Monthly Archives: September 2014

Beyond Breast Cancer Survival

Thanks to earlier detection, improved treatments, and supportive care of family and friends, there are now more than 2.6 million breast cancer survivors in the United States. In fact, we have begun to think of breast cancer survival as a chronic disease similar to diabetes or high blood pressure. Cancer survivors have a complex set of concerns including physical and emotional issues. The physical effects from the cancer or the treatment received can manifest as fatigue, appetite changes, chronic pain, radiation changes, osteoporosis, or chronic arm swelling. Most of the physical problems improve with time or can be treated to alleviate some or all of the symptoms.

Emotional issues typically tend to manifest as depression or anxiety. Depression can impact 20-40% of women with breast cancer either during or after their treatment. It is important to know these feelings will not always be there and they often improve with time and treatment.

One important way to deal with the anxiety from a cancer diagnosis and treatment is to find a support group. This can either be a structured group through organizations like the American Cancer Society or an informal network of family and friends. One survivor said with the strong support from family, friends and a faith in God, she was able to put breast cancer in her past. “Breast cancer no longer defines who she is, but it has made her much more aware of the joys of daily living and reaching out to others instead of looking at her own interests.”

Many ask, what’s next? Mammograms are important for cancer surveillance if a lumpectomy was done, or in the breast without cancer. The first mammogram should be done 6 months after radiation, and then yearly afterwards. If the cancer was treated with a mastectomy with or without reconstruction, yearly mammograms are not necessary. Initially, you should see your doctor 3-4 times per year the first few years. After 3 years, you graduate to every 6 month visits, and at 5 years, you only need yearly visits. This is because as more time passes from the original cancer, it is less likely to return.

I am privileged to have patients entrust me with their medical care and allow me to be an integral part of their healthcare journey from diagnosis to survivorship. I look forward to accompanying you through the journey of your cancer from diagnosis and treatment and into survivorship.

The Novice Division

As we trudged through the dusty field, the blazing sun and stickiness reminded me that late August in Sugar Land was not always a pleasant time to be outside. I was attending a FFA (Future Farmers of America) show at the school district barn with my brand new freshman son. I was ill prepared for the afternoon as I had no idea what to expect. Under the impression this was a short meeting for FFA parents, I was not anticipating a three hour ordeal of standing in the hot sun watching excited teens parade the animals they had been tirelessly raising for the past several months. This was a practice show before the real deal at the Fort Bend County Fair the following month.

As I stood behind the well prepared parents with their comfortable chairs and coolers of drinks, I made a few observations. I didn’t know much about FFA, or about raising a high school child for that matter. When my son began high school, I mandated he had to be involved in something. I didn’t care what, but he needed to have a group where he felt he belonged. FFA, teenagers, it was all unexplored territory I was navigating and I felt like I needed a quick education to gain proficiency in this segment of life.

The first observation I had was, “no wonder my son wants to join FFA…there are a lot of very cute little girls here…in fact, the majority of the club must be girls.” The first group that showed their animals that night was the steers. I’ve since learned this is a male bovine with his masculine parts removed. Six teens (of which 5 were female) waltzed with their steers around the dusty ring. I was amazed at how these willowy 100 lb kids could effortlessly lead a beast 15 times their size with only a small halter. I was more amazed at how profusely these animals slobbered everywhere.

The next division was the lambs. These lambs must be the amazon version. Lambs are little; right…at least Mary’s was in the song. These little lambs were the size of a Great Dane. The young teens spent the next 10 minutes doing their best to drag these animals around the ring. Lambs must be kin to the proverbial “jackass” as they were not compliant like the steers. The goats were next. Similar to the lambs, but the halters were chains, not rope. Eventually I learned this is because they eat any and every thing including their halters.

Next came the final animal…the hogs. Wow, lots of pigs! I would eventually learn this is because they are one of the easier animals to raise. They only have to be fed daily, not twice daily like the steers, lambs, and goats. I still wonder why goats have to be fed twice a day since they eat any and every thing.

In the arena, the hogs wandered aimlessly around the ring with a young teen following them and beating them with a stick every once in a while to give the appearance that they were controlling the direction they went. They weren’t.

Since there were so many pigs, they were divided into the senior division (people who had previously raised an animal) and the novice division (people who were new at this adventure). Novice, that’s me…I have no idea how to raise a teenager. Do they have a novice division for mothers? Having a high school student was a new experience. Choosing the correct courses to take, how to prepare and choose the right college, and dealing with the idea that too soon my son would be launched on his own. How would he do? Would he make good choices? What can I do to help him on his journey?

As I reflected upon the evening, I realized my patients with breast cancer must feel like I did that night… Ill prepared for the journey they are embarking upon. Unsure if they are making the correct decisions. Feeling as if they must gain a vast world of knowledge and understanding in a very short period of time. While this is the first time my patients are dealing with the treatment of breast cancer, most of my life has been devoted to gaining an education and expertise to guide them.

The good news is that breast cancer treatment is highly standardized based on proven historic results. I often refer patients to a website of the national comprehensive cancer network (NCCN.org) which gives the treatment standards for all cancers, including breast cancer. The treatment and outcome are very similar if the patient is treated by a multidisciplinary team (team of doctors made up of multiple specialties) whether they go to a large institution or a more personalized community program. Educating my patients on their disease and their treatment, then walking through the experience with them is one of the most meaningful parts of my job. With education they feel empowered; with companionship they feel encouraged to face what is likely the most critical part of their life’s journey.

What Matters Most?

Diseases and Surgery of the Breast

I was just getting home from a long day at the hospital when I received a phone call from a woman in her 50’s who had just been diagnosed with breast cancer. She was frightened, unsure what her diagnosis would mean for herself or her family. This woman was unsure why cancer had chosen her because no other members of her family had breast cancer.

Unfortunately, she did have the two most common variables associated with breast cancer which are being female and getting older. Most women who have breast cancer do not have a significant family history. Because we can’t always predict who will get breast cancer, mammograms help effectively screen. Most women if they don’t have a strong family history should get a baseline mammogram from 35-40 years of age, and a yearly mammogram after 40.

Fortunately, she was vigilant about getting her mammograms. Although mammograms will not prevent breast cancer, they will find many cancers when they are small. This women’s tumor was still very small. So small it could not be felt; only seen by her yearly mammogram. The size of a tumor and the extent of spread throughout the lymph nodes and the body are very important factors in determining a women’s survival. In fact data from National Cancer Institute suggests that 98% of women with breast cancer localized to their breast are alive 5 years from their cancer diagnosis, yet only 23% of women with breast cancer that has spread to other parts of the body are alive at 5 years. A number of factors, including other tumor characteristics, a person’s age and general health, can also affect outlook, but the size and spread of the tumor matter most.

I spent the next few weeks vicariously walking through this woman’s many doctor visits, further tests, and many decisions. One of the main decisions she had to make was what type of surgery to have…a lumpectomy versus a mastectomy. This is a very personal decision. Before 1982, all women with breast cancer received a mastectomy for any size cancer. In the 80’s several randomized trials showed that women who had a lumpectomy and radiation had the same survival as women who had a mastectomy. In 2002, follow up of these women who participated in these trials in the 80’s became available. They still after 20 years had the same survival despite which operation they chose. Today, the majority of cancers can be treated with a lumpectomy and radiation.

She recently celebrated her 11 year cancer free anniversary. Currently, she travels the country in her RV with her husband, plans a yearly family reunion, spends many hours caring for her neighbors and family, and walks every year in the American Cancer Society’s Relay for Life. Over the past 20 years this woman has been my friend, loved me through life’s triumphs and valleys, and been grandmother to my children and a mother to me even though she is actually my mother-in-law. I’m thankful she was vigilant with her mammograms and breast exams.

Breast Care for Life

Stopping for a break in the climb up the narrow rocky trail along a jagged Pennsylvania mountain, my son’s large frame towered above me, but his hand steadied me, the hand of a man. What happened to the small finger that would reflexly curl around my index finger, or the tiny body that fit into the crook of my arm? This was a 20 year journey from the initial bar on the pregnancy test indicating a new life, through endless soccer games, scout meetings, homework, middle school awkwardness, to high school with daily trips to the barn for FFA, the wonderful Fort Bend County Fair, and finally graduation last May. The hope and excitement of a new beginning at college was unfolding, the journey of life.

Breast care is also a lifelong journey for each woman. The pathways of my two younger sons are different from my older son. They have different strengths and different needs. Likewise, every woman’s breast care journey will be different, as individual as the woman.

Most patients will never have breast cancer, but it’s important to be your own advocate. Know your personal risk factors whether it is a family history, dense breast tissue, or simply the two largest risk factors which are being female and getting older.

While lifestyle choices won’t prevent cancer, a healthy diet and exercise can help mitigate the risk. Regular screening is important for every woman. While the American Cancer Society recommends a baseline mammogram from 35-40 years of age and yearly mammograms after 40 years, the multiple different guidelines can be confusing. While mammogram still find early cancers, the treatment for breast cancer has improved so much that even cancers found slightly larger are often still curable.

In 2013, the Canada National Breast Screening Study showed 25 years of results where annual mammogram did not reduce mortality. This study contradicted 8 other randomized trials that collectively found a 15-30% reduction in mortality from screening mammograms. Because many breast cancers are potentially curable, many more women must be screened to prevent a death.
Additionally, mammograms will miss 15% of all cancers. A mammogram is only a single tool for detection. Breast exams are another tool. I advocate a yearly breast exam by a physician and a monthly self breast exam.

If an abnormality is found, more imaging may help to determine if it is a concern. If the area found is worrisome, it should be biopsied with a needle using the imaging to guide the needle to the correct place. A surgery is usually NOT recommended upfront. The lesion generally should be identified because most abnormalities will not need further treatment.
If you have a diagnosis of breast cancer, the treatment is tailored to your particular needs and cancer type. Today, most patients will need surgery to remove their tumor. They may also need other additional therapies called adjuvant treatment which consists of chemotherapy, radiation, and hormone blocking therapy. Treatment depends on the type and extent of the cancer and often a combination of these modalities is needed.

Every one’s breast care journey is different…as individual as their life.