SILVER LININGS 2005
EDSA Shangri-La, Ortigas
September 25, 2005

TOPIC                         :           BREAST CANCER 101
MODERATOR          :           BIBETH ORTEZA
SPEAKERS                :           DR. MARK KHO
                                                SURGICAL ONCOLOGIST

BIBETH ORTEZA (BO):  Mga kaibigan again, please welcome Dr. Mark Kho.

DR. MARK KHO (MK): Salamat Bibeth.  Can I call you Bibeth?  Or should I call you B (laughs)?  Or darling? Naku, my wife is here.  Mahirap na. 

First of all I’d like to thank Kara who personally invited me here to share some things with  you.  Also, I’d like to take this opportunity first dapat I-congraulate lahat ng babae dito.  Let’s give yourselves a round of applause please.  Thank you for being here.  And thank you for sharing and thank you sort of, we call it coming out.  I told my wife on my way here that all of you are so courageous in coming out and then doing this.  And, also, we have to acknowledge the men behind the women.  Palagi na lang the women behind the men.  Yung mga men din deserve a round of applause also.  Yan. 

Clapping

MK:  So Bibeth, mamya ha?  We might have a date.  Pinagnanasa mo pala kami.  Ayan. 

What I’ll be going through is on.. The topic given is  Breast Cancer 101.  Masyadong malawak na topic at siguro mahabang-mahaba e ang binibigay lang sa amin ilang minuto lang.  So, if things that I don’t cover we would be able, hopefully, we will be able to answer all your questions later on.  But before that we are indeed living in troubled times as you see.  And marami sa atin e, maraming problema, maraming hindi lang sa pampulitika at pang ekonomiya and everything. 

And from those kinds of bad news, we go to more bad news actually.  If we look  at the current statistics right now, according to Fortune Magazine, you see that the deaths from heart disease is actually coming down.  Bumababa yung deaths  from heart disease. Whereas, cancer it has.. it’s being leveled off.  And since we have a lot of things that we can do for heart disease nowadays.  And  there are more drugs, maraming gimmicks also.  Less stress, which helps heart disease.  We have not done much for caner.  And right now actually, we now discovered it came out in a journal that in a study, just this early this year that cancer deaths now out ranked deaths from heart disease.  And this is sad news indeed because now cancer is the leading cause of death among men and women in the United States under age 85.  so wala naming over 85 dito ano?  Kung meron, congratulations din.

And if we look at the statistics across the board, from the Philippines, the world to the US, you see very prominently breast cancer of course, ranks one, among the top 3 lead cancer sites.  And if we look even more closely in the US, breast cancer is the no. 1 cancer for women or in women.  And here in the Philippines, according to our most recent cancer facts and estimates, breast cancer also is leading in females and it outranks the second leading site, which is cervical cancer by a least half.  So it’s two times as much as the second leading site of cancer.  So perhaps this is the time I know we had a prayer this morning, perhaps it’s time to pray again because we are indeed again, living in these troubled time. 

And there is no better saint, I think, to invoke to than Saint Agatha of Catana.  And I’ll tell you why.  She’s the patroness of nurses also, which is becoming the most sought after sub specialty in medicine.  As you know, marami po sa ating mga kaibigan at colleagues in medicine who are now shifting to nursing because of all these problems.  And Saint Agatha is tamang-tama patron saint din.  She’s frequently invoked versus earthquakes and breasts diseases.  Now the exact relationship between nurses, earthquakes and breasts… Mamaya tanunigin natin si Direk Carlitos… hala!  Magsusumbong ako sa husband ni Bibeth tungkol dun.
A little background about her.  She was born from an illustrious family in Italy during the 3rd century.  And she consecrated her life early on to the works of the Lord.  She had vows chastity, obedience and poverty.   But unfortunately, there is this senator who wanted her to his wife.  And you know how bad it is to jilt senators even nowadays.  Mrs. Cecile Alvares will attest to that how bad it is to jilt senators.  This jilted suitor named Senator Quintianus so ordered her flagging.  She was flagged like that of the Passion of the Christ.  And there were many versions of how she was punished for that.  This is one version where her, she was tied to a tree and her breasts were crushed or taken out using vices or clamps.  I don’t know what they all them back then.  There’s another version that she was stretched out on a rack, iron hooks were placed on her body, and her breasts were cruelly crushed and cut off.  And so, if you see a picture of saintly figure with her breasts on a plate, that would be Saint Agatha.  And before she died, for who could endure that kind of suffering and aren’t you glad that you don’t have to, even if you have breast cancer, she said “Lord, my Creator, You have taken me from the love of the world and given me patience to suffer, receive now my soul”.  And we hope that this prayer can encourage you and encourage all our senators, as well, to suffer a little bit for us so that we can have a better Philippines to live in. 

So from politics, I shift to breast cancer.  And this is our special focus, of course.  You know that the United States Postal Service actually has a stamp commemorating Breast Cancer Awareness.  And Time Magazine has come up with cover stories on Breast Cancers so that  people would be more aware.  And many people are hit by breast cancer not only the ones who are close to the stars or the brothers, I’m sorry, the sisters, the relatives of the stars but also the stars themselves.  You see, again, this picture tells us that only beautiful people get breast cancer.  Susan Summers and Olivia Newton John as  well as the elder set of Angel, Jacqueline Smith.  Of course, hindi tayo puwedeng matalo.  We have our own version di ba?  Iyan.  We have our own beautiful people who are also cancer survivors.  And however, recently, there is sort of news or scare na that breast cancer made the news because hormonal replacement therapy actually was related, has been related or associated with breast cancer in a major trial that was done on HRT.  This led to another article from the Wall Street Journal to say that research shows little benefit in estrogen pills.  And another story from Newsweek that says there was more bad news for hormonal replacement therapy.  And in a very, very either controversial or very popular Time issue featuring our protagonist at the time of the elections, another article within it showed that there was a problem really with the giving of a routine hormonal replacement therapy.

So what is breast cancer? Ano ba daw ang breast cancer?  Sabi ni Bibeth hindi nakukuha sa kulam.  Ganun nga ba?
Breast cancer comes in many forms as you know.  Merong maliit na maliit na breast cancer na hindi pa na… not even palpable.  And these are usually  seen on mammography as represented by dots or micro calcifications.  And these micro calcifications can indeed tell you that you have, you may have breast cancer.  It can also be a little bigger, presenting as a lump behind the breast.  Or it can grow out of the breast and … or almost eat up the whole breast and consume the whole breast so that it affects even the rest of the body. 

Of course, mga males don’t think that we are exempted from getting breast cancer.  There are male breast cancer cases although much, much less.  And so the male will also have to be aware that such can occur. 

Many signs and symptoms of breast cancer however, the most important for you to understand and to bring home to is that about 75 % of cases present with a breast lump, “bukol” lang po and it’s usually painless.  So anybody with a breast mass on examination should of course, have this examined carefully to see whether this can already be a sign or symptom of breast cancer.

What causes breast cancer?  Ito Nobel Prize.  Kung Bibeth can answer this e, di you’ll win the Nobel Prize, sigurado.   Unfortunately, we have not pinpointed exactly one cause.  But we know that hormones or estrogens are indeed associated.  Why?  Because we know that breast cancer, almost exclusively in women.  And we know that estrogens are almost exclusively again, found in women more than in men.  And there are increased risks, decreased risks depending on your hormonal level in your body.  And breast cancer can be prevented and can be treated using tomoxifen, which is an anti-estrogen.  E di siguro naman kung anti-estrogen and treatment e di estrogen din ang cause.  And there’s better survival in older women who have decreased levels of hormones. 

There are other risk factors that we have to look at and to see to consider because we don’t, again, we don’t know the exact cause.  So #1 as I’ve already told you, is sex.  Sex meaning hindi yung sex na iniisip ni Bibeth.  Yung sex na gender.  Female gender ayan.  Ang females kasi as you know are, is a risk factor.  Being a female, being a beautiful female ayan. 

Age of course, is another factor. When we have.. well, as you grow older, you have a higher risk of getting breast cancer.  And there are other established and probable factors.  Let’s look at age for example.  As you age, from birth to 39, and comparing it to 60 to 79, you see that your risk rises from 1 in 229 to 1 in 14.  So that the birth to death rate in the United States actually, is 1 in 7, 1 out of 7 or 1 out of every 7 females in the United States will get breast cancer.  Here, it’s a little lower but as our statistics get better, we might be able, we might approach, approach that of, hopefully not though, the statistics we see in the United States. 

Race is another issue or factor that… depending on what race you come from.  Anong uri ng tao.  And you will have higher rates or lower rates of getting breast cancer. 

Hereditary, sabi nila.  O mana-mana ba yan?  Well, yes.  Part of it is.  But you know, it’s only a small percentage.  When we look at breast cancer, it’s 5 to 10, maybe up to as much as 15 to 20% only, ONLY.  So that most cases are still what we call sporadic.  Or they just come.  Hindi natin, ma-pinpoint.  Walang family history, wala sa genes andiyan lang.  It just comes.  So that’s again another  take home message.  We have found though some genes that are associated with breast cancer.  Like, the BRCA1 gene.  When you have a mutation in one of these spots of the big gene or the long gene, then you may develop breast cancer as high as 50 to 85% lifetime risk.  Nakakatakot.  Sometimes when we inherit that gene, that mutation in that gene, then our  risk can go as high as 85%.  Meaning to say, that parang we’re really going to get it.  Alright…

So, how do we prevent it though? How do we lower our risks?  There are some preventive, prevention options here that I’m going to show.  For example, this would be. this would apply mostly to patients who have, who inherit the breast caner gene or the mutation.  You’ll tell this girl, for example, who doesn’t have breast cancer yet to do some of these things if she is eligible so that she can prevent breast cancer. 

The first of course, is prophylactic mastectomy.  E kung tanggalin ba yung breasts, e di wala nang breast cancer.  Di ba?  Kaya lang siyempre this is surgery and has its own risks, etc.  And in fact, when we do a mastectomy not all of the breast tissue is actually removed.  But you need to go through this discussion and this option with your doctor also, if you want.  But we’re getting better and better at it because we now have techniques to reconstruct the breasts for those who have small breasts and want to have Dolly Parton sized breasts.  Now, you can have it.  Like in this patient, we can put actually implants.  Alam ko diyan, merong diyan mga implants na hindi lang sinasabi.  Pero this is one form of breast reconstruction if you’ve had a mastectomy.  Or we now have a technique wherein we move some of your bilbil up and make that your breasts.  And this is what happens and you get a free tummy tuck.  Libreng, libreng plastic surgery pa.  Pagkatanggal ng breasts.  And you can have as nice breasts, nice breasts as this after  what we call a skin sparing mastectomy with immediate reconstruction.  So there, our options are getting bigger, and bigger.

Another preventive option is that of taking tomoxifen, which has been proven of late, to reduce the risk of breast cancer incidents in those who are eligible ha?  Hindi para sa lahat ito ha? Hindi parang candy ito na puwedeng kainin ng lahat.  Kailangan ring pag-usapan what are the risks?  What are the benefits? What are the complications you can get from this?  And kung angkop, kung talagang … compatible sa iyo.  This is a result of a big trial that was done in high risk women, mostly patients who are 60 years and above who are under, who were shown to have a reduction in the risk of breast cancer. 

How about diet? Ano ba ang dapat kainin para ma-prevent ang breast cancer?  Maraming, there’s so many things in the media – Newsweek, Time Magazine, and even our own dailies have come up with their own idea or their own version of how to prevent breast cancer using a diet as a factor. 

But we have to be very cautious.  Some of these things, which we really don’t know or haven’t been tested can in fact, be more dangerous than really prevent you from getting breast cancer.  And we have to be very careful and read the labels because the labels can be very misleading.  They can tell, they can, they say no approved therapeutic claims.   But  left and right they will tell you that ‘Wow, it will boost your immune system.’ Or it will prevent cancer, etc. 

But is this in the realm really of quackery?  Do we call this quack or do we call this alternative medicine?  Magandang pakinggan ano?  Alternative medicine.  All of us though, have to be aware that this type of medicine is being accepted more and more.  Sabagay eh, kung kami kasi when we, when we talk to patients, we say ‘O , you know what if you undergo chemotherapy, if you do surgery you will have a lot of pain.  Masakit. You’ll lose your hair. You’ll get uglier, etc.  While the alternative practitioners will say ‘Alam mo, with this pill, mabango ka na.  You’ll be, you’ll look brighter.  And we’ll give you aromatherapy para you’ll feel rejuvenated.’  And so they’re really viewed with a better approach. , you have to be aware that this is being more and more accepted.  But you see to be able to know which is good and which is, which supplements or which substances are good, which are and which are not, the road is long and tedious.  Look at this drug which is one of the wonder drugs for breast cancer that of Paclitaxel .for example, or Taxol.  It was discovered in 1964, but it got licensed only for use in 1994.  So it took 30 years for us to know that it was a good drug.  But I think, we cannot escape that type of way because and we don’t want to be branded as holding back progress. 

But look at this, Dr. Alexander Fleming, who is the inventor of Penicillin said ‘Penicillin sat on its shelf for 12 years while he was called a Quack.  So he could only think that thousands who died needlessly because my peers could not use my discovery.  And we don’t want to fall into that trap so that it’s good that institutions like the U.S. has come up with the establishments like these, like the Office of Alternative Medicine in Cancer Treatment to really look  at what’s good and what can be bad for you.

Then let’s look at some of the data that has been, that has come up in terms of that type of research.  When we talk about body fat and weight, we’re not really very clear about the relationship in breast cancer and the intake of body fat.  But a simple guide to you would be to stay within 5 to 10 pounds of your weight at age 20.  Sino ngayon ang magsasabi, ‘Ako ay 5 to 10 pounds lang within nung age 20 ako’?  Wala.  Kaya nga kayo nandito. Ayun.

So one of the goals for nutrition for the, of the American Cancer Society said that to avoid overweight and weight gain during childhood.  Coffee. Ayan. I saw everybody taking coffee.  Sabi nila naku, yung coffee daw kung..kasi may caffeine will cause fibrocystic breast lumps.  Tapos, magkaka cancer daw.  Ayan.  Hindi. Recent studies have shown no relationship at all to cancer risks.  So it’s (audience clapping)  You like that?  So, go ahead and take your favorite coffee as you want. Buti na lang the studies came out that way, kung hindi.  Isu-sue natin, pati si Kara maaapektuhan.  Green Tea has been said to be a good agent and contains polyphenolic compounds that inhibit tumors.  However, the data is not very clear so further studies are needed to see whether Tea really can reduce or Green Tea can reduce your risks for cancer.  The same cannot be said about alcohol.  It is very clear, very clear that alcohol does increase your risk of cancer.  So if at all, try to limit your intake of alcohol.  Tama na muna yung mga gimmick.  Si Bibeth isa lang dapat. One drink only, one shot kasi for women.

How about artificial sweeteners?  Saccharin is said to cause cancers in mouse, in mice or in rats.  However, in primates which we are more closer to, and human studies show no increased risk of cancer from saccharin or aspartaine.  So you really don’t have to be afraid of taking artificial sweeteners unless you are a rat.

Cooking methods.  Yung frying daw, yung barbeque daw will cause carcinogenic chemicals and cause cancer in animals.  But it’s of uncertain cancer potential in humans.  But if you want to be on the safe side, sige na lang ano?  You either braze, steam, poach, stew or microwave your meats.  I cannot translate this to tagalog.  I can only translate microwave.  Microwaving meats that’s i-microwave mo yung karne.  Microwave, ang safer. 

How about garlic?  Garlic is said to.. said can protect you and they’ve been highly publicized.  They’re currently under study for their ability to reduce the cancer risk.  So for now we are not sure whether cancer can be scared of.  But what we’re sure of, especially if you’re from Capiz, you can scare off the ghosts.  With garlic.

The vitamins. Vitamin A has been studied but it’s not very clear that there’s an association and one thing, one glaring studies, group of studies actually came out with regards one of the Carotenoids, that of Beta Carotene.  In fact, this was tested to see if it can reduce the risk of lung cancer in smokers.  However, it did not. In fact, it increased the risk of those who, of the smokers to take, in taking lung cancer.  So research actually does not demonstrate benefit of hydo-supplementation of beta carotene.  So you have to be careful again.  Look at the studies so that you’ll know.  Vitamin C no significant trials have been shown to reduce the risk for breast cancer as well as Vitamin E, which is a very difficult vitamin to study as well.  Fish oils, the same. There’s no direct evidence for protective effects.  And however, ito lang ang.. what’s very clear.  There’s mounting evidence for protective effect of vegetables and fruits okay?  The whole vegetable and fruit.  We don’t know however, what in the vegetable or the fruit decreases your risk.  That’s why the American Cancer Society has come up with the recommendation of eating a variety of healthful foods with an emphasis on plants sources.  Eat five or more servings of vegetables and fruits a day to reduce your risk of cancer.

There are some studies, encouraging in folic, folate acid, folic acid.  And so a goal for nutrition is to consider taking a multivitamin containing folic acid particularly if you are taking alcohol.  So Bibeth, take some folic acid I know you take alcohol. 

How do screen for breast cancer?  For an average risk, I think the video showed it very clearly. Monthly self breast exam, clinical breast exam and an annual mammography.  I cannot over emphasize that.  And for patients with increased risk, go see  your doctor so that you will know what you can do. 

A word about mammography.  I know although it cannot get, or cannot pick up all cancers okay,  And even if magnetic resonance cannot do that as well, we have to very careful in terms of substituting mammography with,  for example,  ultra sonography.   Ultra sonography or ultra sound truly is inexpensive and widely available.  However, these are a few points.  Its accuracy is highly dependent on the expertise of the one who does it.  Depende sa gumagawa iyan.  Secondly, I think  at least, that a lot of us think it’s over used here in the Philippines and it.. because of its overly sensitive and has very low specificity.  For example, let’s look at this report.  What would you say and how scared you would be if get this kind of an ultra sound report?  You have 10 nodules on the right breast and 7 nodules on the left breast.  Naku, I get so many patients coming to me with this kind of report.  So this is not really been used for screening so don’t substitute your mammography for any other tests.

Breast cancer can be diagnosed in many ways.  A biopsy of course, is a gold standard.  We need a tissue diagnosis to get a.. to know exactly, to confirm the diagnosis of breast cancer.  And it can be treated  many ways and Dr. Francis Lopez here, will tell you more about the.. how cancer can be treated.  But I would like to say a few points regarding that before definitive treatment, I think it’s better  for you to understand that breast cancer can be best treated by a specialist who also treats a large number of similar patients and who has an access to the full range of treatment options in a multidisciplinary setting. 

And when it comes to surgery, surgical oncology is the field that applies these unique sets of principles and treatment principles to the cancer patient.  There is a small, well, a big difference with the general surgeon because surgical oncologists really do get  additional training beyond that of a general surgeon, which is already five years.  And it’s the Society of Surgical Oncology in the United States which brings all these Surgical Oncology together and trains candidates for surgical, in Surgical Oncology.  And in its most recent membership directory, proudly the Philippines is included in its roster of trained Surgical Oncologists.  It has cancer symposium every year, usually in March.  Last year, it was held in New York.  This year, it was in Atlanta.  Next year, to be in San Diego.  And these are the approved training programs in Surgical Oncology.  And every year, there’s a matching program which all the candidates have to go through to be able to be trained in this specialty as well.

And you ask, ‘Well, is there any proof that there’s any difference’ or there’s a difference of you get treated by a specialist and by non-specialist.  Here is a study done at the USC in LA showing that in those patients who were compared between those who were treated by a Surgical Oncologists and those who are not, the treatment resulted in a 36.3% risk reduction.  Telling you that the conclusion was that breast cancer patients are treated by specialist have indeed a better outcome.

And so Surgical Oncologists have indeed been in the forefront of cancer care.  This is a picture of Dr. Alex Egermont who now heads the biggest European organization against cancer.  And in the United States, Dr. Charles Bousche who is a Surgical Oncologist also is the CEO of the ASCO or the American Society of Clinical Oncology which is also the biggest body of oncologists and also the Editor In Chief of the Annals of Surgical Oncology which is the official journal.  Many times there are.. the Surgical Oncologists lead forums.  And also President George Bush actually, appointed  a Surgical Oncologist to be his Director of the National Cancer Institute, his name  is Dr. Andrew C. von Eschenbach, who is an SSO member as well.

Locally, here, we try our best at the University of the Philippines, PGH, with the help of groups like Avon, and your own foundation, I Can Serve to try to treat as much, as many patients as we can in our own little way.  Also, we try to educate the surgeons as well, in terms of how to treat breast cancer properly by coming up with studies like Evidence Based Practice Guidelines, as well as our Post Graduate Courses which we hold every year.  This year, we held it again at Pan Pacific just a few weeks ago.

I’d like to end my talk therefore, with a, by sharing you a philosophy.  Before we get too much mired technique and in technical aspect in what to eat, what not to eat, how live our lives, etc. I think I’d like to quote Sir Charles Chaplin who was not actually a simple guy.  He was quite an intelligent guy when he said ‘Man is an animal with primary instincts of survival. Consequently, his ingenuity has developed first and his soul afterwards.  Thus, the progress of science is far ahead of man’s ethical behavior.’  We tend to forget that  there is ethics behind everything that we do.  And so I’d like to share with you a philosophy that I gained from the place where both me and Dr. Lopez come from.  And it’s a place called the City of Hope in LA, which dedicates its work in the area of cancer.  And this is a picture of it.  It’s a wide campus.  This is the group of the Department of Surgery at that time and we have some symposium. Symposia that we do every year and it has a campus strewn with gardens, with a small water fall, Japanese garden to provide what we call a healing environment. Again to emphasize that the spirit is very important.  And there are other areas in the campus which  cater to all kinds of people including a grotto of the Virgin Mary behind, in the Rose Garden.  And it is behind this grotto that there is a metal, lies a metal sculpture which embodies the philosophy of the City of Hope. And that is, there is no profit in curing the body if we destroy the soul.  So what you’re doing here indeed feeds the soul.  And I  so I congratulate you again, and hope that you give everybody more hope in their fight against breast cancer.

Thank you very much.