Breast cancer treatment

>>loricoming up next on being well. a subject important to women of all ages and that is breast cancer.my guest this week is dr. abdur shakir, director of the sarah bush lincoln regional cancercenter. dr. shakir will discuss risk factors and prevention strategies. in addition wewill learn more about the latest advancements in breast cancer screening, surgery, and treatments.that is coming up next on being well, so dont go away. dr. shakir thank you so much forcoming on the show and talking today about breast cancer. lets get right into it andtalk about what makes the breast such a place for cancer to grow. >>shakirso normally why women develop breast cancer

is that they have a lenghty period of menstralcycles through out their life. by the time they have their first period, or menarchy,till the time they have menopause, they have constant stimulation to their breast withestrogen and pegesteron. this stimulation to their breasts make their breast swell,makes their breast go back down, swell, and go back down, that happens every single monthfor a woman. that stimualtion changes the architecture for the breast. when you changethe architecture of the breast over time that can lead to breast cancer. >>loriso what do you mean by architecture? is it the tissues?

>>shakircorrect. the breast tissues change. that is why the risk factors developing breast cancerusually happen around the time of 45 or 50. meaning they have had thirty years of stimulationto their breast. so that change of architecture over that lengthy period of time or changingthose tissues can lead to breast tumors. >>loriok you brought up risk factors and that is something that a lot of women have thoughtabout. talk about the primary risk factors. >>shakirsure. i usually divide them into nonmodifiable risk factors that you cannot change in yourbody, and their are modifiable risk factors. non-modifiable risk factors that you cantchange in your body. non modifiable risk factors

are gender. when i say gender people lookat me funny. women have breast cancer, about 200.000 a year. but men also get breast cancer,about 2,000. so women have 100 times more liklihood than men do. so being a woman isa first risk. the secon risk is age, women between 45-50 and up to 75 years old havean increased chance for breast cancer. what we also look at is the race and ethnicity.if a woman is caucasian, they have about 124 out of 100,00 risk of developing breast cancerversus an asian woman who have about an 80,000. what is different for race is for africanamerican women although they have a less incident for caucasian women, they have a much moreaggressive type of tumor than caucasian women. so they can die sooner from breast cancerthan caucasian women do. lastly what we look

at is if someone has already had a historyof breast cancer. so if someone had a history of breast cancer you can not change that.their increased risked of developing breat cancer on the opposite breast is about onepercent per year. so those things you can not change. but there are also modifiablerisk factors. the first modifiable risk factor i always talk about with the woman is theirweight. there is a large study about nurses where they evaluated over 50,000 nurses. whatthey looked at was if a woman weighed more than 175 pounds versus less than 130 pounds.this is only for post menopausal women. if a woman weighs more than 175 pounds she hasabout a 25% increase risk of developing breast cancer. so weight plays a significant role.secondly is smoking and alcohol. we know that

smoking is related to cancer in general especiallyfor young women. so if you are over weight and a smoker you need to stop. one of theother common risk factors is alcohol. there have been at least over 40 different studiesthat look at alcohol in relation to breast cancer. what they found out is that womenthat drink more than three drinks of alcohol per day increase their risk of breast cancerany where from 10 to 20 percent. so what we do tell women that if you are overweight,a smoker, and you are a drinker, those are things that you can change in your body todecrease your risk of breast cancer >>lorilets talk about family history because i know that is a concern for a lot of women.

>>shakirsure. so family history when you think of breast cancer accounts fo 15 percent of breastcancer. so really not a whole lot. so 85% of women are developing cancer without familyhistory. when we look at family history, if you have a mother with breast cancer, if youhave a sister, or daughter with breast cancer, those are first degree relatives. when youhave a first degree relative that doubles your risk of developing breast cancer. nowif you have a mother and a sister with breast cancer, that triples your risk with breastcancer. or if you have a mother less than thirty and develops breast cancer that triplesyour risk as well, so if you had a mother, and a sister and they were less than thirty,your risks are pretty exponential. so family

history is quite important. not just for theoncologyst but for the family doctor who is going to be doing the screening tests. soif he knows that hey my mother had breast cancer at 35 years old he is going to be evaluatingyou by the time you are 25 to make sure things are going ok. lets talk about screening, wehave heard for years, a mammagram every year after 40 and then some things came out thatsaid no you do not need that. very confusing. what are you reccommending? >>shakirthere is going to be a caviat. our philosophy for the sbl center is three fold. the us preventativetask force in 2009 came out and said, mammograms should be done for women above 50 and older,these were a panel of experts that came out

with this reccommendation. they not only saidwomen over fifty, but women over 75 should not have mammograms, they also said womenshould not be taught to do self breast exams. they also said that women less than 50 unlessthey have family risk factors, should not be having mammograms. like i mentioned only10-15 percent of women have that family history. so we take a different approach, we take athree tier approach from male clinic. what we say is, we tell a woman, if you are examiningyour breast, you should be doing that one a 1-2 month basis, being familiar with yourbreast tissue. this should start at the time that you are 40 at least. you should havea breast exam by a health care provider every single year till the age of 40 and we recommendmammograms at the age of 40. and we made this

three tier apporach based on a swedish studythat looked at 1 million women and what they found from this 1 milliion wome is if youstart screening them after the age of 40 you decrease the chance of breast cancer deathby 29% that is signifcant enough in my mind and i have seen enough patients to know thatbreast cancer can happen in the 30s and 40s. like i explained also before with age. wesee incidents of breast cancer shoot up at 45, so we need to catch women before the ageof 45, not 50. >>loriwhy does it go up at 45? >>shakiri think mainly what happens is that is their menopausal state. between 45 and 50 that iswhen women develop menopause, that is their

longest time of exposure to their menstrualcycle as well. >>loriit seems like estrogen has played a significant role in breast cancer. >>shakirthe reason why estrogen plays a significant role is two fold. we know this by if yourbody produces estrogen, or if you are taking estrogen. so from women in 2002, there werewomen who were promoted to say, take estrogen. if you are post menopasal and you take estrogenit is going to help your heart, it is going to help your bones, and you are going to feelgreat. what we found out in 2002 that it was not true. what we found out in 2002 was thatthere is a huge rise of breast cancer. they

said what happened? what they correlated thatwith is women who were post menopausal taking this estrogen supplements. now there is astrong debate on how true that is and how significant that is. my opinion is that ifa woman is menopausal, they should not be on any estrogen, because there is a clearcut reason why we see women develop breast cancer and that is estrogen stimulation totheir body. >>loriare there things that we can do now in terms of our diet and exercise that can help lessenour risks of getting breast cancer? >>shakirabsolutely. there is a large study that is going on by the national cancer instituteas well as stanford on how do we tell women

what to eat to prevent cancer in general,not just breast cancer, but cancer in general. they have done a series of studies, nothingis very conclusive yet, but there are three main groups that they are looking at. thefirst type of foods that they are loking at are phytochemicals. this is a chemical substancethat is produced agains plants. this is used to fight againts bacteria and funguses inthe body. what they find out that these phytochemicals can hopefully prevent cancers, not just breastcancer alone. these phytochemicals are found in certain fruits and vegetables, usuallybrighlty covered fruits and vegetables, like green ones, red ones, and orange ones. thenational cancer institute is looking at these and seeing how much they can help women. nowi dont go out and say this is going to help

prevent cancer but i always tell women thati know it cant hurt you but i know it can help you. what we also hear about is anitoxidantsand cancer. what you have to understand is how anitioxidants work. what they do is stopthe free radicals in our body. what free radicals are a process in our body that when we breakup materials thats houw free radicals develop. what free radicals do, they go and attacknormal dna in our body and that allows tumor to grow. there is a bunch of food that haveantioxidants in it. vitamin c, selenium, blueberries, blackberries, fruits that have antioxidantsin them. i tell women yes, they may help you, but i cant tell you they wont hurt you, butthere is some data that is still on going with the antioxidants. we do not recommendthe taking of antioxidants when you are on

radiation therapy. but to hopefully preventcancer they may help along the way. lastly is omega three fatty acids. there is somedata out there that says that can help with breast cancer and colon cancer, again thedata is not conclusive. so yes women can take some steps of how do i do fresh fruits andvegetables and grains and cereals, but that not only will help cancer prevention but thatwill help parkinsons disease, obesity, diabetes as well. >>lorithats right it is all things that we need to do for a healty diet anyway. you mentionedthat there are different type of breast cancer grades, that can be confusing because thatdrives the treatment. can you explain the

different types and grades? >>shakirsure. so when we see a breast cancer patient, the first thing that happens is usually abiopsy. after a biopsy is done, our pathologist looks at that tissue under the microscopeand sometimes i do as well. and they make a point to say that these are the type ofbreast cancer that the woman has. that really drives what type of treatment we do. so thereare certain type of breast cancer that are very low grade. these type of cancers areusually treated with surgery and radiation, and sometimes anti estrogen therapy and notvery commonly with chemotherapy. we have a different grade called infiltrating whichis a higher grade type of breast cancer that

not only do we do just surgery and radiation,but sometimes we offer chemotherapy as well. so when a woman goes and sees their oncologistor their family doctor or surgeon, you should ask what type of breast cancer do i have?is it low grade breast cancer or is it a high grade breast cancer? and that will dictatetreatment. >>lorithe doctor team can be intimidating and very confusing if you are diagnosed. there is awhole group of people, everyone plays a different role, can you kind of explain how you workas a doctor team. how does the patient sort of digest all of that and deal with all ofthese opinions that you might be getting? >>shakirsure. what i always reccommend to women and

men is that once they get a diagnosis withcancer is that they should look towards their oncologist to be the ring leader and say whatdo we do next. you are going to have surgeons involved, radiologists involved, family doctorsinvolved bu i think the final opinion for what to do next should be relied on theironcologyst. so you have to develop the rapport and hopefully the relationship with your oncologistwhere you can ask them anything and be able to spend time with them and say this is whatwe should do for your type of cancer. >>loriokay. what advice do you have for family members? how do you get them to cope and advice iftheir family member has breast cancer? >>shakirthe thing i always recommend for all of our

new patients that come to the sarah bush lincolncenter is bring your family members or friends with you. not just for support but as a recordingsecretary, another set of ears, another question asker. the reason why that is important isbecause when you go home as a cancer patient there is a flood of information that is throwntowards you, and you may not be able to comprehend everything that is going on, but if you haveclose family members that are in that room with you, they are able to at least put thingsinto perspective. the thing i always tell people that come alone, and they may not havea close family, is that you should absorb the information that i tell you and go goback home, and come back again and we will do it all over again. we will explain thethings from the top all over again.i always

tell people that they should relay informationto close family and friends simply because you have people that tend to ask a lot ofquestions. that frustrtates a person. what are you doing? are you really doing this?or that is not what my doctor told me to do. that puts anxiety on a person. so i thinkthat it is really important that you relay information in probably small groups of peoplethat you know closely and little information so they may not ask you so many questions.you will know who to give that information too, obviously parents, sisters, and evenchildren, those people will probably absorb the information, versus friends thaty mayask you pestering questions sometimes as to why you are doing this.

>>loriso how do you as a doctor decide with patients, this person needs a lompectomy, what is thecriteria? >>shakirsure. this is an excellent question because we get this very commonly. how do i chooseto have part of my breast removed versus the whole breast removed? there are some prosand cons to both. with a mastectomy, is is removing the whole breast tissue. there willbe no breast left. versus a lompectomy. you are removing basically a smally portion ofthe breast tissue and conserving the breast that is there. with the mastectomy it is amore, detailed procedure, so not only will you have to have that surgery that day, andnot only will it have general anesthesia that

day, you will have to stay in the hospitalthat day. the pros with the mastectomy is that you do not have to typically, go underradiation therapy for six to seven weeks. with a lompectomy, what we know is that wecan do the lompectomy, but you will have to do the radiation for six to seven weeks. themain question a woman should always ask me, is well what is good for my breast cancer?forget the aesthetics look, forget doing radiation, is there something that is better for my breastcancer. forget the aesthetics look, forget me doing radiation, is there something thatis better for my breast cancer than me doing the mastectomy plus radiation? there has beenenough clinical trials that tell us that they are fairly equal. there maybe some that saysthat mastectomy decreases the risk of reoccurance

rate by slightly bit more, but when you lookat the statistics, they are identical and the same. so if a woman comes in and saysshe doesnt want to do radiation because she is traveling, i am working, i cant sit herefor 6-7 weeks coming monday through friday, or you can have the mastectomy is a reasonableoption here. if a woman says she wants to conserve her breast it makes me feel good,then i say a lompectomy and do radiation. its more of a personalized approach, whatwould you like to do? >>loriif a woman does have a mastectomy, when can they have reconstruction done? >>shakirthat really depends on two things, how well

you have healed from you mastectomy. sometimesyou can do the mastectomy in the reconstruction at the same time as well. so reconstructiveis still a good way of doing things, the issue with reconstruction from a cancer standpointis that, one they put in implants. we can not evaluate the chest wall anymore. so whenthe implants are there, we can not tell if there are any reoccurance of the breast canceris happening where they did the incision before. so we sometimes have to offer mri so theycan look at the chest wall so they can tell if the chest wall is ok. >>loriyou mentioned mastectomy and radiation, do you do chemotherapy for breast cancer?

>>shakirit depends on a bunch of different factors. anytime i see a breast cancer patient i say,we are going to be looking at certain things, first thing i look at is what is the sizeof the tumor? if the tumor is more than one cenimeter you are going to be looking at chemotherapy. if the tumors have lymph nodes involved, you are going to be looking at chemo therapy.if the tumor has a high grade three then we are going to be looking at chemo therapy.if the tumor has her 2 positive which is a marker that sits on breast cancer, you aregoing to be looking at chemo therapy. so when a woman decides to do chemo therapy or not,it is a very individualized approach to this. >>lorithere is always new technololgy and new things

coming out. do you want to talk about someof the new treatments that are avialable to women out there? >>shakirsure i think this is a good change because we talked about who do we choose for breastcancer treatment and chemo therapy, there is a test that looks at genes in women. itis call oncotype, there is a sister test to that called mama print. these two tests lookat genes in the breast cancer. the reason why these two tests are important is thatits very complicated on who gets chemo therapy and who does not. this type of gene anaylysislooks at sixteen cancer genes and five controlled genes in the body and it gives the oncologyistwhat are the risks of the breast cancer coming

back if we do chemo therapy or if we dont.that is a good way of approaching a woman, you could say listen if we dont do anyhingthere is a 35% risk that breast cancer is going to come back. this type of test is nowadvocated and promoted by the national conference of care network and i usually offer it towomen and they have to follow a certain circumstance. meaning a tumor size that is more than onecentimeter and has no lymph nodes involved and that is where it becomes kind of fishy.this type of test is very expensive but it could save women from having chemo therapy,which we used to have chemo therapy before hand. >>loriwhat about technology, im assuming in mamamograms,

the technology to read those have gotten alot better. >>shakirit is. what we have at sarah bush is a digital mammogram. not only do we have a digital mammogram,you have to have an expert radiologist reading that digital mammogram and that is what isvery important. during that time when a woman has a mmamogram, we are able to say immediately,you need to stay here, we need to do another mammogram and we need to do an ultrasoundand a biopsy so if a woman comes in to do a mammogram, they are going to know that daywhat is going to happen next. if there is something fishy. technology of doing digitalmammograms has kind of revloutionized things, we are able to pick up immediately and havea radiologist say things look ok, go ahead

for the next year. there is also a huge numberof other tests that are available for cancer, like mri, like cat scans, but i always warnwoment that we should used an individualized certain cases. when a woman comes in and asksme, i heard my friend had a cat scan, i heard my friend had an mri, we want to limit theradiation exposure so we use that in selective cases. >>lorithis was a couple years ago, the testing for the breast cancer gene. is that still goingon? >>shakirabsolutely, that test is called bacagene, that test i offer in every singal woman withless than 50 years old that develop breast

cancer. the reason being is if we can pickup this gene, in a woman, we know that we have an increased risk of developing breastcancer on the opposite breast, and we also know that they have an increase in ovariancancer as well so that gene is vitally important in checking in women. >>lorithis happened to a friend of mine, you go in for your first mammogram and they findsomething, sometimes it is scary. it is not always breast cancer, there are other thingsthat can be in there correct? >>shakirabsolutely, you have the preventative task force in 2009 saying mammograms should beafter 50, they did report a lot of false positives.

women would have this abnormality, they wouldhave the stress of having a biopsy, they would have a repeat mammogram in three months orsix months time, have another biopsy negative, and all those procedures take a toll on awoman and a cost to society as well. so yes it is frustrating but the way that i lookat it isthat if we can catch a woman early with breast cancer and save their life thensome of those have to be worth it. some of those extra tests have to be worth it becausemaybe we caught a 40 year old with breast cancer so some of those do take a count andi think the cost of life of earlier detection far outweighs the risk of waiting till 50. >>loriso what is it when you get called back in

and you have an abnormal mammogram. well whatis it then? >>shakirsometimes women have dense tissue or something called fribroid atanomas or benign tissuethat are developing and it happens for no good reason. it is maybe just a part of theirnormal breast tissue that is developing an abnormal benign tumor that is there. so yesit is scary, but the good thing that i reccommend is that if you have a close follow up withyour physician, youre having close mammograms and you are doing self breast exams at thesame time, all that will keep account to make sure that things are okay. if there is a highenough suspicion, so i get second opinion on should we do something or should we not,if there is a high enough suspicion for me

meaning that if a woman who is 45 or 50 andis a smoker, alcoholic, obese, has a family history, and has this goofy looking abnormalityon the mammogram, im going to say go ahead and biopsy it. >>lorias we wrap things up here, you see cancer patients all the time, give us some advice,if you are diagnosed. what advice do you have for cancer patients? >>shakirwhat i always recommend to every single breast cancer patient is, you have to have a verygood relationship with your oncologist, because this is not a marathon race, it is a journey,you have to be able to ask your oncologist

questions, have the freedom to ask him questions,and have him or her be able to reply back in an appropriate manner. so i always tellwomen to ask for information, have a list of questions when you come back to see me.i usually sometimes have women come in and they have no idea what breast cancer is aboutand havent done any sort of research so i say let me give you all the information onbreast cancer like we did here today then you go back home, think about it, think aboutsome questions, write on a piece of paper for the next week then, then come back tosee me because you need to ask me some questions about what is going to affect you. so i thinkasking questions to your oncologist and having the relationship with your oncologist is vitallyimportant.

>>loriwell thank you so much, this has been very helpful and i think that is going to be goodfor women to hear this information. lots of new things that i didnt know so thank youso much for coming on being well, we appreciate it. >>shakirthank you for having me >>loridont forget you can watch full episodes and demonstration segments from the "being well"series. visit us at youtube.com/weiutv

Friday, January 6, 2017