Wednesday, October 1, 2014

Know:BRCA

Know:BRCA logo
Most breast cancers are found in women who are 50 years old or older, but about 9,000 women who are younger than 40 years old are diagnosed with breast cancer each year in the United States. In this younger group, breast cancer is generally more aggressive, found at a later stage, and has lower survival rates.
Two genes influence risk for breast cancer: BRCA1 and BRCA2. All men and women have these genes. Normally, they help protect you from getting cancer. But when one or both of them have a mutation(change), they increase your breast and ovarian cancer risk. Without treatment, women with a BRCA gene mutation are seven times more likely to get breast cancer and 30 times more likely to get ovarian cancer before age 70 than other women.

How do I know if I have a higher risk for a BRCA gene mutation?

Learn your family history of cancer. Talk to your doctor if you have—
  • Multiple relatives with breast cancer.
  • Any relatives with ovarian cancer.
  • Relatives who were diagnosed with breast or ovarian cancer before age 50.
The Know:BRCAExternal Web Site Icon tool can help you learn about BRCA genes and assess your risk of having a BRCA mutation. Learning your risk can help you and your doctor make important decisions about your health. There is also a Know:BRCA tool for clinicians.External Web Site Icon
Understand your risk for hereditary breast and ovarian cancer. Use the know b r c a online tool. Learn about hereditary breast and ovarian cancer and your risk for having a b r c a gene mutation. Help protect your patients from hereditary breast and ovarian cancer. Use the know b r c a online tool. Find out more about b r c a gene mutations and how to counsel your patients.

What should I do if I am at increased risk?

The only way to know for sure if you have a BRCA1 or BRCA2 gene mutation is to get a genetic test. You should meet with a genetic counselor before getting a genetic test. Your doctor can refer you to one. Most people do not need genetic counseling and testing. A genetic test helps only the small number of people with a higher risk for having a mutation.
If you learn that you have a BRCA gene mutation, you can take important steps to reduce your cancer risk.

What should I do if I am NOT at increased risk?

Most women who get breast and ovarian cancer do not have a BRCA gene mutation. If you do not have a family history of breast or ovarian cancer, follow recommended breast cancer screening guidelines.

How can I help others?

Help us promote awareness about hereditary breast and ovarian cancer by sharing this page and the infographics below.

Know:BRCA Education Initiative

The Know:BRCA education initiative aims to build awareness about how BRCA gene mutations affect risk for breast and ovarian cancer. It was authorized by the Education and Awareness Requires Learning Young (EARLY) Act, section 10413 of the Patient Protection and Affordable Care Act (Public Law 111-148). The EARLY Act authorizes CDC to develop initiatives to increase knowledge of breast health and breast cancer among women, particularly among those under age 40 and those at higher risk for developing the disease.

Thursday, September 25, 2014

Foods That Help Ease Cancer-Related Nausea

Cancer treatments such as chemotherapyradiation, and certain medications can take a toll on patients, with side effects such as nausea. Although you may experience  a loss of appetite during treatment, it is important to find ways to give your body the nutrients it needs.
Here are simple strategies to help you manage nausea.
  • Eat or drink ginger.
There is evidence that ginger can help settle your stomach, so try incorporating it into your meals and drinks in the form of ginger tea, fresh ginger root and lemon tea, ginger chews, or ginger ale. Try ourginger crinkle cookies for a nausea-fighting treat.
  •  Drink lemonade or lemon water.
Lemons are a natural nausea-reliever. Staying hydrated can often be a challenge during treatment, especially when plain water is not always appealing. Try ginger-zapped lemonade, which incorporates lemons and ginger to reduce queasiness. You can also add a slice of fresh lemon to your glass of water.
  •  Incorporate fresh lemon into meals.
Lemons can be a flavorful addition to many dishes. Adding lemon to protein-rich dishes, such as fish or chicken, helps improve the smell and flavor of your  meals,  which makes them more appealing when you’re nauseous or don’t have much appetite. Our whole roasted tarragon chicken is one way to incorporate lemons into a tasty meal.
  • Eat a small portion of potatoes.
Potatoes, including baked, sweet, roasted, and yes, even potato chips, eaten in small amounts, can help to reduce nausea. Enjoy a few chips with a healthy snack, such as our three seed hummus, or alongside a small meal.
  • Control the room where you are eating.
Make sure the room where you’re eating meals is comfortable, whether it is your own dining room, kitchen, or hospital room. Try to create an inviting and calm ambiance to whatever extent you can.  Control the temperature and air circulation, and seek out a room that is free of odors that may cause nausea.
Dana-Farber’s nutritionists can advise you on the nutrients you need during and after treatment. Visit the Nutrition Services website for more information on nutrition resources, meal planning, andhealthy recipes. You can also download the Dana-Farber Ask the Nutritionist: Recipes for Fighting Cancer app for iPhone or Android devices.

Tuesday, September 16, 2014

The 2014 Breast Cancer Symposium was held September 4-6 in San Francisco. This is a unique meeting as it is multidisciplinary, co-sponsored by 6 organizations: the American Society of Clinical Oncology (ASCO), The American Society of Breast Surgeons (ASBrS), the Society of Surgical Oncology (SSO), the American Society for Radiation Oncology (ASTRO), the National Consortium of Breast Centers (NCBC) and the American Society of Breast Disease (ASBD). This is a unique meeting as it brings together all of the specialists involved in treating patients with breast cancer.
As usual, this was a well-attended meeting. Many interesting abstracts were presented, and the general sessions covered timely issues related to the care of breast cancer patients. However, I did hear several patients and advocates (via twitter) who were in attendance express frustration about the lack of consensus for management of certain conditions, the focus on obesity and exercise as methods to reduce the risk of disease development and recurrence, and the lack of “real” progress.
Unfortunately, while we currently know more about breast cancer than at any other point in time, meetings like this reinforce that what we know is just the tip of the iceberg – cancer is incredibly complex. Various pathways have been identified as targets for treatment, but no one treatment will work in all patients. Targeted therapies, immune system modulators, and other novel treatments are in development, but may not come fast enough for the individual patient, especially those living with metastatic disease. Trust me, this is just as frustrating for the physicians as it is for patients. But this is also what motivates us to keep asking questions and researching, until we have some real solutions – ones that work for everyone.
Some of the topics that stood out for me:
Mammography and MRI screening: we are trying to identify which women should be screened and with what technology (mammogram, ultrasound, MRI). Personalized screening based on an individual’s risk is the ideal, but we cannot yet truly pinpoint an individual patient’s risk. Even in those with BRCA gene mutations, not all will develop breast cancer. Dr. Steven Feig discusses that personalized screening must be based on only well-established medical knowledge.
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Can we identify patients with breast cancer who do not need treatment? We know that many early-stage breast cancers, especially ductal carcinoma in-situ (stage 0 breast cancer, or DCIS) will never progress to invasive disease, and are not a threat to a woman’s breast or life. DCIS Treatment vs. Observation was the subject of a debate between Drs. Henry Kuerer (MD Anderson) and Shelly Hwang (Duke University). Both surgeons made excellent points, but in the end, there was no consensus on how to identify an individual patient who would not progress without treatment. The best we can do right now is use assessments of tumor biology, volume of disease, and patient factors to help guide discussions with our patients.
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An excellent talk was given by Dr. Susan Boolbol (Mount Sinai Beth Israel in New York) on genetic testing. A key point made is that all cancer is genetic, but not all cancer is hereditary. All cancers have at their core a mutation in one or more genes, but not all cancer-inducing mutations are passed down from one generation to the next.  Approximately 5-10% of breast cancers are hereditary; the majority are sporadic. Taking a thorough family history is essential to provide a cancer risk assessment, to identify other family members who may be at increased risk, and to recommend risk management options such as increased surveillance, genetic testing, chemoprevention and prophylactic surgery.
Red flags for hereditary breast cancer –
-       3 or more family members with the same or similar type of cancer
-       2 or more generations affected
-       1 or more cancers diagnosed before age 50
BRCA 1 and 2 are the most common DNA repair genes; there are 2 copies in each cell. When one copy of BRCA 1 or 2 is defective, other malignant DNA mutations (which occur from time to time for various reasons) cannot be repaired, which leads to uncontrolled cell reproduction and cancer growth.  Approximately 1 in 500-800 patients in the general population are estimated to have a BRCA 1/2 mutation; in patients of Ashkenazi Jewish ancestry, approximately 1 in 40 may carry a mutation.
When possible, the family member who has had cancer should be tested, and if a mutation is found, then other family members can undergo targeted testing. If testing is negative, counseling is still required as it can have a variable meaning depending on the overall family history. The risk of breast and ovarian cancer development depends on the specific mutation as well as the age of the patient.  Contralateral (opposite side) breast cancer incidence is increased, and is also related to age of the patient and her age at initial diagnosis.
Dr. Boolbol touched on the 2013 Supreme Court decision regarding gene copyrights. This has increased the number of companies offering genetic testing.  Many companies now offer extended panel testing, as it is recognized that other gene mutations may also be responsible for breast cancer development. However, guidelines for treatment do not necessarily exist for many of these other mutations (such as PALB2). An additional caution in evaluating any genetic test results is that an abnormal test may not necessarily indicate an increased risk of developing breast cancer. Some of the mutations detected (including in the BRCA 1/2 genes) may be variants of unknown significance (VUS) which may or may not lead to an increased risk of breast and/or other cancers.  It is important for patients undergoing genetic testing to have thorough consultations with their physicians and/or a genetic counselor, as “not all genetic mutations are created equal”.
Dr. Banu Arun from MD Anderson discussed the management of patients with hereditary mutations or who are otherwise considered to be high-risk.  Options include surveillance / screening, prophylactic surgery, and chemoprevention.
For surveillance / screening, clinical breast exams (an exam by your physician) is recommended every 6-12 months starting around age 25. Annual MRI is recommended from age 25-29 (mammogram if MRI not available), annual mammogram and MRI age 30-75, and after age 75 individualized management is recommended.  These recommendations may change depending on a relative’s age at diagnosis. Note that at this point, the 2014 NCCN guidelines do not specify the use of screening ultrasound although it is often used.
Preventive mastectomy can reduce the risk of breast cancer by >95%. Patients already diagnosed with breast cancer  may have as high as a 65% risk of developing a contralateral breast cancer which is why bilateral mastectomy is often recommended. A bilateral salpingo-oophorectomy (BSO – removal of the ovaries and fallopian tubes) can reduce the risk of breast cancer by 50%, and is ideally performed between age 35-40 (for maximum breast cancer risk reduction).  BSO is also associated with a 95% reduction in the risk of developing ovarian cancer.
75% of BRCA1 related breast cancers are ER negative; 58% are triple negative. Studies evaluating tamoxifen for chemoprevention in BRCA positive patients have conflicting results.
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Dr. Ann Partridge from Dana Farber discussed the non-medicinal approach to risk modification. Opportunities to modify risk factors include reducing exposure to environmental toxins and health behaviors. Much of the research to date has focused on individual points in time, but current research is focusing on the exposure a woman faces over her lifetime.
Modifiable exposures include radiation exposure, exposure to contributor chemicals, combination hormone replacement therapy, active / passive smoking, alcohol intake, and diet.
Exercise and weight control are crucial to helping to reduce the risk of breast cancer – we’ve all heard this many times, but the evidence continues to grow. Clearly this is not the only factor – we all know women who exercised regularly and still developed breast cancer – but it is important. The benefit appears to be with 3+ hours of moderate paced walking per week. No studies have looked at survival benefits to weight training, but weight training does help with overall weight maintenance.
Interestingly, a low body mass index (BMI) as a young adult or premenopausal woman is associated with an increased breast cancer risk, yet in postmenopausal women, an elevated BMI is associated with an increased breast cancer risk. The reasons are unclear, but Dr. Partridge did not recommend that premenopausal women gain unhealthy amounts of weight!
It’s very challenging to study nutrition and cancer. Many food items are inter-related, and nutrition is often related to weight and other health behaviors.  Long-term dietary habits are more important than short-term, and she reinforced that the concept of a “magic bullet” is not likely. She also cautioned about over-interpreting the results of small nutritional studies.  Regarding alcohol, there does not seem to be any increased risk of breast cancer with consumption of <3 drinks per week, but increased consumption is associated with an increased risk.
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The metastatic breast cancer tumor board was also a good session. As with the other sessions, there was no true “news”. However, it was a good example of the multidisciplinary discussions that we all have with our colleagues in order to decide what treatment options are best for an individual patient.  Dr. Ben Anderson (a surgical oncologist with Seattle Cancer Care Alliance) also stressed that the patient needs to be treated, not the disease – we need to work with our patients to get their thoughts on quality of life and symptom control, and then tailor our treatments to their preferences.
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Finally, I had the opportunity to present the #BCSM research as a poster. Based on the survey earlier this year, we found that knowledge regarding various aspects of breast cancer increased, and anxiety was diminished. Obviously these are the results as a whole, and as they say, “individual results may vary”.  I believe we have a lot to do to improve this community, but these results tell me that we’re on the right track.

Monday, September 15, 2014

Mentoring for new cancer survivors

By Sheryl M. Ness, R.N. June 22, 2013
This week, I'd like to put a call out to all of the veteran cancer survivors who are reading and participating on the blog. One of the primary goals for the blog is to support and reassure each other on this journey.
My question to you is this: "What do you know today that you wish you'd known in the beginning as a new cancer survivor?"
We frequently partner mentors with newly diagnosed cancer patients in person. I thought it would be interesting to try virtual mentoring through this discussion.
If you're interested in posting your pearls of wisdom for other survivors, keep a few things in mind as you write your comments.
In the first year after diagnosis:
  • What did you experience that was most unexpected?
  • What about your emotions in the first weeks and months? It's OK to talk about the negative feelings too — that way everyone knows this is a normal experience.
  • What was the most difficult experience of the first year? What helped you get through?
Everyone's experience is unique — however, it can be a great comfort to hear from others who've already been down the path yet to come. Please share your words of support and wisdom.
Follow me on Twitter at @SherylNess1. Join the discussion at#livingwithcancer.

Thursday, September 4, 2014

I'm on my third round of chemotherapy, and I've been diagnosed with anemia. I feel very tired and weak. Why does chemo cause anemia? Is there anything I can do to feel better?

Answers from Timothy J. Moynihan, M.D.
Your bone marrow makes blood cells, including red blood cells. Chemotherapy can damage your bone marrow. When this happens, your body makes fewer red blood cells or destroys them before their normal life span is over.
Your body's ability to produce platelets — a blood cell that plays an important role in forming clots — also may decrease, so you're more likely to bleed, further reducing your red blood cell levels.
Your red blood cells contain an iron protein called hemoglobin, which carries oxygen from your lungs to the rest of your body. Anemia means you have too little hemoglobin, so parts of your body aren't getting enough oxygen, which is why you feel tired and weak a lot.

What you can do

Consider the following step to help manage your anemia.
  • Talk to your doctor. Ask about getting a blood transfusion or certain medications to increase production of red blood cells, which can relieve your anemia.
  • Prioritize your tasks. Do only the most important ones. Let your family and friends help with other tasks.
  • Get plenty of sleep. Aim for at least eight hours a night. Take short naps during the day.
  • Eat well. Foods high in iron such as red meat and leafy greens are good choices.

What's taboo to you as a cancer survivor?

By Sheryl M. Ness, R.N. August 28, 2014
This week, let's talk about taboo topics. As a cancer survivor, you probably have certain topics that are taboo to either you, or your family and friends.
Taboo topics aren't easy to talk about. A few that come to my mind are diagnosis, prognosis, recurrence, and end-of-life discussions. Others include sex, body image, and feelings of guilt and loss. Perhaps you're returning to work after treatment and you need a way to update your co-workers on how you're doing.
Taboo topics are difficult to think about, talk about and confront. However, they're probably the ones that cause a lot of emotional pain or anxiety if you have no way of talking about them. This is true for both a person living with cancer and their family and close friends. We worry about each other, this is a natural reaction. We also have fear and anxiety over things that we can't control.
So, how do you bring up taboo topics?
One way is to first write out your thoughts so that you have a way of putting words to your feelings and emotions. Next, reflect on what you wrote, and next to each concern, identify one way that those around you might help you with the concern. Also think about what you can do to address the fear or concern on your own.
Practice bringing up the topic, like you would when you're with the other person. This is a practical way to lessen the fear and anxiety when the time comes to talk about it for real.
Many times, the people around you who love and care about you are waiting for a cue from you, to let them know it's OK to talk about the subject. Once you open up, you may find that they're ready to talk about it and provide the support you need. If you never bring it up, they may think you aren't worried about it or are also too afraid to bring it up.
What's taboo to you? Share on the blog the topics that you've found difficult to bring up to others around you. This is the perfect, safe place to talk about it with others who are probably feeling the same way. What worked best for you?

Tuesday, September 2, 2014

Patient Voices: Pancreatic Cancer



http://www.nytimes.com/interactive/2008/09/17/health/healthguide/TE_PANCREATIC_CLIPS.html?emc=edit_tnt_20140902&nlid=52389906&tntemail0=y

Patient Voices: Pancreatic Cancer


It is estimated that 5 percent of patients diagnosed with pancreatic cancer survive past five years. What is it like to be faced with such statistics? To survive? Here, in their own words, are the experiences of seven men and women. (Join the discussion here. )

Saturday, August 30, 2014


'Strikingly Effective' Approach for Depression

in Cancer Patients

Roxanne Nelson
August 28, 2014


A new integrated program for treating depression in cancer patients is reported to be "strikingly more effective" at both reducing depressive symptoms and improving quality of life than the current standard of care. The new approach, known as Depression Care for People with Cancer (DCPC), was tested in 2 clinical trials: the SMaRT-2 study, reported in theLancet , and the SMaRT-3 study, reported in the Lancet Oncology.
The integrated collaborative care model that was tested in these trials utilized a team of specially trained nurses, primary care doctors, and psychiatrists and showed that this strategy can greatly improve outcomes for depressed patients with cancer compared with usual care, David Kissane, MD, head of psychiatry for Monash University, Victoria, Australia, writes in an accompanying commentary in the Lancet Psychiatry.
"The approach used in the SMaRT Oncology trials combined with systematic screening provides an outstanding model of how to begin to deliver this much-needed care for patients with cancer everywhere," he says.
The commentary accompanied a new analysis published in theLancet Psychiatry showing that the majority of cancer patients (73%) with depression are not getting any treatment for their depression, as reported by Medscape Medical News.
This finding comes from a study of 21,000 cancer patients using clinics in Scotland, which found that major depression is substantially more common in cancer patients than in the general population. These symptoms were most commonly observed in lung cancer patients (13%) and were the least common in genitourinary cancer patients (6%).
 
Unrecognized and untreated depression in patients with cancer shortens survival, harms quality of life, and increases risk for suicide...Dr. David Kissane
 
"If unrecognized and untreated depression in patients with cancer shortens survival, harms quality of life, and increases risk for suicide, a compelling case emerges for using both screening and an integrated collaborative model of depression management," Dr. Kissane noted.
New 'Strikingly Effective' Protocol
One of the clinical trials that tested the new DCPC protocol was the SMaRT Oncology-2 randomized trial, which found that at 6 months, significantly more of the patients who received DCPC responded to treatment (with at least a 50% reduction in the severity of their depression) compared with those who received usual care. The overall response to treatment was 62% with DCPC vs 17% with usual care (< .001).
"The huge benefit that DCPC delivers for patients with cancer and depression shows what we can achieve for patients if we take as much care with the treatment of their depression as we do with the treatment of their cancer," lead author Michael Sharpe, MD, from the Department of Psychiatry, University of Oxford, United Kingdom, commented in a statement.
Dr. Sharpe and colleagues compared the effectiveness of the DCPC for major depression in cancer patients with usual care. The integrated program is delivered by a multidisciplinary group working in collaboration with the patient's cancer team and general practitioner. The program includes both pharmaceutical and psychological therapy.
The study included 500 adults with major depression as well as cancer who had a good prognosis (predicted survival of longer than 12 months). The patients were randomly assigned to receive either DCPC or usual care. Treatment for the usual-care group consisted of informing the patient's primary care physician and oncologist of the major depression diagnosis; they were then asked to treat the patient under normal protocol. In the United Kingdom, this might mean antidepressant drug therapy or a referral to mental health services, the authors note.
When compared with those in the usual-care group, participants in the DCPC arm had less depression, anxiety, pain, and fatigue; and better functioning, health, quality of life, and perceived quality of depression care at all time points (all < .05).
During the study period, there were 34 cancer-related deaths (19 in the DCPC group and 15 in the usual-care group). In addition, 1 patient was admitted to a psychiatric ward, and 1 attempted suicide. Although both were in the DCPC group, the events were not deemed to be related to the trial treatments or procedures.
Effective for Good- and Poor-Prognosis Patients
The other trial, SMaRT-3, evaluated a version of DCPC that was specifically adapted for patients with cancer who had a typically poor prognosis. For this study, lead author Jane Walker, MBChB, PhD, a consultant psychiatrist at the University of Oxford, and colleagues randomly assigned 142 patients with primary lung cancer and with a predicted survival of at least 3 months to DCPC (n = 68) or usual care (n = 72).
The DCPC arm and the usual-care arm followed protocols and care similar to those followed in the SMaRT Oncology-2 study. The primary outcome was depression severity (on the Symptom Checklist Depression Scale [SCL-20], range 0 - 4) averaged over the patient's time in the trial (up to a maximum of 32 weeks).
Of this group, 43 (30%) of the patients had died of cancer-related causes by 32 weeks. Outcome data were based on 131 (92%) of the cohort (59 in the group receiving depression care for people with lung cancer and 72 in the usual-care group).
The authors found that the average depression severity was significantly lower in the DCPC group (mean score on the SCL-20, 1.24 [SD, 0.64]) than in those who received usual care (mean score, 1.61 [SD, 0.58]; difference, -0·38). The self-rated depression improvement, anxiety, quality of life, role functioning, perceived quality of care, and proportion of patients achieving a 12-week treatment response were also significantly higher among patients in the DCPC group, compared with usual care.
"Patients with lung cancer often have a poor prognosis," said Dr. Walker in a release. "If they also have major depression, that can blight the time they have left to live. This trial shows that we can effectively treat depression in patients with poor-prognosis cancers like lung cancer and really improve patients' lives."
Both studies were funded by Cancer Research UK and Chief Scientist Office of the Scottish Government. None of the authors or the editorialist have reported any relevant financial relationships.
Lancet. Published online August 28, 2014. Abstract
Lancet Oncol. Published online August 28, 2014. Abstract
Lancet Psychiatry. Published online August 28, 2014. Commentary