Breast Cancer Treatment

Eribulin is a newer drug (FDA approved for metastatic breast cancer in 2010) that is effective in individuals who have been previously treated with chemotherapy. In a study, known as the EMBRACE trial, women were assigned to receive eribulin or to the treatment chosen by their doctors as predicted to have the best effect. There was a significant survival benefit of about 2.5 months in favor of the eribulin. The drug, derived from sea sponges, works by targeting a scaffolding protein (microtubule) within a cell and interferes with the construction of the scaffolding and stops the cancer cell from dividing.

Hi Brandi, I did not take this, but I took Arimidex and had such severe side effects that I had to stop. Reactions to these meds vary; some women do fine on one drug and have reactions to others. I told my doctor right away, she had me stop for a while, tried again, but was always immobilized with pain. It can be dangerous to stop a drug without supervision, as some meds can cause a rebound effect, so check with your doctor. You can look up side effects of fareston here, and search for any other med: www.rxlist.com/fareston-drug.htm
Good luck!

I opted for a bilateral. I only had cancer on the right side, but after finding that and getting my MRI, something popped on the left. We weren't sure what it was. I could have had it tested, but at that point I just knew I wanted to have both sides removed. So I chose to not get that side tested and proceed with a bilateral mastectomy.

After surgery, pathology showed it was not cancer, but I don't regret
making that decision. It was 100% correct for me.

That said, what is right for me, may not be right for you. And it's a hard decision to make. And I wish you best of luck making it. You have to do what you think is right for you, and only you. ((hugs))

Preferably immediately after diagnosis. I feel it is very important for patients to learn about all their breast cancer treatment options, including breast reconstruction, at the very beginning of their journey. This is the only way to ensure they are truly involved in their treatment plan. It also allows those patients interested in immediate breast reconstruction to pursue it if they are candidates. For those that may not be candidates, knowing they will have the option once all their other breast cancer treatment is completed is often a huge source of strength.

Dr C
http://www.PRMA-enhance.com

I see. I did not realize it was an individual plan related to autonomy. Very helpful.

Generally lumpectomy is offered for unifocal (one site of disease), and the patient is willing to undergo radiation. If the tumor is large relative to the breast size, neo-
adjuvant (up-front) treatment may be given to shrink the cancer before lumpectomy.

Questions to ask would be:
How large is the cancer? Can clear margins be obtained? Should I receive chemotherapy or endocrine therapy prior to surgery to shrink the tumor? How will the incision lines be placed? Will oncoplastic techniques be used? How much deformity will there be? Is there a reason not to preserve the breast?

The duration of treatment is very variable, depending on the exact type of cancer, the biologic behavior of the cancer (how aggressive it is), and the stage of diagnosis. Some cases of breast cancer, especially low-grade DCIS, may be treated by surgery alone; some cases of breast cancer are treated with a combination of surgery, chemotherapy, radiation therapy, and anti-estrogen therapy. Radiation therapy, if needed is now able to be administered in several ways, including intraoperative therapy, accelerated partial-breast irradiation, accelerated whole-breast irradiation, and standard whole breast therapy – with the newer forms of more concentrated therapy, the duration of treatment is often significantly reduced. There are multiple chemotherapy and targeted therapy regimens, which may range in duration from several months to years. In some cases of metastatic disease, continued maintenance chemotherapy is required.

The way I made it through chemo was just by dragging myself in, and doing it. No special strategies or skills. But I will say that what I learned to be helpful along the way was the other patients. We shared snacks, boob jokes, a little about ourselves. I called them my chemo clic.

Of course part of getting through chemo is dealing with side effects. I had very few. But let me tell you about the couple I had and what I did:

I had a few mouth sores and my oncologist prescribed a mouth wash that worked beautifully. I’m sorry I don’t remember the brand name, but know that your onc can prescribe something more effective than the over-the-counters if you have this problem.

I became severely neutropenic (very low white blood cells). I had to stop chemo for a few rounds and then push and push my doctor to give me booster shots to raise my white cells. (I was in a clinical trial that would not allow the boosters). So the point I want to make here is that in my case, I wanted to get around the road block that was preventing me from resuming treatment, and the way I dealt with it was to be my own advocate.

I was dawg tired! Who isn’t when they go through treatments? The neutropenia definitely heightened the fatigue. I was not good at taking naps, but I would suggest that you do this. Sleep or at least rest in bed or out in the sun on a nice day. Let your house work go some. If you have anyone around to help with the jobs you’re used to taking on, have them help you. I graciously accepted the few meals friends made and I made enough food to have leftovers to save me cooking the next night.

What else helped was having someone to talk to who would just listen, not tell me what to do, not make judgment calls. I found very few friends who were this supportive. But I’d suggest gravitating toward the ones who are, and maybe getting in a support group of other survivors or patients on similar paths.

If you have metastatic breast cancer and chemotherapy is part of your treatment plan, your doctor may use different tests to determine how well the chemotherapy is working and how you're handling the chemotherapy. These tests may include CT scans, bone scan, MRI, X-rays, laboratory studies, among others. If these tests show that the cancer is growing or that the cancer is showing up in new areas then that may signal a time when the chemotherapy needs to change. Chemotherapy may also change if it is causing too many side effects and problems for you.

The study presented by Dr. Grace Smith at the San Antonio Breast Cancer Symposium entitled Partial Breast Brachytherapy is Associated with Inferior Effectiveness and Increased Toxicity Compared with Whole Breast Irradiation in Older Patients has garnered a tremendous amount of print and internet media attention. After reading the abstract (paper not in press yet), seeing the talk live in San Antonio, and discussing the study with many colleagues in the breast surgery and radiation oncology fields, it has become necessary to try to clarify the data on APBI, discuss the 'information' in the abstract and the hyperbole in the lay press that is distressing our patients.

First and unequivocally, Acellerated Partial Breast Irradiation is a safe and effective form of treating the breast after appropriately performed lumpectomy in patients over age 45-50 with early stage invasive (typically <3cm primaries and lymph node negative) and non-invasive breast cancer. Numerous retrospective studies and 2 prospective randomized (the gold standard) studies have shown no difference in survival, local-regional recurrence rates or complications between APBI and Whole Breast Irradiation (WBI). The American Society of Breast Surgeons Mammosite Registry has published more than 16 papes showing the safety and efficacy (comparable to WBI) of Mammosite APBI.

The abstract and presentation is drawn from the Medicare claims-SEER database which is a large database with cancer patient data linked to Medicare claims data. The database is managed by the NCI and sold to institutions to do research. The linked database has information about cancer type and treatments but no specific data on margin status, prognostic factors such as ER/PR and Her2Neu, or even local, regional or distant recurrence. The study stated that 'subsequent mastectomy' is a 'validated surrogate for local failure' although I am unaware of any literature that states this. The 'two-fold increased risk for subsequent mastectomy' is misleading (and inaccurate - it's 4.0% for APBI vs. 2.2% for Whole Breast Irradiation in their study). Both of these rates are quite small and questionable whether there is any clinical significance between the two. Not emphasized but equally (?more) important is the overall survival rates which were equivalent. The study also stated that infections were higher for APBI (not surprising since it involves the insertion of one or more catheters in the breast) but there is no statement regarding severity (were the APBI patients just placed on prophylactic antiobiotics and that is how an infection was defined?). Fat necrosis and breast pain were also significantly higher in the APBI group although there is absolutely no uniform definition of what fat necrosis is nor a statement about the severity or the fat necrosis or breast pain. Lastly, they state there was a 9.6% hospitalization rate for APBI patients vs 5.7% for WBI patients. This is quizzical since no diagnosis was given for hospitalization nor the time period over which they were hospitalized (was it APBI related[doubtful] or related to first chemotherapy cycle [perhaps] or other unrelated health issues [APBI often used in older, sicker patients who may not be candidates for 6-7 weeks of WBI]). In summary, this retrospective study of an inherently inacurate (no data on tumor characteristics and margin status - both known to be significant determiners of local recurrence) database with questionable outcomes (admission rate) and non-validated 'surrogate endpoints' (subsequent mastectomy=local recurrence) should be looked at with appropriate skepticism in the face of 20 years of retrospective studies and 2 prospective randomized trial to the contrary.

The MINDACT clinical trial was designed to test whether a molecular test of 70 genes (MammaPrint) is better than standard clinical/pathological tests at predicting which women with early stage breast cancer will benefit from receiving chemotherapy. More details on the trial can be found on the NCI website at http://www.cancer.gov/clinicaltrials/search/view?cdrid=526522&version=healthprofessional and from the manufacturer at http://www.agendia.com/pages/mindact/128.php. The trial is ongoing (in Europe). A recent publication from Germany suggests that the test may be better at grouping patients into 'low' and 'high' risk of recurrence than currently used tests (http://www.ncbi.nlm.nih.gov/pubmed/20383789).

The Mammaprint test, developed by Agendia (http://www.agendia.com/pages/mammaprint/21.php), is used to predict whether early breast cancer is likely to spread (metastasize) to other parts of the body. This is accomplished by looking (at the molecular level) at the activity of 70 different genes known to be involved in the progression of cancer. The results group the cancers into 'low' or 'high' risk for spread of cancer and can be used to guide treatment decisions. The test was initially approved in 2007 (http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm048477.htm).

The development of accurate molecular tests for drug sensitivity and prediction of disease progression is critical. These tests have the potential to spare patients treatments that are unlikely to work for their cancer and let them begin more effective treatments immediately. Essentially, the tests allow clinicians to treat each cancer case individually. These types of test will (and already have had) have a great impact on cancer survival and quality of life for patients.

Chemotherapy was definitely the most challenging for me. I had a 16-week course with treatments every two weeks. Although the physical challenges of chemo are intense, I found the emotional and mental aspects of it to be also very hard. Many people refer to chemo as "poison" and I found that to be not a good way for me to think about it. I needed to think about chemo as a healing agent that was promoting my health rather than "killing" bad cells. I had a meditation practice during my chemo in which I visualized the chemo liquid as rapid and purifying waves of ocean water coursing through my blood. It helped to transform the experience into a healing one. I still had many physical challenges, including fatigue, loss of sleep, skin and mouth issues, etc. but I think my meditation practice helped to mitigate them and keep me on track with the treatment.

James played a huge role when I'd get down. I'm famous for asking "What if....?" questions. James would always remind me that I had no reason to think those things. Essentially, he'd look at me and sternly say, "Stop that!" Then we'd break up laughing, which defused the moment. Between great doctors, James and God, I felt like I was in the best possible hands.

I also meditate a lot on the 23rd Psalm when I get scared or anxious... It's more than meditating, I actually see it as a movie. I lay down in the green pastures, I walked beside the still waters, and I see my version of the valley of death. I focus on this over and over until my mind becomes calm. Generally that takes 5 times of saying the 23rd Psalm over and over.

During treatment, I found myself in a "code blue" situation, and while the doctors and nurses were "working" on me, I was saying the 23rd Psalm. As I was laying on the gurney, I guess my lips were moving because a doctor leaned down and got close to my face and said, "I don't know what you're doing, but keep it up. It's working."