Technical vs. conventional wisdom

If you're into the breast cancer rates of recurrence conversation (as I am), check out these two articles for some totally different takes.


The full Medscape article is here.

The Mystery of a Common Breast Cancer Statistic -- Solved?
Nick Mulcahy
August 18, 2015

A commonly cited breast cancer statistic — that 30% of all early-stage breast cancers will progress, despite treatment, to deadly metastatic disease — appears to have no strong contemporary evidence to back it up. 

Nonetheless, the statistic appears widely. For example, it is cited in an academic report (J Intern Med. 2013;274:113-126), in a breast cancer charity report, in a pharmaceutical marketing piece, and on a major cancer center website. 

In short, the 30% figure is conventional wisdom — despite the absence of an authoritative epidemiologic source. 

But is that statistic accurate and reflective of current clinical reality? And should clinicians repeat it to patients? Perhaps more importantly, does the statistic really matter? After all, the treatment of women with early-stage disease will not change whatever the statistic is, correct? 

Medscape Medical News went in search of answers to these questions and found angry patients, a clinician author trusted blindly by a lot of people, and special access to a common database that, in fact, appears to solve the mystery of the proportion of early-stage patients who progress to metastatic disease. 

Our story begins with multiple women with metastatic breast cancer who are dismayed or angry about the fuzziness and mystery of the 30% statistic, and have said so online.

I would like to know the true stats of how many breast cancers come back no matter what the hell we do for treatment.

For example, in a 2013 post on the breastcancer.org bulletin board, "SusansGarden" from Gig Harbor, Washington, wrote: "I would like to know the true stats of how many breast cancers come back no matter what the hell we do for treatment." 

The topic has been discussed repeatedly by "metsers" for a few years, but a recent blog post got a lot of attention. 

On July 21, metastatic breast cancer patient and blogger Ann Silberman, from Sacramento, California, examined the 30% statistic. For the individual patient, "none of this matters," she wrote. "You will relapse or you won't." But Silberman, who unsuccessfully looked for a credible source for the statistic for 7 months, added that "it's harmful to mis-state things, use scare tactics, and otherwise try to make a bad thing worse." 

The post, with its reference to scare tactics by prominent breast cancer organizations, including Komen for the Cure, prompted a response from the Metastatic Breast Cancer Network (MBCN), a respected patient advocacy group. (continues on pages 2 and 3.)

NOTE: This next article is NOT the  2005 CME review on metastatic disease referred to above and published in the Oncologist by prominent medical oncologist Joyce O'Shaughnessy, MD, from Baylor University in Houston, which is quoted above.

Images from the full scientific abstract from PubMed are here. 

Breast Cancer Res Treat. 2013 Jan;137(2):449-55. doi: 10.1007/s10549-012-2366-0. Epub 2012 Dec 6.
Effect of HER2 status on distant recurrence in early stage breast cancer.
Hess KR1, Esteva FJ.Author informationAbstract
It has long been recognized in breast cancer that the effect of hormone receptor (HR) status on recurrence rates varies over time and with the site of recurrence. However, there is relatively little in the literature on the effect of human epidermal growth factor receptor 2 (HER2) on recurrence patterns. We wanted to assess whether the effect of HER2 status on the risk of distant recurrence changed over time and/or with HR status and whether these relationships varied with site of recurrence. We retrospectively studied 11,011 women diagnosed with stage I, II, or III breast cancer after 1997 who had data on HR status and HER2 status. 20 % were HR negative and HER2 negative (so-called "triple-negatives"), 7 % were HR negative and HER2 positive, 64 % were HR positive and HER2 negative, and 10 % were HR positive and HER2 positive. The estimated overall cumulative incidence of developing distant metastases is 20 % at 4 years, 30 % at 8 years, and 36 % at 12 years. The 12-year cumulative incidence was 23 % for bone, 16 % for liver, 14 % for lung, 13 % for distant lymph node, 10 % for brain, and 8 % for pleura. After adjusting for potential confounding factors, the nature of the effect of HER2 on recurrence rates was found to differ markedly across the sites of recurrence. For brain and pleura recurrences, the effect of HER2 depended on HR status in ways that significantly changed over time. For bone recurrences, the effect of HER2 did not depend on HR status, but did change significantly over time. For liver and distant lymph node recurrences, there was a significant effect of HER2 status that did not change with time or HR status. For lung recurrences, rates did not significantly vary with HER2 status.PMID:

23225147

 

[PubMed - indexed for MEDLINE] 

PMCID:

 

PMC3544467

 

Shorter radiation is better

Sometimes editing takes out all the important information. This took  a lot of digging to find out what the hell it was talking about.

I first came across this article which says higher dose shorter radiation is better that the traditional radiation given to breast cancer patients. This makes sense because the damage from radiation is cumulative meaning that it gets worse and worse after each treatment. Other side effects such as fatigue are also lessened from the shorter course of treatment.

Well that is nice to know but how much shorter is it? I couldn't tell but did go find the referenced article, Differences in the Acute Toxic Effects of Breast Radiotherapy by Fractionation Schedule: Comparative Analysis of Physician-Assessed and Patient-Reported Outcomes in a Large Multicenter Cohort, on JAMA Oncology. You got that?

How's this instead?

"Randomized trials have established that hypofractionated regimens of radiotherapy to the whole breast can provide long-term disease control that is equivalent to the excellent outcomes of more protracted conventional fractionation schedules in selected patients undergoing lumpectomy for breast cancer. Hypofractionation might also result in lower rates of late toxic effects than conventional fractionation. Although the American Society for Radiation Oncology has issued consensus guidelines to identify patients in whom hypofractionation is appropriate and endorsed consideration of hypofractionation in its Choosing Wisely campaign, uptake of hypofractionated regimens has demonstrated considerable variability worldwide and has been relatively slow within the United States."

Okay, what if I tell you this:

"Traditionally, women undergoing lumpectomy for breast cancer were treated with 5-6 weeks of daily radiation after surgery. "Hypofractionated" regimens are shorter courses of radiation, in which a slightly larger dose of radiation is given per day, allowing radiation to be delivered in a shorter period of time, most commonly in 3-4 weeks."

Finally, I get to the truth and find that 2 weeks less, slightly higher dose radiation offers fewer side effects? Why couldn't they say that first?

I'm so smart I could diagnose myself

Yesterday will probably go down as one of the not so greatest days in my life. Why? Because I pretended I was a healthy person. And it didn't end up so well.

Allow me to provide some of the story. We had to dig up a lot of the plants in our garden because our retaining walls are collapsing and we have to pay big bucks to a mason to fix them. It has been very hot and dry here for the past few weeks. 90s for the last few days even - which rarely happens in Boston. My poor plants which should be in the ground and in the shade are in pots in the back yard in the hot sun.

I noticed yesterday that some of them were very dry and wanted to water them. The spigot in the back yard was put up by giants and I have to stand on something to reach it. I pulled out my usual little 12" high little table to stand on. As I reached up, the table collapsed and I felt my knee bend sideways. That was a very bad moment. No one was home but the mason's assistant but he came to help me get back to the front door and inside. I could hobble.

But because of my extensive medical background, I knew exactly what to do. I went to the freezer and got an ice pack. Then I picked up the phone and called my doctor's office. I knew I needed an x-ray and possibly more. They suggested I go to the walk in clinic last evening but I declined and asked for an appointment today instead. But as I sat with my knee elevated it really started to hurt (even through all my RA/fibromyalgia meds) and I asked my husband to take me to the walk in clinic.

I saw a doctor and got an x-ray as I expected. The bones look fine (as I expected) but the doctor thinks there is ligament/muscle damage (as I also thought) and referred me to an orthopedic doctor. This is exactly as I assumed would happen. I need to call today if I do not hear from them by noon to get to see a knee doctor. (Maybe I should have just called my knee doctor first -  yes I have a knee doctor, and an ankle doctor, and many other specialists.)

They did send me home with a knee immobilizer, a totally worthless piece of equipment as it forces me to overwork my hip (and my bursitis) and causes more pain than is in my knee. They also recommended crutches or a cane, both of which I declined. But I did ask my husband to find one of the crutches in the basement as it turns out I need it for stability and weight bearing.

So one moment of pretending I was healthy allowed me to sprawl on the backyard in pain. The good side? I really need a positive here. I have a reason to sit around on my butt all day (except going to the dr and possibly getting my nails done) with an ice pack on my knee during this 90 degree weather. I am not discussing the downside at this point because I am pretending it doesn't exist. Denial? Yes. But I did know what to do and what I needed medically right away. 

Wash Your Hands

What is the single most important easy thing you can do to improve your health? Wash your hands. Often.

Now that I have rheumatoid arthritis and am on immune suppressing drugs that make me much more susceptible to colds and infections, I am becoming a germaphobe. I will not alter my lifestyle and avoid crowds, malls, movie theaters, and other groups of people. Nor do I believe in those stupid hand sanitizers which help create super bugs which are resistant to treatment.

But I do believe in hand washing. When I go to the gym, I wash my hands before I work out and I wash my hands as soon as I am done with my work out. And I try to remember to wash my hands when I come home from being out. As well as when cooking, before eating, etc.

Friday at the gym I was speaking with a woman as she was washing her hands after working out. She said that since she started washing her hands regularly, she has had fewer colds herself.

It amazes me how many people do not wash their hands, even after using the bathroom. I am particularly disgusted by people who do not wash their hands after using the bathroom and then use the gym or eat in a restaurant or other places. Speaking of restaurants, menus are disgustingly germ covered.

You can try all kinds of arguments with me about washing your hands and how it might dry out your skins or any other silly reason. The real reason for washing your hands is to clean germs (and dirt) off of them so you don't carry them around with you and on to other places. You can always put lotion on your hands if you are concerned about dry skin.

I was quite pleased to read this article about hospitals do to prevent infections and the top item on the list was hand washing.

If you get home at the end of the day and can't remember washing your hands, do yourself a favor and wash them.