Breast Cancer Patients

September 29, 2011 (Stockholm, Sweden) — Tumor hormone-receptor and HER2 status can change in breast cancer patients during the course of their disease. Because these changes can significantly influence survival and can completely change the patient's clinical management, these patients should undergo regular biopsies, according to a new study.
The results of that study, presented here at the 2011 European Multidisciplinary Cancer Congress (EMCC), showed that there is substantial tumor instability during tumor progression.
"For example, we saw that 1 in 3 breast cancer patients alter estrogen or progesterone hormone-receptor status, and 15% of patients change human epidermal growth-factor receptor 2, or HER2, status during the course of disease," explained lead author Linda Lindström, PhD, a postdoctoral fellow from the Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.
Estrogen-receptor (ER) status, which was assessed in the primary tumor and after the first relapse, showed a change in 32.4% of patients. Similar results were observed for progesterone-receptor (PR) status, and tumor changes were noted 40.7% of patients.
The researchers observed a change in HER2 status from the primary tumor to the first relapse in 14.5% of patients.
These data emphasize the importance of regular biopsies in patients who relapse, she told Medscape Medical News.
A similar pattern was seen in patients who experienced multiple consecutive relapses. In this group, ER, PR, and HER2 status changed in 33.6%, 30.2%, and 15.7% of patients, respectively.
Building on Evidence
Several recent small studies have suggested that the HER2 and hormone-receptor status of the relapsed tumor can be different than the status of the original lesion. In such cases, treatment options that were effective in the primary cancer might not be optimal for the relapsed/metastatic disease.
A study presented at the 2008 annual meeting of the American Society of Clinical Oncology, as previously reported by Medscape Medical News, showed that 45 of 160 samples (11%) exhibited changes in receptor status. Of this group, 11 (7%) were local recurrences and 34 (21%) were regional or distant relapses.
Findings published in the Annals of Oncology (2010; 21:1254-1261) showed a much higher proportion of changes in these key receptors than has been previously reported. In that study, differences between nodal tumor tissue and primary breast cancer was seen in 46.9% of the patients with metastatic disease. In addition, many of the differences in expression between the primary tumor and the node were "large-magnitude (>5-fold) changes," those researchers noted.
Multiple Changes Seen

Dr. Linda Lindström

Dr. Lindström explained that her team conducted the first sizeable study to look at changes in tumors in multiple relapses in breast cancer patients, analyzing data on nearly 500 women. "Our aim was to assess ER, PR, and HER2 status throughout tumor progression, and specifically to understand how they change in relapsed disease."
The researchers evaluated breast cancer patients in the Stockholm healthcare region who experienced a disease recurrence from January 1, 1997 to December 31, 2007.
In 459, 430, and 104 patients, ER, PR, and HER2 status, respectively, was assessed in the primary tumor and after first relapse. Information on ER, PR, and HER2 status in multiple consecutive relapses was evaluated in 119, 116, and 32 patients, respectively.
ER status changed in almost 34% of a cohort of 119 women, and between the different sites of relapse (local, loco-regional, and metastases). ER-positive status remained stable in 36.1% of patients, and ER-negative status remained stable in 30.3%. However, ER status changed from positive to negative in 16.0% during the course of their disease, changed from negative to positive in 12.6%, and alternated between positive and negative in 5%.
"In the clinical setting, the implication of estrogen-receptor instability is important," said Dr. Lindström. "The loss of estrogen receptor generally means resistance to hormonal therapy; these patients would benefit from a change in therapy."
"An estrogen-receptor gain would introduce an additional choice of therapy, which in some patients could lead to tumor response and improved survival in the metastatic setting," she explained.
Changes in receptor status appeared to adversely affect outcome, Dr. Lindström pointed out. Women with ER-positive primary tumors that switched to ER-negative status had an approximately 2-fold increased risk of dying, compared with those with stable ER-positive tumors.
The data suggest that hormonal therapy promotes changes in ER status during disease progression. The researchers stratified the intrapatient ER status in primary tumor and relapse according to the treatment they received: none, adjuvant hormonal therapy or chemotherapy, or a combination of both. One third of patients who received hormonal therapy lost ER expression when their disease relapsed, whereas only 1 of 10 untreated patients experienced altered ER status.
In addition, only a few patients who gained ER had received hormonal therapy. Conversely, in the those who received chemotherapy alone or no treatment, the proportion who gained ER status was 3 times greater.
Need to Do Biopsies
The technology is moving forward, and "we really need to do biopsies and stratification," said Anne-Lise Børresen-Dale, PhD, cochair of the EMCC scientific program and moderator of the press briefing where the findings were presented. "We need to do this to correctly treat our patients."
Rob Coleman, MBBS, MD, professor of medical oncology at the University of Sheffield, United Kingdom, noted that in the United Kingdom, "not been enough biopsies were done."
"But there is an increasing uptake of biopsies," said Dr. Coleman, who was not involved with the study. "We are moving in that direction."
2011 European Multidisciplinary Cancer Congress (EMCC): Abstract 5024. Presented September 25, 2011.

Breast Cancer Lumps

Eight out of 10 lumps that women may feel in their breasts are benign (not cancerous). A benign lump can be a collection of normal or hyperactive breast gland cells, or it may be a water-filled sac (cyst).
In any event, if you feel a lump and you're worried about it, DON'T HESITATE TO SEE A DOCTOR. By getting a doctor to check the lump you'll ease your fears. And if it's something serious, you can start getting treatment right away.
One way to make lumps less frightening is to get to know what your breasts normally feel like. There's no better way to find out than by doing your monthly breast self-exam. The upper, outer area—near your armpit—tends to have the most prominent lumps and bumps. The lower half of your breast can feel like a sandy or pebbly beach. The area under the nipple can feel like a collection of large grains. Another part might feel like a lumpy bowl of oatmeal.
If you notice any changes in your breasts that last over a full month's cycle or that seem to get worse or more obvious over time, tell your doctor. Knowing how your breasts usually look and feel may also help you avoid needless biopsies.
If you're worried about getting breast cancer, read about breast cancer risk factors to find out what your risk is.

Breast Cancer Diet

While a diet emphasizing vegetables and fruit and de-emphasizing alcohol, red meat and omega-3 fats may reduce the likelihood of breast cancer or recurrence compared to the typical U.S. diet, simply following these rules will not maximize the chemopreventive potential of your diet. Tailoring your diet to your individual circumstances and breast cancer subtype will increase the diet's potential benefits. This web page is designed to enable you to customize your diet using the information in the Food for Breast Cancer web site. The overall goal is to bathe your normal cells with nutrients that promote healthy growth and cell division. Any new breast cancer cells that do arise are to find themselves in an environment that promotes their death and inhibits their proliferation and migration.

A word about enjoying your food, food variety, and supplements

Before outlining a strategy to develop a customized diet, we would like to say a few words about food and supplements. It is important to enjoy your food because what you eat and drink counts. The idea is to replace the elements of your current diet that promote breast cancer (see foods to avoid) with foods that prevent it (recommended foods) or are neutral. Adding beneficial foods to an unhealthy diet is not likely to make as much difference as an overhaul of your diet which substantially eliminates harmful foods. This can only happen if you enjoy what you eat. For example, if you do not like broccoli, do not eat it. But maybe you might enjoy broccoli sprouts, kale or watercress, which have many of the same chemopreventive characteristics.

Several studies have found that consuming a wide variety of foods is more beneficial in preventing breast cancer than consuming a limited selection. There are synergistic actions between foods, most of which may remain to be discovered. For example, the combination of mushrooms and green tea appears to be more chemopreventive than consuming either alone. Also, simultaneously consuming olive oil and orange vegetables increases the bioavailability of the beta-carotene in the vegetables.

Vitamins and supplements can make sense for deficiency states. For example, it appears to be difficult for most of us to get enough vitamin D through exposure to sunshine and in the diet. Adequate vitamin D is important for breast cancer chemoprevention. Supplementation with vitamin D has been found to be safe at dosages required to bring most women up to optimal levels. Similarly, taking fish oil could benefit those who wish to increase their ratio of omega-3 to omega-6 fats, although note that taking fish oil is not recommended during chemotherapy.

However, it has been found that cancer can be promoted by large doses of some compounds that are chemopreventive when consumed in foods. Famous examples are vitamin A and vitamin C. Coenzyme Q10 (CoQ10) may be another example. This is one reason why we tend to de-emphasize supplements. Often there is a U-shaped curve in which both low and high levels of a given micronutrient promotes cancer and we simply do not have enough information to determine the dosage that aligns with the cancer-preventive sweet spot at the bottom of the curve. It is not that we do not understand the attraction of genistein, DIM, ellagic acid, resveratrol, etc. However, based on the available evidence, consuming micronutrients in pill form whose safety and effective dosage have not been established is as likely to be harmful as helpful. Nor do we believe that diet alone is able to effectively treat breast cancer (please see our articles on food as cancer cure and the raw food diet).

How to design your anti-cancer diet

Your diet should depend on whether you are at high risk for breast cancer (but not diagnosed with the disease), in active treatment, or a breast cancer survivor. Each of these situations is addressed below.

High risk, but not diagnosed with breast cancer

Women at high risk for breast cancer should use the recommended, avoid and alphabetical food lists to select their foods. The goal is to consume a wide variety of chemopreventive foods while limiting cancer-promoting foods such as processed meat. While many breast cancer risk factors (such as early puberty or being tall) cannot be influenced by diet in adulthood, some risk factors can be. The links below are to web pages that provide detailed information and food lists for some high-risk circumstances:

Symptoms and Diagnosis

Breast cancer symptoms vary widely — from lumps to swelling to skin changes — and many breast cancers have no obvious symptoms at all. Symptoms that are similar to those of breast cancer may be the result of non-cancerous conditions like infection or a cyst.
Breast self-exam should be part of your monthly health care routine, and you should visit your doctor if you experience breast changes. If you're over 40 or at a high risk for the disease, you should also have an annual mammogram and physical exam by a doctor. The earlier breast cancer is found and diagnosed, the better your chances of beating it.
The actual process of diagnosis can take weeks and involve many different kinds of tests. Waiting for results can feel like a lifetime. The uncertainty stinks. But once you understand your own unique “big picture,” you can make better decisions. You and your doctors can formulate a treatment plan tailored just for you.
In the following pages of the Symptoms and Diagnosis section, you can learn about:

Understanding Breast Cancer

How breast cancer happens, how it progresses, the stages, and a look at risk factors.

Screening and Testing

The tests used for screening, diagnosis, and monitoring, including mammograms, ultrasound, MRI, CAT scans, PET scans, and more.

Types of Breast Cancer

The different types of breast cancer, including ductal carcinoma in situ (DCIS), invasive ductal carcinoma (IDC), invasive lobular carcinoma (ILC), inflammatory breast cancer, male breast cancer, recurrent breast cancer, metastatic breast cancer, and more.

Your Diagnosis

The characteristics of the cancer -- featured on your pathology report -- that might affect your treatment plan, including size, stage, lymph node status, hormone receptor status, and more.

IMPORTANT FACTS YOU SHOULD KNOW

HEALTHY BREASTS  
Firstly, and most importantly, you need to understand that every change and every lump found in your breasts does not mean you have Breast Cancer, especially as your breasts are growing and changing, they'll have lumps and bumps anyway.
IMPORTANT FACTS YOU SHOULD KNOW

• On average, the final stage of puberty is around 15 years of age and at this time, you are physically an adult.
  
  
• In your late teens and early twenties you have more lumps, bumps and pain in your breasts that seem to come about just because your body is growing.
  
  
• Lumps can form in your breasts due to hormonal changes during your period cycle and they usually go away at the end of that time of the month.
  
  
• In your late teens and early twenties you sometimes can have round rubbery types of tumors called Fibroadenomas and these are not cancerous.

Sociological factors with breastfeeding

Researchers have found several social factors that correlate with differences in initiation, frequency, and duration of breastfeeding practices of mothers. Race, ethnic differences and socioeconomic status and other factors have been shown to affect a mother’s choice whether or not to breastfeed and how long she breastfeeds her child.

• Race and culture Singh et al. also found that African American women are less likely than white women of similar socioeconomic status to breastfeed and Hispanic women are more likely to breastfeed. The Center of Disease Control used information from the National Immunization Survey to determine the proportion of Caucasian and African American children that were ever breast fed. They found that 71.5% of Caucasians had breastfed their child while only 50.1% of African Americans had. At six months of age this fell to 53.9% of Caucasian mothers and 43.2% of African American mothers who were still breastfeeding.
• Income Deborah L. Dee's research found that women and children who qualify for WIC, Special Supplemental Nutrition Program for Women, Infants, and Children were among those who were least likely to initiate breastfeeding. Income level can also contribute to women discontinuing breastfeeding early. More highly educated women are more likely to have access to information regarding difficulties with breastfeeding, allowing them to continue breastfeeding through difficulty rather than weaning early. Women in higher status jobs are more likely to have access to a lactation room and suffer less social stigma from having to breastfeed or express breastmilk at work. In addition, women who are unable to take an extended leave from work following the birth of their child are less likely to continue breastfeeding when they return to work. Low income women are more likely to have unintended pregnancies,and women who's pregnancies are unintended are less likely to breast feed their babies.
• Other factors Other factors they found to have an effect on breastfeeding are “household composition, metropolitan/non-metropolitan residence, parental education, household income or poverty status, neighborhood safety, familial support, maternal physical activity, and household smoking status.”

History of breastfeeding

Before the 20th century, breastfeeding was the main way of feeding babies. If for any reason the natural mother was unable to breastfeed, a wet nurse was used. Attempts were made in 15th century Europe to use cow or goat milk, but these attempts were not successful. In the 18th century, flour or cereal mixed with broth were introduced as substitutes for breastfeeding, but this did not have a favorable outcome, either. True commercial infant formulas appeared on the market in the mid 19th century but their use did not become widespread until after WWII. As the superior qualities of breast milk became better-established in medical literature, breastfeeding rates have increased and countries have enacted measures to protect the rights of infants and mothers to breastfeed.