Cancer Tests

When a woman is diagnosed with cancer, she needs to consider her family’s history of cancer. Some cancers are inherited; however, most are spontaneous. If there is a concern with a family pattern of cancer, then a thorough family history should be taken. Sometimes this leads to formal genetic counseling with blood testing for specific gene mutations. If you have a specific gene mutation putting you at risk for breast or ovarian cancer, then surveillance testing or procedures are different from those with a spontaneous cancer. Therefore, start with telling your oncologist your family history.

The NCCN publishes guidelines for followup.
http://www.nccn.com/files/cancer-guidelines/breast/index.html#/86/
Physical exam is indicated every 4-6 months initially. Annual blood work and tumor markers are often drawn. There is a trend away from routine imaging in asymptomatic patients.

The HALO test is a way to obtain fluid from the nipple which then can be analyzed to see if there are any abnormal, or atypical cells. Cellular atypia is a risk factor for the future development of breast cancer, and patients who have atypia usually are followed more closely. The HALO test is not a substitute for mammogram or other imaging as it is not meant to diagnose breast cancer - it is a way to determine if a woman might be at increased risk and therefore might need additional imaging. The HALO test is typically used in women under the age of 40, who are not yet undergoing routine screening with mammography.

Uncertainty, especially under the circumstances of a cancer diagnosis, is one of most stressful experiences. I recommend exercise, meditation, and relaxation exercises as ways to cope with stress during this time. Check out this book by Dr. Michael Antoni, one of the leading researchers in this area: http://www.amazon.com/Stress-Management-Intervention-Breast-Cancer/dp/1557989419/ref=sr_1_2?s=books&ie=UTF8&qid=1332591278&sr=1-2 I also highly recommend finding online social networks, like on http://www.PatientsLikeMe.com to find and connect with others going through what you are going through. Even though family and friends may be supportive, it can be so helpful to talk to people who have been through or are going through what you are going through. Only they can truly understand your fears and concerns. And, because the people you meet in online social networks are not close family and friends, you may actually be able to speak more freely about your thoughts, feelings and challenges, especially to the extent that some of the challenges involve family and friends reactions to your cancer.

When you’re given drugs that can cause cardiac damage, your heart is carefully monitored so that if damage occurs that outweighs the benefit of the drugs, your oncologist can change your treatment. I was given two drugs—Adriamycin and Herceptin—that are known to cause heart damage in some people.

In my case, the test used to monitor my heart function was the MUGA (short for Multi Gated Acquisition Scan), which provides a very accurate, real-time image of your beating heart and shows how efficiently your left ventricle is pumping blood. I was given a baseline MUGA before I began Adriamycin, and a follow-up every three months until I finished Herceptin over a year later.

The test isn’t particularly difficult or painful, but it’s time-consuming: a couple of hours from start to finish. First a small amount of your blood is drawn, mixed with a radioactive substance, and injected back into your bloodstream. Then you lie on a table under a special camera that records the movement of the radioactive blood through your beating heart. The technician measures the percentage of blood pumped through the left ventricle with each heartbeat. This figure is called the Left Ventricular Ejection Fraction or LVEF. Each time you go for a MUGA, your LVEF is compared with your previous LVEF and your baseline LVEF so that changes can be noted.

My heart function dropped slowly throughout my treatment, and I was afraid I might have to stop or delay the rest of my scheduled Herceptin infusions. But it didn’t drop so fast or so low that my oncologist felt the risk outweighed the benefit of continuing treatment.

The only disturbing thing about the MUGA was the piece of paper I was given to carry with me for 24 hours after the test in case I set off any alarms at, say, an airport. I was also instructed not to hug or hold babies during that time.

My advice: Drink enough water to be well hydrated for the blood draw. And bring a book or your knitting; there’s a fair amount of downtime between the initial blood draw and the actual scan.

Extracapsular extension is usually only seen under the microscope by the pathologist examining the involved lymph node. Rarely, extracapsular extension can be so extensive that the lymph nodes 'grow together' or become matted - this is ominous and denotes a very aggressive melanoma.

Most commonly this is done with a high sensitivity c-reactive protein (hs CRP in medspeak), IL-6 (usually limited to research studies), and serum amyloid A was measured in the study by Pierce, et al. (noted here: http://talkabouthealth.com/what-is-meant-by-the-term-inflammation-in-the-context-of-cancer-and-integrative-medicine) but I’m not as familiar with it. Most likely your insurance won’t cover a hs CRP unless you have heart disease.

Melanoma does have a predilection to spread to the lymph nodes. Rarely the lymph nodes can have a large amount of melanoma in them and they can be felt (palpable lymph nodes). More typically the lymph nodes feel normal (and appear normal on ultrasound) but may have a microscopic deposit of melanoma in them. To determine whether there is a small deposit in the regional lymph nodes (neck, axilla, or inguinal areas), surgeons will 'map' the skin to determine which lymph nodes 'drain' the patch of skin where the melanoma was located. The skin is 'mapped' by injecting a small amount of radioactive fluid in the skin at the site of the melanoma. This fluid drains just like the melanoma COULD drain and makes a regional lymph node slightly radioactive. The patient then goes to the operating room where the surgeon then uses a small geiger counter to find the lymph nodes. These lymph nodes are called the Sentinel Lymph Nodes and are the ones that drain the patch of skin where the melanoma was. A small incision is made over these lymph nodes and they are physically removed and given to the pathologist to look at under the microscope. Even just a few cells of melanoma in the sentinel lymph node are significant although the bigger the deposit of melanoma the more likely the melanoma is to spread throughout the body.

Many surgical oncologists will make sure the melanoma has not spread elsewehere in the body by doing several scans. The most widely used is the PET/CT scan for checking everything (except the brain) including the lungs, liver, and bones - all places to which the melanoma could spread. The brain is often scanned with either a CT scan or MRI - unfortunately the brain is one place to which the melanoma can metastasize. Some oncologists are more selective, only scanning the patients with more extensive melanoma - either very thick (>4mm) , thinner (>2mm) with ulceration, or those with lymph node spread.

Genetic mutations play a key role in NSCLC. Identifying certain, key mutations can help select targeted therapy. The two most important mutations in lung cancer right now are the EGFR and EML-4ALK mutation and are found in the subtype of lung cancer called adenocarcinoma. These mutations are more commonly found in female, asian, non-smokers. However, they are also found in smokers and males, but to a lesser degree.

Patients with the EGFR mutation are generally treated with a drug (pill) called Tarceva as first line treatment, rather than chemotherapy. Similarly, patients with the EML-4 ALK mutation are treated with a recently approved drug (pill) called Xalqori (Crizotinib). Generally patients with these mutations who are treated with the appropriate drug do very well when compared to patients who don't have the mutation and are treated with chemotherapy

Due to the dramatic responses with the use of these drugs when a mutation is identified, it is important to test for these mutation at diagnosis. Generally, when the initally biopsy is done, I make sure that there is enough material left over to send for molecular testing. It takes roughly 2 weeks to get the results back, so based on patient preference, I may start the patient on chemotherapy until the results come back.

To note, the testing of these mutations should routinely be performed in patients with stage IV NSCLC, not in patients with stage I-III (yet). Outside of a clinical trial, there is just not enough evidence yet on how to use these molecular markers in stage I to III NSCLC although this may change very soon.

The tests that generally used to determine is lung cancer has travelled to other parts of the body (metastasized) is either a CT scan of the chest, abdomen and pelvis or more commonly a PET scan. A PET scan in a cancer scan of the whole body that picks up tumor growth. Generally, a PET scan is considered the standard of care for patients in the initial workup of their cancer. However, if a patient has already been diagnosed and treated, either a CT scan of chest/abdomen/pelvis or a PET scan can be used. Finally, a brain MRI is generally done as well to make sure the cancer has not moved to the brain.

Cancers produce novel proteins that can suggest, though not diagnose, a source of the tumor. The original blood tests included CEA, known to occur in many adenocarcinomas including lung, gastrointestinal and breast. CA 27-29 and CA15-3 have been most closely associated with breast cancers. CA 125 is the marker for ovarian as is HE4, a more recently developed test. PSA and prostatic acid phosphatase are used in prostate cancer. CA 19-9 is associated with pancreatic cancer. Germ cell tumors can produce B-HCG and AFP. AFP is also associated with hepatocellular cancer. Despite all of this, some tumors express no markers while other tumors express markers not generally associated with that disease type. This is part of the reason why markers are not promoted for general use at academic centers.