TOPIC : Multidisciplinary Approach to Breast Cancer
MODERATOR : Dr. Orland Diomampo
SPEAKERS : Dr. Conrado Lorenzo III
DR. ORLANDO DIOMAMPO (OD): And lastly, we are requesting all of you to attend the Silver Linings Session at 3:30 pm today at the Garden Ballroom. There’s a little announcement here, Asian Hospital and Medical Center will be giving away copies of its coffee table book entitled “Your Health and Wellness: An Asian Hospital and Medical Center Guide”, to two lucky winners of our special raffle. Health Today will also give a gift check of the Health Guide 2005-2006. To join, make sure your names are registered at the registration table. All of you registered right? Okay. Names of the winners will be announced after the forum.
I would like to acknowledge our panelist. He is a cancer survivor who was diagnosed with non-Hodgkin’s Lymphoma when he was 13. He is currently studying at the Trinity College and enjoys playing tennis with friends. Ladies and gentlemen, Yaren Agustin. Yaren, you’ll be one of our panelists.
For this session, we are indeed honored and privileged to have one of the younger and more promising medical oncologists we have in our country today. He studied at the UP College of Medicine, trained abroad, several distinctions in America and Europe, ladies and gentlemen without much further ado, I would like to introduce my friend, my colleague, Dr. Conrado Gary Lorenzo.
DR. CONRADO LORENZO III (CL): Good morning everybody! This is actually a very informal talk. This is not really a lecture. Actually, I’m quite happy that today’s event has appeared to be very well-attended, and I think it’s a testimony to the fact that a lot of our general public is more aware of breast cancer and its importance today. I’d like to congratulate Silver Linings and Asian Hospital for taking part here.
I think breast cancer is a special illness. I think it has a special place in a lot of the oncologists because breast cancer by itself is not always equal to a death sentence. I think that the numerous people who are here today is proof enough that unlike other cancers, there truly, truly have a very large number of survivors. In fact, have you ever asked yourself, why is it that breast cancer is the only one that has a support group? Not only because they are all women and that they like to talk but I think mainly it is because they are true survivors.
You have to understand the natural biology of breast cancer allows some diversity. You seldom hear, advanced stage lung cancer, advanced stage pancreatic cancer where patients do well, they usually don’t do very well. But with breast cancer it is not uncommon that in everybody’s practice or she would probably know somebody who even with advanced breast cancer is able to celebrate life or continue their activities of daily living. It is for that reason that we have to put a lot of importance in breast cancer. Today’s talk actually, has to do with the multidisciplinary approach or the team approach to breast cancer.
Today, we are bombarded with a lot of information, new developments, and new discoveries, that it becomes a complex process now when you see a patient. I can imagine even for the patients themselves to be able to understand what they have and who they have to see. Gone are the days when it started out that breast cancer is a purely surgical disease, where the surgeons will do the operation and that’s it. Slowly it has evolved into what we called a multidisciplinary care.
So before we talk about multidisciplinary care, let me discuss some statistics of breast cancer. Breast cancer remains to be the number 1 leading cause of cancer in women today. In 2005, there is an estimated 40,000 new cases of breast cancer with 6,500 deaths. It continues to be a major public health concern due to its increasing prevalence. We are discovering breast cancer at an earlier stage because of both private and government sponsored screening programs and of education venues like this; but it still is an increasing prevalence. To the average Filipino family, being diagnosed with breast cancer would be mean great economic implications. In the Philippines where health insurance is extremely inadequate, the diagnosis can mean a serious financial setback, not to mention the emotional impact it has on the patient and the family, where it often pushes them to extreme exhaustion.
Therefore, I think it becomes, I will repeat, becomes both the duty and the obligation for all hospitals like Asian Hospital and the physicians of Asian Hospital to ensure that proper care and management is delivered. I think we should take it upon ourselves that when a patient comes to see us, to give them a complete total care so that not one modality is left out, because a patient walks in and it happens so fast. They are diagnosed with breast cancer and they really don’t know what to do. So I think we have take cancer care to a different level today. It should be really the duty of the hospital and the physicians to make sure that there is interaction and communication amongst us. So each patient who leaves the hospital gets a total picture of what they have.
To be able to understand the history of the evolution of breast cancer care, you have to know it did not happen overnight. The principles in both diagnosis and management for me stemmed from a monolithic discipline. In the past there was something we called the Halstedian approach where historically they felt breast cancer was purely a “bukol” that we have to remove, and the surgeries then were big, the radical mastectomy, and it evolved over time and now we accept lumpectomies. And it was only later that we found out that there is such a thing as metastatic disease and recurrence where the school of thought that perhaps that breast cancer is likewise a systemic illness, it is not just a local problem that has to be removed surgically, but perhaps there is something, something more involved. So that actually gave rise to the medical oncology as a formalized subspecialty. Medical Oncology is fairly new and its origins were probably in the 1960s. And this was basically fueled by the fact that there were remote studies all around the world that showed advantages, improve survival in patients with metastatic and adjuvant treatment. So it was a period where that there were dynamic discoveries.
Initially, a lot of energy was put into drug development. It was also that period of time you were allowed to experiment. It was drug testing, it was intelligent hypothesis, but that was not enough. We did not have data at that time to say “This is better than this.” We had to take the charge in trying new medications. And that later evolved into what we call collaborative investigators where the studies were done by different groups. There were interactions, clinical trials were basically developed and these were comparative testing, and this gave birth to what we now call evidence-based medicine.
I think it is important to explain. Evidence-based medicine is basically one of the fundamental principles in medical oncology and that means when we see a patient we are duty bound to be able to read and to understand the literature and to tell our patients that: “Today this is the standard of care, this is first line therapy.” It is often tempting for us to say: “You know in my clinic where I have 20 patients with, let’s say lung cancer, this medicine works the best.” It is almost tempting but that is wrong. We cannot put our experience above the society which as a whole is the one who dictates which is first line and which is not.
In the past there was no evidence, we have a paucity of evidence. So as time went by it became more complicated, it became more scientific and when we render a recommendation for patient we have to be very sure that we are up to date with the literature.
Radiation oncology is a branch of oncology where together with surgery and medical oncology, is important in the multi-modality approach to breast cancer. Its impact is more on local control and palliation. The other historical development was this happened in a period where there were a lot of new things and new discoveries. With pathology alone, they finally realized that there’s a difference between DCIS versus invasive ductal, invasive lobular. The more favorable types of cancer are the tubular, medullary. This, you are allowed to have a bigger ‘bukol’ when you have a medullary or tubular, no. The threshold for starting chemotherapy is very different than that of the more common invasive ductal or the invasive lobular. DCIS now although is a still a very much surgical disease, patients are now starting on tamoxifen. These are all, these all are new developments that have to be understood.
With regards to surgical techniques, I am not a surgeon but I guessed there are also new methods that have evolved over time like now, lumpectomy is a very well recognized as equal to lumpectomy plus radiation. There’s also the axillary dissection, the number of axillary nodes that are minimumly accepted. Sentinel node and I think reconstructive surgery. I think there are more and more women that before undergoing primary surgery to the breast would like to ask about reconstructive surgery, mga plastic surgeons po. And sometimes it’s best to ask them up front because there are several techniques and sometimes it is better to do it at one shot. Sometimes they do it after radiation and I think Dr. Arcilla will be here this afternoon to give us some tips on reconstructive surgery.
And then even with diagnostic tools, these are all new again. The use of FNA (fine needle aspiration) versus core biopsy for palpable tumors, I think today it is widely accepted that core biopsy is the preferred route of a diagnosis. You see, you need a very good site for the pathologist to be able to differentiate DCIS and invasive ductal when you do FNA. You see FNA is a very fine needle. And up to this day there are still some biopsies that are done in FNA. The emergence of CT and bone scanning, we did not have this before, this is important in staging when we do primary surgery all our patients are required to have a bone scan. That’s something that is still controversial, and then of course the more famous PET scan, every body wants a PET scan.
With treatment naman, there this newer, again very noble treatments, including hormonal agents, newer chemotherapy, and the monoclonal and the targeted therapy, which can be very, very expensive. They raised about a hundred thousand pesos. So I think due to the rapid advancement in all aspects of breast cancer care, I think it drives us to improve the direction of treatment to something that requires really a collaboration. And I think the thrust of my talk today is with the advancement of the knowledge we have of breast cancer care, each cancer patient should be attended by really a group of doctors. And I even take it to a different level. I think that the hospital who houses the doctors should establish some institutionalized protocols to help these patients. Here basically it says multi-disciplinary approach is when there is a need to collaborate among physicians. No longer can we work in our own pigeon holes.
In 2005, it is almost painful to see a patient who underwent chemotherapy when they should have had surgery and vice-versa, patient who had surgery and needed chemotherapy but was not given that chance. I often here from patients who say, “well hindi kami ni-refer sa radiation, hindi kami ni-refer sa surgeon, hindi kami na refer.” I think the primary physician takes a very, very crucial role. And it’s not easy to educate one doctor, the other doctor. I think it would be easier to approach the hospital and the departments to say that please institute guidelines so our dear patients will not be shortchanged. So and these are basic guidelines we don’t always have to follow it but it will make us all aware that it needs an interaction among many doctors. So with development of guidelines create tumor specific workshops which I will explain later. So these are other nice definitions of multi-disciplinary care. It says it is a complex process that involves a collaboration of a team of doctors specializing in breast cancer with the end goal of giving the patient a complete and thorough treatment recommendation. A multi-disciplinary approach assures that the combine knowledge and wisdom of many experienced breast cancer specialists are made available to the patients.
And lastly, it says, this approach ensures that all forms of treatment modalities are utilized when clinically indicated and that none is spared. The cancer patient thus leaves the hospital knowing that an exhaustive collaboration of minds has taken place. For this to take place, not only our patients should be made aware but I think it’s really, again, I’ll repeat, it’s the physicians and better still, the hospital itself who should carry out the responsibility of delivering comprehensive care. And that’s what we in Asian Hospital are striving for. The responsibility of both physician and hospital to recognize that cancer care is often suboptimal. I think this is because of, again, the conventional pigeon-hole mentality where we just take care of our own patients. Again, we raise this to the level of a multidisciplinary thing, then we will see less of these patients who were not referred or who has not, does not have a clear understanding of the disease process.
And lastly here, it says the creation of tumor-specific workshops. So this is not true for only breast cancer. This is true for colorectal cancer, for lung cancer, head and neck cancer. I think the hospital should get all the people involve with breast cancer and among ourselves first discuss and clarify issues that are not clear to us. Only before that we can go to the patient and say, “ah, malaki masyadong yung bukol mo, maybe you need chemotherapy first.” or “you need surgery up front or you don’t need radiation.” I think it’s really in the development of this probably what we can call the breast cancer clinic.
The breast cancer workshop. You see all these people involve: Surgeon, medical, radiation, oncologist, pathologist, mammographer, nuclear medicine, rehab, pain, psychiatrist, and pharmacists. The mammographer is the first one who usually interprets the lesion and guides us to whether it is deemed to be pursued. Surgery, here is the time we discuss lumpectomy, mastectomy, the need for sentinal node, induction chemotherapy. So the workshop is really a collaboration of minds, with the end goal really of giving the patients what they rightfully deserve. The objectives of the workshops are many, but really is to identify and to clarify important issues. It’s a fertile ground of discussion, and to develop guidelines and algorithms, and to discuss what we called proposed institutionalized protocols. Again, with the end goal of giving the patient what’s they rightfully deserves.
So, I think the following slides which I will show is basically just to illustrate that even in 2005 certain practices may still be unclear. You know in medicine you have to understand, in medicine there are many correct answers sometimes. Sometimes it’s not just one answer but certainly there is a wrong answer. And that is what we try to avoid. It is not uncommon that one oncologist will say, “Why don’t you try CMF?” or the other will say another regiment. But many of these are correct. It may need fine tuning. But sometimes, there is a wrong answer. And that is what we’re trying to avoid.
Your basic illustrations, no, okay number 1: Preoperative recommendations. How many of you, or this is a small group but if you get a larger group. Although mammogram is basic and essential to a preoperative evaluations not many patients, well not, I think that’s not fair. There are some patients who at this point still missed out in a mammogram. See what happens when the “bukol” is big enough and it’s palpable then a biopsy is done right away if it’s confirmed they do surgery. But it is important that a mammogram be done because the mammogram serves the following. The mammogram will tell you if you have a tumor in the other side of the breast. The mammogram that is highly seen and lobular. Lobular has a high propensity for
bi-laterality.
Sometimes when you have the satellite nodules of the same breast even if you have a dominant lesion. Especially if you think of doing a lumpectomy. A lumpectomy, ladies, is a what you call breast conserving surgery where you can only remove a lump. And if you do not do a mammogram one cannot even decide whether one should get lumpectomy. So again, no, a mammogram. Now it is bone scan and liver CT, even amongst doctors, I will be the first one to admit, if you put 20 doctors to a room, there may be some there may be some controversies as to when a bone scan and a liver scan is required preoperatively. You see when a patient presents you with a “bukol,” we have to make sure that the “kalaban” is only on the breast. The only way we could do that is to make sure that patients do not have bone involvement or patients do not have liver involvement, the more common sites of the past disease, but even in the United States the recommendations are not all patients will get CTs or bone because the predictive value of a Stage 1 that they may have positive bone scans is so small that it will cause the health insurance billions of dollars if everybody gets bone scans. But perhaps in a stage 3 patient when it is locally advanced or if you suspect a, you know, or maybe it is important to get the bone scans because if it is otherwise positive with the liver than in the bone, surgery may be deferred at a later time because it has already spread. So I think fundamental basic stuff has mammogram, when to do a CT, when to do bone scan, has to be discussed among the doctors, not patients and doctors. And if the hospital have a protocol then it would be easier for everybody who cares for breast cancer in that particular hospital to more or less sing the same song.
Okay, the other things that will illustrate the need for a workshop is tissue biopsy. I often hear they say, “Doc, pag kinalikut yan baka kumalat.” It’s a common thing I hear but I guess in good hands of our surgeons they do a biopsy, they don’t make it. Maybe ako, I’ll do that, I’m not a surgeon. But in good hands, a tissue is necessary and the only way to make sure that we’re dealing with cancer. Now there’s a saying that says the tissue is the issue, no meat, no treat. All cancers, regardless breast or others, before they’re labeled as cancer have to be documented. It is irresponsible of a doctor today to label the patient “cancer yan”. It has to be proven.
Now, again I’ve spoke earlier about the need that core biopsy is better than FNA because you see not only a row of cells but I think the other thing and I don’t know the answer to this, maybe our surgeons can help us later on. When a patient presents with the mass, what is commonly seen here is patients are educated about the possibility of a mastectomy. But they do it in what they call a double set of approach, where a patient goes to the room. They put to sleep. They get a frozen section. And then decide whether if it is cancer. Then they’re told beforehand that a mastectomy maybe done. And then you wake up and it’s done. And that is accepted. I don’t think there’s anything wrong with that. But there’s another approach and maybe the surgeons can answer the question later. I think that’s more economical when you do it as a double set up.
The other one which is a two-step approach is you put your energies into proving that it is cancer first. It is usually done as an outpatient setting. So the “bukol,” you prove that it is cancer, you send the patient home. Only then will you discuss, “Misis, these are the possibilities: Pwedeng lumpectomy, pwedeng mastectomy, pwedeng induction-chemotherapy.” So it’s longer though, and I think it’s gonna be more costly because there are two steps. The reason I share this with you is my own mother was a breast cancer survivor. She lived 22 years with stage 4 breast cancer. She was 33 years old when she was diagnosed. I was 8 years old when she was diagnosed.
I remember she was telling me, when she woke up, she was given during that time the double set up. They said she had a “bukol,” it might be cancer. But siyempre, the dear husband, my father, would downplay it. “Baka hindi naman cancer yan.” But as a doctor he knew it was cancer. So my mom went into the operating room thinking that there’s a chance it is not cancer. But they did a double set up. When they prove it was frozen section positive, when she woke up she had no breasts. A 33-year-old woman at that time, whose husband was downplaying the disease, woke up with no breasts. I remember during one of her crazy days she said your father maybe the best doctor but he is the most terrible husband. You have to tell a woman that she would lose her breast. But that‘s not done today, even today when they counsel their patients you can tell the patients beforehand that there’s that possibility that you may lose your breasts. But this probably is best discussed with the patients.
Some patients prefer a double set up for economic reasons, for they want it right away. But some people prefer a, what do you call a not a double setup but a two step approach. So even this can be discussed in the workshop then we can give options to the patients.
The other issues to illustrate the need for collaborations are histopath reports. You know there is nothing more frustrating than getting a pathology report that says “Submitted is a piece of tissue weighing 3 pounds with the size of 5 centimeters by 3 centimeters. In it there is a cavity that measures 1.3 centimeters and beside is a fibro glandular whitish tissue.” It’s the longest paragraph but in the end of the day you won’t even know the size of the tumor. And the easiest one is the T&M classification where all it says is T is equal to 1.3. Rather than giving a whole paragraph that says “submitted is a….” you get lost in the process. I think that has to be standard as a universal thing.
The other thing is, with breast cancer today, I think everybody should get an ER/PR determination upfront. It’s a waste of time when it’s reported to you then you sent it back for ER/PR. And I think, again, this has to be discussed among all breast doctors, be it surgeons, pathologists, or oncologists. Isn’t important to include size? Yes, the grain, I think the grain should be there, degree of differentiation and the ER/PR, and the margins. I think what is debatable whether all specimens should have ploidy, s phase, HER-2 Neu. I think that might be a little more controversial because why put the money there when you can put the money somewhere else. But again what I try to illustrate is even among doctors we have to first agree.
Okay, the other issue is the lumpectomy and mastectomy issue. I think this has to be clarified that a lumpectomy plus radiation is equal to a mastectomy. Some people think otherwise, that’s dogma. We have studies that show that they are equal. But not all patients can get lumpectomy. There are contraindications to lumpectomy. Those who never got a mammogram don’t get a lumpectomy. Those patients who have presence of 2 or more tumors in separate areas of the breast, hindi pwede yung lumpectomy diyan. Patients with diffused micro calcifications, patients who are pregnant, who at the time of radiation is pregnant, hindi pwede yan, no.
If the patient has prior history of radiation and then you going to offer lumpectomy plus radiation and the radiation is not to be given in a full dose, just go for a mastectomy. And relative contraindications for patients with connective tissue diseases, yung mga may lupus. I think it has something to do with the healing.
Okay, so the next we would like to illustrate is something called neo-adjuvant chemotherapy or induction chemotherapy. This is when chemotherapy is given prior to surgery. Sometimes a patient will be deemed inoperable, masyadong malaki yung bukol, that the surgery can be so deforming. These are the patients that who would benefit from upfront chemotherapy. The other indication would be called downsizing where a patient wishes to get a lumpectomy instead of a mastectomy. I had have patients who refused surgery and you give chemotherapy and that the primary tumor disappears by MRI. Of course, these are very rare cases. And in cases like that, you just do radiation because you don’t know what to operate. But even I, I don’t know. You see when a patient go the surgeon or to the primary physician, even amongst us, I don’t know when, what size will make one prefer induction chemotherapy or not. Remember induction chemotherapy is not better, it’s not better than post surgical chemotherapy. There is no advantage in survival. But what the advantage is it can shrink tumors if it is especially which deemed inoperable or you can downsize.
The other thing is, you can actually have an in vivo test of your chemotherapy because when you get chemotherapy, and you have no more breast and you will asked your doctor, “Am I getting better? Well the answer to that is we really don’t know. Because there is nothing we can measure. But with induction chemotherapy if you get it beforehand, if you see it shrink then at least the doctor can say: “Guess what, Ma’am? Malalaki ang iniliit, so mukhang tong chemotherapy na pinili natin ay wasto sa inyo.” But I’m not saying that this induction should be upfront always. No, no, no. Surgery still remains number 1. If we can remove it, that’s still the best way. It’s only at times when it is inoperable.
Ok, the other issues, ah, I think I did include it here that is the number of lymph nodes and the level of dissection. I don’t know but I think if I’m not mistaken the minimum required lymph nodes are eight, ten, so ten lymph nodes. Why? Because if you get 0 out of two lymph nodes, it does not tell you anything. Whereas if you have zero out of twelve, the power of prediction is more correct. So the issue here is what do we do with patients with zero out of two? Are we going to believe that 0 out of 2? Are we going to say, “Let’s operate again?” See, many times, many times also there’s not enough. Many times when the surgeons submit it to the pathologists, initially they will only yield 5. And when the surgeons go to the pathologists: “Hoy, I gave you so much and you gave me 5.” Then they will come back to the report and says 12.
So it’s more meticulously needing the sample given by the surgeon. The other example is an illustration of the need for collaboration is the timing and sequence of reconstructive surgery. Do you want to know up front before surgery when to do radiation? Should it be a sandwich treatment for those patients who get 8 cycles of chemotherapy? Hormonal therapy, a lot of times when patients come to oncologists, tamoxifen has been started. No, but we do not need tamoxifen concurrently with chemotherapy because they’re contradictory. So these things, we as doctors can
co-educate ourselves.
Ok, in the next example, this is an opinion, the rest is my opinion. But the question is who among the doctors that is most appropriate to decide and administer systemic chemotherapy? I think this is something, this is my opinion too, who are the most appropriate to decide and administer systemic chemotherapy? I think this brings back historically this being a very new subspecialty. In the past, it was, you know, the surgeons took care of breast cancer patients, you know, from diagnosis to follow up. And there was paucity of medical oncology. There were oncologists, and there was also not too much data around. I think today, 2005, when there are not only developments but a rapid burst of knowledge. In fact it’s so fast, that what I learned when I graduated in 1999 is completely passe from what it is today. Gone are the days when CMF was given from 1975 to 1980, and adriamycin and cytoxan were given from 1980 to 1990. For colon cancer, there was nothing but 5FU.
So I guess historically, people would say “madali lang pala mag-chemo, eh.” Just give him the medicine, everybody uses a CMF. But today it’s very, very, different. And I think it requires formal and continuing studies. And I think most hospitals will limit the doctors who have formal training to give chemotherapy.
The other thing that needs the collaboration and understanding is followup studies. Sometimes patients are lost to followup. After the surgery they disappear. After the chemo they disappear. Remember that there are still recommendations that patients that you should see every three to four months on the first year after treatment, every six months on the second year after and then it gets less and less. And then also what studies are recommended? Should every body get a CT scan? Should every body get the CA53? Should every body get, and this has to be discussed amongst us.
A CA53 is helpful but it’s best when it’s found to be the very elevated presurgery, goes down to zero and on followups slowly goes up, it’s has when it becomes very important. Because not all breast cancer has elevated CA53. CT scan, PET scan, what’s this response to period of followup? I think that what I wanted to explain. Sometimes, you know, whether it is three months or four months, it is a period that we are responsible. Some, some patients would say, “Why the other four months, the other five months?” I think there is a irresponsible period. If I tell a patient, ‘you see me two years from now. That’s irresponsible.’ If you tell a patient, “you see me every month.” I think, kawawa naman ang pasyente.
But I think there is a range which I think you can tailor to the level of anxiety and need of a patient. Remember, the care for Filipino patients are very different from the American patients. In America, they have these recommendations. When they have 20 people at a table, 10 are from insurance companies. Imagine if the recommendations says, you get a bone scan every year, or see your patients six times a year instead of five. That one extra year translates to billion of dollars. That’s why in America recommendations are followed strictly because of the insurance phrase.
In the Philippines, it’s usually a fee for a service, where the patient will ask you, ”is it better if I get the CT or ultrasound?” The answer to the question is that CT scan gives you more information but it is not standard recommendation in the United States. But if you ask me, “is it better?” My answer to that is ‘yes’. So the practice is very different from there from here.
I think I guess this is really my last line but I guess the, the talk for today was really a multi-disciplinary approach. I think many hospitals including ours are beginning to raise the level of care that no longer is it monolithic, pigeon-hole influence type of treatment where you come and end in my clinic. Our departments at Asian Hospital are beginning to have some interactions and we will try as soon as we can to bring this into practice. But I think the important thing is there, first it’s the recognition of the need is number one.
So in summary, there is a need to take a new direction with regards to cancer care where it embraces the principle of a multi-disciplinary approach. This is the most complete approach where patients can be given what they are due, what you all are due, and that they can leave the hospital knowing that an exhaustive collaboration of minds have taken place. Thank you and God bless. (audience clapping).
Q1: Good afternoon. I’d like to know more about the result of my ER and the PR. Is that the estrogen and the progesterone? It’s negative, positive. Somebody told me mas maganda daw pag negative-negative o positive-positive. For my part, it’s negative and positive. I’d like to know more about my results.
A. The current practice if you have one, either estrogen or progesterone, that is positive, you still would be a candidate for hormonal therapy. Earlier this afternoon,
Dr. Lopez was talking about hormonal treatment. It’s whether one should go to tamoxifen or Arimidex, but the answer to your question is yes. Anybody with a positive, whether it’s ER or PR, should be placed on hormonal therapy.
Q2: I’m Mila. I’m here on behalf of my sister who has stage 4 breast cancer. I was late for the lecture so I don’t know if this was already taken up before I arrived. My question is what is the prescription period for radiation therapy. I was told that radiation should be done in six months after the surgery. Why is that so? I’d like to know because my sister is now on her four month after surgery and she has not been given radiation because she is not psychological prepared for it. So I was wondering if you can do the radiation after six months what would happen.
A: I think, your sister is stage 4? Probably not.
Q2: She is. She has metastases.
A: Because radiation is given to patients with stage 4 disease for what we call palliative reasons. It is not to prevent the tumor from coming back. In stage 1, 2 and 3 disease, M’am, where they do surgery to the breast. There is an important period where one should deliver radiation, for it to have maximal benefit and protection. Because most of the studies are performed where radiation is given several months whether it’s 5 or 6 months after. But in your sister’s case po, na this is stage 4, it doesn’t matter whether it’s given 2 months, 4 months, or 6 months. What matters is we have to prioritize whether chemotherapy should go before radiation or whether radiation should be or sometimes it can even be given together. She has metastases, tama po kayo, that’s a stage 4 and we’re giving chemotherapy to address whatever solid disease that can be measured and even also the bone. Sometimes we don’t even do radiation to the area of surgery anymore. We do radiation to the area that is painful, that if there’s a bukol that prevents you from eating and swallowing, you want to shrink it. If there’s a bukol that makes it difficult for you to breathe or a bukol that causes you pain. On the primary side of surgery, I don’t have answer to your question. Do you know what you are going to radiate? The breast?
Q2: Yes. The area where the surgery was done.
A: And there’s no more measurable disease?
Q2: I beg your pardon?
A: Wala na yung tumor? Wala na pong bukol sa area ng breast?
Q2: No more. She’s not given chemotherapy because they said she is not a candidate for chemotherapy for the reason that she has a psychiatric problem, she’s taking anti-psychotic drugs, and she’s clinically depressed, and she cannot comprehend the therapy.
A: I think what we have here, ladies and gentlemen, is a patient who has stage 4 disease and has spread to the bones. So, tumor has already escaped the primary site, and so it is in the bone. From the bone, it can go elsewhere; from the breast, it can go elsewhere. Maybe they did the surgery…was this done because of toilet mastectomy? dahil may sugat na po?
Q2: No naman.
A: Well, in this case, if she has no psychiatric problem, they probably would have done chemotherapy upfront. Because to do surgery in the breast when it has escaped, is usually done for toilet reasons only, if kumalat.
Q3: I’m Myrna. I just finished 6 treatments of chemo and I’m on tamoxifen. I was very interested in your horizon of multi-disciplinary that is from a hospital perspective. My perspective comes from religious, missionaries, and poor, who may not always have the choice of hospital treatment, but multi-disciplinary, is definitely with another perspective that is herbal. So, actually, I had a difficulty of choices because having and being involved to meet a lot of grassroot women, let’s say, and sisters who are into alternative medicine, like developing the immune system, I opted for surgery and chemotherapy. However, I was trying also to put the herbal and the development of the immune system. Could I hear from you on this aspect, which is very Filipino in terms of multi-disciplinary outside the hospital, but which may be conflictual to one form of treatment. Therefore, when I asked my oncologist, she said, if it doesn’t do you any harm, go ahead. However, it fell heavy on my liver, and so she said stop it muna. That is my question in terms of can we develop further the content of multi-disciplinary within the Philippine situation, which does not have health insurance for most of our people.
A: That’s a very important issue, and I think, yes. All of us people who are sick, you’re often counseled that you should otherwise do this or there are other alternative medications. I think this is really a very personal thing for me. I think each oncologist have their ways of answering this question. I think there are people who are very formal and very rigid, that to them, there’s no other form of therapy but chemotherapy. And I think they usually say that because they are afraid that anything you give may have that potential interactions to a given medicine, and therefore, it may antagonize.
The other thing also, which is probably an equal and practical issue here, is if you start on current alternative medicine and chemotherapy, especially if your alternative medicine is also costly, and this is not the usual herbal, herbal, but costly. And then you see a response, how do you know which treatment to continue? The chemotherapy or the herbal alternative? It’s a very practical issue.
So, I think that those are the reasons why I think most doctors who are against the practice, they have these reasons. I, for one, this is not anymore medical, this is probably a personal thing. Oncologist cannot promise results, unfortunately, we can only promise good judgment and good care. Unlike our surgeon here, and this is true when they remove the bukol, they will put it in a bottle and send it home with you. Oncologist cannot do that, we can only promise good judgment and good care. If I cannot promise a patient that with the best, most expensive 150,000, that I can shrink the tumor, who am I to say don’t take the alternative medicine. Even when we counsel patients, when we say primary therapy, secondary therapy, in the Filipino context. When a patient comes to you and says: “Ito mas magaling ito, 100,000. Ito pangalawa. It’s good, but the first one is modestly better. Ito 10,000 lang ito.” You have to explain in that context, because the poor guy will sell his carabao to get the 100,000; if the benefits are only modest, it has to be explained in that context. And many times, we start with the bigger, the better, the big mac theory, the 100,000, and then guess what? It got bigger, parang fertilizer. And then you switch to the cheaper one and it shrank. There is that last dance between chemotherapy and the patient.
So going back to alternative medicine, my personal stance is I don’t mind. I always tell the patient, which is true, I don’t know too much about what you’re taking, if you feel comfortable, I have no problem. I really think there should be a branch of alternative medicine. Problem is, anything outside chemotherapy is alternative, maybe China No. 1, you have this mangosteen shake, the gallbladder, you have the shark cartilage, you have malunggay. They all belong to alternative. And there is no order. There is anarchy. The hard part is to be able to truly discern which is well meaning through semi-scientific versus the many evils out there. I would be the first proponent to admit that we need help, but there must be a system to be able to regulate.
A: Yes, Gary. I totally agree with you. I see a lot of patients. I do a lot of breast cancer surgeries and sometimes they do not want to go to chemotherapy for so many reasons like costs, side effects, whatever. And they usually asked me about alternative medicine. I tell them, I don’t mind but we do not have enough literature to support the effects of alternative medicine. That’s the main reason why we cannot push for alternative medicine. And what we give our patients are founded, researched, scientific based effects of cure – surgery, radiation and chemotherapy.
We don’t have figures for alternative medicine. Doctors who practiced alternative medicine might have some figures but these are not well-researched studies. Remember when we subject our patients to chemotherapy, these drugs of choice, these drug agents have come through a lot of studies before even when we put them out in the market. So we don’t mind, alternative medicine if you think it works for you, God Bless. But if it doesn’t work, God bless, too. Because that was your choice, okay, but we cannot push for that.
Q4: This is about the surge on alternative therapy wherein they harvest the antibodies from the blood and they create a specific vaccine for a particular patient. What do you think of this?
A: Yeah, I have a lot of patients who actually have tried out this treatment. I have to be very objective. I think the reasoning behind modifying the new system fight for cancer has been done in the past and continues to be studied. What he does is, he gets your blood, this is called leukophoresis, it’s dentritic cell treatment. They get your blood and then they maximize. They, they mature your dentritic cells which are truly the soldiers of the body. And then they reintroduce it. They get your cancer cells. They mixed it together. And the cancer cell recognizes the enemy and says, “hoy, kalaban yan,” And then they make this vaccine and then they give it to you. And then it is suppose to, your body will now say, ‘ah this is the enemy. Let’s call the neighboring dentritic cells and let’s fight the enemy.” In concept, it is good, and I think it’s something that is exciting and merits further studies.
We at Asian Hospital has a similar study and myself and Dr. de Ocampo, the neurologists, the, ah, we do this in the context of a clinical study, ok. What I’m trying to say, I am the first one to say that this is not standard of care, that we offer this to patients who failed everything and we offer this to patients who are intelligent enough to understand that we are doing this under a clinical trial, but not in a commercialized basis, okay? I think the concept of Dr. Bernal’s is sound, probably it is not approved as even in the United States. But if we do it under a clinical trial for the benefit of future patients and we do it under, you know, BFAD Guidelines, you know, ah, I think that is accepted.
Q5: If it is it just like clinical trial, would you have to charge the patient?
A: It depends. That’s a very good question. There are some clinical trials that are sponsored by certain philanthropic groups. But there are some clinical trials that patients will have to pay for some parts of it, like the hospitalization. And we have a clinical trial established in Asian Hospital, it’s called the Gene Therapy. There is a study now that you’re given the drug for free but you have to pay for the hospitalization for the ICU, for the use of the CT Scan.
In the ideal way, yes, but you know, that’s why I think if you, if you really examine, number 1, patients are not, that’s why if you’re on trial, you don’t invite patients and say “Come here, M’am. Come, come here to my clinical trial.” No, no, no’. It’s different. You seek the trial. We’re running out of bullets. We need help. You’re the first to admit that you are not doing conventional treatment anymore. Now when you go out, you say “No more clinical trial.” That’s a, there’s a different, but sometimes you have to charge. You know the problem in the Philippines, there’s no tax deductible. In America, the rich guy who says tax deductible don’t make it to the trial. In the Philippines, it’s all given to my grandchildren.
Q6: After a stint of around 3 years, since Sept 2002, would you consider to a patient to be a survivor?
A: That’s a very common question, Sir, no. I think, I think anybody who survived the surgery and survived chemotherapy with no measure of the disease begins to be a survivor. There’s no magic moment in time.
Q6: She’s taking tamoxifen, she’s continuing and she’s surviving.
A: The survival of that patient who’s on the 6th or the 7th year may not be due to tamoxifen itself.
Q6: Will the prolonged administration of the drug boomerang as a carcinogenic drug?
A: There were studies conducted where patients were given 10 years of tamoxifen, versus 5. Wala pong added benefit ang 10 years. There are studies that show that patients of tamoxifen have a higher risk, although small, less than 5%, risk of uterine cancer.
Q6: Last question, sir. Will herbal therapy fortified with hormonal therapy do any harm in the process?
A: I do not know po. That’s my honest answer. Depends what herb, because there may be some interaction that is not known to us.