Ask the Expert

Southern Ocean County Hospital would like to thank everyone who e-mailed questions for this edition of Ask-The-Expert and would like to especially thank Dr. Sara McGee for taking part in the program.

Dr. McGee's answers are informational only and should not be used as a diagnosis or for treatment. Please talk to your physician about official diagnosis of your condition and treatment.

June : Breast Cancer

Question 1
How accutare is CA27.29 testing?

The usefulness of tumor markers such as CA 27.29 in the management of breast cancer is questionable because of the low diagnostic sensitivity for early disease.  CA 27.29 is not recommended for routine use.  Even thought the FDA approved the test, it does not require that the test show a clinical benefit.  As such, the American Society for Clinical Oncology does not routinely advise it.  There was one study from John Hopkins University in 1997 showing a 57 percent sensitivity in Stage II and III patients.  As of yet, there are no further studies or newer assays that have changed the current recommendations.

Question 2
Is Oncotype Dx reliable and worth doing to predict recurrence and Tamoxifen benefit? 

Actually, Oncotype Dx testing is used in newly diagnosed Stage I or II patients who are lymph node negative and estrogen receptor positive.  These patients who would have been formerly advised to get chemotherapy, now with Oncotype Dx, may have another option.

Oncotype Dx is a test where normal breast tissue from breast reduction surgery as well as tissue from low, intermediate and high risk breast cancer patients is used to design a 21 gene profile pattern for predictability of disease recurrence.  A recurrence score is assigned based on that gene expression in a given patient’s sample.  A recurrence score of less than 10 is low risk, one of 11-25 is intermediate risk and greater than 25 is considered high risk.

There is a large national trial called TAILORx that is designed for women with early stage breast cancer.  The trial takes the intermediate risk patients and randomizes them to either chemo therapy plus hormonal treatment or hormonal treatment alone.  The result of this trial will take a few years bur it is open for interested candidates. 

The Oncotype Dx study is validated by a large study published in the New England Journal of Medicine and further supported by 2 other large national trials. 

Question 3
What treatment follows tamoxifen?

A large trial conducted by the Princess Margret Hospital in Toronto as well as the Mayo Clinic in 2003 sowed that postmenopausal women with early stage breast cancer who completed 5 years of Tomoxifen continued to benefit from decreased breast cancer recurrence by taking an additional drug for 5 more years called letrazole.  (Femara)

4-8% of the women taking letrazole experienced more hot flashes and a decrease in sexual functioning.  Tamoxofin works by binding estrogen to cancer cells but also works as a pro-estrogen in the bones helping to maintain good bone density.  The Aromatase inhibitors, such as letrazole, work by decreasing estrogen production even in postmenopausal women.  A baseline bone density is advised and then a repeat one during the course of treatment.  If the bone density falls during this time, your doctor may advise a drug called a biophosphonate such as Actonel or Boniva.

Question 4
Is breast cancer really curable or just treatable?

A cure of the breast cancer would depend upon the stage of your disease.  Many patients are alive decades after their original diagnosis.  With appropriate early detection, surgery, radiation chemotherapy and hormonal therapy, breast cancer cure is your doctor’s goal. 

Other patients may present with advanced disease and this is certainly treatable.  A discussion of your particular stage and treatment options would be individualized for each patient.  Seeking second opinions may also be a healthy option for the breast cancer patient.

Question 5
Recently a lump was found in my breast.  I went for an ultrasound and was told that it was fatty tissue.  Lately my breast where the lump is has started hurting when the breast is touched.  Should I go for a second opinion?

Whenever you continue to have symptoms of any pain, a repeat visit to your doctor is advised.  A surgical opinion may be suggested as a repeat ultrasound or aspiration may be advised.  A surgeon is unique in that he (she) can correlate what the ultrasound of mammogram shows to the feel and appearance of any lump in surgery.  Your doctor needs to know that your symptoms are returning or getting worse.  

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