|
Gloria:
Do you suggest a second opinion before a mastectomy
is performed?
|
|
Dr. Douglas Fraker:
I always encourage a second opinion particularly
when there are different options involved such
as in the surgical treatment of breast cancer.
I certainly don't have all the specific information
regarding your case, but it is important that
you have all reasons for recommending a procedure
adequately explained to you. If you'd like to
schedule an appointment call 1-800-789-PENN.
|
|
Debbie:
How come the drugs used today are the same for
the past 30 years (Cytoxan, Adriamycin)?
|
|
Dr. Kevin Fox:
The drugs we are using now are not exactly the
same as we did originally, although some of them
are the same, including the ones you mentioned.
We have added a few new ones to the ones you mentioned
in your question. We have done clinical studies,
and are continuing to do clinical studies, to
explore new drugs in our treatment of breast cancer.
Many of the drugs used in treatment will actually
probably change in the next five years. Unfortunately,
these kinds of clinical studies take five to ten
years to complete.
|
|
Denise:
In order to establish a diagnosis of cancer is
a biopsy necessary or can I rely on a CAT Scan,
X-ray or mammography alone?
|
|
Dr. Douglas Fraker:
A biopsy is always needed to confirm the diagnosis
of breast cancer. Mammograms, ultrasound, and
MRI may be very suggestive of a cancer (CAT scans
are not useful to image the breast), but it is
mandatory to perform some type of biopsy to diagnose
cancer. Also, there are various types and characteristics
of cancer (e.g., estrogen receptors) that are
important and can only be determined by pathology
analysis.
|
|
Gloria:
Do you only take patients who live in the immediate
Philadelphia area?
|
|
Dr. Kevin Fox:
We welcome patients from any region in the United
States and abroad who are seeking care for breast
cancer. If you would like to make an appointment,
you may call 1-800-789-PENN now.
|
|
JEANNE:
I have regular mammograms, but I have a discharge
from my nipple. The fluid was collected and it
was not cancer. I have asked for them to do an
ultra sound but they say I do not need one. Is
it normal not to want to
do an u/s.
|
|
Dr. Douglas Fraker:
One important feature of nipple discharge is whether
it comes from only one breast or both breasts.
If both breasts have a nipple discharge it is
almost never cancer but some hormonal problem.
If it is a discharge from only one breast then
it is appropriate to take a sample for analysis.
An ultrasound is generally not the best test to
evaluate a nipple discharge. Better tests would
be ductal lavage which involves placing a small
tube in the nipple to get a better specimen. Another
good test would be breast MRI. If you would like
to schedule an appointment, call 1-800-789-PENN
now.
|
|
Darin:
Dr. Fraker...at what age should a woman check
for breast cancer (mammogram)?
|
|
Dr. Douglas Fraker:
I would recommend getting into the habit of monthly
breast self-examination in early adulthood (for
further information about breast self-exam visit
our website). The recommended age for an initial
screening mammogram is between 35 and 40. If there
is a strong family history of breast cancer it
would be appropriate to get an initial mammogram
earlier between age 25 and 30.
|
|
Ratchada:
Is PET imaging used for detection of a tumor or
only when a tumor has been found?
|
|
Maurspok:
I just heard on the show about a PET test? Could
you explain this procedure? Also what is happening
with the 3 year study that was at Penn on MRIs
for high risk women?
|
|
Dr. Emily Conant:
At this point in time PET scanning is mostly used
to determine if a breast cancer has spread beyond
the breast to other parts of the body. It looks
at the body in a very complementary way and has
potential to find small sites of tumor that have
escaped beyond the breast. It's an exciting new
technique to look at the whole body in one imaging
session and find areas of tumor involvement that
might not be found by any other imaging test.
However, at this time, PET is not used a screening
tool. Research protocols are ongoing that use
PET to screen women but it is not a routine practice
at this particular time.
The MRI trial for women at high risk for breast
cancer continues in a different program. We do
have research studies that look at high risk women
with multiple modalities through digital mammogram,
breast ultrasound and breast MRI. We are hopeful
that women who have high risk breast symptoms
or who have mammograms that are difficult to interpret
will be able to undergo MRI as a complementary
test to mammography and breast ultrasound.
|
|
Therese:
What a great show, very informative
|
|
Rhonda:
I'm having an allergic reaction to the medicine
Tamoxifen I don't know what to do about the next
step
|
|
Dr. Kevin Fox:
I am unable to answer the question without more
information. You must discuss the nature of your
allergic reaction with your doctor. There may
be alternative drugs, but your doctor should talk
to you further about your options.
|
|
Joyce:
I am scheduled for a biopsy on Tuesday. I am so
afraid, I don't know if I am doing right. If I
now have a lump under the arm also, is that a
bad sign??? |
|
Dr. Douglas Fraker:
It is hard to give you an answer without more
information such as why you are having the biopsy
(an abnormal mammogram or a lump in the breast).
Lumps under the arm could be from a variety of
causes such as a cyst under the skin or a lymph
node. You should ask your doctor what their impression
is of the mass.
|
|
Gail:
I was interested in knowing if tomography is a
better method of detecting a lump versus mammogram
|
|
Dr. Emily Conant:
If you are referring to computed tomography or
CAT scanning, this test is not routinely used
for breast cancer screening. There have been other
forms of tomography used in the past but at this
point in time screening mammography is the most
accepted technique for detecting early breast
cancer. You can call 1-800-789-PENN for a mammogram
appointment.
|
|
Diana:
I have been told my breast are very dense. Two
years ago I had a removal of tissue for biopsy
after my mammogram showed tissue that was suspect.
The biopsy came back negative. I have a mammogram
every year. Should I be concerned about the risk
of breast cancer.
|
|
Dr. Douglas Fraker:
You are not at any increased risk of breast cancer
just because you have dense breast tissue. It
may be true that mammograms will be less sensitive
for certain small lesions with dense breast tissue.
One thing that will help is to have your mammograms
done just after your menstrual period as the breast
tissue is less dense at that time. It is still
important to get your annual mammograms and continue
with monthly self
breast exams.
|
|
Gloria:
Because you are a teaching hospital, do you have
options for treatment that might not be available
here? I live in the Lancaster area.
|
|
Dr. Kevin Fox:
It is always possible that we have options not
available to you, but this is impossible to say
specifically. We do have relationships with hospitals
in your area that are part of the University
of Pennsylvania Cancer Network. You may want
to investigate options through Pennhealth.com.
|
|
Sandy:
I am a patient with DCIS trying to decide whether
to take tamoxifen after radiation.
|
|
Dr. Kevin Fox:
If you have DCIS, tamoxifen will reduce the risk
of the cancer regrowing in the breast. We generally
recommend tamoxifen treatment to most but not
all patients with DCIS. You should discuss the
risks and benefits with your doctor.
|
|
Therese:
Is the PET scan taking the place of the bone scan?
|
|
Dr. Emily Conant:
At this point in time as an initial workup the
bone scan remains very important. The PET scan
also looks at areas of soft tissue involvement
of breast cancer such as lymph nodes. PET scanning
is a new technique and is not available at all
hospitals. Please call your doctor about the appropriateness
of PET in your specific case or call 1-800-789-PENN
for an appointment.
|
|
Ratchada:
I have just been diagnosed with breast cancer
and wonder what my 21 year old daughter needs
to do now. She is on birth control pills. Should
she begin having mammograms now?
|
|
Dr. Douglas Fraker:
It would be most important for your daughter to
get in the habit of monthly self breast examination
(see
technique of breast self-exam). She would
be too young to start mammograms now. If there
is additional family history which would increase
her lifelong risk of breast cancer it would be
okay to get an initial screening mammogram at
age 30 instead of age 35.
|
|
Maureen:
I was diagnosed with breast cancer and recently
had a mastectomy. The tumor was 1.1 cm. Out of
17 lymph nodes tested, all were negative. My oncologists
are torn and leaving me with the decision whether
I should have chemo. They said there would be
a 2 - 3% benefit with chemo. What would your opinion
be?
|
|
Dr. Kevin Fox:
The decision to take chemotherapy is often a very
individual decision. We generally recommend chemotherapy
for most patients with breast cancers more than
1 centimeter in size.
|
|
Steve:
My wife is scheduled to have a lumpectomy but
is concerned about the timing of surgery vs the
timing of her menstrual cycle. Could you please
provide the latest update as to whether the timing
of breast cancer surgery vs menstrual cycle has
on survival rates, etc.
|
|
Dr. Douglas Fraker:
There is no definitive evidence to suggest that
when in a menstrual cycle a biopsy is performed
has any outcome on the results. There may be some
relationship between menstrual cycle and the accuracy
of mammograms.
|
|
Gloria:
Dr. Conant, what exactly is considered "early"
BC ?
|
|
Dr. Emily Conant:
In general early breast cancer refers to cancer
that is still contained within the breast. This
means the breast cancer has not spread to the
lymph nodes under the arm or other parts of the
body. The earliest form of breast cancer is ductal
carcinoma in situ or DCIS. This is the type of
cancer that can be treated usually with lumpectomy
and has the best prognosis and frequently complete
cure. The goal of screening mammography is to
find the earliest smallest cancers so that a patient
has the most treatment options and the greatest
chance of cure.
|
|
Debbie:
What is the difference in cure rate when surgical
removal in Stage 2 is NOT followed by chemotherapy?
|
|
Dr. Kevin Fox:
The risk of recurrence of breast cancer (metastasis)
is reduced by 25 - 30% for stage two patients
receiving chemotherapy.
|
|
Cleanth:
I recently read that the progesterone receptor
is more prognostic than the estrogen receptor.
I'm guessing that a consensus on this has not
yet been reached.
|
|
Dr. Kevin Fox:
You are correct, there is no consensus regarding
the relative prognostic strengths of the progesterone
or the estrogen receptor. In clinical practice,
we accept either value as important.
|
|
Denise:
My brother had a positive urine cytology following
bcg treatment and he wants to know if that in
conjunction with a suspicious CT scan is enough
evidence of cancer that he should have his bladder
removed?
|
|
Dr. Douglas Fraker:
This is a good question for a urologist. You can
call 1-800-789-PENN to make an appointment with
Penn Urology.
|
|
Deanna:
If I had a sister at 37 with breast cancer, and
a sister-in-law with breast cancer at 45, what
precautions do I need to take for my daughter?
|
|
Dr. Douglas Fraker:
In other words, your daughter has two aunts (who
are second degree relatives - two steps away on
the family tree) with breast cancer. This puts
her at a small increased lifelong risk of breast
cancer and she should perform monthly self examination
and get annual screening mammograms at age 35.
|
|
Deanna:
So my risk is greater than hers (since it was
my sister with breast cancer at 37). (I am 43)
Does the paternal aunt play a part in her risk
of breast cancer?
|
|
Dr. Douglas Fraker:
You are correct. Having one first degree relative
with breast cancer at an early age is a slightly
greater risk than having two second degree relatives
with breast cancer.
|
|
Beth:
Has the Breast Center at Penn come to any consensus
regarding the use of tamoxifen vs. new drug therapies
for patients who have already started tamoxifen?
Question 2: What is your opinion of the use of
ductal lavage for breast cancer detection post
treatment for DCIS. I am participating in such
a study.
|
|
Dr. Kevin Fox:
Our general consensus is that tamoxifen is still
our treatment of choice, and we do not discontinue
tamoxifen and start the newer drugs unless the
patient has a problem with tamoxifen. Regarding
ductal lavage, there is not enough information
yet regarding its use after the diagnosis of DCIS.
I am delighted that you are participating in a
study to advance our knowledge of this important
issue.
|
|
Cleanth:
What "life-long" services are offered
through the Lance Armstrong Foundation?
|
|
Dr. Kevin Fox:
Our Living Well After Cancer Program offers ongoing
meetings with nutritionists, ongoing medical consultation
to seek and address other medical risk factors,
and ongoing recommendations regarding exercise
and lifestyle.
|
|
Rhonda:
Can you have chemotherapy after you are done radiation
or should you stop the radiation in the middle
of treatment.
|
|
Dr. Kevin Fox:
Radiation treatments should not be interrupted.
You may start chemotherapy after radiation is
completed.
|
|
Sandy:
Is the drug Arimidex used in place of tamoxifen
and what are the side effects?
|
|
Dr. Kevin Fox:
We are not yet recommending arimidex in place
of tamoxifen. We are using arimidex for patients
who can't tolerate tamoxifen. The side effects
of arimidex include hot flashes, vaginal dryness,
and slight weight gain. There are other side effects
but they are uncommon.
|
|
Jill:
I recently discovered a lump in my breast and
another under my arm. I know that I need to make
an appointment as soon as possible, but at this
time have no insurance (getting married in spring
and will then) are there any programs or grants
I can look into. I don't want to 'rack up' huge
medical bills, and also am afraid of not getting
'the best' treatment or getting trapped by a 'pre-diagnosed'
condition if I start treatment now. I hate to
think I would have to get married early just for
the insurance it doesn't seem right somehow.
|
|
Dr. Douglas Fraker:
You shouldn't delay care for insurance reasons
for an important problem such as a mass in the
breast. Seek aid through your community's social
service to see what options are available to you
(for example, Medicaid) so you can get appropriate
evaluation.
|
|
Sandy:
What tests show whether or not you have estrogen
receptors?
|
|
Dr. Kevin Fox:
There is an actual estrogen receptor test that
is performed directly on breast cancer tissue
taken at the time of a biopsy.
|
|
Ratchada:
Dr. Fox - Could you elaborate a bit more about
chemotherapy and the 1 centimeter cut off? Is
there an assumption that invasive cells may have
snuck beyond a clean margin or is something else
maybe going on?
|
|
Dr. Kevin Fox:
All patients with invasive breast cancer, no matter
what the size, have some chance that the cancer
has already spread beyond the breast. The chance
is greater the larger the tumor. We feel that
this risk is high enough to warrant chemotherapy
in patients whose tumors exceed one cm in size.
|
|
Natalie:
I was listening to your show & thought the
women whose "cases" were discussed were
very interesting. I have a personal situation
myself because I'm trying to find a good gynecologist.
|
|
Dr. Emily Conant:
Thank you for your compliment. You can call 1-800-789-PENN
to find a gynecologist close to home.
|
|
Gloria:
In your opinion, how long after a patient has
been diagnosed with breast cancer in both the
breast tissue and in the lymph nodes should treatment
(either surgical or otherwise) begin?
|
|
Dr. Douglas Fraker:
If the diagnosis is made then some sort of biopsy
must have been performed. I would get consultation
from a breast surgeon and a medical oncologist
and begin treatment as soon as possible. It would
be fine to get a second opinion if needed so that
you are comfortable with the treatment plan but
I would try to start some sort of treatment within
a few weeks.
|
|
Therese:
How is it decided what you receive first- radiation
or chemo?
|
|
Dr. Kevin Fox:
In general, we give chemotherapy first. However,
there is really no information about which order
of treatments is best.
|
|
Deanna:
I work at Penn and personally know one of you,
and have dealt with another as a fellow... I am
glad to see that you've taken the time to provide
this service.
|
|
Fran:
I'm having a mammo done then it will be read by
a R2Checker, it that good?
|
|
Dr. Emily Conant:
The R2Checker is a form of computer aided diagnosis
or a second read after the radiologist has interpreted
your mammogram. Research has shown that in some
practices these computer programs may help radiologists
detect breast cancer on mammograms. However, if
you are being seen at an imaging center that has
specialized breast imagers who read a high volume
of mammograms, research has shown that the computer
enhancement may actually cause false-positives
or unnecessary biopsies. The most important factor
in choosing your mammography site is to make sure
the radiologists are specialied in breast imaging
and the technologist are well trained and performed
the highest quality imaging. An R2 imager is not
necessary in this kind of practice.
|
|
Kathleen:
I am 42 and was diagnosed with breast cancer in
late June. I have had a lumpectomy, but no further
treatment. How effective is removal of just the
sentinel node treatment? The doctor is recommending
that along with radiation, but I am wondering
if it would be better to have all of the lymph
nodes removed.
|
|
Dr. Fraker:
The sentinel node mapping and biopsy by an experienced
surgeon is an extremely accurate technique. If
the sentinel node or nodes (there are often two
or three of them) are negative for tumor then
the patient does not need an auxillary dissection.
It would only be necessary to remove the other
sentinel node(s) if it is positive for tumor.
|
|
Michelle:
I know you have previously answered this question,
but my mother was just diagnosed with breast cancer.
She did not require a mastectomy. What is my risk
factor for developing breast cancer?
|
|
Dr. Fraker:
A person has an increased risk of developing breast
cancer if a first degree relative (like your mother)
has breast cancer. If she was older when she was
diagnosed, then the risk is not as great as it
would be if she was younger. As her daughter,
it does not mean you are desitned to have breast
cancer but regulare self breast exams and mammograms
are important tools for you to use.
|
|
Moderator:
Thank you for joining us for this evening's chat.
|
