Jolie’s Bold Move Spotlights Elective Mastectomy

Angelina Jolie sparked a lot of buzz last week when she announced that she had undergone a double-mastectomy—at age 37—as a preemptive measure against breast cancer. Many have hailed the actress’s frankness as courageous and enlightening.

First, let’s note that Jolie’s circumstances are rare. The catalyst for Jolie’s decision was a genetic mutation that meant an 87 percent lifetime risk of breast cancer, along with a 50 percent lifetime risk of ovarian cancer (the disease that claimed her mother’s life at a young age). Without a doubt, these are astounding and frightening odds.

The vast majority of women diagnosed with breast cancer, however, don’t have a mutation of the BRCA1 (Jolie’s) or BRCA2 gene. Even women with a prominent family history of the disease—such as Jolie—might not carry the mutation, but fall into another category of hereditary cancer. What’s more, non-genetic factors can influence a breast cancer diagnosis—these include early menstruation or late menopause, lifestyle (smoking, overeating, excessive alcohol intake and lack of exercise), and exposure to environmental toxins.

Ten years ago, breast cancer was treated as a single disease, but today we are mining information from genes within tumors to guide treatment decisions. This strategy minimizes side effects and improves quality of life for patients.

In the video below, Sohnee Ahmed, a certified genetic counselor at URMC, discusses why it’s important to understand your family’s history of cancer, considerations for genetic testing if a pattern is present, and what options are available should a BRCA1 or BRCA 2 gene mutation be identified.

Interested in genetic counseling? To reach a certified genetic counselor at URMC, call (585) 275-3461.

Sohnee Ahmed is a certified genetic counselor in the departments of Medicine and Child Neurology. She provides counseling for families at the URMC’s Neurogenetics Consultation Service, Huntington Disease Center of Excellence, and Cancer Genetics Service. Ahmed is involved in research endeavors including the implementation of universal Lynch Syndrome screening among colorectal cancer patients. A frequent speaker on the importance of genetic counseling, she’s also a member of the National Society of Genetic Counselors and of the Canadian Association of Genetic Counsellors.

Examine Your Birthday Suit Yearly, Doc Says

A few blistering, lobster-red sunburns as a kid. Fair skin, light eyes, sprinkled with a hearty helping of freckles. A family history of melanoma.

When it comes to protecting your skin from cancer, you can’t be too safe. Each year there are more new cases of skin cancer than breast, prostate, lung and colon cancers combined, according to the American Center Society, with an estimated 76,690 new annual cases of invasive melanoma—a skin cancer related to UV exposure—diagnosed in the U.S. alone.

Luckily, skin cancer is almost always curable if caught early. But how can you discern between a normal, healthy mole and one that’s cause for concern? In the clip below (we’re re-sharing a favorite one from a couple years back, so please ignore the incorrect screening date at the end), you can hear URMC dermatologist Dr. Marc Brown discuss skin cancer, the importance of practicing “safe sun,” and some tips to help you identify suspicious moles (while wearing your birthday suit!) at home.

 

Free Skin Screenings May 11

What’s more, if you’re in Rochester, you can be proactive about your skin health this weekend by stopping by Strong Memorial Hospital’s Free Skin Cancer Screening Clinic between 8 a.m. and noon this Saturday, May 11. No registration is required; take the Silver Elevators to the 2^nd floor to find the Dermatology Suite. Each screening takes about five to ten minutes and offers a written report of findings. Information on skin cancer, including prevention tips, will be available.

“Sun damage is cumulative, so it includes exposures that can seem just a part of our daily lives such as walking the dog, mowing the lawn or a trip to the store,” Dr. Brown said. “Making a skin cancer screening part of your annual routine will not only make sure that you are identifying a current issue, but it’s a terrific way to uncover potential risk factors for the future.”

For more information about the free detection clinic, contact the Dermatology Department at (585) 275-3871.

Dr. Brown also recommends the following ways to protect your skin:

• Slather on sunscreen. The sun can damage your skin in as little as 15 minutes. Apply sunscreen, with SPF 30 or greater and both UVA and UVB protection, 15 to 20 minutes before you head outdoors. Don’t forget areas such as the back of your neck, top of your ears arms and legs, and scalp if you’ve lost some hair. Reapply every two hours—or sooner after swimming or actively sweating.
• Wear a hat and loose-fitting clothing.  A hat with a four-inch brim will shade more than 95 percent of the face, head, ears and neck. Wear light-weight clothes that cover your arms and legs.
• Avoid the most intense sunlight. Schedule outside activities for the early morning or late afternoon to keep out of the most intense sunlight between 10 a.m. and 3 p.m.
• Don’t tan indoors. Heading on vacation? Getting prepped for swimsuit season? Let’s bust  a relentless myth: Getting a base tan from a tanning bed or booth will NOT give protection from sun damage. In fact, it’s been linked to skin cancers.

This annual skin screening event is sponsored by the American Academy of Dermatology, Rochester Dermatologic Society, and URMC’s Department of Dermatology.

Dr. Brown specializes in the diagnosis, treatment and prevention of skin cancers. In addition to performing Mohs surgery on more than 1,200 patients a year, he also runs a multidisciplinary melanoma group practice.

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When Heartburn Paves Way for Cancer

Dan Gnagy sought his PCP’s advice when he started having difficulty swallowing. The 52-year old had experienced chronic reflux since his 20s, and thought he just needed adjustment to his medication.

But when the doctor peered into Mr. Gnagy’s throat, what he saw alarmed him, and he immediately referred him to thoracic surgeon Dr. Jeffrey Peters. After tests and a biopsy, the doctor’s initial diagnosis was confirmed: stage IV esophageal cancer. This week, we’re sharing Mr. Gnagy’s video account of his story, which originally published with Canandaigua Daily Messenger.

A Deadly Cancer

Esophageal cancer strikes only three percent of cancer victims but boasts the second highest death rate of all cancers—making it one of the deadliest in the U.S. Largely preventable through early detection and behavior modification, esophageal cancer is a disease that slowly targets older individuals—men in particular—who may have  experienced symptoms of reflux for years. As the giant cohort of Baby Boomers move into middle age, heartburn has now become a common condition, making esophageal cancer awareness all the more important.

What’s It Got to Do with Reflux?

Reflux is a condition where the muscle around the opening from the stomach to the esophagus becomes lax, allowing stomach acid to wash up into the esophagus ulcerating its delicate epithelial cells. Years of reflux can cause the esophagus to undergo enough changes to lead to precancerous conditions and even cancer.

Treatment is targeted at eliminating the corrosive effects of stomach acid by using antacids, proton pump inhibitors and lifestyle modification. URMC is one of just 13 U.S. surgery sites chosen to offer the LINX Reflux Management System, a ring of small, bead-sized magnets that mechanically prevents the backwash of acid into the esophagus. The force between the magnets strikes the just-right balance: Weak enough that it opens wide for swallowing, but strong enough that it tightens the faulty seal back up after food has passed down.

Because reflux affects one in 10 Americans and is a precursor to esophageal cancer, it’s important to treat it as aggressively and completely as possible in the beginning stages. Important interventions include eliminating risk factors like obesity, smoking and drinking.

Gnagy’s cancer is now being treated at the James P. Wilmot Cancer Center, and he has responded well. He makes the trek to Wilmot every two weeks for chemotherapy and has been told that his cancer is now inactive.

April has been designated Esophageal Cancer Awareness Month. To learn more about the disease and what you can do to prevent it visit the Esophageal Cancer Action Network.

An interview with Dan Gnagy  also appeared in the Messenger-Post News, here.

For more information about the LINX* heartburn ring being implanted at URMC, click here.

* Of note, Peters has served as a consultant to the device’s parent company, TORAX Medical, and received nominal compensation for sharing his clinical expertise at meetings over the past three years. You can hear from a patient who has enjoyed success with the device here.

Colorectal Cancer: Simple Screenings Save Lives

We’ll be blunt. Colorectal cancer is one of the most common cancers, and the second leading cause of cancer deaths in the United States. It will kill more than 50,000 Americans this year – more than die in car crashes.

But it doesn’t have to be so deadly. Ninety percent of colorectal cancers are completely curable, if diagnosed early, but the odds plummet to just 10 percent if tumors are found late. Many are; only about 30 percent of Americans over age 50 have had a simple colonoscopy.

The encouraging news about this lethal cancer is that a little education and adopting a few healthful habits can go a long way in conferring protection. Consider the expert advice below:

• When you turn 50, schedule your first colonoscopy screening and repeat it every five years. If your primary care physician doesn’t suggest it, you should. In this preventive scan, you’ll be sedated while a small, lighted endoscope inspects your colon and rectum for polyps – mushroom-like growths at risk for turning cancerous. If discovered during the scan, the polyps can be removed immediately, greatly diminishing your future risk.
  

  A polyp.

• Eat grilled meats in moderation, and avoid smoking and chewing tobacco. Whether inhaled or swallowed, carcinogens in charred or smoked meats, tobacco smoke and “chew” all eventually pass through the colon, where they can up your risk for cancer.
• Balance your diet between “red” and “green” foods. Over-indulgence in red meats (eating more than a pound a week) has been linked to increased risk for colon cancer; on the contrary, adding more green, leafy vegetables to your diet and reducing your intake of foods with high-carb, high-fat, high-cholesterol content, has been shown to reduce risk.
• Stay active. Incorporating more physical activity – walking a pet, taking the stairs over the elevators, cleaning your house – helps stimulate your body’s waste to keep moving along (the longer stool sits in your rectum or colon, the more time toxic chemicals have to leach out into the surrounding tissues).
• Maintain a healthy weight, and know your shape. Obese men and women are at greater risk for colon cancer; “apple” shapes, which gain weight around the waist and vital organs, tend to be at greater risk than “pear” shapes, which store fat in their thighs and hips.
• Learn the obvious symptoms. Through colorectal cancer is a notoriously “quiet” killer, in the later stages, it can give undeniable clues. If you experience bloody stools, diarrhea, cramping and unexplained weight loss, call your doctor immediately.

Put simply, colorectal screening can save your life. If all Americans were screened regularly, colorectal cancer deaths could be cut in half. March is Colorectal Cancer Awareness Month, so why not schedule your test today?

No health insurance? Learn how we can still help you get screened.

We originally published these tips last year, courtesy of Dr. John Monson, chief of the Division of Colorectal Surgery at URMC. His areas of expertise include minimally invasive technologies for colorectal cancer treatment, in addition to basic research exploring a broad range of cancer-related subjects.

For more information about colon cancer screening, talk to your primary care physician. You can also find doctor videos, patient stories, health facts and more on our colorectal cancer information site.

Breast Density: Radiologist Puts New Notification Law into Perspective

A healthy lifestyle means knowing a few things about your body – even if you’d rather ignore those facts. Weight, cholesterol readings, hormonal cycles, and osteoporosis risk are starting points for many women. Now you can add something else to the list – breast density.

Density refers to the amount of fibroglandular tissue (tissue besides fat or muscle, including milk ducts and lobules, connective tissue, etc.)  in the breast. On a mammogram (which looks like an x-ray to the untrained eye), dense tissue appears white and opaque, while the fatty tissue appears black.

The problem is that breast tumors or benign masses also appear white on the mammogram. So, for radiologists, searching for very small lesions in dense breasts is like looking for a snowman in a blizzard. Most women don’t know what type of tissue they have, and therefore don’t have enough information to start a conversation with their doctors.

A new law in New York changes everything. As of Jan. 19, 2013, providers are required to notify women if more than 50 percent of their breast tissue is dense. To learn more about why this is important, we spoke with Dr. Avice O’Connell, director of Women’s Imaging at the University of Rochester Medical Center and Highland Breast Imaging.

Scripts: It seems that many women might not realize that density is an issue in breast health. Is this true, in your experience?

O’Connell: Yes, absolutely. I see many women who are not familiar with their own breasts. They may not do monthly self-breast exams, and they often don’t ask questions during their routine mammograms. Awareness of breast density is low.  However, later, if women do find out that they have very dense tissue, they’ll say, ‘if I only had known this.’ The new law gives women more information – and in my opinion, more information is usually a good thing.

Scripts: Why do some people have dense breast tissue?

O’Connell: We’re not sure why some people have dense breasts. You can’t tell from the outside. In other words, it’s not related to a person’s size, age, or any other characteristic. We do know that density tends to ebb slightly with age (50s and post-menopause) – but only a mammogram can give us that information.

Scripts: Why is dense breast tissue a health hazard?

O’Connell: It’s a problem for two main reasons. First and foremost, small cancers can hide more easily in dense tissue. And simply having dense breasts slightly increases the risk of cancer.

The latter issue, however, is still being investigated and the risk is slight. In general we still have many questions about the impact of breast density on breast health. But from a practical standpoint as a radiologist who reviews thousands of films a year, I can say with certainty that detecting breast cancer in dense tissue is more difficult. A cancerous mass appears white and can be obscured by the white dense breast tissue and the spidery-looking fibrous glands surrounding it.

Scripts: Can you explain how the new law works — and why it’s important?

O’Connell: When a woman gets a routine, screening mammogram and we find no problems – other than dense breast tissue – she’ll receive a letter in a few days notifying her that her tissue is dense. The law’s intention is to boost awareness, not necessarily to prompt more testing. At that point, most healthy women with few or no risk factors for cancer will choose to do nothing. Radiologists are not required to make any recommendations on testing, either.

However, if you get one of those letters, we’re urging women to talk to their primary care physician or ob/gyn about their personal risk for breast cancer. Discuss family history, start of menstruation and early menopause (an early start and late finish are both risk factors), childbirth (if you’re older with your first pregnancy, that’s also a risk factor), and lifestyle habits such as overeating and excessive drinking. Based on an assessment of your personal risk for breast cancer, coupled with your dense breasts, your physician may recommend supplemental testing with a screening ultrasound or an MRI.

But this isn’t a simple decision, or a perfect solution. Sometimes an ultrasound opens a Pandora’s Box. Plus, additional testing takes time and money. The law doesn’t require insurance to cover screening breast ultrasounds, but most insurers have indicated they’ll pay for it with a physician’s referral.

Scripts: By ‘Pandora’s Box,’ you must mean that more information will cause needless worry for some women, correct?

O’Connell:  Yes. The main drawback is that the more ultrasounds we do, the greater likelihood of finding small, solid masses that need to be biopsied and followed up.  More than 90 percent of the time they will turn out to be benign. But an ultrasound provides a different view of the breast tissue, and studies show that ultrasounds will detect about three more cancers per thousand patients with an otherwise normal mammogram. And when cancer is detected earlier, it’s often more treatable. So, I like to say: “A little worry is better than a little cancer.”

Avice O’Connell, M.D., has practiced radiology for over 30 years in Rochester, New York. To contact Dr. O’Connell or to make an appointment at University Breast Imaging, please call 585-334-5519. Locations include 500 Red Creek Drive, Suite 130, in Henrietta; and Highland Breast Imaging at Highland Hospital, 1000 South Ave., Rochester

To learn more about good breast health and protective breast screening exams, watch Dr. O’Connell in this video clip, produced by URMC-based Peri-FACTS Academy, a multimedia continuing education program for OB/GYN healthcare providers.

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Gotta Go? Women of Every Age Can Improve Bladder Health

While there’s no shortage of advertisements touting products for “leaky pipes,” many women hesitate to broach the topic of bladder problems with their doctors. Some may dismiss the issue, believing that it’s a normal part of aging.

Certainly, urologists can tackle some of the issues women face, but the proximity of a woman’s bladder and urinary tract to her reproductive organs can complicate issues. Urogynecologists — specially trained physicians with expertise in both gynecology and urology — may be best equipped to address issues unique to women’s bladder health.

We sat down to discuss bladder health issues specific to women with urogynecologist Gunhilde Buchsbaum, M.D., who is hosting a free educational event for women on Nov. 14, “Maintaining Your Bladder Health.” (Please click here for details.)

Scripts:  When women think of the term “bladder health” they probably think mostly about incontinence. Are there other related issues they should be concerned about?

Buchsbaum:  Besides the common concern of incontinence, many women experience urinary tract infections, problems with frequent urination, and even bedwetting. Other concerns include painful bladder syndrome, bacterial cystitis, and bladder cancer.

It’s important for women to be aware of these problems, and to know they aren’t alone in facing them. So many women suffer in silence, either embarrassed by the problem or believing nothing can be done for it. In reality, there are many tools for evaluating and treating bladder problems, as well as steps women can take on their own to improve bladder health.

Scripts: What are some symptoms that might signal bladder problems?

Buchsbaum:  There are many things women can look for, some of which they might write off as normal, but may be worth investigating. Take urine leakage. It’s a common complaint of women. If you have this problem, you should tell your doctor. Don’t assume it’s something you just have to live with; there are many things that can be done to address it. Frequent or painful urination is another fairly common symptom, which may be a sign of infection or urethral stricture.

Other signs include blood in urine, which can indicate infection, kidney or bladder stones, or, in some cases, even bladder cancer. Without exception, if you find blood in your urine, you should consult your doctor. While it doesn’t necessarily mean there is a serious problem, if there is one, catching it early can make a big difference in identifying and treating a problem.

Scripts:  Issues with incontinence and that “gotta go” feeling seem so prevalent now. TV ads tout medications for it and women often crack jokes about it. Is it a normal part of a woman’s aging, especially if the woman has gone through childbirth? And is there really anything you can do to avoid it, or to treat it?

Buchsbaum: While it’s true that urinary incontinence becomes more common with age, it’s not a normal part of aging. There are steps women can take to help prevent it. These include doing pelvic floor exercises (think Kegel’s exercises); avoiding consumption of bladder irritants like caffeine, alcohol, and artificial sweeteners; and developing habits that will help with the urge to go to the bathroom.

When necessary, there are various treatment options depending on the type of incontinence and of the needs of the woman. For instance, stress incontinence – which occurs commonly with exercise, coughing, sneezing, or laughing – may be corrected with pelvic floor exercises, insertion of a device called a pessary to help control leakage, or surgical intervention.  Urge incontinence – a sudden and/or strong urge to urinate – can be treated with behavioral changes and, in some cases, medication or nerve stimulation techniques. Overflow incontinence – also known as urinary retention, when bladder is unable to fully empty – is usually treated with self-catheterization or, in certain cases, surgical intervention.

The bottom line is that there are very effective treatment options. Just ask.

Scripts:  What should women in their 20s know that might help them in their 30s, 40s and beyond? And if a woman is 50+, is it too late?

Buchsbaum: It is never too early and rarely too late for starting good bladder habits. Developing strong pelvic floor muscles (again, by performing Kegel’s excercises) is key for addressing stress and urge incontinence at all ages, but it’s best to start young, especially for women in childbearing years.  Limiting caffeine in your diet is a smart habit at any age.

Also, it is helpful for women to recognize symptoms of urinary tract infections (bladder) infections. These may vary from person to person and become less obvious in elderly women. For example, a young woman usually has the classic symptoms: urgency, frequency, and pain with urinating. An older woman may notice fatigue, confusion, low backache, or perhaps an increase in urinary incontinence. Women of all ages should know that incontinence is not normal.  Bladder leakage can get worse if not treated.

Scripts: What one thing do you recommend that a woman asks her doctor at her annual checkup with her primary care physician or gynecologist?

Buchsbaum: All women should ask about Kegel’s exercises, why they are important, and how to do them properly. They are perhaps the simplest step a woman can take to maintaining her bladder health.

Gunhilde Buchsbaum is a professor Obstetrics and Gynecology, professor of Urology, and director of urogynecology at URMC. She founded and directs the Pelvic Health and Continence Specialties practice at URMC’s Women’s Health Pavilion.

Statistics Tell Story of Cancer and Aging

Quit smoking, eat a plant-based diet, exercise, and dodge environmental toxins. These are within our control in the quest to keep cancer at bay. And yet the unavoidable process of aging also makes us vulnerable – in fact, more than 50 percent of all cancers occur in people 65 and older.

Statistics shape a compelling need for doctors and scientists to focus on how aging transforms cancer care. The number of 65-year-olds who live to age 90, for example, has soared 400 percent since 1940, which explains why oncologists are seeing so many active, fit, older adults. And this population is only expected to grow, according to the U.S. Census.

Dr. Supriya Mohile, of the James P. Wilmot Cancer Center, is among the very few geriatric oncology specialists in the country. We spoke to her to learn more.

Q:  Much of cancer prevention seems to center on lifestyle choices. Can you discuss why age is actually the biggest concern?

Mohile: Absolutely. The simple fact remains that the single most important risk factor for cancer is age.  As life expectancy in the U.S. continues to rise, cancer in older adults is becoming increasingly common.  Recent data compiled by the American Cancer Society shows that 77 percent of all cancers are diagnosed in people over the age of 50.  Cancer-related deaths also occur far more often in people 65 and older.

Q:  What are some of the challenges in treating older cancer patients?

Mohile: As people age, they naturally develop co-existing conditions that make their cancer treatment more complex. We need better data on how to both manage and cure cancer in older patients.  We’re seeing very healthy people well into their 80s who’re still working, traveling, playing golf — and then they get cancer. Unfortunately, due to their advanced age, many of these patients aren’t adequately treated for their cancers. We’re trying to educate the thought-leaders in oncology of the need for hard data to address these unique situations.

Within the geriatric and oncology communities, we still don’t have standards of care for treating older patients. Yes, there are some overlaps in the (separate) care models for oncology and geriatrics. However, my colleagues and I advocate for a more collaborative approach that melds the fields and ultimately evaluates when the benefits of therapy outweigh the risks, given the underlying health status of the patient.

Q:   You have established the SOCARE (Specialized Oncology Care and Research for the Elderly) clinic, which runs at the Wilmot Cancer Center and Highland Hospital. Why did you believe it was important to have a clinic?

Mohile: My patients were my inspiration. One of the first people I treated after I arrived in Rochester had a very serious form of stomach cancer but was otherwise fit and healthy. It simply wasn’t appropriate to withhold aggressive treatment for him based solely on his age. On the other hand, if he had been faced with other significant health problems that we refer to as co-morbidities or disabilities, the likelihood of side effects from cancer treatment would’ve been greater. After carefully assessing him with tools used in both geriatrics and oncology, we decided on aggressive therapy – and now he’s living without evidence of disease and he’s back to enjoying a very active lifestyle.

SOCARE is one just three programs on the entire east coast, and one of the few in the country.  The overarching goals of the clinic are to help with decision-making for cancer treatment, as well as maintaining function and quality of life during treatment. The clinic offers a comprehensive assessment and multidisciplinary approach to older people with cancer. 

Q:  What unique services does the SOCARE clinic offer?

Mohile: We are trained to offer a complete geriatric assessment. This is a very comprehensive approach that helps us to look past a person’s chronological age. Instead, we evaluate physiological variables such as frailty, cognitive function, nutrition, psychological health, social support and other medical conditions such as heart disease or diabetes. Approximately 80 percent of our patients have co-morbidities that can influence treatment decisions.  

At the end of the complete geriatric assessment, we classify our patients into one of three “stages” of aging:  fit, vulnerable, and frail.  This system guides us in how aggressively we treat the cancer and how to predict the need for and sources of extra support during treatment.

Q: You mentioned earlier that we have few study results to inform treatment choices for older patients. So, the need for more education and research must be a priority, correct?

A:  Yes, we need to really accelerate our research. This includes enrolling elderly patients in available clinical trials and designing prospective trials specifically for the older population. We also need to promote collaboration between researchers in geriatric medicine, the biology of aging, translational research, and palliative care.

We see nuances every day that need to be addressed through research: From the seemingly fit person whose unseen medical problems might put him at risk for life-threatening toxicities, to the apparently frail person who could actually tolerate aggressive treatment. It’s critically important that oncologists learn to correctly assess elderly people. We’re proud that our studies and our educational seminars are beginning begin to fill this gap in knowledge. 

For more information about SOCARE, please call (585) 276-5652. To meet with one of our geriatric oncology specialists, call (585) 275-6124. To reach Dr. Mohile: (585) 275-5823.

 

Cancer and Fertility: Will Treatment Dash Your Parenthood Dreams?

Getting a cancer diagnosis can be heartbreaking. Learning that a life-saving treatment might dash your dream of having a family can compound that heartbreak to an indescribable degree.

Fertility specialist Dr. Wendy Vitek, who recently joined the Strong Fertility Center team, helps women understand how cancer treatment might affect their fertility. As a specialist in fertility preservation, Dr. Vitek partners with women and couples to explore their options for putting the odds of conceiving – after cancer – in their favor.

Scripts: What is fertility preservation?

Vitek: Fertility preservation helps people keep their ability to have children despite facing treatment for cancer or other medical disorders that can compromise fertility. Getting a cancer diagnosis is especially difficult for a young person. When the situation allows, it is ideal to discuss fertility preservation before starting treatment so that we can assess the fertility risk and discuss all the options for preservation. As part of a multi-disciplinary team, we work closely with a patient’s oncologist to offer counseling and treatment that consider the individual’s circumstances before and after treatment.

Scripts: Shouldn’t treating a woman’s cancer be Job #1?

Vitek: Without question, the priority should always be to treat the cancer. Still, if a woman is of childbearing age and hopes to become pregnant in the future, she should ask her oncologist about her fertility while they are planning her treatment.  In many cases, oncologists will know if the treatment will impair fertility.

Additionally, consulting a fertility preservation specialist as early as possible affords an independent assessment of the impact a woman’s cancer treatment may have on her fertility. This assessment may round out her knowledge and help a woman fully understand and explore her options.

Scripts: What does fertility preservation entail?

Vitek: In general, it involves banking embryos, eggs or tissue prior to cancer treatments. Later, after a woman is treated for cancer, we can use the tissues to achieve a pregnancy. Several options are available, with research under way to find additional methods.

Embryo banking is currently the ideal option. With this method, eggs are retrieved from the ovaries and fertilized in the lab to create embryos that are frozen. Once a woman is ready to start a family, the frozen embryos are thawed and transferred to the uterus to achieve a pregnancy. This option has the highest success rate, but may require taking medication to prepare for the egg retrieval and also requires sperm to fertilize the eggs to create embryos. This option may not be practical for women who must start cancer treatment immediately, or for women who do not have access to sperm.

Another method is egg banking, which is considered experimental by the American Society of Reproductive Medicine. Egg banking involves retrieving eggs from the ovaries, then freezing the eggs. When a woman is ready to start a family, the frozen eggs are thawed and fertilized and the embryos are transferred to the uterus. This is considered experimental because there is less information about pregnancy rates with frozen eggs, though a recent, large study found no difference in pregnancy rates when using fresh or frozen donor eggs. This option also typically involves taking fertility medication to prepare for egg retrieval, which, again, may not be practical for women who cannot delay their cancer treatment.

Scripts: You mentioned research into new methods. What’s on the horizon?

Vitek: The future holds much promise for other methods, including ovarian tissue banking. This relatively new and experimental method involves a surgical procedure to remove ovarian tissue, which is then frozen. When a woman is ready to conceive, the ovarian tissue is thawed and surgically transplanted or grafted over the ovaries. With this method, a woman would most likely require in vitro fertilization to conceive, though some cases of spontaneous pregnancies have been documented. Because it is a fairly new method, data on its success is limited. And the procedure to harvest and transplant the tissue is not without risks, as is true with any surgery.

Additionally, if a woman has a cancer that could spread to the ovary, there are concerns that transplanting the tissue could reintroduce the cancer. To avoid this concern, an alternative to transplantation would be to mature the eggs from the ovarian tissue in the lab. The mature eggs could be fertilized to produce embryos. While this technology is not currently available, research is under way that may someday make this possible.

Scripts: Are there any fertility preservation options for men?

Vitek: Fertility preservation isn’t exclusive to women and has been offered to men for many years. Sperm banking is the best way for men to preserve fertility. Additional techniques are being developed to bank testicular tissue as an option for boys who have not undergone puberty.

Scripts: Does health insurance cover fertility preservation?

Vitek: No, most health insurances do not cover fertility preservation. Dealing with the cost of fertility preservation can certainly add anxiety at a time when a woman should be focused on her health. However, the Strong Fertility Center sponsors events for raising funds to help those who seek fertility preservation services but cannot afford it.

 Wendy S. Vitek is a fellowship-trained reproductive endocrinologist. To reach her please call (585) 487-3378, or visit the Strong Fertility Center at http://www.urmc.rochester.edu/fertility-center/

 

 

 

Cancer Survivors Look to Exercise for Better Life

A morning jog, fast walking, weightlifting and other forms of exercise were off-limits for most cancer patients as recently as 15 years ago.

Fast forward to today, and the latest research suggests that exercise is not only safe for many people with cancer, but might relieve the side effects of cancer treatments—and might even improve survival.

Researcher Karen Mustian, a University of Rochester Medical Center exercise psychologist and physiologist specializing in cancer, designs and studies exercise programs specifically for patients and survivors.

We spoke with her about the evolving story of exercise and cancer.

Scripts: How has the view of exercise for cancer patients changed?

Mustian: It was not that long ago that we were very hesitant to promote exercise for people with cancer, particularly those receiving treatments. We worried they were too sick to work out, and that exercise somehow would make them worse and compromise their ability to complete their treatments and recover.

By 1999, however, almost a dozen small studies suggested exercise might be safe and helpful for cancer patients. Since then, there’s been a dramatic increase in scientific evidence supporting exercise, ranging from simple walking, weightlifting, Tai Chi, yoga and even activities as vigorous as team paddling or dragon boat racing.

Scripts: So, given the changes in thinking, how much exercise do you recommend?

Mustian: Studies have shown exercise to be helpful for a wide variety of debilitating problems. It can improve cancer-related fatigue, sleep problems, depression, anxiety, physical function, immune function and overall quality of life. Experts now suggest that cancer patients and survivors should strive to reach the recommended public health guidelines for physical activity – either moderate-intensity aerobic activity for a minimum of 30 minutes, five days a week, or vigorous-intensity aerobic activity for a minimum of 20 minutes, three days a week.

But the story is not completely done. Some people treated for cancer will need exercise programs that are modified to ensure safety and effectiveness without making cancer-related side effects or other health conditions worse. At this point, scientific evidence does not provide the detailed knowledge to allow us to write explicit exercise “prescriptions” with precise doses, modified for specific cancer-related side effects. Still, we can make broad recommendations.

Scripts: What do you advise for your patients?

Mustian: First, I ask them what they like to do. Do they prefer to be inside or outside? If they like the outdoors, I encourage them to find a physical activity they can do in each season. In Rochester, even in the winter, this might mean cross-country skiing or simply getting outside and playing in the snow. It’s really important to find something you like to do.

I also suggest they work with an exercise professional who has additional training in the unique needs of people treated for cancer. I also encourage them to speak with their oncologist and ask if there are special limitations that they need to consider.

Some cancer patients come through my lab, asking about the amount of exercise they have to do to get rid of their fatigue. Unfortunately, there is no “dose” of exercise specifically designed to reduce fatigue. So, my staff tailors the exercise prescription to each individual, taking into account the baseline level of physical fitness, unique limitations and preferences, along with their goals and whether they’re interested in achieving improvements in mental health, physical health, or some combination.

It’s important to give people a range of options. Cancer patients and survivors have a lot of obligations to manage — jobs, family, and treatments. Asking them simply to add 30 minutes of exercise a day is not always practical or even necessary to achieve significant reductions in cancer-related side effects. For instance, if one person’s main goal is to lift depression or anxiety or fatigue, and they might be able to achieve that with as little as 10 minutes of exercise a day.

Scripts: Do we know exactly how exercise helps cancer patients?

Mustian: It is difficult to say.  To begin with, we don’t know precisely what causes the many side effects of cancer in the first place. We know cancer-related fatigue, neuropathies and cognitive impairments are real, but we can’t articulate a specific cause. We think they are linked to the disease and treatments. We also can’t describe exactly how exercise — either through biological or psychological mechanisms — alleviates these side effects.

It is likely exercise works because it’s what we call a “multi-targeted, multi- system” intervention. Just think: When you do something simple, like standing up from your chair and walking across the room, you activate your entire body from the cellular to the whole organ level, triggering multiple systems, including your muscles, heart, lungs, brain, immune system and more.

Scripts: Your research has shown that yoga can improve sleep and quality of life for cancer survivors. Is that the best exercise?

Mustian: Yoga is a wonderful exercise, but it’s not for everyone. Some people simply don’t enjoy it. For those who do, it helps to reduce several side effects associated with cancer and its treatments. Remember, while some yoga is “gentle,” that does not mean it is easy.

My study and others have shown that yoga works best for cancer patients when it integrates breathing exercises, mindfulness and meditative exercises, and imagery components with yoga postures. Collectively, those components seem to make yoga enjoyable. They’re also what probably make yoga successful.

Again, the people I see in my research studies are interested in living longer, but they also emphasize they want their quality of life to be high. They are not so much looking to exercise to gain extra years, even though they suspect it may help with this, but they are interested in using it to help them maintain their functional independence so they can participate fully in all they want to do. I think that is what most of us, even those of us lucky enough not to have experienced cancer, want for ourselves.

Karen Mustian directs the Physical Exercise Activity Kinesiology Clinical Research Core Laboratory, or PEAK Lab, at the Medical Center. For more information or to contact her, call 585-273-1796 or visit: http://www.urmc.rochester.edu/physiology-exercise-lab/index.cfm

 

Hashing Out the PSA Test: Alleviate Worry by Getting the Facts

Prostate cancer is by far the most commonly diagnosed cancer among men, tallying about 230,000 cases each year. But never has the disease topped headlines like it has in the recent months.

You can chalk it up to a controversial debate within the medical community, revolving around new screening recommendations made by the United States Preventive Services Task Force last year, and re-affirmed just last month: That healthy men shouldn’t get prostate-specific antigen (PSA) tests. The panel said resulting diagnoses might lead to an over-treatment of prostate tumors – many of which are slow-growing and not likely to ever cause serious problems.

But many experts – including URMC urologist Dr. Edward Messing,  who serves as president of the Society of Urologic Oncologists – strongly disagree, seeing PSA testing as a life-saving measure, and warning that fewer screenings could result in more deaths down the road.

We spoke to Dr. Messing to learn more.

Scripts: Let’s back up, and talk about some symptoms men should be aware of.

Messing: With prostate cancer (or, simply with an enlarged prostate), men mainly notice urinary symptoms. Your stream is less forceful than it was once, or you feel that you are not emptying your bladder as well, and because of that you’re urinating more often. You begin to search for bathrooms when you never really cared about them before, or you begin to stop drives on the freeway earlier so you don’t get into trouble. Maybe you wake up at night because of the need to urinate.

Scripts: Why do you (and so many fellow clinicians) disagree with the government panel’s recommendations?

Messing: The panel based its recommendations on what many consider to be a flawed study. We disagree with the basic premise that there is harm from routine screening. See, the panel equates the side effects of some treatments (impotence, incontinence, infections, and even death) with screening-induced diagnostic biopsies, which isn’t appropriate; in fact, many men diagnosed with indolent, slow-growing cancers now undergo expectant management (the “watch and wait” approach) and don’t ever receive active therapy. The panel is looking at only one side of the debate, and it references older studies.

Globally, the newest studies related to PSA testing actually support its use. The largest and best study – the European Study of Screening for Prostate Cancer – showed a more than 20 percent reduction in prostate cancer deaths for men who underwent routine screening with the PSA test, compared to men in a control group who didn’t undergo such screening. And according to our research at URMC, which will soon publish nationally, eliminating the use of PSA as a diagnostic test could increase the number of men diagnosed with incurable, distant metastatic disease three-fold.

Scripts: That’s a dramatic finding. Clearly, you think screening is pretty important?

Messing: Yes. The bottom line is that prostate cancer remains a major health problem, and much of the improvement in prostate cancer death rates is due to the combination of PSA-based early detection and aggressive therapy. In the U.S. alone, over the past 20 years of PSA-based screening, prostate cancer mortality rates have dropped nearly 40 percent, and that’s without any substantial changes in how men with prostate cancer were treated (e.g., surgery and radiation therapy). Models have suggested more than half of this reduction can be attributed to early detection.

Many physicians and researchers also are deeply concerned that the panel’s recommendations may actually harm many men. Research conducted by my colleague, Dr. Guan Wu, suggests that contrary to common belief, men 75 and older are diagnosed with late-stage and more aggressive prostate cancer, and thus die from the disease more often than younger men. Several of our urologists at URMC have observed that many otherwise healthy older men are presenting with very advanced disease at diagnosis, and reporting that they had never had a PSA test. There are some who argue that older men wouldn’t benefit much from early detection because of their shorter remaining life expectancy. We contend that overall health, more than age, impacts life expectancy following a cancer diagnosis. More studies are needed to identify ways to manage the disease in older patients.

Scripts: But, is an elevated PSA necessarily a sign of cancer?

Messing: Not necessarily. As men age, the prostate gland grows. Men who are older will have a higher baseline PSA, simply because their prostate is bigger.

Some disease processes also raise PSA levels, including inflammation or infection, and even benign or non-cancerous enlargement — common in almost the entire middle-aged and elderly male population – will boost PSA to some degree as well.

Scripts: One of the biggest fears of men diagnosed with prostate cancer is that treatment always causes impotence or incontinence. Is this true?

Messing: While erectile dysfunction and urinary incontinence certainly are possibilities following surgery or radiation therapy for prostate cancer, not all men experience these complications.

Half of men who receive treatment for prostate cancer will experience some impotence (problems with potency), albeit temporarily. However, other men have few or no problems. (Specifically, treatment for prostate cancer may cause erectile dysfunction – impotence – in men because of the effects of surgery or radiation on the nerves and blood vessels that control erections; but hormone shots also can cause impotence by drastically lowering sex drive).

Fortunately, today’s surgery and treatment options have substantially increased the chances for an eventual return to normal urinary and erectile function. When detected early, most patients are candidates for nerve-sparing radical prostatectomies, and the vast majority of these patients see a full return of urinary continence after a recovery period. Most also regain potency, although there’s no guarantee.

Scripts: Is active surveillance, without any active treatment, an option for those with prostate cancer?

Messing: Even with the best of our abilities, there’s a general tendency to – and I don’t want to use this term pejoratively – over treat. Most of us — physicians, patients and, quite frankly, patients’ families, especially their wives – lean towards wanting to treat the disease even when we’re not really sure it will amount to a real problem.

But in the past five or six years, we see the trend starting to reverse; it’s become much more accepted by patients, families and treating doctors to just monitor patients, following them carefully. We typically re-biopsy the prostate at various intervals – usually every few years – and if we only find a small, non-aggressive prostate cancer, we keep on monitoring. As far as we can tell, if you follow all the rules, many of these people will avoid ever needing treatment.

Of course, the best approach to care for prostate cancer begins with a thorough and thoughtful discussion with your physician.

Dr. Messing serves as chief of Urology at URMC. To learn more about URMC’s Department of Urology, patients and families can call (585) 275-2838, or visit: http://www.urmc.rochester.edu/urology/.