Sunday, November 27, 2011

Alcohol and Breast Cancer: November News and Research

This month, there's been a lot of buzz (forgive the pun) about alcohol use and breast cancer. As the holidays approach, we thought it might be a good time to share the latest news and research. Links may be found on the alcoholic beverages page of our website.

The JAMA study: Even moderate drinking increases risk

The big story this month was a November 1 JAMA (Journal of the American Medical Association) study which followed over 100,000 nurses for almost 30 years. The New York Times, Los Angeles Times and Reuters covered the study.

According to the study, "Low levels of alcohol consumption were associated with a small increase in breast cancer risk." Greater consumption was associated with greater risk. The "most consistent measure" of risk was "cumulative alcohol intake throughout adult life."

The media attempted to sort out the details and put the findings in perspective.

All sources reported that moderate consumption (three to six drinks a week) was associated with a 15% increased risk. For women with a lifetime risk of 12%, three to six drinks a week would correlate with a 13.8% risk.

According to Reuters, the 10-year risk would be 2.8% for abstainers, 3.3% for three to six drinks a week and 3.5% for up to 13 drinks a week.

The Los Angeles Times further explained that women who consumed at least two drinks a day were 51% more likely to develop breast cancer than those who did not drink at all. Binge drinking (six or more drinks in one sitting) increased risk regardless of total consumption. Alcohol use between the ages of 18 and 40 was associated with increased risk, regardless of alcohol use after 40.

The New York Times highlighted some of the study limitations. First, the increase in risk associated with three to six drinks a week was "modest", and "for many women may not be enough to outweigh the heart-healthy benefits of drinking in moderation." Plus, "the new study was observational and lacked a control group, and it drew from self-reports, which can be unreliable."

The Los Angeles Times revisited the study and the balance between breast cancer risk and heart disease in a November 21 piece, "Women, the occasional drink, breast cancer and heart disease." In balancing the risks and benefits of drinking, the story was careful to note that any benefits associated with alcohol consumption relate to moderate, not heavy drinking.

The CANCER study: Alcohol and girls with a family history

Adults aren't the only ones who drink alcohol. How does adolescent alcohol consumption affect breast cancer risk?

A November 14 study in the journal Cancer examined the risk of benign breast disease, a "well-documented" breast cancer risk factor, among young women. A EurekAlert! press release covered the details.

The participants, aged 9 to 15 at the start of the study in 1996, completed periodic questionnaires until 2007 about family history of breast cancer and benign breast disease, alcohol use, height and weight.

The study found that young women with a family history of breast cancer or maternal history of benign breast disease had an increased risk of developing benign breast disease. Consuming seven alcoholic drinks a week doubled that already increased risk. The authors concluded, "Adolescents with family history may reduce their risk by avoiding alcohol."

Interestingly, among girls with no family history, the risk of benign breast disease was associated with other factors, such as weight, waist size and adult height. The authors note that this may possibly reflect different causes of breast cancer.

Alcoholics more likely to die of cancer

The JAMA study above addressed moderate alcohol use. On the other extreme, a November 15 US News and World Report/HealthDay story covered an Italian study of 2,300 alcoholics in Florence.

Compared to the general population, alcoholics were more likely to die from oral cancers, liver cancer, pancreatic cancer and breast cancer. They were also more likely to die from infections, diabetes, other diseases and violent crimes. Female alcoholics had higher survival rates than males, "possibly because women are more likely to get help for alcoholism."

The study author noted that the increased risk of death may be due to the effects of alcohol on human organs and lifestyle factors such as smoking, drug abuse, promiscuity and poor diet.

At, we follow breast cancer news and research daily. New studies and media stories are added to our website and database, sorted by topic. Topics include imaging, diagnostic testing, chemotherapy, radiation, targeted drugs, surgeries, complementary therapies and lifestyle options, such as alcohol use. We highlight the latest developments in this blog. However, topics may be explored on our website anytime. Simply click the Treatments tab to get started.

Our goal is to make internet research easy. Please stay tuned!

Wednesday, November 16, 2011

TRAM Flap and DIEP Flap Breast Reconstruction: The Latest Research on Side Effects and Complications

There are several options for breast reconstruction after a mastectomy. Some, such as the TRAM (transverse rectus abdominis myocutaneous) Flap and DIEP (deep inferior epigastric perforator) Flap procedures, use tissue from the abdomen to reconstruct the breast.

How does this affect the abdominal region? Are there any other potential complications?

A couple of recent studies and several recent news items have addressed the potential side effects and complications of TRAM Flap and DIEP Flap reconstruction. Links may be found on the TRAM Flap or DIEP Flap page of our website.

Potential abdominal side effects of TRAM Flap with muscle removal

Traditional TRAM Flap procedures remove a section of abdominal muscle. For some women, this may cause abdominal weakness and pain. On November 9, a CBS News affiliate in Minnesota published a video and story about two young mothers who suffer with abdominal pain and weakness after TRAM Flap procedures.

Dr. David Ruebeck, a plastic surgeon who was interviewed for the story, said that extreme side effects, such as those experienced by the women in the story are rare, but can happen. He noted that the benefits, such as a natural reconstruction from your own tissue and related tummy flattening, sound "really good," but have "some tradeoffs and some risks women have to be aware of."

He said it usually takes about a month to recover from a TRAM Flap procedure.

“The worst case scenario would be a situation where weakness or pain or bulging becomes a daily problem. A disability keeps a person from working or exercising the way they like of effecting posture or other comfort,” Dr. Ruebeck said. “That’s quite unusual. There’s not much that can be done about it.”
Potential abdominal side effects of muscle-sparing TRAM Flap and DIEP Flap

Whereas the original TRAM Flap procedure involves the removal of abdominal muscle, newer procedures, such as muscle-sparing TRAM Flap and the DIEP Flap surgeries attempt to spare the abdominal muscles. Even with these newer procedures, the risk of abdominal pain and weakness remains.

An October 21 study in the journal Cancer evaluated the quality of life of patients after muscle-sparing TRAM Flap and DIEP Flap procedures. Several media sources, such as US News and World Report/HealthDay, Medical News Today and the Canadian National Post covered the study.

On the positive side, the study found that gains in breast satisfaction, psychosocial and sexual well being were "clinically meaningful" as early as three weeks after surgery.

However, the authors noted that "these gains are accompanied by significant deterioration in physical well being of the abdominal donor site."

According to the National Post story, Dr. Toni Zhong, the study's lead author, "was surprised to find that even . . . in the most careful attempts to remove tissue without disturbing muscle, patients sometimes experienced muscle weakness or a bulge that persisted even three months after surgery."

She noted that the abdominal effects did not render the patients bed-ridden or inhibit everyday activities. She said, "“Some people are happy to put up with it and say it’s the price that I paid in order to have such a great breast reconstruction.” But "it can be a problem" for active women who notice the loss of muscle strength.

The study of 51 women collected satisfaction data up to three months post surgery. Dr. Zhong plans to evaluate abdominal function at six months and one year post surgery.

Tamoxifen use may cause complications in microvascular flap procedures

In a microvascular flap reconstruction, blood vessels and veins are cut and reattached using microsurgical techniques. The DIEP Flap procedure and a type of TRAM procedure called the TRAM Free Flap are microvascular procedures.

As with any surgery, microvascular flap procedures carry a risk of complications, such as ultimate flap loss.

An October 7 study from MD Anderson in Plastic and Reconstructive Surgery found that tamoxifen use "may increase the risk of microvascular flap complications." In the study, patients on tamoxifen has a "significantly increased rate of immediate total flap loss . . . and a lower rate of flap salvage. . ." The authors concluded that, "Surgeons should consider temporarily stopping the drug 28-days before microsurgical breast reconstruction."

These are only the most recent studies on TRAM Flap and DIEP Flap breast reconstruction. For two years of news and research, plus information on other reconstruction procedures, please visit our website. From the home page, click the treatments tab to explore the surgery section of our website.

Wednesday, November 2, 2011

Oncotype DX for Breast Cancer: October News and Research

The Oncotype DX Breast Cancer Assay has been the subject of several recent studies. Topics include how the Oncotype DX compares to and affects doctor assessment of risk, how it compares to other markers and how well it quantifies HER2 status. Today we'll highlight the seven most recent studies. Links may be found on the Oncotype DX page of our website.

A little background

The Oncotype DX Breast Cancer Assay is a test used to assess the risk of breast cancer recurrence in women with early-stage, estrogen-receptor positive, node-negative tumors. The Recurrence Score, which is calculated based on the expression of 21 genes, may help with the decision on whether to pursue chemotherapy. For example, patients with a very low risk of recurrence may decide that the small potential benefit from chemotherapy may not be worth the risk of side effects.

In addition to the Recurrence Score, the Oncotype DX report includes quantitative scores that reflect estrogen receptor (ER), progesterone receptor (PR) and Human Epidermal Growth Factor Receptor 2 (HER2) gene expression. This data may assist with decisions on whether to treat with hormonal therapy, such as tamoxifen, or anti-HER2 drugs, such as Herceptin.

Comparing Oncotype DX to doctors' assessment of risk

In a classic man versus machine match-up, two recent studies in The Oncologist explored how doctor assessment of risk compared to the Oncotype DX Recurrence Score and whether the Recurrence Score changes treatment decisions.

In the first, published online September 20, six academic oncologists predicted whether various pathological scenarios would receive low, intermediate or high Oncotype DX Recurrence Scores. As a whole, the oncologists were able to accurately predict the high risk scores, but were less able to distinguish between low and intermediate risk scenarios. In addition, when the actual Recurrence Scores were provided, treatment decisions changed in 19% of the cases. The authors noted that additional studies are needed to assess whether changes in treatment decisions affect outcomes.

In the second study, dated October 20, four surgeons, four medical oncologists and four pathologists estimated recurrence risk and made treatment recommendations for 154 patients based on pathology data. The medical professionals' estimations agreed with the Oncotype DX Score in 54% of the cases. The professionals tended to overestimate risk compared to the Recurrence Score. The authors concluded that the Recurrence Score "provides useful information that improves patient selection for chemotherapy and changes treatment recommendations in approximately 25% of cases."

How accurate is the Oncotype DX HER2 status score?

As mentioned above, in addition to the Recurrence Score, the Oncotype DX provides a score to quantify HER2 expression. An October 11 Journal of Clinical Oncology study found "an unacceptable false-negative rate" for HER2 status. published a video and story about the study on October 24.

The study used standard IHC and FISH HER2 testing to check the quality of the Oncotype DX HER2 status score for 843 patients. Of the 784 patients negative by IHC/FISH, 779 (99%) were also negative by Oncotype. However, all of the 23 patients deemed equivocal by IHC/FISH were classified as negative by Oncotype. Of the 36 positive by IHC/FISH, only 10 (28%) were classified as positive by Oncotype, 12 (33%) were reported as equivocal and 14 (39%) as negative.

The authors concluded that the high false-negative rate "could create confusion in the decision-making process for targeted treatment and potentially lead to mismanagement of patients with breast cancer if only GHI [Genomic Health] HER2 information is used."

How does IHC4 compare to Oncotype DX?

There's been some buzz in the UK about an alternative to the Oncotype DX. An October 19 article in The Telegraph (UK) discussed an IHC4 test, noting that it could be available in as little as a year, and "should cost a tenth" of the Oncotype DX in the UK.

What's the buzz about?

An October 11 study in the Journal of Clinical Oncology compared the Oncotype DX Recurrence Score to an IHC4 prognostic model, which used estrogen receptor (ER), progesterone receptor (PR), Ki-67 and HER2 status from standard IHC testing. IHC stands for 'Immunohistochemistry,' a very common (and inexpensive) test used to analyze the amounts of those four proteins in a biopsy sample.

In the study, all four IHC markers provided independent prognostic information. Combined in the IHC4 model, the information was similar to the Oncotype DX Recurrence Score, with "little additional prognostic value" seen by combining IHC4 and the Recurrence Score.

The study suggested that "the amount of prognostic information contained in four widely performed IHC assays is similar" to that in the Oncotype DX Recurrence Score. The authors noted that further studies are needed to "determine the general applicability of the IHC4."

In the UK, the National Institute for Health and Clinical Excellence (NICE) is reviewing several genetic risk assessment tests to make recommendations for the National Health System (NHS). The Oncotype DX and IHC4 are included, as well as the MammaPrint test, Breast Cancer Index and others. (Link to review protocol.)

How does Ki-67 expression compare to Oncotype DX?

Ki-67 expression is one of the 21 factors considered in the Oncotype DX Recurrence Score. An October 4 study in the British Journal of Cancer, noting that Ki-67 testing "is less expensive than Oncotype DX," compared the two values for 53 patients. The study found a "strong linear correlation" between the two scores. All patients with low Ki-67 were low to intermediate risk with Oncotype DX. All with high Ki-67 were high or intermediate with Oncotype DX. The authors concluded that Ki-67 status is a "major, but not the sole determinant of Oncotype Dx score."

Can additional data improve the Oncotype DX?

An October 17 Journal of Clinical Oncology study found that supplementing the Oncotype DX score with other factors such as tumor size and patient age "refines the assessment of distant recurrence risk and reduces the number of patients classified as intermediate risk." However, the additional information "did not seem to enhance the value" of the Recurrence Score in terms of predicting chemotherapy benefit.

Oncotype DX report format may be difficult to understand

Finally, an October 1 Breast Cancer Research and Treatment study asked if the current Oncotype DX report format is "a good approach for communicating results to patients." Compared to other sample reporting formats, the standard report was more difficult to understand and interpret. The authors suggest that a less complex report might be more effective in communicating test results to patients.

These are only the seven most recent studies on the Oncotype DX assay for breast cancer. For two years of news and research, plus general overviews, please check the Oncotype DX page of our website. From the home page, click the Treatments tab and search for 'Oncotype' in the search box on the top right of the page.