Breast Cancer Basics and Beyond with Gabriel Hortobagyi, MD, Chat Transcript
Wednesday, October 11, 2006, 2:00 - 3:00 PM ET

Moderator: On behalf of the American Society of Clinical Oncology (ASCO), welcome to the Cancer.Net (Cancer.Net) "Ask the ASCO Expert" chat on Breast Cancer Basics and Beyond, a live question-and-answer session hosted by Gabriel Hortobagyi, MD.

Dr. Hortobagyi will take your questions from 2:00 - 3:00 PM ET. As you prepare your questions, please keep in mind that Dr. Hortobagyi is unable to give individual medical advice in this setting, nor is he able to address questions that include information specific to one person's medical profile. Some questions may be adapted so that his answers can help as many people as possible.

During this hour, Dr. Hortobagyi will answer as many questions as possible. Due to time constraints, he may not be able to address all questions, and as always, we encourage you to consult your doctor and health-care team for additional information.

The information presented here is for informational and educational purposes only. It is not intended to be a substitute for the professional medical advice or treatment recommendations provided by your doctor.

This forum is neither intended nor appropriate to serve as a means of obtaining a second opinion on cancer diagnosis or treatment. In response to questions about specific drugs, Dr. Hortobagyi's comments will focus only on the state of current research and clinical trials.

It is advised that you do not delay seeking professional medical advice based on any information received during this chat event.

The chat is governed by all terms and conditions of the Cancer.Net website. Participation in this chat event means that you fully understand and agree to abide by the terms and conditions of the Cancer.Net website.

Good afternoon and welcome. Thank you for joining us. Dr. Hortobagyi will now begin taking questions.

Dr. Hortobagyi currently serves as ASCO's President, and is Chair of the Department of Breast Medical Oncology and Professor of Medicine at The University of Texas M. D. Anderson Cancer Center in Houston. He holds the Nellie B. Connally Chair in Breast Cancer and serves as Director of the Multidisciplinary Breast Cancer Research Program at M. D. Anderson.

Dr. Hortobagyi is also Chair of the Health Advisory Board of the Susan G. Komen Breast Cancer Foundation, and Chair of the Data and Safety Monitoring Committee of the National Surgical Adjuvant Breast and Bowel Project.

Dr. Hortobagyi, thank you for taking the time to join us today.

Jules940: I've been having breast pain in my left breast for a couple of months, but haven't felt any lumps. Is having a lump the only definite sign of cancer? Should I be concerned about the pain?

Dr. Hortobagyi: Breast pain is usually NOT a sign of cancer, but it can be. If it persists, you should have your physician examine you and check it out.

Guest44: Could you please explain what DCIS is? If it is not really cancer, why is it treated like cancer?

Dr. Hortobagyi: DCIS stands for ductal carcinoma in situ. It is really a pre-malignant lesion, and it is treated to prevent invasive breast cancer from developing. If untreated, about 30% to 50% of patients would develop breast cancer over the following 20 years. DCIS is highly curable with surgery and radiotherapy.

guest444: For a breast cancer survivor who has taken tamoxifen (Nolvadex) for five years, is it possible to determine the risk of recurrence? My doctor recommends that I start letrozole (Femara) but I am concerned about the long-term side effects.

Dr. Hortobagyi: There are ways to estimate remaining risk of recurrence after five years of tamoxifen based on recently completed clinical trials comparing tamoxifen with aromatase inhibitors. In general, if a postmenopausal patient has a greater than 5% to 10% risk of recurrence, she would be advised to take an aromatase inhibitor, such as letrozole.

Lynlie: Do fertility drugs or in-vitro fertilization techniques increase the risk of breast cancer?

Dr. Hortobagyi: No, they have not been shown to increase the risk of breast cancer.

guest21: What can you tell me about Mammosite radiation therapy? How does it compare with regular radiation therapy? My wife's oncologist recommended it and I'm not sure what he's talking about.

Dr. Hortobagyi: Conventional radiation therapy after lumpectomy is administered from an external source and covers the entire breast and sometimes the regional lymph node areas. Mammosite is a device that is inserted into the lumpectomy cavity, and it contains a source of radiation, so it delivers radiation to a part of the breast, but not the entire breast. The duration of treatment is very short, compared with six weeks for standard radiotherapy. However, studies to compare Mammosite to standard radiation therapy are just now being completed, so we are not sure whether it will be as effective as and equally or better tolerated than standard radiotherapy.

guest07: What are the known long-term effects of carboplatin (Paraplatin)/docetaxel (Taxotere)?

Dr. Hortobagyi: Most of the side effects of this combination are short term and include nausea, vomiting, low blood counts, and numbness. Long-term effects include persistent numbness of fingers and toes, persistent low blood counts, and possibly leukemia. However, these are rare, although there is only modest experience with this combination in patients with early breast cancer, and therefore, longer follow-up is needed to know how common these effects are.

guest456: How long after chemotherapy does it usually take the immune system to return to its normal strength so that a breast cancer patient can visit with a mildly sick person (for example, someone with a cold or sinus infection)? Does having radiation therapy affect this time?

Dr. Hortobagyi: The immune system rebounds pretty rapidly, so within about three weeks after a dose of chemotherapy it should be back to normal. It is uncertain whether radiation therapy has a contributing effect to the immune suppression by chemotherapy.

L: There are so many conflicting questions about diet and breast cancer-besides eating a low-fat diet to be healthy and staying in shape, what else should I be doing?

Dr. Hortobagyi: Probably the most important part about diet and breast cancer is to avoid becoming overweight and to undertake regular physical activity or exercise. Both of these approaches have been associated with reduced risk of breast cancer. Alcohol consumption above one drink/day is associated with increased risk of breast cancer.

guest33: Do you have any recommendations for staying healthy after cancer? I finished my last course of chemotherapy a month ago and I need to feel like I am doing something for my health.

Dr. Hortobagyi: Stay close to your ideal weight, and exercise. It's good for you.

guest06: Is the combination of lapatinib (Tykerb), trastuzumab (Herceptin), and paclitaxel (Abraxane) an effective treatment for metastatic breast cancer?

Dr. Hortobagyi: We don't know. Trastuzumab and paclitaxel represent an effective combination for women with HER-2-positive breast cancer. Whether the addition of lapatinib increases the efficacy of the two-drug combination is under investigation.

TMD292: My 72-yr-old mother-in-law was recently diagnosed as having "high-grade invasive ductal cancer." What is this, and is it treatable?

Dr. Hortobagyi: It means garden-variety breast cancer and it is definitely treatable. Depending on the stage, it is also highly curable.

L: Following up on the diet question, what about caffeine? How much is ok?

Dr. Hortobagyi: There is no known correlation between caffeine and breast cancer. However, recent studies suggest that drinking up to 4 to 6 cups of coffee per day REDUCES the risk of diabetes and possibly the risk of dementia.

guest345: I recently read the Susan G. Komen Foundation's report, Why Current Breast Pathology Practices Must Be Evaluated (Oct. 2), which states there are major inconsistencies in current breast cancer pathology guidelines and procedures. Are these charges valid?

Dr. Hortobagyi: As diagnosis and treatment of breast cancer have become more sophisticated, the need for increasingly higher quality pathology procedures and interpretation has become very important. Therefore, there is continued emphasis on every pathologist and every pathology laboratory to focus on quality improvement to reduce differences in results and interpretation between labs. This applies to the initial diagnosis of breast cancer (what type), estrogen receptor (ER) status, and human epidermal growth factor receptor-2 (HER-2) status.

The College of American Pathologists (CAP) has worked on standardized diagnostic criteria. ASCO and CAP will soon release guidelines for performing and interpreting HER-2 tests. Guidelines for ER will hopefully follow.

Moderator: Transcripts of today's chat will be available October 12, 2006, on Cancer.Net by 12:00 PM ET. More information about receiving transcripts will be provided at the end of the chat.

De: Can you explain why the cancer rate is so high among black women vs. other races?

Dr. Hortobagyi: Breast cancer rates are actually lower for black women than for non-Hispanic whites, but higher than for Hispanic women and Asians. Unfortunately, despite lower rates, mortality is highest among black women. There is intensive research to try to understand these differences and especially to reduce mortality rates in all ethnic and cultural groups.

Susannah: My grandmother and an aunt died of breast cancer and my husband's mother is currently in treatment for breast cancer. Will our children be at higher risk than the general population?

Dr. Hortobagyi: The short answer is probably yes, BUT the more precise answer will depend on a careful analysis of the family pedigree. Did the relatives mentioned develop breast cancer in their 30s or in their 70s? Did they develop breast cancer in one breast or both breasts? Were there other cancers in the family?

All these pieces of information, plus the personal characteristics of each child will determine the magnitude of the risk. Most cancer centers have facilities where personal risk of breast cancer can be estimated with a fairly high degree of accuracy.

tomk: Can a patient's estrogen receptor/progesterone receptor (ER/PR) status change with a recurrence? I thought this was something that stayed the same over time.

Dr. Hortobagyi: ER and PR can change between the primary cancer and the recurrence in about 20% of patients. The changes can go from positive to negative or from negative to positive. For this reason, it is important to re-biopsy upon recurrence whenever possible. The same applies to HER-2 status.

guest22: About 15 months ago I was diagnosed with stage IV breast cancer, and I was advised not to undergo removal of the breast. However, I saw a study in the Journal of Clinical Oncology that said that women had a better chance of surviving if the primary tumor was removed. Should I go ahead and schedule surgery, or is too late for that? I've had a course of radiation therapy.

Dr. Hortobagyi: There is no definitive information about the benefit of removing the primary breast cancer after metastases have been detected, so the standard of care is not to do it. There have been three publications on the topic, but all three have serious biases that preclude their application to patient care in the absence of confirmation by a well-designed clinical trial. Such a clinical trial is ongoing in Mumbai, India, but it will take several years until we get definitive answers. Until then, only your physician can advise you about this course of action, although it is not considered the standard of care.

Nan: Is there any promising research on the horizon for women with triple negative breast cancer (ER-/PR-/HER-2-)?

Dr. Hortobagyi: There is much interest in triple negative breast cancer, and several groups and centers are working on identifying appropriate treatment targets so that novel therapies can be developed and validated. There are ongoing clinical trials with cisplatin (Platinol) and carboplatin, as well as angiogenesis inhibitors such as bevacizumab (Avastin). However, there is no reliable evidence that these are better than standard chemotherapy approaches.

SaraR: I have been cancer-free for nearly three years. I am wondering if I can start seeing my regular doctor instead of my oncologist for my care. His office is closer to home, plus I'd really feel on my way to being normal if I'm not at the cancer center every six months!

Dr. Hortobagyi: The recommended follow-up procedures beyond three years are a physical examination by a physician every six months until five years have elapsed, and then yearly thereafter. In addition, a yearly mammogram of the remaining breast tissue is recommended. If your primary physician feels comfortable following you and you have a good breast screening center in your area, it would be fine. More information can be found in the What to Know: ASCO's Guideline on Follow-up Care for Breast Cancer.

guest345: Do you recommend that patients get second opinions before deciding on breast cancer treatments?

Dr. Hortobagyi: The optimal management of breast cancer requires the involvement of multiple specialists and should start with multidisciplinary planning. In general terms, that means that treatment shouldn't start until there have been consultations among the primary specialists (surgery, radiation therapy, and medical oncology) based on the information provided by the radiologist and the pathologist. If such a team exists, additional opinions are seldom needed or useful, unless there is controversy within the initial team.

Emma: What is the latest research for new treatments for metastatic breast cancer?

Dr. Hortobagyi: It is estimated that there are several hundred new drugs under development for cancer, and most of these will undergo testing for breast cancer. New drugs include newer forms of chemotherapy, hormonal therapy, and what has been called molecularly targeted therapy (trastuzumab and bevacizumab are examples). Therefore, it is expected that each of the following years there will be a number of interesting new drugs entering clinical trials, and at least some of them will be shown to have important effects in the control of metastatic breast cancer. Our best bet today is for all those patients who can do it to seek out available clinical trials in their area to enhance their options of having the largest number of treatment alternatives. Read more about clinical trials.

guest444: What can I do to reduce my risk of breast cancer recurrence?

Dr. Hortobagyi: At the time of initial diagnosis, your physicians should be able to estimate fairly accurately your risk of experiencing a recurrence within the next five to 10 years. On that basis, it is considered that patients with risks that exceed about 10% should receive adjuvant treatments to reduce such risks. Depending on the characteristics of the tumor (ER and HER-2 status) different treatments would be selected to accomplish this objective. These are standard treatments and are very well documented and established.

JR: What are the latest research developments for male breast cancer?

Dr. Hortogabyi: There are only about 1400 new cases of male breast cancer per year in the United States, a number that is insufficient to conduct the necessary clinical trials to determine optimal treatment. Therefore, over the past few decades, treatment for male breast cancer has been extrapolated from the results of clinical trials on women with breast cancer.

A few large cancer centers (MD Anderson, Memorial Sloan-Kettering, Fox Chase, etc.) care for a somewhat larger number of males with breast cancer and sometimes have small clinical trials for this purpose. The Southwest Oncology Group currently runs a clinical trial combining two hormonal agents for males with metastatic breast cancer.

Moderator: The chat is now ending. Thank you for your thoughtful questions.

We hope this discussion has been valuable, and we regret not being able to answer every question. We want to thank Dr. Hortobagyi for lending us his time and expertise.

TRANSCRIPTS: The full text of today's chat will be available on Cancer.Net (www.cancer.net) October 12, 2006, by 12:00 PM ET. To receive a copy of the transcript by e-mail, please send a message to contactus@cancer.net.

UPCOMING EVENT: On November 8, 2006, visit Cancer.Net for a live question-and-answer chat on "Living With Lung Cancer" hosted by Mark Kris, MD, Memorial Sloan-Kettering Cancer Center. The chat will be held from 2:00-3:00 PM ET.

The chat room is now closed. Thanks again for joining us.