“I HAVE BEEN TOLD THAT THE LUMP IN MY BREAST IS CANCER THIS MORNING. MY DOCTOR TOLD ME THAT I SHOULD GET OPERATED IMMEDIATELY OR ELSE MY CANCER WILL SPREAD. SURGERY HAS BEEN SCHEDULED FOR TOMORROW. I AM WORRIED THAT IT MIGHT SPREAD BY THEN”

This kind of knee jerk reaction surgery happens very commonly in our Country.

While we cannot afford to lose too much time to decide and plan treatment, there is no urgency in removing the lump or the breast in an unplanned fashion.

The diagnosis has to be ascertained by tests that will include mammogram, breast ultrasound and a core biopsy from the lump. Mammogram and ultrasound are useful tests that help us in diagnosis and planning of surgery. A well done mammogram and ultrasound should map out the extent of the disease to plan complete or partial removal of the breast and the need for axillary lymph node clearance. Sometimes a breast MRI is also done to add to information.

In very young people or patients with strong family history, we may consider genetic testing at this time. The results of this test also influence the management of the disease.

Additional tests may be required to assess general health and to stage the disease. These tests take a few days to organize. Besides the window of time available is useful to get as much information as possible and understand the options of treatment available. Repeated visits with your consultant doctor and specialist nurse will be required to clarify doubts and then go ahead with the treatment.

The clarity in diagnosis and available options of treatment helps the patient to choose and accept the treatment and its outcomes. It is definitely easier to cope with treatment with a complete understanding of what’s going on.

An unplanned surgery often spoils the chance to preserve the breasts and axillary lymph nodes. Removal of all the lymph nodes when it is not necessary may add to the risk of arm swelling after treatment. Reoperations may become essential adding to stress, time and money.

In most developed countries, there is usually a waiting time to get appointments to see a doctor, schedule tests and arrive at a plan of action. Sometimes this can be distressing when it is too long a wait but generally within reasonable time everything gets sorted out. In our country, especially in private practice the specialist’s access is quick and everything gets done in a frenzy with a sense of panic. This situation creates chaos and also does not allow a systematic reasoning and understanding of the disease and its management. The fears and doubts persist when inadequately addressed and cause enormous stress for a long time.

A well-organized private practice in our country can comfortably provide all the information and a plan with a couple of rounds of discussion in about a week to 2 weeks. And it is perfectly safe without the risk of cancer spreading elsewhere in this time frame.

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All about PET CT scan for Breast Cancer

Pet CT in our country has become a house hold name when cancer is diagnosed or suspected. It is ironic that there is so much reservation about having a mammogram done since it involves some exposure to radiation, but when a cancer is diagnosed there is so much fear that no one questions about the radiation involved with Pet CT scans.  Pet CT is overused in breast cancer in our country.

 

What is a PET CT scan?

PET CT scan is a procedure in which a small amount of radioactive glucose (sugar) is injected into a vein. Then a scanner is used to make detailed and computerized pictures of areas inside the body where the glucose is taken up. The pictures can be used to find cancer cells in the body, because cancer cells often take up more glucose than normal cells.
It usually difficult to find lesions that a very small (ie less than 1 cms) on a Pet CT scan because of lack of spatial resolution.

Is it necessary in early breast cancer?

Stage 1 and 2 breast cancers are considered as early breast cancer. The probability of spread is so low that a Pet CT scan to look for spread is not required.

Pet CT scan sometimes cause confusion. As the radioactive glucose accumulates in tissues where there is higher metabolism, there can be a false alarm if there is some inflammation or infection as this tissue also will pick up the tracer and can be mistaken for a cancer. This might lead to anxiety, more tests to clear the confusion, delay treatment unnecessarily and adds to cost as well.
The radiotracer gives very small levels of radiation, which go away very quickly. But for the rest of the day patients should be instructed not to have close contact with pregnant women, babies or young children.

So when is Pet Ct useful?

It is particularly useful to plan treatment when the cancer is locally advanced. The probability of having metastatic disease is higher in locally advanced breast cancer. If there is evidence of cancer in other parts of the body (ie) liver, lung or brain, then the treatment is planned differently.

What is the role of Pet Ct scan after treatment?

Pet Ct scans usually don’t help people who have completed cancer treatments and don’t have symptoms. For most breast cancer patients, these tests don’t help patients live longer or with a better quality of life. Pet Ct scans done without a good reason can lead to anxiety, false alarms, wrong diagnoses, unneces­sary procedures, and more costs. Also frequent scans lead to high levels of radiation. The effects of radia­tion add up over one’s lifetime. It is more useful in clinical situations where metastatic disease is suspected. FDG PET has high accuracy for the diagnosis of recurrent or metastatic breast cancer. Pet Ct scan will be recommended for patients treat­ed for advanced cancer to find out the response to the treatment.

Conclusion

Pet Ct scan costs close to 20,000 to 25,000 rupees. Our society assumes that any technology with a high price tag has value, but the latest technology is not necessarily the required technology for all patients. The NCCN Breast Cancer Panel also discourages the use of PET or PET/CT scanning in the work-up of staging early breast cancer.

Reference

http://snmmi.files.cms-plus.com/images/NCCN%20Narrative%20Summary%20Feb%202016.pdf

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Mammogram : Getting it right matters

Master health checks have become very attractive for providers and patients. A set of tests are put together under various packages ranging from 600 rupees to 25,000 or called bronze, silver, gold, diamond and platinum checks!!!

A mammogram or ultrasound or both are thrown in for women depending on age.

The films and reports are usually packaged very nicely and given to the patient. The interpretation, reporting, and discussion of the results are usually discussed by general medical or gynaecology colleagues. They may not be equipped with the decision making tools and hence the patient is left with a lot of anxiety and stress seeking second or third opinions.

What can go wrong with Mammograms?

 

1. Technology:

Using the right technology has its advantage. Digital technology, tomosynthesis, workstation that has a high resolution helps in spotting early disease. There are tools to measure breast density and computer-aided diagnosis which add to the information.

The newer machines also deliver less radiation dose and the resolution is fantastic. Like the 18 megapixel camera as against the 3-megapixel cameras of the earlier versions.

Many centres may not have all the facilities. Although this is a disadvantage, a good mammogram can still be done with older analog machines with a little attention to detail.

Older machines have to pass the QA and QC and calibrated periodically to ensure radiation dose is not exceeding the permissible limits and safety. AERB monitors these details. But seldom these are done properly.

2. Technique of performing mammogram

A. Compression: Unfortunately the test involves some breast compression which might be uncomfortable. The compression can last up to 4 to 5 seconds.
If the compression is inadequate then the image quality will suffer.

B. Positioning: The entire breast has to be included in the study. If the whole breast is not included then parts of breasts will not be imaged. There is a risk of missing details or cancer in the area which gets missed out in the image. This leads to a false negative mammogram. A missed opportunity to detect cancer. So the technologist’s role is very important in ensuring a good mammogram.

It can be very intimidating for a woman to undress in front of a stranger in a cold room for the procedure. As rule mammograms are always done by a lady technologist. A good technologist can make the entire procedure comfortable and painless for the patient.

C. Interpretation: the mammograms should be read in a room where there is very little distraction with suitable lighting. The monitors displaying the images should be medical grade monitors with resolution of at least 5 megapixels.

3.Interpretation

What the mind doesn't know the eyes cannot see.

Training to understand the normal anatomy, physiology, pathology and imaging features is important to recognize the various breast conditions.

Mammographic interpretation needs specialist radiologists. Otherwise, there is a serious risk of missing cancer diagnosis and creating false alarms. It is also important to compare with previous studies to see if there is any new change.

Diagnostic mammograms in conjunction with breast ultrasound and MRI sometimes will give all the necessary information to plan surgery.

Even in the best of health, there is a 10% probability of missing cancer, therefore mammograms should not be just another master health check. And when cancer is diagnosed mammogram provides a roadmap for further surgical planning.

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WHY ARE WE DOING MORE MASTECTOMIES FOR BREAST CANCER IN OUR COUNTRY?

Breast cancer is the most common cancer affecting women in India. About 1 lakh new cases are being diagnosed every year in India. Majority of them present at a very advanced stage and consequent to this the morality is also very high.

Lack of awareness, reluctance to see medical professionals, fear of diagnosis, fear of losing the breast, fear of treatments like chemotherapy or radiotherapy are some of the reasons why women do not seek medical attention early.

Western world amidst debates about the benefit of screening started screening program in the 80’s and 90’s. A significant stage migration has been observed in countries where screening is done. Besides breast surgery has developed as a specialty in its own right in most parts of the western world. It is no longer a situation of where a surgeon is a jack of all trades operating from head to foot. Organ-based super specialization has lead to better outcomes in patient care.

Cancer care and its outcome in India is a lottery. About 50% of breast cancers that we see in the Metros are stage 1 and 2 breast cancers that are suitable to have their breast preserved. Nearly half of this group will have a mastectomy rather than breast preservation surgery for various reasons. An unconvinced surgeon about breast preservation is not likely to offer this procedure to his or her patients. There are myths among medical fraternity that,

• Indian patients are not suitable for breast preservation and reconstruction.
• Breast preservation surgery is associated with increased recurrence.
• Indian women are not concerned about the body image as much as western women do.
• Fear in the surgeon's mind that the woman may not come for regular check-ups after the procedure.

Surgeon’s awareness, and developing a specialty training in breast surgery is crucial to dispense with these myths. Positive versus negative counseling by a surgeon is an important factor in improving breast preservation rates.

Besides the surgeon factor, socioeconomic factors influence the decision for having a mastectomy rather than a breast preserving operation. Breast preservation entails radiotherapy subsequently and this involves time and money. Most patients in tier 2 and 3 cities do not have access to these treatments and cannot afford to stay in Metros for prolonged periods ( 3-5 weeks) for radiotherapy. This factor sways the decision in favor of mastectomy over breast preservation.

Another major influence in the treatment process is that the women rarely participate in the decision-making process in most families. It the husband or the near and dear who decide for the patient and it is often a case of mute acceptance of her fate and undergoes a mastectomy.

Breast reconstruction after a mastectomy again is largely ignored by both the oncosurgeon and the patient. Factors like availability of plastic surgeon with adequate training and multi-specialty involvement in the management influence the reconstruction rates after the mastectomy. Another major hurdle is our medical insurance procedures. Medical insurance companies consider breast reconstruction after a mastectomy as a cosmetic procedure and hence will not reimburse the same.

After a mastectomy there is very little support or help given to a woman to cope with a loss of her breast, many are not aware of the availability of prosthesis that can be used to improve body image. Faced with the deformity that occurs from a mastectomy, many women withdraw from social life and have a very poor quality of life after breast cancer surgery.

Improvements in public and surgeon awareness are likely to reverse the trend in the stage at presentation of the disease as well as the outcomes of the treatment.

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NEWSPAPER SAYS 70% OF BREAST CANCER PATIENTS DO NOT NEED CHEMOTHERAPY….WHY ARE YOU SUGGESTING THAT I SHOULD HAVE CHEMOTHERAPY?

Today’s newspaper headlines reported that “fewer women needing chemotherapy” and another said, “70% of breast cancer patients do not need chemotherapy”. This caused a lot of confusion. I was inundated with phone calls and my clinic was flooded with concerned patients and /or their relatives wanting to check whether they should continue chemotherapy.

Let’s understand the context clearly. Before the advent of genomic tests, we traditionally used tumour size, grade, lymph nodal status and hormone receptor status to decide the need for adjuvant chemotherapy for early breast cancer (stage 1, 2 a). With the advent of genomic tests (i.e. Oncotype Dx etc ), we were able to stratify the patients with early breast cancer into a low, intermediate and high-risk group. By risk, we refer to the possibility of developing a recurrence of the breast cancer. The high risk group would be recommended chemotherapy. The low risk group will not need chemotherapy as the potential risk of relapse is very negligible.

The grey area is the intermediate risk group. It is frustrating for patients and clinicians when a definite answer cannot be provided, that too after spending a lot of money on these tests. We ended up individualising again based on the traditional prognostic factors like age and tumour size.

The results of the tailorX study which was published a few days back addressed this group. Patients falling in the intermediate risk category were randomized to chemotherapy and no chemotherapy treatment arms and after 9 years of follow up the recurrence rates were analysed and presented on June 3rd, 2018. According to this study results, in a select group patients with receptor positive, node negative early breast cancer who fall in the intermediate category adjuvant chemotherapy will not add to benefit over hormonal therapy. Chemotherapy can be avoided in this group.

So, this recommendation will not apply to her2 positive, triple negative and node positive patients.

To stratify the risk, genomic tests like Oncotype DX (which was used in this study) will have to be done. The paraffin block of the tumour tissue is sent to the lab in USA (this test is currently done only in the USA) and it takes about 3 weeks to get the result. It costs roughly about 4000 USD (ie) 2.72 lakh Indian rupees.

A vast majority of our patients in our country are diagnosed at an advanced stage. The relapse rates are higher in advanced breast cancer and therefore chemotherapy is still a very essential component of the treatment protocol. Contrary to this, in the western world, the vast majority of breast cancers are diagnosed early. Genomic tests and selectively administering chemotherapy based on risk based on genomic tests are widely practiced. Sadly this cannot be applied to a great majority of our patients because of the advanced stage at presentation and the costs of these tests.

Is there an alternative method to stratify risk?

In addition to traditional prognostic factors like tumour size, grade, lymph nodal status we look at the estrogen receptor (ER), progesterone receptor (PR), Her2 and Ki 67 values. The ER, PR, Her2, and ki67 together are tested currently by immunohistochemistry. Together they could potentially closely reflect the Oncotype dx risk stratification. It could be the poor man’s alternative to Oncotype dx.

The challenges with IHC 4 tests is with the subjectivity of Ki 67 values. Less expensive test kits which have more objective Ki 67values could be the answer and these have to be validated in clinical trials with Oncotype dx.

Breast cancers are heterogeneous. The treatment is largely individualized and the one size fits all is probably not applicable anymore. But one has to be very cautious when reporting results of these studies in the print and visual News media. The headlines like” 70 % of breast cancer patients will not require chemotherapy” can lead to misunderstanding on the part of patients and there is a serious risk of patients skipping chemotherapy and dropping out of treatment and follow up which result in poor survival outcomes.

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YET ANOTHER BREAST CANCER PATIENT FALLS FOR THE NATURAL REMEDY PROMISE…

There is a lot of information that is being circulated in social media about natural cures for cancer. They passionately talk about the doctors and scientists hiding lifesaving nature cures from patients in cahoots with the big bad Pharma industry to promote allopathic drugs.

The self-styled experts claim that everything from lemon juice to baking soda, to vitamin B17 to green juice can cure cancer. Despite the fact that there are no scientific data to substantiate these claims, even educated and intelligent young people buy into and promote cancer misinformation. The idea of nature cure from baking soda to soursop is being sold with such conviction quoting the so-called researchers and catchy headlines that scream “It's Time for The Truth to be Told About Breast Cancer...”

While there are plenty of ‘miracle cures’ out there, the fact is that there’s very little evidence that any of them actually work. Attractively made videos and websites are not scientific evidence and effectiveness of any cancer treatment. They seduce cancer patients into abandoning their best shot at survival in favour of these unproven remedies. When it comes to cancer, thinking that food and natural measures are a good alternative to “pharma and allopathic medical greed” can be a deadly choice.

Some of these miracle cure specialists see about 100 to 150 cancer patients a day spending barely few minutes with each patient. They also treat all types of cancers from head to foot. It amazes me that someone who asks me a lot of questions would submit themselves without any doubts to the miracle makers. I also wonder how the miracle makers master various aspects of cancer biology and pathology that are heterogeneous not only in different organ systems but also within the same organ. Like breast cancer is not one disease. All breast cancers cannot be treated alike.

We only hear of success stories and not the failures. The so called success stories of cure by natural remedies may have confounding factors about the medical diagnosis, the stage, aggressiveness of the disease etc. Often it turns out that people have had conventional cancer treatments like surgery and yet this may not be mentioned. Many low-grade tumours have an indolent course and may do well anyway. They end up attributing the survival to alternative treatments.

As a breast cancer surgeon, I must express my concern and outrage here.

It is tempting to turn to Dr. Google when faced with the diagnosis of breast cancer. There are millions of pages out there with all sorts of information. During the stressful and distressing time of dealing with the diagnosis, the misinformation that comes through these portals are dangerous, gives them false hope and puts people at risk of losing time, money and the advantage of appropriate treatment at the right time.

Allopathy is not perfect. But right now, it comes with the best evidence that we have. Researchers are constantly working on improving the treatment modalities. Discuss the side effects and benefits clearly with your doctor, understand the risk versus benefits of conventional breast cancer treatment and complement recovery process with holistic health.

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Will my cancer spread after a breast biopsy?

A common patient concern is that biopsies may cause cancer to spread. Many patients ask me if removal of the lump straight away is better.

My answer to the question starts off with an example. If you get transferred  from Chennai to Delhi , would you prefer to land up in Delhi Railway station with family , bags and baggage straight away or would you like to visit the place a couple of times, find out about possible housing, schools and other facilities and then plan to shift the family ?

Likewise, before removing the lump we need a diagnosis followed by a clear plan based on the diagnosis and further information. A biopsy removes a bit of tissue by using a specially designed core needle from the suspicious area of the breast. The tissue is then fixed and studied under a microscope to see if cancer is present. This is done with a local anaesthetic.

If it is benign lump, then surgery may not be required at all. Therefore unnecessary surgery and scar on the breast can be avoided.

If the breast lump is cancerous, then it is staged and tested for hormone receptor sensitivity and Her 2 status. We then assess the possibility of preserving the breast and axillary lymph nodes. Surgical plan including breast conservation, sentinel lymph node biopsy and reconstruction are possibilities that can be discussed and decided upfront with best possible results. Repeat surgeries are avoided with good planning and information for further treatment planning is complete and adequate without any undue time delay.

Does the needle biopsy cause the cancer to spread?

No. this is a myth and studies have shown that needle track seedling or displacement of cancer cells do not increase the risk of recurrence or spread. The chance that surgery or biopsy will cause cancer to spread to other parts of the body is extremely low. Doctors use special methods and take many steps to prevent cancer cells from spreading during biopsies or surgery to remove cancer.

Breast Biopsy is an incredibly important step in the diagnosis for the patient, as having a definitive cancer diagnosis is important in determining and planning the correct treatment for the patient. The potential gain from a breast biopsy outweighs the risks such as discomfort and bruising.

Can a needle biopsy miss a cancer?

A needle biopsy can sometimes miss breast cancer if the needle takes a sample of tissue or cells from the wrong area. Ultrasound or stereotactic guidance is immensely useful to target the correct area. The sample should be fixed immediately in buffered formalin. A delay in fixing or improper fixing can cause diagnostic difficulties.

Sometimes false negative results can occur due to errors in interpretation. If there is a cause for concern about the possibility of a false negative result ( ie ) if the lesion is suspicious on clinical examination and imaging studies , then a repeat biopsy or surgical excision should be carried out.

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