. Therefore they are screened every three months using mammogram, ultrasound, and breast MRI. Additionally, they may elect to have prophylactic mastectomies with reconstruction. They also need have their ovaries monitored or removed as these patients are also at risk for ovarian cancer.

Question: I just had surgery. The tumor was removed and the doctor said that I'm fine. What does that mean? And, what's the risk of it coming back if he removed it all? What does recurrence mean?

Dr. Hollister: When the primary breast cancer is removed, the specimen is sent to the pathologist. He or she will examine the various characteristics of the tumor and any lymph nodes that the surgeon obtains. That information will help your oncologist predict the chance of this breast cancer returning.

There are two kinds of recurrence. The first is a “local recurrence”. That means the tumor comes back in the same breast. It is treated by additional surgery, which could be either another lumpectomy or a mastectomy. The second one is more serious. That is the "distant recurrence," where breast cancer has spread to another organ, such as the bone, liver or lung. That will require a systemic treatment, i.e.: a medical treatment as opposed to surgery. Such treatments could be hormone therapy and/or chemotherapy.

Moderator: A question about family history...

Question: If I don't have a family history of breast cancer, what are the changes I will get it?

Dr. Ward: That is also a very good question. The main risk for getting breast cancer is being female. Eighty percent of women who develop breast cancer do NOT have a family history or any other obvious risk factors. There is a model to estimate the risk of developing breast cancer called the GAIL Risk Model. You can access it via the National Cancer Institute's web site. It includes age, age that one started their period, age that she had her first child, number of first-degree relatives with breast cancer, number of breast biopsies, and whether or not they showed atypical hyperplasia.

Moderator: Dr. Hollister will answer this next question.

Question: Controlled studies have shown that there are less recurrences among post-menopausal women with hormone receptor breast cancer who are advised to take aromatase inhibitor Arimidex (anastrazole) for five years following their cancer treatment. The benefits of continuing the adjuvant treatment past the 5 years are currently under controlled studies. Do you recommend these women to continue with the adjuvant treatment past the 5 years?

Dr. Hollister: There is a great deal of controversy among oncologists about the optimal duration of hormone treatment. Currently, five years is the minimum recommended either for tamoxifen or one of the aromatase inhibitors such as Arimidex. Many patients will take two years of tamoxifen followed by three years of Arimidex, or five years of either drug alone. In some women at very high risk of recurrence, oncologists are recommending up to ten years of aromatase inhibitor. That is certainly a very reasonable approach.

Moderator: Dr. Ward will answer the next question.

Question: What are the different options for reconstruction if a woman requires a mastectomy?

Dr. Ward: There are now a number of options for reconstruction. Interestingly, some women prefer not to be reconstructed, and for them that is the right option. On the other hand, most women prefer reconstruction and this can be done using implant reconstruction or tissue reconstruction. Implants generally require a two step process with the first being placement of a tissue expander followed by permanent implant placement. Tissue reconstruction can be done for those with enough body fat. We are happy to offer new techniques called the DIEP flap, GAP flap and other techniques.

Moderator: Dr. Hollister will answer the next question. Here's information about a test for ovarian cancer.

Question: Is the new test for ovarian cancer, OvaSure, applicable to breast cancer survivors?

Dr. Hollister: The screening to detect early ovarian cancer is another controversial area. Despite many studies using the tumor marker CA125 with frequent ultrasound examinations of the ovaries, we have not been able to reliably diagnose early ovarian cancers and increase our cure rate for this disease. Many of these tests are under development to improve on our ability to diagnose this disease early. But we cannot recommend any particular test as of proven benefit at this time. We do recommend that the patient consult her gynecologist regularly, and certainly if found to be a gene carrier for either BRCA1 or BRCA2 to consider surgical removal of the ovaries after childbearing.

Moderator: Dr. Ward will answer the question about what is unique about the Breast Center at Greenwich Hospital.

Dr. Ward: Thanks for that question. Although not necessarily exclusive to our Breast Center, there are a number of things that makes it special. The Breast Center is located in the Cohen Pavilion, which also houses the breast surgeons’ offices, as well as the medical oncologists and radiation therapy center. For the patient diagnosed with breast cancer, she can receive most if not all of her care in one location. Our radiologists speak directly to the patient after her diagnostic mammogram or ultrasound. This direct communication is extremely helpful. Mammogram and ultrasound pictures are directly sent to the surgeon's office via the computer, also assisting in efficiency and accuracy. The patients are often seen the same day and her pictures can be reviewed with the patient. We have a nurse navigator and cancer counselor to help as well. After patients have completed their treatment we offer the NEXT Step program to assist in “Nutrition, Exercise and other Therapies” as needed.

Moderator: Dr. Hollister will answer the next question.

Question: I went through 6 cycles of IVF and now I have breast cancer. Did the drugs I took cause breast cancer?

Dr. Hollister: No one knows for sure. What we do know about breast cancer is that in the post-menopausal patients who have chronic, low-dose estrogen therapies as hormone replacement do have an increased risk for breast cancer. Your situation is quite different. You are pre-menopausal, and have had brief periods of high-dose hormone therapy. We do not have enough data to know whether there is any increased incidence of breast cancer among IVF patients. The problem is complicated by the fact that IVF patients tend to be at the end of their childbearing years when the risk of breast cancer is already increasing. I do believe that given the insufficient information, that women who wish childbearing should pursue IVF if needed. This is because, if there is any increased risk of breast cancer, I suspect it is quite small.

Moderator: The questioner was asking about whether African American women are at any greater risk for breast cancer.

Dr. Ward: That is an interesting question. Young African-American women are at a higher risk for breast cancer and this risk decreases with age such that an older African-American woman is at a lower risk in her later years.

Moderator: Here is another question for Dr. Hollister.

Question: Could you please explain the relationship, if any, between breast and ovarian cancers and the relationship between infertility and those cancers?

Dr. Hollister: The major link between breast and ovarian cancer occurs in the patients who test for BRCA1 or BRCA2. In patients for whom those tests are negative, there may be a very slight increased risk of ovarian cancer and other tumors of glandular tissue such as colon cancer. Because of this I recommend that all my breast cancer patients see their gynecologist at least annually and have a colonoscopy if they are over the age of 45, every 5-10 years. There is a slight increased risk of breast cancer among women who have never been pregnant.

Moderator: Here's a question for Dr. Ward.

Question: What is your feeling about removing a breast because of a threat of cancer? I have a friend who had breast cancer and had the infected breast removed, but also had the other healthy one removed as a precaution. What do you think?

Dr. Ward: Many women opt for surgery on both breasts. This is called bilateral mastectomies. Young patients are particularly interested in this to recreate symmetry and to decrease the need to have the opposite breast monitored.

Question: Is there a relationship in risk factors for breast cancer if there is a close family history of prostate cancer (and vice versa)?

Dr. Ward: There is a relationship of breast and prostate cancer if there is a family history of carrying the BRCA2 gene.

Question: I am 37 and my mother and her sister had breast cancer. Should I be tested for the BRCA1 or BRCA2 gene? What does it mean if I test negative? Does that mean I won't get breast cancer?

Dr. Hollister: This is a terrific question! The current recommendation is that the first persons to test in a family are those who have already had breast cancer. In your case, your mother and/or your sister. If either of them test positive for either BRCA1 or BRCA2, you, too, should consider testing yourself. If they are positive and you are negative for this gene, then your risk of either breast or ovarian cancer is the same as anyone else's. If they are negative, then that information is less helpful because there are undoubtedly other genes which we have not yet identified that can lead to familial breast cancer. Therefore, you could still be at increased risk for breast cancer. Finally, if both your mother and your sister are negative, there is no reason for you to have a gene test.

Question: Is the Cancer Center at Greenwich Hospital approved by the Commission on Cancer?

Moderator: Dr. Hollister will answer this question.

Dr. Hollister: I am pleased to say that Greenwich Hospital is approved by the Commission on Cancer. Our most recent approval was given with eight commendations, which puts us in the very top of community cancer centers in the nation.

Question: Doctor, I got a pathology report that I'm not confident is correct. Do you believe that they (pathology reports) are always accurate?

Dr. Ward: Pathology reports are typically accurate. Having said that, pathology slides can always be reviewed by other pathologists at the same institution and sent to outside institutions. There can be a difference in opinion among pathologists, in which case the slides are sent to an expert in that particular specialty. This can be common when "atypical hyperplasia" is a question. Additionally minor (typo) issues can occur and, of course, can be corrected after the fact.

Moderator: The next question is for Dr. Hollister.

Question: Why do some patients get Herceptin and others don't?

Dr. Hollister: One of the major breakthroughs in the treatment of breast cancer in the last decade has been the development of the antibody called Herceptin. This drug is given in conjunction with traditional chemotherapy to further reduce the risk of breast cancer occurrence in newly diagnosed patients, and also to treat women whose breast cancer has recurred. However, only about 30 percent of women with breast cancer will have tumors that respond to Herceptin. Herceptin will be of no benefit to the remaining 70 percent. To determine if your cancer is sensitive to Herceptin, the pathologist will run tests on the tissue. This can be done even if your surgery was years ago, as the specimens are retained by the hospital. You should discuss your own situation with either your medical oncologist or surgeon, as every case is different.

Moderator: Dr. Ward will answer the next question.

Question: Doctor, do you recommend MRI's for women with cystic breasts?

Dr. Ward: I may recommend MRIs for some women with extremely cystic, that is dense, lumpy breasts. The American Cancer Society has recommended that MRIs be considered if the patient has a greater than 20-30% lifetime risk of breast cancer. At the same time, not all insurance companies pay for the test, even in women diagnosed with breast cancer.

Question: Doc, if I have an annual mammogram do you think that's enough to prevent/detect breast cancer or is there something else I should do?

Dr. Ward: Thank you for your question. As you know, the act of getting a mammogram will not prevent breast cancer. By getting your annual mammogram, if you are over 40 years of age, you are taking an excellent first step for early detection of breast cancer. You should also do a monthly self exam and see your doctor or nurse practitioner for an annual exam. Your primary care provider can also guide you regarding the role of other imaging such as breast ultrasound and MRI. If a woman has a lumpy breast and a dense mammogram, we tend to add breast ultrasound to the annual exam.

Question: What are the new discoveries and treatments on the horizon?

Dr. Hollister: A host of new treatments are under development. In terms of systemic treatment, there are new drugs that act differently than traditional chemotherapy. One class is the m-TOR inhibitors, which are now undergoing clinical trials. There are more traditional chemotherapy agents under development, which your oncologist can recommend in the setting of a clinical trial. Finally, there are new supportive treatments that are becoming increasingly important, such as the use of Zometa to lessen the incidence of thinning bones (osteoporosis) after treatment.

Dr. Hollister: Dr. Ward and I have been very pleased to answer your questions. There is much more to say about new developments in breast cancer. The prognosis has never been more optimistic. Thank you for joining us.

Conclusion
Thank you very much for joining us today for our online chat with oncologist Dr. Dickerman Hollister, Jr. and breast surgeon Dr. Barbara Ward. Please feel free to e-mail this transcript to others who you feel will be interested. Information is provided below if you wish to schedule an appointment with Dr.Hollister or Dr. Ward.

Dickerman Hollister Jr., M.D.
Hematology & Oncology Associates of Greenwich, LLP
77 Lafayette Place, Suite 260
Greenwich, CT 06830 - map
Telephone: (203) 863-3737

Dr. Barbara Ward
Breast Care Services of Greenwich, LLC
77 Lafayette Place, Suite 302
Greenwich, CT 06830  - map
Telephone: (203) 863-4250