New Guidelines Might Limit Need for Lymph Node Removal for Breast Cancer

MONDAY, March 24, 2014 (HealthDay News) -- Biopsies of so-called "sentinel" lymph nodes under the arms should become more widespread among breast cancer patients, according to updated guidelines from the American Society of Clinical Oncology (ASCO).

The group, which represents cancer specialists, said the new recommendations should also restrict the number of women who will require further removal of multiple nodes after biopsy, cutting down on painful side effects.

In sentinel lymph node biopsy, a few lymph nodes are removed and checked for signs of cancer -- hence the name "sentinel." Usually, if these lymph nodes have no cancer, it means the remaining, unchecked lymph nodes should also be cancer-free.

The new ASCO recommendations expand eligibility for sentinel node biopsy and will reduce the number of patients who undergo a more invasive procedure called axillary -- underarm -- lymph node dissection, which carries a higher risk of complications, the group said.

In axillary lymph node dissection, most lymph nodes under the arm on the same side as the breast tumor are removed and examined for cancer. This procedure can cause long-term side effects such as pain and numbness in the arm and swelling due to a build-up of lymph fluid.

The new guidelines state that for women whose sentinel lymph nodes show no signs of cancer, removal of more underarm lymph nodes is not recommended.

The guidelines also addressed the case of women who undergo lumpectomy instead of full mastectomy and are also scheduled for whole-breast radiation therapy to help "mop up" residual cancer. If these patients have signs of cancer in only one or two sentinel lymph nodes upon biopsy, they too may opt to avoid further node removal, the ASCO experts said.

Women who have undergone mastectomy but show signs of cancer's spread in sentinel lymph nodes should be offered further node removal, the guidelines reaffirmed.

The ASCO also said women who are diagnosed with certain breast cancers while pregnant can skip sentinel node biopsy.

The ASCO issued initial guidelines on sentinel node biopsy in 2005. The new guidelines, published March 24 in the Journal of Clinical Oncology, are based on the findings of a panel of experts who reviewed studies published between 2004 and 2013.

"The updated guideline incorporates new evidence from more recent studies -- nine randomized controlled trials and 13 cohort studies since 2005," panel co-chairman Dr. Armando Giuliano said in an ASCO news release.

"Based on these studies, we're saying more patients can safely get sentinel node biopsy without axillary lymph node [removal]," he said. "These guidelines help determine for whom sentinel node biopsy is appropriate."

Panel co-chairman Dr. Gary Lyman said, "We strongly encourage patients to talk with their surgeon and other members of their multidisciplinary team to understand their options and make sure everybody is on the same page."

"The most critical determinant of breast cancer prognosis is still the presence and extent of lymph node involvement," he said. "Therefore, the lymph nodes need to be evaluated so we can understand the extent of the disease."

Two breast cancer specialists welcomed the new guidelines.

"Over the past few years, there has been a movement to limit the amount of axillary [lymph node] surgery in patients undergoing breast conservation," said Dr. Stephanie Bernik, chief of surgical oncology at Lenox Hill Hospital in New York City.

Bernik said the new guidelines are important because some doctors have been reluctant to move away from further underarm node removal when a patient has even one affected sentinel node. "This update will give surgeons the confidence to tell patients that a sentinel lymph node biopsy may be enough, even if there is evidence of spread, in patients undergoing [lumpectomy]," Bernik said.

"However, it is still important for surgeons to discuss the pros and cons with a patient, as not all [real-world] patients fit the study criteria," she said. "Furthermore, it needs to be stressed that the more limited surgery does not apply to women undergoing mastectomies."

Dr. Debra Patt is the medical director of an expert panel that assesses cancer care guidelines for the US Oncology Network. She said she was "thrilled" at the new ASCO guidelines because they seem to echo the results of recent studies.

"In 2010, a study presented at the ASCO annual meeting showed that women undergoing breast-conservation surgery with clinically node-negative small breast cancers could safely avoid removing all the lymph nodes from under the arm in most cases," Patt said. "There has been greater variance in treatment patterns in my community practice, and I believe these updated guidelines will direct practitioners to evidence-based patient care."

-- Robert Preidt
Copyright © 2014 HealthDay. All rights reserved. SOURCES: Stephanie Bernik, M.D., chief, surgical oncology, Lenox Hill Hospital, New York City; Debra Patt, M.D., medical director, Pathways Task Force and Healthcare Informatics, US Oncology Network; American Society of Clinical Oncology, news release, March 24, 2014

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Targeted Radiation Might Help Fight Advanced Breast Cancer: Study

MONDAY, March 24, 2014 (HealthDay News) -- A minimally invasive treatment that delivers radiation directly to tumors may slow progression of breast cancer that has spread to the liver, a new study suggests.

The treatment is called yttrium 90 (Y-90) radioembolization. Doctors insert a catheter through a tiny cut in the groin and guide it into the artery that supplies the liver. Radiation-emitting micro beads are then sent through the catheter and float out to kill small blood vessels that feed the tumor.

Researchers led by Dr. Robert Lewandowski, an associate professor of radiology at Northwestern University Feinberg School of Medicine in Chicago, looked at the outcomes of 75 patients. The women ranged in age from 26 to 82, and had chemotherapy-resistant breast cancer that had spread to the liver ("metastatic" disease). Their liver tumors were too large or too numerous to be treated with other methods, the authors noted.

Y-90 radioembolization therapy stabilized 98.5 percent of the treated liver tumors, according to the study, which was to be presented Monday in San Diego at the annual meeting of the Society of Interventional Radiology.

In addition, 24 of the women experienced a more than 30 percent shrinkage in tumor size after treatment, which caused few side effects.

"Although this is not a cure, Y-90 radioembolization can shrink liver tumors, relieve painful symptoms, improve the quality of life and potentially extend survival," Lewandowski said in a society news release.

"While patient selection is important, the therapy is not limited by tumor size, shape, location or number, and it can ease the severity of disease in patients who cannot be treated effectively with other approaches," he added.

Two breast cancer experts were cautiously optimistic about the findings.

According to Dr. Neelima Denduluri, "while these results appear promising, this is a very small retrospective study," meaning that it fell short of the "gold standard" type of prospective trial that tracks patients going forward over time. "Randomized controlled prospective studies addressing this issue are necessary before radioembolization can be incorporated routinely," she believes.

For now, "in women that cannot receive systemic therapy due to toxicities [side effects], are not eligible for clinical trials that utilize new agents, or have exhausted conventional chemotherapy options, radioembolization may be a choice," said Denduluri, a medical oncologist with Virginia Cancer Specialists in Arlington, Va., a US Oncology Network affiliate.

Dr. Stephanie Bernik is chief of surgical oncology at Lenox Hill Hospital in New York City. She said that while this type of therapy has been used to fight liver tumors, "the ability to use this therapy in treatment of metastatic breast cancer to the liver offers some hope to patients with the disease."

Bernik stressed that, right now, the treatment can only extend survival for women with advanced breast cancer, it is not a cure. However, "as the technique is modified and perfected, it is hoped the [treatment] can help achieve remission in women with advanced disease."

Each year in the United States, about 117,000 patients are diagnosed with breast cancer that has spread to the liver. Chemotherapy is the standard treatment in such cases, but is not effective in, or suitable for, all patients.

Experts note that studies presented at medical meetings are typically considered preliminary until published in a peer-reviewed journal.

-- Robert Preidt
Copyright © 2014 HealthDay. All rights reserved. SOURCES: Neelima Denduluri, M.D., medical oncologist, Virginia Cancer Specialists, Arlington, Va., a US Oncology Network affiliate; Stephanie Bernik, M.D., chief of surgical oncology, Lenox Hill Hospital, New York City; Society of Interventional Radiology, news release, March 24, 2014

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Current Colon Cancer Screening Guidelines Might Miss Some Patients

FRIDAY, Oct. 25 (HealthDay News) -- Current U.S. colon cancer screening guidelines may result in 10 percent of colon cancers being missed in people with a family history of colon polyps that can lead to cancer, a new study suggests.

"The biggest surprise was the percentage of missed cancers under the current guidelines. We figured there would be a few percent, but 10 percent is a large number," study author Dr. N. Jewel Samadder, of the Huntsman Cancer Institute at the University of Utah, said in a university news release.

Colorectal cancer is the third most common cancer in the United States and the second deadliest.

Samadder's team looked at data from nearly 127,000 people, aged 50- to 80, who underwent colonoscopy in Utah between 1995 and 2009. They found that first-degree relatives -- parents, siblings, children -- of people with adenomas (polyps linked to cancer) or advanced adenomas had a 35 percent to 70 percent increased risk of developing colon cancer than relatives of patients without these growths.

Second-degree relatives (aunts, uncles, grandparents) and third-degree relatives (cousins, nieces, nephews, great-grandparents) of people with adenomas were also at increased risk for colon cancer, according to the study published online Oct. 25 in the journal Cancer.

"We expected to see increased risk in first-degree relatives, but we weren't sure the risk would also be higher for more distant relatives in multiple generations," Samadder said.

Current national guidelines for colon cancer screening recommend colonoscopy every 10 years starting at age 50 for the general population. But first-degree relatives of people diagnosed with either colorectal cancer or advanced adenomas before age 60 should have a colonoscopy every five years beginning at age 40, according to the guidelines.

However, screening recommendations for second- and third-degree relatives of people diagnosed before age 60 are the same as for the general public.

So, the new findings "raise the issue of whether some level of more aggressive screening should be considered, not only for first-degree relatives of patients with polyps diagnosed at or below age 60, but also for those first-degree relatives of patients diagnosed above age 60," Samadder said.

One expert not connected to the study said the findings may be important, but it's often difficult to assess a patient's family history when it comes to colon cancer.

"This information is important not only to specialists who treat colon and rectal and cancer but all primary care providers who recommend screening programs for their patients," said Dr. Jerald Wishner, director of colorectal surgery at Northern Westchester Hospital in Mount KIsco, NY.

However, he added that, "It will be difficult to apply this information in everyday clinical practice. I regularly see patients who know their relatives have had surgery for cancer don't know the type. Finding out if their relatives have had adenomas or advanced adenomas will be very difficult. This will be further complicated as we seek information about second or third degree relatives."

-- Robert Preidt
Copyright © 2013 HealthDay. All rights reserved. SOURCES: Jerald Wishner, M.D., director, colorectal surgery, Northern Westchester Hospital, Mount Kisco, N.Y; University of Utah, news release, Oct. 22, 2013

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Study Ties Y Chromosome Variations to Prostate Cancer Risk

FRIDAY, Oct. 25 (HealthDay News) -- Men with certain inherited variations in their Y chromosome may have a higher risk of prostate cancer, according to a large new study.

Researchers from the University of Utah School of Medicine said the identification of these genetic mutations could help scientists develop tests to determine men's risk for developing the disease and also improve prostate cancer treatments.

In conducting the study, the researchers used the Utah Population Database, which dates back to the 1800s and identifies more than 6.5 million people, spanning 15 generations. The study was narrowed down to 1.25 million men who had at least two parents, four grandparents and six or eight great-grandparents also in the database.

All of the men who did not have a father in the database were labeled as "founders" and assigned a specific Y chromosome identification (YID). Founders' sons, grandsons and great-grandsons also were assigned the same YID. Of these groups, nearly 260,000 had at least two men sharing the same Y chromosome.

The men's genealogical and medical records also were linked to the Utah Cancer Registry, enabling the researchers to determine which of the men developed prostate cancer.

The researchers said that since most of the Y chromosome does not recombine during cell division, it is passed almost entirely unchanged from father to son.

"As a result, each male resident of Utah shares the Y chromosome of his father and his father's father and so on," study leader Lisa Cannon-Albright said in a news release from the American Society of Human Genetics.

"This provided the ability to estimate the risk for prostate cancer in independent Y chromosomes represented in Utah," said Cannon-Albright, chief of the genetic epidemiology division at the University of Utah School of Medicine.

Once the researchers estimated the number of prostate cancer cases expected to occur in each YID group, they compared this estimate to the actual number of prostate cancers.

Focusing on 1,000 YID groups that included between about 200 and 2,300 men, the study revealed the prostate cancer incidence was significantly higher than expected in 73 specific Y chromosome groups.

The researchers said that in one YID group of nearly 9,800 men, they predicted that about 45 prostate cancer cases would have occurred. When they compared their estimate to the state's cancer registry, they found that 65 men in the group had actually been diagnosed with prostate cancer.

A separate group of about 500 men revealed that 26 had prostate cancer. The researchers had estimated, however, that about 10 cases would develop among this group.

Among the men who did not share the Y chromosome of the founder, 39 developed prostate cancer. This rate was not statistically different from the 36 cases of the disease predicted by the researchers, who concluded that there is a Y chromosome-linked risk for prostate cancer that is not seen among men who do not share a common Y chromosome.

The study findings were scheduled for presentation Friday at the American Society of Human Genetics meeting, in Boston. The data and conclusions should be viewed as preliminary until published in a peer-reviewed journal.

-- Mary Elizabeth Dallas
Copyright © 2013 HealthDay. All rights reserved. SOURCE: American Society of Human Genetics, news release, Oct. 25, 2013

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After Breast Cancer Surgery, Patient Assistance Programs Can Help

FRIDAY, Oct. 25 (HealthDay News) -- Patient assistance programs make it more likely that breast cancer patients will get additional treatments after they have surgery, and receive other kinds of support, a new study finds.

These recommended additional -- or "adjuvant" -- therapies include radiation, chemotherapy and hormonal treatments.

"Doctors have been frustrated by data showing that perhaps as many as 20 percent of women with breast cancer -- especially black and Hispanic women -- do not take advantage of lifesaving adjuvant therapies," study author Dr. Nina Bickell, a professor of health evidence and policy and a professor of medicine at Mount Sinai Hospital, in New York City, said in a Mount Sinai news release.

"Some women lack critical information about the value of these treatments, while others need help dealing with the emotional aspects of breast cancer treatment, or with practical matters -- such as transportation, insurance or childcare -- before taking the next step," she said. "Fortunately, there are many high-quality patient assistance programs that can help women address these issues."

Bickell and her colleagues looked at 374 women with early stage breast cancer who had recently undergone surgery for their cancer. Nearly 80 percent of those who contacted a patient assistance program had some or all of their needs met, compared with 35 percent of those who did not connect with a program.

The programs were especially effective in meeting patients' needs for information about adjuvant treatment or counseling, according to the study recently published online in the Journal of Oncology Practice.

"We were delighted to discover that most of the women in our study who needed some type of assistance had a successful encounter with a patient assistance program and got the treatments they needed," Bickell said.

"Nevertheless, national statistics suggest that women in the U.S. continue to face economic and logistical barriers to getting adjuvant therapy for breast cancer," she added. "To ensure that patient assistance programs have the greatest impact on reducing national disparities in care, private philanthropies, which represent the biggest source of funding for these valuable programs, will be challenged to increase development in this area."

-- Robert Preidt
Copyright © 2013 HealthDay. All rights reserved. SOURCE: Mount Sinai Hospital, news release, Oct. 22, 2013

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Skin Cancer Patients Not Avoiding Sun, Study Suggests

WEDNESDAY, Oct. 2 (HealthDay News) -- Some people with melanoma aren't cautious about sun exposure, a small new study suggests, even though ultraviolet (UV) radiation from the sun is a major cause of skin cancer.

Researchers looked at 20 patients with malignant melanoma -- the most deadly type of skin cancer -- and a comparison group of 20 people without melanoma, all of whom carried portable UV-dose-detection devices and kept sun exposure diaries to measure their exposure to UV radiation.

Patients' overall daily UV radiation exposure rose 25 percent from the first to second summer after their melanoma diagnosis, and increased 33 percent from the first to the third summer, found the study published online Oct. 2 in the journal JAMA Dermatology.

The patients' UV exposure was also higher on vacation days and when they traveled to other countries, said Dr. Luise Winkel Idorn, of Bispebjerg Hospital and the University of Copenhagen in Denmark, and colleagues.

In comparison, people without melanoma had steady levels of UV radiation exposure, according to a journal news release.

-- Robert Preidt
Copyright © 2013 HealthDay. All rights reserved. SOURCE: JAMA Dermatology, news release, Oct. 2, 2013

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Fatty, High-Calorie Diet Linked to Pancreatic Cancer in Mouse Study

WEDNESDAY, Oct. 2 (HealthDay News) -- A high-fat, high-calorie diet may increase the risk of deadly pancreatic cancer, a new animal study suggests.

Researchers found that mice who became obese by eating high-calorie, high-fat diets developed abnormally high numbers of lesions known to be precursors to pancreatic cancer.

The study, published Sept. 30 in the journal Cancer Prevention Research, is the first to show a direct link in animals between obesity and the risk of pancreatic cancer, according to the researchers at the Jonsson Comprehensive Cancer Center at the University of California, Los Angeles.

However, findings in animals do not always bear out in human trials and while the study showed an association, it did not prove a cause-and-effect link between diet and pancreatic cancer risk.

The researchers did say that their findings support eating a low-fat, low-calorie diet as a way to prevent pancreatic cancer.

"The development of these lesions in mice is very similar to what happens in humans," study leader Dr. Guido Eibl said in a UCLA news release. "These lesions take a long time to develop into cancer, so there is enough time for cancer-preventive strategies, such as changing to a lower-fat, lower-calorie diet, to have a positive effect."

The researchers found that the mice fed the high-calorie, high-fat foods gained significantly more weight than mice on a lower-fat, lower-calorie regimen. They also had metabolic abnormalities, increased insulin levels and inflammation of pancreatic tissue.

Pancreatic cancer is one of the deadliest types of cancers. Overall five-year survival rates for this type of cancer are 3 percent to 5 percent, and the average length of survival after diagnosis is four to six months.

In many cases, patients only begin to develop symptoms when pancreatic cancer is in the advanced stages. There is a lack of effective treatments, so researchers are focusing on prevention strategies.

-- Robert Preidt
Copyright © 2013 HealthDay. All rights reserved. SOURCE: University of California, Los Angeles, news release, Sept. 30, 2013

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Fatigue in Cancer Treatment

Fatigue is a vague yet common complaint. Fatigue can be defined as a daily lack of energy, an unusual or excessive whole-body tiredness not relieved by sleep. It can be acute (lasting a month or less) or chronic (lasting for months or longer). Fatigue can prevent a person from functioning normally and have significant impact on a person's quality of life.

Fatigue is the most frequently reported symptom of cancer and cancer treatment. Although well recognised by health professionals as a significant problem, cancer fatigue is still poorly understood. It manifests as a chronic or long-lasting sense of exhaustion and decreased ability to do normal activities that is not relieved by rest or sleep.  

There are many possible causes of fatigue, most of which are completely unrelated to cancer.

General causes 

Some general causes include:

Cancer-related causes 

How exactly cancer causes fatigue is still poorly understood.

Cancer treatments commonly associated with fatigue include:

Chemotherapy: Any chemotherapy drug may cause fatigue. For some patients, fatigue lasts only a few days, while for others it may persist throughout the course of treatment and continuing after the treatment is complete. The fatigue may be due to anaemia which chemotherapy drugs can cause. Radiotherapy: Radiotherapy can cause fatigue that increases over time. This can occur regardless of the treatment site. Fatigue usually lasts from 3 to 4 weeks after treatment stops but can continue for up to 2 to 3 months. In addition, radiation therapy to the neck area can affect the thyroid gland and cause hypothyroidism (which can contribute to fatigue). Bone marrow transplant: Bone marrow transplant can cause fatigue that lasting up to one year. Biological agents: Interferons and interleukins are cytokines, chemicals that are normally released by white blood cells in response to infection. They carry messages that regulate other elements of the immune and endocrine systems. At high levels, these cytokines can be toxic and lead to persistent fatigue. Combination therapy: if more than one type of treatment is used, eg. chemotherapy and radiotherapy, the chances of treatment related fatigue will increase.

Other factors that may contribute to cancer-related fatigue include:

Tumour-induced "hypermetabolic" state: Due to tumour cells competing for nutrients, often at the expense of the normal cells' growth. Poor nutrition: Due to weight loss and nausea from the side effects of treatments can contribute to fatigue. Other medications: Medications used to treat side effects (e.g. nausea, pain, depression, anxiety, seizures) can cause fatigue. Pain and stress: Research shows that chronic pain increases fatigue, as does stress. Depression: Depression/adjustment disorder which may be pre-existing or related to stress caused by the diagnosis of cancer.

Treating fatigue is often difficult as usually there is no obvious cause or there may be many contributing causes. When there is an obvious cause, such as anaemia or low thyroid hormone levels, then this should be treated appropriately.

Exercise

In terms of cancer related fatigue, so far the only treatment which has been proven to improve energy levels is exercise. Studies have shown that a properly designed exercise programme helps maintain muscle strength, prevent worsening fatigue, and in many people, can actually lead to an increase in energy levels. Patients should be encouraged to keep active for as long as possible, within their abilities. Physiotherapy may also help people to stay active.

Pharmacotherapy

Appetite stimulants

A number of studies have suggested that drugs can be used to treat anorexia. The most commonly used drugs include corticosteroids and progesterone. Patients who have problems with nutritional intake may also be advised to take a high calorie diet. Referral to a dietician may be helpful.

Other drug intervention

Any treatments that relieve the effects of cancer or side effects of treatment may also affect energy levels. Effectively treating problems such as pain, nausea, anaemia or depression, is likely to have an impact on symptoms of fatigue.

Treatment of anaemia

Anaemia is a common problem in cancer patients, with frequency related to the type of cancer and the way it is being treated. There are medications available which can encourage the patient's body to produce more red blood cells, resulting in reduced anaemia-related fatigue and improvement in patient's ability to perform daily tasks.

Antidepressants

Depression or adjustment disorder can commonly occur in patients with cancer, particularly those with advanced disease. Antidepressants may be of value when patients have fatigue associated with depression.

Psychological support

Patients may receive helpful advice on managing their anxiety through professional and self-help sources, such as counselling, patient support groups, psychological support and occupational therapy. Other methods that may reduce fatigue include relaxation methods, yoga and massage. Activities such as music, humour and socialising with friends and family may help, and so may energy conserving strategies such as planning and pacing activities and work, and eliminating unnecessary tasks.

For more information on cancer, including breast, prostate, kidney and stomach cancer, see Cancer: Overview.

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Imaging gives clues to how nanoparticles attack cancer

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MRI and microscopy combine to study cancer cells' workings

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