BREAST CANCER 101 By DR. FRANCIS LOPEZ MEDICAL ONCOLOGIST

BIBETH ORTEZA (BO): Graduate po sya ng UST nung 1989, graduate sya ng college nung ikinasal ako (laughs). He completed his Internal Medicine and fellowship training in Medical Oncology and Hematology at the Brown University School of Medicine in Rhode Island, USA; pursued further training in Bone Marrow Transplantation in City of Hope Cancer Center in California; bumalik sa Pilipinas after 8 years in 2002. He is 1 of the 2 Bone Marrow Specialists in the country. He performed the first Autologous Stem Cell transplant in the country this year. Sa kasalukuyan sya po ang Section Head of Hematology Bone Marrow Transplant Program at the Asian Hospital Medical Center at Chairman ho siya ng Oncology Center in the Victor Potenciano Medical Center na dapat po niyong pasyalan sa kanto ng Shaw Blvd. at Edsa, yung dating Polymedic Hospital na ang nagpapatakbo po nun ay pinsan ko si Virma Potenciano Vergel de Dios. So mga kaibigan buong lingkod kong binibigay ko sa inyo, at buong lingkod kong pinahihiram sa inyo, si Dr. Francis Lopez. 
 

DR. FRANCIS LOPEZ (FL): My 101 course in college is usually 3 hours every week, per semester; I’d always try to cram it in 10 minutes. I practiced this morning for 18 minutes.  

Let’s talk about the Pathology report which we all get after the surgery, the staging of the disease, the treatment, and follow up care, some of which were already explained to you by Dr. Mark Kho.  

So, what we always get in the report is Invasive Ductal Carcinoma or Infiltrating Ductal Carcinoma, ano ba yun? (Points to visual presentation) So, here we have a cross-section of the duct and next, we have a cross-section of the duct with cancer cells forming. That’s what we call Ductal Carcinoma, inside, or in other words, its still inside the duct. But once it has already invaded or come out of the duct, we have already a tumor here, that’s what we call Invasive or Infiltrating Ductal Carcinoma.  

Ductal Carcinoma is probably the most common kind, but there are many other kinds of carcinoma. This is a very simplified staging system that I placed here. It is more complicated than that but for our purposes... Stage 1, when the tumor is less than 2 cm. Staging will depend on tumor size, how many lymph nodes, and whether it had spread to other organs, mainly the lung, liver, bone or brain. So, Stage 1, the tumor is less than 2 cm., there’s no lymph node involvement and it hasn’t spread to other organs. Stage 2, when the tumor is between 2-5 cm., you may or may not have a lymph node involved on the same side but it has not yet spread. Stage 3, the tumor is more 5 cm in size and you have already the presence of lymph nodes, and again, it has not yet spread. Stage 4, it has already spread to other organs such as the lungs, liver, bone or brain.  

We often hear the doctors say estrogen receptor or progesterone receptor. Ano ba yun?

Let me explain. All normal breast tissues have estrogen or progesterone receptors. As I always tell my patient, my analogy there is like a plug and a socket. The socket is the receptor and the plug is your estrogen and progesterone. So, during your monthly cycle, the estrogen and the progesterone that leave your ovaries to look for the receptors or the sockets in the breast tissue attach to it, and then stimulate the breast. Cancer (inaudible) is, again, another defect. We all have Her2nu in our normal cells and the function the Her2nu, basically, (points to visual presentation) here in the drawing you see it here, in the normal cells, the Her2nu is like a promoter gene, it helps in the cell division of a normal cell but once it gets mutated or there’s already a defect in the Her2nu, it then just keeps on dividing and dividing and it does not stop dividing. So, it’s a promoter gene. Here in the next diagram we have a cancer cell that is now expressing too much of the Her2nu gene and you have a lot of receptors on the surface of the cancer cells. There’s a grading system that we use here 0+1+2+3. When you look at the pathology report and it says 2+ or 3+, that is over expressed. That it’s not a good feature. 

So, the approach in the cancer treatment or breast cancer treatment is really a multimodality approach when you have all doctors, or the three doctors working together, the medical oncologist, who usually gives the chemotherapy, the surgeon or surgical oncologist to operate on the patient, and the radiation oncologist to administer the radiation, if you need radiation. So, I’ll divide into local control versus systemic control. When we say local control of the breast cancer, you’re only dealing with breast, and that’s through the surgery and radiation after.  

So, we are very familiar with chemotherapy, perhaps most of you here have received some form of chemotherapy and the more common one is a red drug, yung pula, drug called Adriamycin or Doxorubicin and the newer drugs that we have are the Taxanes, namely the Docetaxel and Paclitaxel, mentioned earlier of Dr. Kho. (Points to prsentation) Here are some common regimens that we frequently use, CMF x6, which can be used and can be given for 6 cycles and every 3 weeks. And we have the AC x4 or EC x4; E stands for Epirubicin which is by Phizer. It is similar to Adriamycin, it just has less nausea and vomiting, and it’s more gentle to the heart, that’s the only main difference. Then we have the FAC or the FEC given again for 6 cycles every 3 weeks. We have the TAC, where Taxotere is now given instead of the 5FU for 6 cycles. We have the new one now, the FEC x3 which is followed by Taxotere x3 cycles, the AC x4 followed by Paclitaxel x4 and the dose of the chemotherapy now is given every 2 weeks with the GCSF, the booster shot, given in between so that the patient recovers on time for the next dose.  

What one gets depends really on the medical oncologist or the doctor you have. I basically decide on what chemo to give depending on the pathology report, the estrogen receptor status, and the Her2nu and other features which I mentioned earlier like the grade of the tumor, if it is fully differentiated or an lymphovascular invasion, which basically means that when they look at it under the microscope, there are already cancer cells inside the blood vessels, so that is also not good feature. 

There’s this new drug called Herceptin and it’s given to patients who overexpress the Her2nu gene, if you have 2+ or 3+. This is by Roche. When it came out it was first being used in the metastatic setting. Now it’s already in used in the adjuvant setting, for patients who have been diagnose, but they have to have a 2+ or 3+ Her2nu for expression. It is given over one year.  

Hormonal therapy is also a form of adjuvant treatment. Sometimes patients, because of their features of the pathology seems very good or the tumor size is rather small, so instead of getting chemotherapy, they are just given a hormonal therapy and that could be either Tamoxifen or one of the Aromatase inhibitors that are currently available in our country. Sometimes, after chemotherapy they are ER/PR positive then they are given hormonal therapy. So, we have Arimedex which is by Anastrozole, Femara, Aromasin or Exemestane.  

So, adjuvant treatment consists of a chemotherapy, which is a set number of drugs, whether 2 or 3, and a set number of cycles, whether it is given for 4 sessions, 6 sessions or 8 sessions, but basically it should not exceed more than 6 months. 

Hormonal therapy is given for a total of five years whether it’s Tamoxifen for 5 or Arimedex or one of the Aromatase inhibitors if you make a switch in between, but a total of 5 years. The monoclonal anti-bodies is the Herceptin, which I mentioned earlier, can be given for one year for those who have Her2nu over-expression.  

Radiation therapy is indicated if you had a lumpectomy. A Lumpectomy means you just removed the lump, and if you removed the lump, you need radiation, absolutely, because studies have already shown that when you have a lumpectomy and the radiation, it is as good as having a mastectomy. Adding radiation to the lumpectomy decreases the risk of local incurrence to the breast. So, when you decide to have a lumpectomy, guaranteed you need radiation. Now, when you have a mastectomy, when do you need radiation? When the tumor is 5 centimeters or greater, and you have 4 or more positive positive lymph nodes. It’s rather controversial. There were studies that come from Europe saying that by radiating the area after the mastectomy it improves survival, but the Americans are still questioning the outcome of those studies. 

Follow-up care. When the patient is done with the chemotherapy, what’s next? What do I do? So, let me give you some American Society of Clinical Oncology updates on what a patient should do after they already completed their treatment. And this study or this recommendation was based on the following… the objective here was to determine an effective evidence based…when you say evidence based, what is the data? There should be data to support what the doctor is doing, post-operative surveillance strategy for the detection of recurrent breast cancer. Tests are only recommended only if they have an impact on outcome. Outcome was defined as disease with survival, ‘I am alive without breast cancer,’ or overall survival, ‘I am alive, period,’ or quality of life and cost-effective. So the data is sufficient for the following: a monthly breast examination, annual mammography of the preserved and other breast, careful history and physical examination by the physician every 3 months for 3 years then every 6 months of 2 years then annually. Data is not sufficient or they don’t used solid recommendations for the following: routine bone scans, chest x-ray, CBC… I like doing the CBC because sometimes the chemotherapy can affect the bone marrow; since I am also a Hematologist, I want to make sure that this does not happen…tumor markers, CA53. I frequently get phone calls from my patients who are in I Can Serve, because anytime they have their lunch, they start discussing what tests they do and they call me after and say, “Dr. why don’t you do the CA53? All the others are getting the CA53.” It is because the normal value of CA53, the range is rather wide. So, even if you have breast cancer recurrence and your CA53 is normal then it won’t tell us anything. So, I don’t routinely do CA53’s or CEA’s. I only do this for my stage 4 patients. Neither liver, ultrasound, and CT Scans. This is very difficult for the patients to understand. In my place also, I understand their situation. The American Society does not recommend routine of these tests because if, for example, you do a bone scan and you don’t have bone pain and it’s positive, versus a woman who does a bone scan, who has pain and is positive, it is not mean that the woman who found it, who had a positive bone scan without pain is going to live longer than the other woman who found it with pain. So, there’s no data to support that so they don’t routinely recommend it.  

All my patients ask me that they have to do something, so I discuss it with them. But I understand the situation, that most patients, if not all patients, want something done for some sense of re-assurance that ‘I am clear’, and that I understand.

Next is nutrition which has already discussed fully by Dr. Kho earlier. This is my own personal recommendation, and I got this from all the reading materials from conferences I have attended.

Low-fat diet. Fat produces estrogen and we know estrogen, as mentioned earlier, is a risk factor. 

Low-carbohydrate diet. In a recently concluded American Society of Oncology conference, a low-carbohydrate diet seems to be beneficial. 

Avoid soy and ginseng because soy and ginseng have estrogen-like properties. If you are ER/PR positive then it can stimulate your breast cancer cells. And then as mentioned by Dr. Mark Kho, five fruits and vegetable per day. If you eat five fresh fruits and vegetables per day, you are already taking in the required minerals and vitamins that you need. You do not have to go to Mercury and buy vitamins; it’s already there. And they also advocate 5 kinds and not actually one kind, but large in amount.  

(Points to visual presentation) In this table that we published in our Big C Magazine, March-April 2005, and I lifted this in one of the journals of Clinical Oncology. Basically, what was listed was some of the herbal medicines that we frequently take, and as you can see, it can affect some of the chemotherapy drugs that we receive. I personally have nothing against herbal medicines, I don’t. But I always tell my patients, let me know what you’re taking. 

I have a funny story. I have a patient, the other day I told her, “Are you taking herbal?” “No.” “Are you taking gumamela?” And then she answered me, “Hindi, Doctor, sampaguita.” Natauhan ako dun when she say that..  

So, again, soy and ginseng, avoid with Tamoxifen because they have estrogen-like properties. 

Here are some tips if you plan to take herbal preparations or vitamins…there was a recent study that came out on the Journal of Clinical Oncology looking at Japanese women and 70% of patient’s taking herbal preparations were adviced by relatives and friends to take herbal preparations. Only 30%, really, were the patients who went out to look for these preparations. So, here are some tips…consult your doctor before taking vitamins, minerals and herbs; read the label carefully; beware of ambitious claims like miracle cure; vitamins and minerals should contain 100% of the recommended daily allowance of essential vitamins and minerals, so read the label.

Exercise. Get physical, so couch potatoes arise! Excercise also has some benefit. Some of the physical benefits…it helps your muscles, cardiovascular benefit, it boosts your energy, and emotional benefit; it relieves depression, lessens anxiety and increases self-esteem. 

And I always want my patients to be informed. We thank Kara for coming up with I Can Serve, I think this is one good venue for people to learn about breast cancer. We have published the first and only cancer magazine in the country, The Big C, so we’re try our best to provide information to our patients with all sorts of cancers, not only breast cancer.  

So what are my chances of surviving breast cancer? I know this is not very good slide see becase we are all full of hope. So at the end of today, and perhaps after everthing that has been said and done, I personally still believe in the power of prayer to make the number 100%. And with that I’d like to end it. Thank you very much.