A new study has found that one in three early-stage breast cancer patients who received genomic testing when deciding about treatment options felt they did not fully understand their discussions with physicians about their test results and their risk of recurrence. About one in four experienced distress when receiving their test results.

Published early online in CANCER, a peer-reviewed journal of the American Cancer Society, the findings suggest there is room for improvement in communicating cancer recurrence risks and treatment decisions with patients.

Genomic testing is an increasingly important part of care for patients after they are diagnosed with early stage breast cancer. The test, which looks at 21 genes in breast tumors removed during surgery, can indicate the chance the patient’s cancer will recur. Such information can help guide decisions by physicians and patients about chemotherapy treatments. Patients with a high risk of recurrence may opt for more aggressive treatment, while those with lower risk may safely avoid over-treatment and its potential side effects. It can be challenging, however, for physicians to determine the best way to talk to patients about their test results and to use the results to make important treatment decisions with patients. Currently, there is little consensus regarding the most effective method to communicate risk information to patients.

Noel Brewer, PhD, assistant professor of health behavior and health education at University of North Carolina’s Gillings School of Global Public Health, and Janice Tzeng, MPH, who worked on this study as a graduate student at the school, led a team that examined how women with breast cancer received and understood cancer recurrence risk information after receiving a genomic diagnostic test called Oncotype DX, that is gaining widespread acceptance by oncologists and insurers.

To find out more about women’s reactions, investigators mailed surveys to 77 women with early-stage, estrogen receptor-positive breast cancer who received Oncotype DX between 2004 and 2009. The study was funded by a five-year grant from the American Cancer Society.

“Almost all women agreed that having the test gave them a better understanding of their treatment options’ chances of success,” said Brewer. “Most women said that they would have the test if they had to decide again today, and that they would recommend the test to other women in their same situation,” he added. Also, most women accurately recalled their genomic-based recurrence risk results, he said. These findings suggest that patients have a positive attitude about genomic testing, and testing helps them better understand their treatment options.

While many women understood discussions about their genomic test results, a third reported not fully understanding these discussions. Although 87 percent of women received a low or intermediate breast cancer recurrence risk score, about a quarter of the women experienced distress when receiving their test results. The authors concluded that their findings suggest a need to improve risk communication and treatment decision making after patients undergo genomic testing.

A study published on bmj.com today reports that the longer women wait for radiotherapy after breast cancer surgery, the more chance there is of local recurrence.

Starting radiotherapy as soon as possible will minimize this risk according to the authors.

The reasonable generally accepted interval between cancer surgery and radiotherapy is four to six weeks. Evidence on the effect of waiting times in patients with breast cancer is unclear.

In order to find out more, researchers from the United States, Canada and Japan investigated the link between interval to radiotherapy and recurrence of breast cancer.

A total of 18,050 national cancer records were analyzed. The data were from women aged 65 or older who were diagnosed with early stage breast cancer during 1991-2002. All women received breast conserving surgery and radiotherapy, but not chemotherapy.

Data from the 2000 US population census was used to identify demographic information. Women were monitored for an average of five years.

The findings indicated that starting radiotherapy more than six weeks after surgery was linked to a modest but significant increase in local recurrence. In the study, more than one in four women (30 percent) started radiotherapy after this time. A total of 734 (4 percent) experienced a local recurrence at five years.

Additional investigation showed a continuous relation between time to radiotherapy and local recurrence. This suggests that initiating radiation therapy as soon as possible could minimize local recurrence risk.

Longer periods before undergoing radiotherapy were also found among Black and Hispanic women and among women who lived outside the southern states of the US. The rates of breast conserving surgery were higher, suggesting limitations in capacity of radiation delivery.

The continuous relationship between the start of radiotherapy and local recurrence suggests that there is no “secure” threshold in terms of waiting time. Therefore, the authors recommend that radiotherapy should be started as soon as possible.

The researchers comment that the cost of increasing capacity to consistently ensure short waiting times could be important. This would need to be evaluated in return with the small absolute benefit in local recurrence. The authors conclude that it appears appropriate to consider this is a price to pay, given the recognized negative impact of local recurrence on overall survival, and the large numbers of women treated with radiotherapy for breast cancer.

In an associated editorial, Ruth Jack and Lars Holmberg from King’s College London say that minimizing delay improves outcomes; therefore investment and planning are needed.

They comment that healthcare providers need to evaluate where probable delays are occurring. Then they should make certain that these are reduced. In addition, they should ensure equal opportunities in accessing good care. On the other hand, they point out that if significant investment is required, the modest effects seen in this study would have to be weighed against other opportunities and priorities in cancer care.

“Impact of interval from breast conserving surgery to radiotherapy on local recurrence in older women with breast cancer: retrospective cohort analysis”

Mango. If you know little about this fruit, understand this: It’s been found to prevent or stop certain colon and breast cancer cells in the lab.

That’s according to a new study by Texas AgriLife Research food scientists, who examined the five varieties most common in the U.S.: Kent, Francine, Ataulfo, Tommy/Atkins and Haden.

Though the mango is an ancient fruit heavily consumed in many parts of the world, little has been known about its health aspects. The National Mango Board commissioned a variety of studies with several U.S. researchers to help determine its nutritional value.

“If you look at what people currently perceive as a superfood, people think of high antioxidant capacity, and mango is not quite there,” said Dr. Susanne Talcott, who with her husband, Dr. Steve Talcott, conducted the study on cancer cells. “In comparison with antioxidants in blueberry, acai and pomegranate, it’s not even close.”

But the team checked mango against cancer cells anyway, and found it prevented or stopped cancer growth in certain breast and colon cell lines, Susanne Talcott noted.

“It has about four to five times less antioxidant capacity than an average wine grape, and it still holds up fairly well in anticancer activity. If you look at it from the physiological and nutritional standpoint, taking everything together, it would be a high-ranking super food,” she said. “It would be good to include mangoes as part of the regular diet.”

The Talcotts tested mango polyphenol extracts in vitro on colon, breast, lung, leukemia and prostate cancers. Polyphenols are natural substances in plants and are associated with a variety of compounds known to promote good health.

Mango showed some impact on lung, leukemia and prostate cancers but was most effective on the most common breast and colon cancers.

“What we found is that not all cell lines are sensitive to the same extent to an anticancer agent,” she said. “But the breast and colon cancer lines underwent apotosis, or programmed cell death. Additionally, we found that when we tested normal colon cells side by side with the colon cancer cells, that the mango polyphenolics did not harm the normal cells.”

The duo did further tests on the colon cancer lines because a mango contains both small molecules that are readily absorbed and larger molecules that would not be absorbed and thus remain present in a colon.

“We found the normal cells weren’t killed, so mango is not expected to be damaging in the body,” she said. “That is a general observation for any natural agent, that they target cancer cells and leave the healthy cells alone, in reasonable concentrations at least.”

The Talcotts evaluated polyphenolics, and more specifically gallotannins as being the class of bioactive compounds (responsible for preventing or stopping cancer cells). Tannins are polyphenols that are often bitter or drying and found in such common foods as grape seed, wine and tea.

The study found that the cell cycle, which is the division cells go through, was interrupted. This is crucial information, Suzanne Talcott said, because it indicates a possible mechanism for how the cancer cells are prevented or stopped.

“For cells that may be on the verge of mutating or being damaged, mango polyphenolics prevent this kind of damage,” she said.

The Talcotts hope to do a small clinical trial with individuals who have increased inflamation in their intestines with a higher risk for cancer.

“From there, if there is any proven efficacy, then we would do a larger trial to see if there is any clinical relevance,” she said.

US researchers found that pomegranates contain six natural compounds that may prevent the growth of hormone-dependent breast cancer by blocking the enzyme aromatase, which changes androgen to estrogen. However, experts caution this does not mean people should expect the same results from eating pomegranates, because this was an “in vitro” (test tube) study and results on the lab bench don’t always translate to animals and humans.

The study, which was published in the 1 January issue of Cancer Prevention Research, is the work of Dr Shiuan Chen, director of the Division of Tumor Cell Biology at the Beckman Research Institute of the City of Hope, Duarte, California and colleagues also from City of Hope and the Center for Human Nutrition at the David Geffen School of Medicine, University of California Los Angeles.

For the study, the researchers screened ten compounds in a group known as ellagitannins.

Chen and his team found that the compound with the strongest impact was urolithin B (UB), which appeared to inhibit multiple estrogen-producing mechanisms that fuel the growth of breast cancer.

They also found that UB prevented estrogen-responsive breast cancer cells from multiplying.

Chen told the press that:

“By suppressing the production of estrogen, urolithin B and other phytochemicals found in pomegranates can prevent hormone-responsive breast cancer tumors from growing.”

The other phytochemicals they found were urolithin A (UA), methylated UA, acetylated UB, methylated UB and UB sulfate: these also inhibited aromatase activity but to a lesser extent.

Other studies have found pomegranate juice is high in antioxidants and contains compounds that can control the growth of breast and prostate cancers humans, said the researchers.

Chen said the results of the study suggest that:

“Pomegranate intake may be a viable strategy for preventing breast cancer.”

According to a report by Cancer Research UK, Chen said he and his team were surprised by the findings, explaining that they had previously found other fruits, such as grapes, were also able to inhibit aromatase, “But phytochemicals in pomegranates and in grapes are different”, he said.

Experts are cautioning that further studies are needed before we can be sure that UB is effective against hormone-dependent breast cancer in humans: women should not start consuming lots of pomegranates on the strength of this study.

This was an in vitro (test tube) study, and sometimes such findings don’t translate to animal and human studies: for instance it might turn out that these substances aren’t well absorbed in the body by just eating pomegranates.

Dr Laura Bell, science information officer at Cancer Research UK, told the press that:

“It’s too big a leap to conclude from this early-stage research that eating pomegranates could help prevent hormone-dependent breast cancer as the study was done using large amounts of purified chemicals on cells grown in the lab.”

“In terms of cancer prevention, most foods contain many natural chemicals and we need to understand the combined effect of these when processed in the body to guess what influence, if any, a specific food may have on your chance of developing cancer,” she explained, adding that numerous large studies have shown that:

“By eating a healthy balanced diet high in fibre, fruit and vegetables and low in red and processed meat, saturated fat and salt, you can help to reduce your risk of several different types of cancer.”

Breast cancer drugs like anastrozole (Arimidex from AstraZeneca) are also designed to block the action of aromatase.

As cancer surgeons, we witness the fear and anxiety we create when we tell patients that they may have cancer. This fear is understandable, as cancer can be a deadly disease. Choices for therapy can be overwhelming and treatments emotionally and physically taxing. We want to use all of the tools at our disposal to minimize the impact of cancer and maximize the chance of a good outcome. Screening for cancer is one such tool, but it needs to be used wisely and the results interpreted carefully.

The analysis (JAMA Oct 21, 2009) of the impact of current screening for breast and prostate cancer found significant room for improvement. Screening has led to an increase in cancers detected, many of which are not life threatening, and we haven’t been as successful as we had hoped in preventing more advanced stage cancers. We are not proposing that we stop all screening; we are saying that we can and must do better.

Screening is complex because cancer is complex. Not all breast cancers or prostate cancers behave the same, and as a result, some people benefit more than others from screening. Screening is most effective for moderate to slow growing tumors or where removing a precancerous condition prevents the disease, as in cervical cancer and colon cancer. For fast growing or very aggressive tumors, traditional screening may not be able to help, as these types of tumors pose significant risk even when they are small and seem curable. For very slow growing tumors, finding them early will not make much if any difference.

For both breast and prostate cancer, we have substantially increased the chance of being diagnosed with a slow growing tumor that might never have come to attention in the absence of screening, leading people to think they have a killer cancer when they do not. In this situation, we may be doing harm and creating anxiety, which often leads to more aggressive treatment choices. The more we (public and physicians) are aware of the limitations of mammography and PSA testing, the better we can tailor screening recommendations, use the results of screening wisely and provide more appropriate options for our patients. The new US Preventive Services Task Force recommendations are appropriate given our understanding of how cancers grow and present. They call for more shared decision-making where the population benefit is not clear. We recommend that all men and women understand the benefits and potential harms of screening, which will help decrease anxiety if they are recalled for a biopsy or for a diagnosis of cancer.

Importantly, we propose a strategy for moving forward. First, we must focus on understanding who is at risk for developing the most aggressive cancers and test targeted new drugs to improve treatment and prevention. We also must be aware that the most aggressive cancers can turn up as masses or high PSAs between normal screens, and not ignore symptoms just because there has been a recent normal screening test.

Second, we need to use the tools available (and develop new ones) for determining the aggressiveness of cancers at the time of diagnosis. This will help patients and physicians have conversations weighing the risks and benefits of interventions and lead to new trials designed to help some patients safely forego treatment.

Third, we need to think more about prevention. Our concept of screening should include the use of tools that identify how much risk a person has for developing cancer. For prostate cancer, tools like the online Prostate Cancer Risk Calculator, predict not only the risk of cancer, but the risk for high grade disease. When high, prevention interventions, such as finasteride, should be discussed, not just PSA screening. For breast cancer there are a number of risk models that we can use today to help patients and physicians think about the available medical and surgical prevention options as well as intensive and more frequent surveillance for those at highest risk.

We can also use risk assessment tools to identify people unlikely to benefit from screening; we should avoid screening them. In women over 70, for example, there is no evidence that mammographic screening saves lives, as such women most often develop less aggressive or IDLE tumors. Our advice to women in this age group is to continue to do breast exams, and to seek care if they find a lump. Men, and their physicians, can turn to the prostate cancer risk calculator to inform their decision about whether to get a PSA test as well.

Finally, we need a concerted national effort to invest in large-scale long-term studies and demonstration projects that accelerate the pace of learning about screening and prevention. We will all welcome the day when screening and treatment options are more tailored and effective and fewer women and men have to face the phrase, “you may have cancer”.

Dealing with the complexities of screening honestly will lead to more options for our patients and make care better tomorrow than it is today.

Aside from skin cancer, breast cancer is the most common cancer among American women, and the second leading cause of death in women. The American Cancer Society estimates that the chance of a woman getting breast cancer at some point during her life is slightly less than 1 in 8, and the chance of dying from breast cancer is about 1 in 35. However, as a result of early detection and vast improvements in treatment over the past two decades, breast cancer death rates have been decreasing. Today in America, there are more than 2.5 million survivors.

Although each person’s treatment will be slightly different, it most often involves some combination of surgery, radiation therapy and chemotherapy, followed by five years of hormone therapy and drugs like tamoxifen, which counters the effects of hormones. These treatments often cause uncomfortable and sometimes debilitating side effects, including decreased sexual desire and in younger women, early menopause—hot flashes, night sweats and mood swings. Venlafaxine, an antidepressant drug also known as Effexor, has been the treatment of choice for women undergoing breast cancer treatments, but it comes with its own set of side effects: dry mouth, decreased appetite, nausea and constipation. However, researchers say there is another option for these patients; one that works as well as drugs, without the side effects—acupuncture.

Previous studies have shown that acupuncture can reduce hot flashes in healthy postmenopausal women. So, researchers decided to find out if it could also benefit premenopausal women being treated for breast cancer. “We need something that’s accessible that doesn’t add adverse effects,” said Dr. Eleanor Walker, division director of breast services in the department of radiation oncology at Henry Ford Hospital in Detroit. For the study, 50 women with breast cancer were randomly chosen to receive either 12 weeks of acupuncture (twice a week for four weeks then once a week) or daily Effexor. They were followed for a year.

Initially, both groups experienced a similar reduction (about 50 percent) in hot flashes, depression and other menopausal symptoms as well as improvement in mental health. But two weeks after treatment stopped, hot flashes increased in the antidepressant group but remained minimal in the acupuncture group. It wasn’t until three months after the last treatment that hot flashes began to return for those receiving acupuncture. Additionally, about 25 percent of women receiving acupuncture reported better sex drive and many reported increased energy and clearer thinking. Adverse effects, including nausea, headache, difficulty sleeping and dizziness were reported by the antidepressant users, whereas no adverse effects were reported with acupuncture. “Acupuncture offers patients a safe, effective and durable treatment option for hot flashes, something that affects the majority of breast cancer survivors,” Walker said. “Compared to drug therapy, acupuncture has benefits, as opposed to more side effects.”
Janet Konefal, a licensed acupuncturist and assistant dean of complementary and integrative medicine at the University of Miami Miller School of Medicine, theorized that acupuncture operates as a balancing tool. “It is a regulator for the systems of the body. It doesn’t add or take anything—it simply increases activity or decreases activity depending upon the points used,” she explained. “In this situation, it helped regulate the endocrine system, thus helping to balance the activity of hormones, neurotransmitters, and other biochemical reactions that regulate the body.”

But other experts say it’s too early to take the findings too seriously. “It’s provocative but the problem is it’s a small number of patients and, having participated in research trials in vasomotor (hot flashes, night sweats, etc.) symptoms in women, it’s a field that has a large placebo effect,” said Dr. Jay Brooks, chairman of hematology/oncology at Ochsner Health System in Baton Rouge. “It needs to have a bigger trial.”

The World Health Organization (WHO) recommends acupuncture as an effective treatment for over 40 medical problems, including allergies, respiratory conditions, gastrointestinal disorders, gynecological problems, nervous conditions, and disorders of the eyes, nose and throat, and childhood illnesses, among others. Acupuncture has also been used in the treatment of alcoholism and substance abuse.

In 2010, The Multidisciplinary Group on Breast Cancer Research (GMECM), directed by Dr Eduard Escrich, lecturer of the Department of Cell Biology, Physiology and Immunology from the Universitat Autònoma de Barcelona (UAB) will study in depth how olive oil compounds might prevent and fight breast cancer.

Researchers plan to pursue olive oil benefits, specifically for breast cancer prevention during the next five years. The impetus comes from past studies from the GMECM group that olive oil, consumed moderately, can slow breast cancer growth.

Past studies, finding the ability of olive oil to fight breast cancer were performed in the lab on breast cancer cells. Specific compounds in olive oil – lignans and secoiridoids (compounds in plants that are anti-inflammatory and scavenge free radicals) – seem to kill aggressive types of breast cancer by suppressing the Her2 gene.

According to a UAB press release, “Among the research studies to be carried out, some of the most prominent focus on the effects fats and oils can have on mammary (breast) tumors, and especially those of extra virgin olive oil, and an analysis of the molecular changes found in these tumors in all of the genome and in the specific genes implicated in this pathology.”

Natural compounds have been repeatedly shown to aid in cancer prevention, but studies are sorely lacking when it comes to exploring natural compounds in depth that could lead to development of new and safer drugs.

Dr Escrich, who will lead the study about the potential role of olive oil for fighting breast cancer, has been studying the role of nutrition and the effect on breast cancer, and has won several awards for his research. Studies have shown that diets rich in olive oil, including the Mediterranean diet, are associated with lower risk of several types of cancer. Additionally, one third of cancers are found to be diet related. The scientists will pursue the role of olive oil in the fight against breast cancer, beginning 2010.

Black women with hormone receptor (HR)-positive breast cancer had worse disease-free and overall survival, according to data presented at the CTRC-AACR Annual San Antonio Breast Cancer Symposium, held Dec. 9-13, 2009.

“Black women had a higher risk for disease recurrence and inferior survival compared with women of other races,” said Joseph A. Sparano, M.D., professor of medicine and women’s health at Albert Einstein Medical College of Medicine and associate chairman of the Department of Oncology at Montefiore Medical Center in Bronx, N.Y.

“The worse outcome was seen only in those with HR-positive, HER-2�”negative breast cancer, which is the most common type of breast cancer” he added.

Previous research has shown that black women have worse outcomes in operable breast cancer, likely explained by their higher incidence of more advanced-stage disease, more aggressive triple-negative disease, disparities in medical care, and comorbidities.

“When we controlled for these other factors to the extent possible, black race was still associated with a worse outcome, but only in HR-positive disease – this was a new and surprising finding,” said Sparano.

The researchers evaluated survival outcomes in 4,817 women (405 were black) with stage 1 to 3 axillary lymph node-positive or high-risk node-negative breast cancer who had undergone surgery. The women were part of the Eastern Cooperative Oncology Group and Breast Cancer Intergroup trial E1199; they received doxorubicin and taxane-containing chemotherapy plus standard hormonal therapy.

“We found that black patients exhibited similar adherence to the chemotherapy and hormonal therapy, and they didn’t do worse if they had other breast cancer subtypes. This indicates that black women with HR-positive breast cancer are more prone to have disease recurrence despite state of the art medical care,” said Sparano.

The researchers are planning additional studies to evaluate whether these findings can be attributed to differences in black women’s ability to metabolize hormonal therapies.

Anti-estrogens as therapy for breast cancer may also reduce the risk of death from lung cancer, according to study results presented at the CTRC-AACR San Antonio Breast Cancer Symposium, held here Dec. 9-13, 2009.

“We found a reduction in lung cancer mortality among women treated with anti-estrogens for breast cancer. This work builds on previous studies that had suggested estrogens have a role in lung cancer development and progression,” said Elisabetta Rapiti, M.D., M.P.H., medical researcher with the Geneva Cancer Registry, University of Geneva, Switzerland.

Rapiti and colleagues evaluated whether anti-estrogen therapy for breast cancer patients reduced their risk of subsequently developing and/or dying from lung cancer.

The study included 6,715 women living in the Geneva canton of Switzerland who were diagnosed with breast cancer, between 1980 and 2003. Forty-six percent of the women received anti-estrogen therapy, primarily tamoxifen.

By the end of the study period, 40 cases of lung cancer developed. There was no difference in the incidence of lung cancer among women with or without anti-estrogens compared with the general population. However, the risk of dying from lung cancer was significantly lower among women who received anti-estrogen therapy.

“Our results are particularly relevant to the research agenda exploring endocrine treatment(s) for lung cancer,” said Rapiti. “If prospective studies confirm our results and find that anti-estrogen agents improve lung cancer outcomes, this could have substantial implications for clinical practice.” Phase II clinical trials are currently underway in a number of centers to evaluate the use of anti-hormone therapy as an adjunct to traditional chemotherapy for lung cancer, according to Rapiti.

Moderate to heavy consumption of alcoholic beverages (at least three to four drinks per week) is associated with a 1.3-fold increased risk of breast cancer recurrence. Women who are post-menopausal or overweight may be most susceptible to the effects of alcohol on recurrence. Drinking less than three drinks per week was not associated with an increased risk.

Marilyn L. Kwan, Ph.D., staff scientist in the Division of Research at Kaiser Permanente, Oakland, Calif., presented detailed results of this study at the CTRC-AACR San Antonio Breast Cancer Symposium, held Dec. 9-13, 2009.

Based on these findings, Kwan suggested, “women previously diagnosed with breast cancer should consider limiting their consumption of alcohol to less than three drinks per week, especially women who are postmenopausal and overweight or obese.”

Previous research has shown that consumption of alcohol is associated with an increased risk of breast cancer, but there are limited studies to date about alcohol’s role in patient prognosis and survival among those already diagnosed with breast cancer. Kwan and colleagues examined the effects of alcohol on cancer recurrence and mortality in the Life After Cancer Epidemiology (LACE) Study.

LACE is a prospective cohort study of 1,897 early-stage breast cancer survivors diagnosed with early-stage invasive breast cancer between 1997 and 2000. The researchers recruited participants from the Kaiser Permanente Northern California Cancer Registry.

Information on wine, beer and liquor consumption was documented via questionnaire. Each year, participants also filled out information on health outcomes, including recurrence of breast cancer, which was then verified by their medical records.

After eight years of follow-up, Kwan and colleagues found 349 breast cancer recurrences and 332 deaths. Among drinkers (50 percent of the study population), wine was the most popular choice of alcohol (90 percent), followed by liquor (43 percent) then beer (36 percent). Increased risk of cancer recurrence was most predominant among those who consumed two or more glasses of wine per day.

The increased risk of recurrence appeared to be greater among participants who were postmenopausal and overweight or obese, and was present regardless of type of alcohol. Alcohol consumption was not associated with overall mortality.

“Considering the few studies that have addressed alcohol and its influence on breast cancer prognosis, and that the increased risk of recurrence was observed in only some subgroups, our results should be confirmed in other prospective studies. Yet, these results can help women make a more informed decision about lifestyle choices after a diagnosis of breast cancer,” said Kwan.