This part of the patient's history is pretty straightforward.
In addition, DK carried the BRCA1 gene and had an aunt and 2 of her 3 sisters who also were carriers. The aunt was diagnosed with breast cancer at the age of 50 and is alive with the disease. It is unclear whether a maternal great aunt had either ovarian or uterine cancer.
Here, we get into shorthand that can be confusing for non-specialists who don't have the same implicit knowledge.
Everyone carries the BRCA1 gene. What the author means to say here is that DK and her aunt and sisters carried a particular mutation of the BRCA1 gene, and that particular mutation is linked to high rates of cancer (including breast cancer and ovarian cancer)--so much so that people sometimes get preventive mastectomies or hysterectomies to avoid getting the cancers associated with that mutation of the gene.
Review of DK’s history is fairly unremarkable. Her periods began at age 13 and had been regular from 24 to 34 while she was on oral contraceptive therapy (OCT). She discontinued OCT in April of 2004 in anticipation of marriage in August 2005 and plans for early conception. At that time she began having irregular periods with mild to moderate cramps. Sexually active, she had normal pap smears since her initial one at age 18. She carried out breast self-examinations regularly. Her review of systems had been generally negative with a stable weight of 115 lbs with good nutrition and regular exercise routines. Her only notable past medical history was surgery on her jaw in 1993.
This is all pretty straightforward.
Her initial examination in November 2004 was normal and at that time she was found to carry the BRCA1 gene.
They shorthanded it again, but after our previous discussion, you should understand what they mean to say she carries.
She had her first cancer screening including a pelvic ultrasound which was normal and a CA 125 in the normal range. It was recommended that she continue to have a pelvic ultrasound and CA 125 drawn every 6 months.
CA 125 is a protein in the blood that is used as a blood marker in testing for ovarian cancer. It is useful for that purpose, because it often occurs at elevated levels in women with ovarian cancer, but since other conditions--some of them harmless--can cause the protein levels in the blood to be elevated, it is not a perfect test.
Although elevated CA 125 can point to ovarian cancer, you can also have elevated CA 125 levels without having ovarian cancer.
As a BRCA1 heterozygote, DK was followed in the Dana-Farber Cancer Institute (DFCI ) high risk clinic.
We have two copies of each gene in most of the cells of our bodies, one each from our mother and our father.
If the two copies of the gene are the same, that's called being a homozygote--for example, if we get an X chromosome from our mother, and another X chromosome from our father, then we are homozygotes with XX chromosomes, and we're female.
If we get an X chromosome from our mother, and a Y chromosome from our father, then we are heterozygotes with XY chromosomes, and we're male.
BRCA1 heterozygote means that DK had two different kinds of the same BRCA gene from her mother and father, presumably one copy with the bad mutation, and one normal copy.
She had her first child, a son, in May 2006 and the birth was complicated by a C section infection. She intended to breast feed, but experienced breast pain. In October of 2006, 5 weeks after her son’s birth, she noted a mass in the upper outer aspect of the left breast which did not resolve with massage.
Not the kind of massage MTs perform, by the way--we never try to just massage a suspicious lump away.
An ultrasound of the breast showed a suspicious lesion in the lateral aspect and an ultra sound guided core biopsy showed a grade 3 invasive ductal carcinoma without lymphovascular invasion.
Carcinoma is a kind of cancer that originates in epithelial cells, such as the ones that line the milk ducts of the breast.
Source: http://besthealth.bmj.com/x/images/bh/en-gb/mastitis-image_default.jpg accessed 22 August 2012
Grade 3 means that the cells visible under the microscope are very distorted. Breast Cancer Canada explains in more detail:
Grade 1. Well Differentiated, or low grade
Grade 2. Moderately differentiated, or intermediate grade
Grade 3. Poorly differentiated, or high grade
Note that overall grades are also described as 'highly differentiated, moderately differentiated, and poorly differentiated. Sometimes these terms may be confusing. A cell that has enough functioning normal DNA to form a specific type of tissue, and behave like that tissue, is "differentiated". A cell that has so many mutations, that it forms hideously distorted tissues, is poorly-differentiated. A higher cancer grading corrsponds to more poorly-differentiated cells and cellular structures.--http://www.breast-cancer.ca/staging/infiltratingductalcarcinoma-grading.htm accessed 22 August 2012
Source: http://www.breast-cancer.ca/images/dcis-grade3.jpg accessed 22 August 2012
The fact that it has not yet invaded the lymph or vascular systems around it means that they caught it before it had a chance to spread significantly to the regions around the lump.
The tumor was estrogen receptor, progesterone receptor, and Her 2-Nu negative, often referred to as a triple negative breast cancer.
This refers to receptors in the cancer cells. If the cells have receptors for these hormones, then hormonal therapy can be used to treat the cancer, since the receptors are there for the hormonal therapy to bind to.
Triple-negative cancers don't have any of those receptors, so hormonal therapy won't work, and these cancers are especially aggressive.
One of the bits of implicit knowledge that cancer specialists reading this have, but that has not been said here, is that--although we cannot say anything for sure about DK's specific prognosis--the fact that she has a triple-negative breast cancer means that she is in a population that responds to chemotherapy more poorly than the population with other kinds of breast cancer does, and that the prognosis for DK's group's 5-year survival is worse than for populations with other types of breast cancer.
However, there is evidence that if they do make it through that difficult 5-year window, then survival rates long-term are similar to those of populations with other forms of breast cancer.
On lymph node biopsy, one of 4 nodes showed a 0.5 millimeter micrometastis.
Although not yet widespread, the metastasis of the tumor has begun.
A PET CT was performed which showed intense tracer uptake within the primary tumor in the left breast. There were other areas in the left breast adjacent to the primary tumor where there was a lower grade tracer uptake consistent with inflammatory changes.
Positron emission tomography (PET) is an imaging technique that shows metabolic activity in a living organism. Intense tracer uptake in the primary tumor means that that tumor is quite metabolically active, and other areas in the left breast where the metabolic activity indicates that inflammation is taking place.
Source: http://www.wmicmeeting.org/2011/2011abstracts/data/papers/images/T140_A.jpg accessed 22 August 2012
There was also minimal uptake seen in the left axillary nodes and no FDG evidence of distant disease. The resected breast specimen measured 5.4 by 4.3 by 1.7 centimeters.
Very little or no metabolic activity was observed by PET in the lymph nodes or spread to more distant sites.
5.4 by 4.3 by 1.7 centimeters is about 2 inches by 1-3/4 inches by 2/3 inches in size.
The final pathology report came back as triple negative invasive ductal carcinoma poorly differentiated (modified beam-richardson grade II/III) measuring at least 0.6 centimeters in size with no lymphovascular invasion. In addition, there was also ductal carcinoma in situ, solid type (high nuclear grade), without necrosis or calcifications.
Ductal carcinoma in situ means the cancer is in its original place--in the site where it began, the epithelial tissue of the milk ducts.
You can see necrosis (traumatic cell death) and calcifications (calcium deposits, which can indicate sites of trauma or inflammation) in the previous microphotograph of cancer cells.
Her course of treatment after the initial lumpectomy and sentinel node biopsy would include chemotherapy and then breast and nodal irradiation followed by bilateral mastectomy.
First, they would take out the lump, and some additional lymph nodes that serve as watchguards (sentinels) to indicate whether or not the cancer has spread to the lymphatic system yet.
Next, they would administer chemotherapy.
Third, they would administer radiation therapy.
Finally, they remove both her breasts.
This sounds drastic, and, compared with the treatment for most breast cancers, it is.
The reason they got so aggressive with DK's treatment is her BRCA1 mutation. Not everyone with that mutation gets breast cancer--but if they do, then the cancer is so dangerously aggressive that it can get ahead of more moderate treatments very fast.
BRCA1 mutation-associated cancers are so likely to happen, and are so dangerous, that many women choose to have preventive mastectomies, hysterectomies, and oopherectomies (removal of ovaries) before any signs of cancer ever show up.
Their risk-benefit analysis is that the cancer, if it ever should occur, will be so bad that it is worth running the risk of taking out perfectly healthy organs that may never get sick, in order to get the guarantee that they will not develop cancer.
DK's family history of her mother's early death from ovarian cancer, and her aunt living with breast cancer, reinforce her risk, and were factors in this treatment decision.
She was staged as a T1C, N1 breast cancer.
Grading, which we talked about previously, sounds similar to staging, so it's easy to confuse the two, but they're not the same thing. Grading talks about the form of the cancer itself (the size of the nuclei, or how well or poorly differentiated the cells are); staging refers to how far it's spread at a particular time.
The TNM system is one of the most widely used staging systems. This system has been accepted by the International Union Against Cancer (UICC) and the American Joint Committee on Cancer (AJCC). Most medical facilities use the TNM system as their main method for cancer reporting. PDQ®, NCI’s comprehensive cancer information database, also uses the TNM system.
The TNM system is based on the extent of the tumor (T), the extent of spread to the lymph nodes (N), and the presence of distant metastasis (M). A number is added to each letter to indicate the size or extent of the primary tumor and the extent of cancer spread.
Primary Tumor (T)
TX Primary tumor cannot be evaluated
T0 No evidence of primary tumor
Tis Carcinoma in situ (CIS; abnormal cells are present but have not spread to neighboring tissue; although not cancer, CIS may become cancer and is sometimes called preinvasive cancer)
T1, T2, T3, T4 Size and/or extent of the primary tumor
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be evaluated
N0 No regional lymph node involvement
N1, N2, N3 Involvement of regional lymph nodes (number of lymph nodes and/or extent of spread)
Distant Metastasis (M)
MX Distant metastasis cannot be evaluated
M0 No distant metastasis
M1 Distant metastasis is present
--National Cancer Institute, "Cancer staging", accessed 22 August 2012
So DK's T1C N1 was toward the lower end of the scale in spread, which is better than a more widespread tumor would be.
She did undergo dose-dense Adriamycin/Cytoxan followed by Taxol, then left breast irradiation, and in November 2007 underwent a bilateral S-GAP flap reconstruction with right prophylactic mastectomy and left mastectomy by a reconstructive surgeon. The pathology of the mastectomy specimens was normal. According to her medical providers at the time, she tolerated treatment well with the exception of some mucocitis during chemotherapy, She returned to work as a physical therapist.
Adriamycin, cytoxan, and taxol are all chemotherapy drugs.
The treatment plan followed the sequence previously outlined.
You might wonder why, if they're going to remove her breasts anyway, why put her through chemo and radiation first?
The reason is they're trying to fight a very aggressive cancer on all fronts, and to prevent spread by any means necessary. The fact that the pathology of the mastectomy specimens was normal indicates that they succeeded in that goal--because they took out a lot of healthy tissue that was not infiltrated by the cancer, that means they probably succeeded in getting all of the cancer that was surrounded by that tissue.
Mucocitis: they misspelled "mucositis", from mucosa (mucus membrane) + -itis (inflammation). Mucositis is a condition that is often a side effect of cancer treatment--the lining of the throat and esophagus become inflamed, and eating becomes painful and unappealing.
If you think back to the first day of the first anatomy class you took, what was the very first thing taught in it?
Probably the four tissue types:
As you learned, they're qualitatively very different from each other--they originate and grow in different ways, and they carry out very different jobs.
One of the characteristics of the epithelial tissue in the digestive tract is that it is fast-growing. Since radiation and chemotherapy have the most powerful effects on fast-growing cells, that means that the digestive tract mucosa is especially vulnerable to the side effects of those treatments (the same for hair, by the way, which is why many cancer patients undergoing chemotherapy or radiation lose their hair).
That's pretty much it for the highly technical part of the excerpt I'm presenting here; the rest of it should be fairly easy to read, so I'll see you again on the other side.
DK began to discuss with her physician the timing for her to get pregnant again; how long to wait after chemotherapy, when the risk of recurrence is maximal, whether pregnancy can affect the risk for recurrence, and other questions. It was suggested that she wait 2.5 years after the completion of active treatment. She continued to be followed by her primary oncologist and radiation therapist.
During the course of her therapy, she was seen in consultation by several members of the Leonard P. Zakim Center for Integrative Therapies at Dana-Farber Cancer Institute including a nutritionist, an integrative oncologist, a massage therapist, a Lebed Method instructor, and an acupuncturist. All sessions were held on-site in the cancer hospital and the medical clearance for each therapy was obtained from the primary oncologist. All clinical notes were documented in the patient’s electronic medical record and communication back to the primary oncologist happened as needed.
At the time she had the integrative medicine and nutrition consults, she was receiving her 3rd cycle of Taxol therapy just before her radiation therapy. She was interested in knowing more about nutrition and cancer, and specifically about management of her hot flashes and the use of dietary supplements. She expressed a great deal of anxiety in terms of ending chemotherapy treatment and was very interested in healthy behaviors for cancer survivorship. Her comment was “I want everything I put into my mouth to be the right thing.” Her diet consisted of 3 meals a day and sometimes snacks. Her symptomatology included frequent hot flashes and constipation alongside some bone and muscle pain and some muscle twitching. She continued to be physically active, but less so during the radiation and chemotherapy. She often tried to do some cardiac exercises and weight training but this was limited due to the fatigue she related to the chemotherapy and radiation therapy. She had many questions for both the nutritionist and the integrative oncologist about ginseng and sage supplements.
Her integrative medicine/oncology consult was held shortly thereafter which reinforced the nutritional advice, emphasized the use of the Vitamin D, fish oil and a phytonutrient rich diet. The importance of physical activity was also emphasized. It was revealed that DK had been a high caliber tennis player while at college.
One of the issues brought forth during this consultation was the anxiety of trying to care for her son during radiation therapy while continuing to care for herself. It became obvious during this interview that there was a great deal of anxiety and stress dealing with the breast cancer and raising a child. Various types of integrative therapies were discussed with DK. She expressed a significant interest in acupuncture and other mechanisms of reducing anxiety and stress. In addition, it was suggested that DK find some of her own time separate from demands of her work and her childcare could interfere with. A social worker became involved and facilitated some new arrangements for childcare. She was taught the relaxation response, encouraged to practice the breathing technique daily for 30 minutes. In addition, acupuncture was discussed and she was referred for an acupuncture consultation.
DK also elected to receive massage therapy to help with her left arm discomfort. Massage for her left arm discomfort had a noted marked improvement in her range of motion. She also had been having constant left shoulder discomfort which she wanted addressed as well. She received light to moderate pressure slow speeds general massage techniques She also received regulated neuromuscular techniques (NMT), myofascial release techniques (MFR), manual lymphatic drainage techniques (MLD) and basic acupressure techniques (BA) as called for during her sessions.
She felt that the massage made her feel good and it was suggested that she continue this integrative care treatment with massage, acupuncture, and yoga. She also exercised by participating in the Lebed Method movement classes held at DFCI for her upper extremity lymphedema prevention. With massage, she noted significant improvement after the session and continued to have therapeutic massage every two to three weeks. She increased her physical activity, including the new addition of yoga. Overall, the massage, yoga, Lebed classes, and her physical therapy helped with cording, muscle tension after surgery and radiation and with general relaxation.
Through all of the interventions, DK continued to rehabilitate and feel well. She increased her exercise and was better able to balance her work life and her family life, taking good care of her son.
She started acupuncture during her radiation therapy and continued this for several months afterwards. She received a total of 12 acupuncture treatments and the results were a decreasing back pain and a decreasing in the intensity of the hot flashes. She started her massage therapy at the end of her radiation therapy and continued for 14 massage visits which resulted in improvements in her muscle aches, pains and anxiety. Presently, she continues to feel well with diminishing hot flashes, increasing energy, a balanced diet, and regular, daily exercise.
All massage sessions and techniques at the Zakim Center are modified for the oncology population to ensure a safe and effective treatment for our patients, at different stages of their diagnosis, illness and recovery. DK had very specific reasons for using massage therapy as an integrative modality. One was the physical issue of tension and discomfort manifesting as a deep pain in her left shoulder blade area, rated 3 out of 10. Second was the emotional issue, manifesting as anxiety.
In designing the treatment plan to address these issues, DK and the massage therapist discussed the following:
Understanding that the resolution (temporary vs. permanent) of the anxiety symptom may depend on what is going on with her diagnosis and coping after treatment as well as other factors.
Combination of techniques to address the symptoms and modifications that may be needed.
In DKs situation the following techniques were used:
General massage techniques (MT); effleurage and petrissage to the full body were administered for warm up and integration. Addressing the entire body surface area with light to moderate pressure and slow, rhythmic techniques was a good way to elicit the relaxation response and calm the body back down after doing the focus sessions.
Regulated neuromuscular techniques (NMT) were chosen to address the increased muscle tension on the shoulders and upper back erectors for more focused work and trigger point release.
Manual lymphatic drainage (MLD) techniques were incorporated into the session. Although DK was not at a high risk for lymphedema, the decision to incorporate MLD was more for preventive and proactive purposes after focus work in consideration of the load on the tissues brought about by recent radiation therapy. MLD was also useful in addressing the “cording”, and the techniques in themselves provide a relaxing rhythm.
Myofascial techniques (MFR) were later used for help with tightness after radiation therapy. These also included some light pin and stretch work and muscle energy techniques.
Good intention holds and/or basic acupressure points (BA) were used as transition or termination techniques as a slow way to ease the body back from the massage session.
The combination of these techniques seemed to work very well for DK, with immediate response in addressing both the anxiety and shoulder discomfort. DK always reported feeling very relaxed after her sessions. Complete resolution of the deep left shoulder blade discomfort was achieved after the 3rd visit.
During the subsequent sessions, we had to address any recurring or additional discomfort or sequelae that came up. This included tightness at the area of radiation, pectoral tightness, decrease range of motion of the left shoulder and “cording”. Techniques were added or the combination of the above mentioned techniques modified to address this. General MT was always used to continue to address her need for relaxation.
DK continued to use massage as part of her integrative care with PT, OT, and swimming and yoga for self care throughout recovery and healing.
The last time DK was seen at the Zakim Center, she scheduled a massage to coincide with her oncology check up. A year and 4 months after she first engaged in integrative therapies, she reported feeling well and is now balancing and enjoying her work and family life.
Cancer patients often request support from integrative therapies in addition to their conventional cancer therapy. The evidence-based integrative therapies presented here demonstrated many advantages in being offered through a team approach at this comprehensive cancer center. It is important for cancer patients to be able to speak with and receive guidance from their medical team about integrative therapies so that the best of all available therapies can be safely and effectively offered as part of the patient’s care plan. Future work in integrative oncology should focus on improving clinical effectiveness, enhancing financial sustainability, maintaining high safety standards, and improving communication so that all patients and clinicians are aware of the benefits that integrative therapies can provide during the cancer journey.