Breast Cancer Awareness Oct. 16, 2015

Breast Cancer Awareness • 3B

www.crossville-chronicle.com • Friday, October 16, 2015

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Christmas tells those with breast cancer ‘You can survive this’

By Rebekah K. Bohannon Beeler Chronicle correspondent

Margaret Christmas was going for her annual mammograms as she had a history of breast cancer in the family. Her sister had been diagnosed with breast cancer when she was 27 years old and passed away at the age of 32. Her mother was diagnosed at the age of 70, survived and turned 79 this year.

“I kept up my mammograms and went two or three times a year, basically,” said Christmas, who was diagnosed at the age of 50. “On one of my visits, I was diagnosed with breast cancer in my left breast.”

Following up with a surgeon after her MRI, ultrasound and mammogram on her right breast and given the all clear, she decided since there was a family history of breast cancer to have a double mastectomy Sept.

20, 2013.

“So, I had all the tests run and everything looked good,” said Christmas. “They did the double mastectomy and everything was clear in my lymph nodes. The surgery went great. But, my pathology report came back and it was in my right breast also. They had missed it.”

This meant that Christmas would have to endure another surgery on her lymph nodes which were clear. Prior to her diagnosis of cancer in her left breast, she had had two mammograms that year before they found the cancer. Her specialist said that the cancer, that they had missed, had been in her right breast for at least two to three years before they found it.

“On my right breast, where they’d never diagnosed it at all, I had had three mammograms at least that year, three ultrasounds and an MRI, and all three missed it,” said Christmas. “In my case, it just didn’t pick it up for whatever reason. And even though I was going to specialists and was high-risk, it still [didn’t get diagnosed].”

After having her double mastectomy, Christmas returned to work

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IT’S A LL W E’VE G O T. Margaret Christmas spends time with her treasured grandson, Dawson, playing, swimming and going to the park, helping her bounce back into her life and a very special part of her recovery. within five days. “[The medical team] was awesome. It was wonderful the way they worked with me,” said Christmas.

With having a double mastectomy, her specialists had sent her pathology to be analyzed and they decided that she had a good chance to survive with a medication called Tamoxifen. There are side effects with the medication, including hair loss, leg pain, body pain, nausea, and uterine cancer, among others. However, Christmas has been responding well to the medication.

“With the uterine cancer, we have to keep a watch on that. But, as far as me taking it, I can’t grumble because except for the pain in my legs, I’ve had no problems,” she said.

It’s been just over two years since her diagnosis and surgery. She bounced back into her life, went back to work, spent time with her grandson, even though she was told after her surgery she wouldn’t be able to everything like she used to do.

“But, I do,” said Christmas. “You push yourself. You don’t just say, ‘Okay, I can’t.’ You just try your best to live a normal life and not to

dwell on any of this.”

Much of Christmas’ encouragement came from a friend who was going through the same thing who talked to her a lot.

“When I was feeling down, she would tell me, ‘Margaret, you can’t put a timeline on your life just because you have cancer.

You’ve got to go on like it never happened because we’re not promised tomorrow anyway.’ You have got to keep going,” Christmas said.

Talking to people was her biggest ally to get through it without being depressed. She talked to a lot of people who had been diagnosed, talked about treatments and how they were doing. Christmas bounced back with hope and, even after her second surgery, she decided she didn’t want to be sick. Keeping a positive attitude and working and doing things she had done before made her feel like she was returning to her normal.

“As of today, I go every four months to Thompson Cancer Center and they do follow-up with bloodwork,” said Christmas. “As of right now, I am cancer free. I did not have to have radiation.

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chemo because it wasn’t in my lymph nodes. Had I not had the double mastectomy I would have See survive page 5B

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Researchers look for new ways to treat breast cancer

By Heather Mullinix Chronicle assistant editor

Cancer research offers the chance to find new treatments for advanced cancer and to understand more about how breast cancer develops and progresses.

“Today, we have a lot more to tell our patients.

We have a lot more to offer, both in terms of meaningful clinical trials and hope,” said Vandana Abramson, MD with the Vanderbilt-Ingram Cancer Center, during the Impact on Breast Cancer Research and Clinical Care hosted by VICC and Susan G. Komen Greater Nashville Oct. 5. Abramson works with patients diagnosed with an aggressive form of breast cancer known as triple negative.

Two weeks ago, Susan G. Komen announced two Vanderbilt-Ingram Cancer Center researchers — Jennifer Pietenpol, Ph.D. and director of VICC, and Valerie Jansen, M.D., Ph.D. — have been awarded new cancer research grants providing nearly $600,000 over three years for the two research projects.

Pietenpol is investigating the causes and potential treatments for triple-negative breast cancer. These tumors lack receptors for the hormones estrogen and progesterone as well as amplifications in the HER2 gene. These tumors do not respond to current targeted treatments that have helped improve outcomes and reduce side effects for patients with other types of breast cancer.

Jansen, who works in the laboratory of Carlos Arteaga, MD, director of the Center for Cancer Targeted Therapies and the Breast Cancer Program at VICC, is investigating breast cancers that depend on estrogen for growth. While these estrogen receptor (ER)-positive tumors usually respond to therapies that block that function, many tumors later develop resistance and start growing again.

Vanderbilt has conducted a great deal of research in genotyping of more than 5,000 cancer tumors.

“Many of these mutations we’ve identified are

what we call actionable, meaning you could make a decision for clinical care, or for survivorship, or for outcomes, based on that mutation,” said Pietenpol.

VICC manages My Cancer Genome, an online resource that provides information on particular genomes which serves as a resource for doctors, patients, caregivers and researchers, with information on available clinical trials and therapies.

The laboratory research can often move to clinical trials. There are currently 800 patients in clinical trials, particularly in areas of precision medicine.

Researchers noted those patients taking part in clinical trials still receive the standard of care treatment but, depending on the study, receive something in addition to that standard of care.

“Five years ago, I could only tell my patients with triple-negative breast cancer what their cancer was not,” said Abramson. “In effect, I was listing for them were all the therapies I could not use on them. Even clinical trials for this group of breast cancer patients were relatively sparse.”

Abramson said the advances in breast cancer care of the prior decade, such as the use of Herceptin or Tamoxifen, had left these patients behind.

Research at Vanderbilt has helped provide more answers for patients with triple negative breast cancer.

“We are actively taking the discoveries in our laboratories and translating them to treatments. These are clinical trials that will one day, hopefully, change the standard of care, and ultimately save lives,” she said.

These trials came from studying the gene expression of triple-negative breast cancer tumors learn which specific subtype the tumor is. It is estimated about 20 to 25 percent of breast cancer diagnosis is triple negative breast cancer made up of an array of subtypes, all of which have different biology and pathways for growth.

One such trial involves the luminal androgen

receptor, which relies on androgen receptors much like prostate cancer. A randomized trial is treating patients with an anti-androgen agent which, in laboratory tests, killed the cells without the use of chemotherapy or other therapies.

“It’s an oral drug tolerated very well,” Abramson said.

The cell lines also have PI3K mutations, which can be treated with a PI3K inhibitors.

“What they found is that by exposing the cells to these two drugs, they had a synergistic effect and the cells died,” Abramson.

A clinical trial for patients with androgen receptor-positive metastatic triple-negative breast cancer opened earlier this year at 15 academic centers nationally. There is a waiting list for the trial.

“This study is poised to confirm that the luminal androgen subtype really is a distinct breast cancer subtype,” Abramson said. “We can give them a name. But more importantly, we actually feel we might have a therapy for them. Even more exciting, this isn’t just conventional chemotherapy. This is targeted therapy that is going to go after these cells.”

Another trial that is set to open in the first quarter of 2016 will look at immunomodulatory therapy for androgen receptor negative triple negative breast cancer.

Komen research grants are important sources of funding for breast cancer research, especially as government funding continues to stay flat or even go down in some areas.

“Our knowledge of what makes genes go wrong is greater than it ever has been before,” said Orrin Ingram, chairman of the Vanderbilt-Ingram Cancer Center board of overseers.

“While we have all these opportunities, we are lacking the financial resources to act on these opportunities. Without partners like you (Komen), we would be even more frustrated than we are today.”

A commitment to funding early career scientists has helped several Vanderbilt researchers, particularly Justin Balko, PharmD,

What do dense breasts mean for cancer risk?

Breast cancer risk is influenced by many things, including heredity, age and gender. Breast density is another factor that may affect cancer risk and the ability to detect breast cancer in its earliest stages, say some experts.

According to the report, “Mammographic density and the risk and detection of breast cancer,” published

by The New England Jour-

nal of Medicine, as well as data from the National Cancer Institute, women with high breast density are four to five times more likely to get breast cancer.

Only age and BRCA1 and BRCA2 mutations increase risk more. However, at this time, health care providers do not routinely use a woman’s breast density to assess her breast cancer risk, according to Susan G.

Komen for the Cure.

Density does not refer to the size or shape of the breast, and it may not be apparent by just looking at the breasts. Usually women do not learn they have dense breasts until their first mammograms.

Dense breasts have more glandular and fibrous tissue. Density may be heredSee dense page 6B

Ph.D. “Getting this investment from Susan G. Komen is one of the things that allowed me to get additional funding. That investment from the foundation catapulted me to have other people have that faith and interest in my career,” said Balko, who was awarded a postdoctoral fellowship award in 2012 and a Career Catalyst Research Award in 2014. Since that time, he has been awarded additional funding through the National Institutes of Health and National Cancer Institute, k99 and the Department of Defense Breakthrough Award. “It meant a lot to me that Susan G. Komen was capable and interested in making that investment in my career and research.”

Balko’s research includes advancing nonchemotherapy treatments in triple negative breast cancer and immunotherapy treatment of breast cancer.

“This is a new field that I’m starting to get into, but if you haven’t heard about this — this is something to get excited about,” Balko said of immunotherapy.

“This is showing us that we are in fact getting closer to a cure, including for metastatic breast cancer.” n Heather Mullinix may be reached at hmullinix@ crossville-chronicle.com.

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Breast Cancer Awareness • 5B

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Biopsy helps determine next steps in breast cancer treatment

By Heather Mullinix Chronicle assistant editor

When someone finds a lump in their breast, or screening tests find areas of concern and in need of further investigation, surgeons are able to guide patients on the next steps of their diagnostic journey and remove cancerous tissue.

“With the push for everyone to have mammograms, we find a lot more patients who need biopsies on areas of the breast that you can’t palpate,” said Rick Gibbs, general surgeon. “One of the best ways is a stereotactic core needle biopsy where you are able to focus the biopsy on the spot that you see on the mammogram.”

CMC’s general surgeons include Gibbs, Dr. Mark Fox and Dr. Brian Kwitkin.

“The radiologists have gotten really good at recognizing things that are concerning and recommending biopsy. One of those is the deposition of calcium specks, which is a characteristic of some types of breast cancer.”

At CMC, patients are seated for stereotactic biopsy procedures, which are also done under local anethestic as an outpatient procedure.

“The accuracy of it is checked a couple of ways.

You can take images of the breast after the biopsy to see if the abnormal area is gone,” Gibbs said. “And the breast tissue that’s biopsied is placed in a pathology cassette and imaged so that the things you see on the mammogram are contained in the specimen.

“I think patients do well with it, and that’s one of the easiest ways for them to have biopsies done.”

Fox cautions that a stereotactic biopsy or core needle biopsy is not intended to remove the entire lesion.

“It is a diagnostic test, not a therapeutic procedure,” Fox said, adding a biopsy can only test for the presence of cancerous cells in the tissue extracted. “That’s why some opt for the complete removal of the area, which is then tested in pathology.”

In that case, a biopsy

SURVIVE

• Continued from 3B had to have chemo and radiation. I was very fortunate it wasn’t in the lymph nodes and, with me choosing to have both breasts removed, I’m on medication for the rest of my life, to be honest. But, I was one of the fortunate ones.”

“I think there’s always hope,” said Christmas.

done under sedation or general anesthesia is needed to remove the suspect area.

The radiologist places a guidewire, using mammogram imaging, to help the surgeon go directly to the area of concern.

“That’s our marker to go up to the operating room and remove the tissue at the end of the wire,” Fox said.

Markers can be placed where the tissue is removed for future reference should additional tissue be needed or for future imaging.

These type of biopsies are useful when the area of concern cannot be felt, and are also outpatient procedures. Should a patient have a new lump that can be felt, the localizing techniques are not needed.

Fox noted that a biopsy removing the entire lesion is not the same as a lumpectomy, a surgical treatment for diagnosed breast cancer.

“If we still don’t know if something is benign or malignant, we’ll go in and our goal will be to remove the entire area and get it looked at,” Fox said.

If pathology reveals noncancerous cells, no further treatment is necessary. If cancer is found, a larger portion of breast tissue may be removed from around where the abnormality was found.

“We try to remove as little breast tissue as possible to cause the least amount of distortion of the breast tissue,” Fox said. “If we went in each time before we knew if something was benign or malignant and did a ‘lumpectomy,’ we might be causing some unnecessary distortion.”

A lumpectomy is one method of surgical treatment of breast cancer, along with mastectomy, the removal of all breast tissue and skin. Often, lymph nodes are sampled to determine if cancer cells have made it to these interconnected glands that collect fluid and other materials.

“Part of the staging of breast cancer, in addition to the size and type of cancer, is the status of lymph nodes on that side,” said Fox. Testing can help determine the first lymph node that drains the breast fluid, the sentinel node, so that it

can be dissected and, possibly, eliminate the need to remove all lymph nodes.

The decision on whether to have a mastectomy or lumpectomy, which removes just the lump and a small portion of the breast, is often left to patient preference.

“Some patients want it gone, with all of the breast removed, and to be done with it,” Gibbs said. “Other’s want to spare the breast and opt for that knowing they’re signing up for radiation treatments post opt.

“Some of the younger women think about reconstruction. As a surgeon, you want to operate in such a way that their reconstruction is as good as it can be, usually performed by a plastic surgeon.”

If a patient wants to opt for a lumpectomy for the affected area, radiation treatment will follow to treat the remaining breast tissue. Radiation treatments are given five days a week over a course of six weeks, so ability to be at daily appointments is another factor in a patient’s decision on which type of surgery to pursue.

Chemotherapy treatment is based on the size of the tumor and characteristics of the breast cancer, lymph node involvement and other factors.

“It’s not an á la carte,” Fox said. “That treatment options includes a lumpectomy, lymph node study, probable radiation to the remaining breast and then possible chemotherapy based on the lymph nodes.

That’s all rolled into one option.”

A modified mastectomy removes all breast tissue and skin, but does not remove chest wall muscles.

“For the majority of patients, we’ve learned that removing those muscles and nerves does nothing to improve their survival or to minimize the chances of recurrence,” Fox said.

Occasionally, genetic testing may reveal a woman has genetic markers that greatly increase the odds of developing breast cancer in his or her lifetime. Genetic testing is available through Covenant partner facilities, which patients can be referred to.

A positive BRCA 1 or BRCA2 test does indicate increased risk for developing breast cancer in the opposite breast.

“I have had patients who, for the reason they don’t want to worry about it anymore, have elected to have the other breast removed at the same time. It’s personal preference.” Gibbs said.

Fox said, “We find that, the younger the individual, the more likely they are to choose that option, where an elderly man or woman, the interval time it might take for breast cancer to show up on the other side may not make that a relevant point.”

Regardless of the option chosen, both Gibbs and Fox noted they perform surgery to increase the chance of successful reconstruction surgery following treatment. Fox said it was his recommendation patients wait until all treatment is complete to undergo reconstruction.

“If a patient knows on the front end they desire reconstruction, my personal, professional recommendation is that they not have that done at the initial mastectomy,” Fox said. “They may not be sure what treatment they’re going to need post-operatively.”

A symmetrical appearance can be affected by other treatments, such as radiation, which can affect the appearance.

All surgical options can be completed at Cumberland Medical Center, both surgeons noted, though plastic surgery and reconstruction are not currently available.

“The technology available here and the capabilities of this facility are very good. We follow the same guidelines as bigger cities and hospitals,” Gibbs said.

Patients seeking surgical treatment for breast biopsy or breast cancer treatment may be referred by the Regional Breast Center, their primary care physician, the nurse navigator at CMC, or he or she can call the office for an appointment if they have a specific breast problem.

“There’s none of us that knows what’s going to happen tomorrow, so we’ve got to keep a positive attitude. I really do think with a positive attitude you’re going to go further. I knew this was all in God’s hands and I had a lot of support with people’s prayers that prayed for me and helped get me through this. I think if you are going

through something like this, that if you talk to others that would help.

I talked to a lot of people that gave me support, gave me hope; other women that had survived 13 years. The only

encouragement we’ve got is prayer, through friends and family and people that have gone through this that can tell you, ‘You can survive this.’”

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Every two minutes, a woman in the United States is diagnosed with breast cancer. In fact, breast cancer is the leading cancer among Caucasian and African American women.

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How to speak to your doctor after a cancer diagnosis Receiving a cancer diagnosis can be overwhelming.

Upon receiving such a diagnosis, men and women typically want to learn as much as possible about their disease and what they can do to fight it.

The Internet can be a valuable resource for cancer patients, but the sheer volume of information available online can be difficult to sift through. The best way for cancer patients to learn about their disease is to speak directly to their physicians, who can share their own expertise while also directing patients to places they can find reliable information, both online and in other areas.

Some people find it easy to speak with their physicians, while others may find it more difficult to communicate, especially after a cancer diagnosis. The following tips can help open the channels of communication with your physician so you can learn more about your disease and how to fight it.

• Don’t be embarrassed to bring up your concerns.

Don’t be afraid to ask questions about your disease and its side effects, no matter how inconsequential your concerns may seem.

Many cancer patients want to know about the potential side effects of their treatments, and some might be sheepish to ask about side effects that are more personal in nature. But no concern

DENSE

• Continued from 4B itary, meaning mothers and daughters can share similar breast characteristics.

Dense breasts cannot easily be seen through on a mammogram, which can make detecting lumps and other abnormalities more difficult. This can lead to missed cancers or cancers that are discovered at later stages. Women with dense breasts may require additional screening methods, such as a breast ultrasound or an MRI, in addition to yearly mammogram

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The best way for cancer patients to learn about their disease is to speak directly to their physicians, who can share their own expertise while also directing patients to places they can find reliable information, both online and in other areas. is too small or insignificant to bring up with your doctor, and cancer patients should never feel embarrassed to ask about their disease.

• Be direct. When asking your doctor about your disease, be as direct as possible.

Beating around the bush or masking your concerns may only lead to misinformation that won’t teach you anything about your disease or address your concerns.

• Ask for specific information about your disease.

Cancer is a broad term that does not indicate the type or stage of the cancer. When speaking to your physician about your disease, ask the doctor to be as specific as possible, writing down the

type and stage of cancer in your body. If doctors determine the cancer has metastasized, ask for detailed information about where the cancer has spread and the treatments being considered.

You can then use this information to learn more about your disease.

• Ask the doctor to recommend resources to help you learn about your disease. A simple search for the words “breast cancer” on Google turns up more than 95 million results. The Internet is awash in information about cancer and other diseases, and finding up-todate information you can trust can be akin to finding a needle in a haystack. So ask

your doctor to recommend specific resources, be it a website, magazine or even a forum or support group where patients discuss their disease, so you can learn about your disease without getting lost in the jungle of information online.

• Bring a loved one.

Learning about your disease, treatment options and prognosis can be overwhelming and emotional, so bring a loved one along for support when speaking to your physician.

Physicians are great resources for cancer patients, who can take several steps to make discussions with their doctors as informative as possible.

screenings.

Education about breast density is gaining traction in some areas, thanks to informed women and advocacy groups like AreYouDense.org. Some states in the United States are part of “inform” lists, in which radiologists include information about breast density on mammogram reports so women and doctors can make decisions about extra testing.

Even if a woman does not live in a state where density is shared, she can request the information from the radiologist or doc-

tor. Dense breasts show up with more pockets of white on mammograms than gray fatty tissue in less dense breasts. Cancer also appears white, and, therefore, tumors can be hidden.

In addition to more indepth screenings, women with dense breasts can lower cancer risk by following these guidelines: • Maintain a healthy weight.

• Eat nutritious food.

• Exercise regularly.

• Never smoke or quit immediately.

• Limit alcohol consumption.

• Ask for digital mammography.

Women can consider breast density with other risk factors in the fight against breast cancer.

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