Emerging trends in radiation therapy for women over 70 with early stage breast cancer

ScienceDaily (June 2, 2011) — Patterns of radiation usage in breast conserving therapy for women 70 years and older with stage I breast cancer are changing: more women are opting for radioactive implants and those with estrogen positive tumors are opting out of radiation therapy, according to an abstract being presented at the American Society of Clinical Oncology annual meeting in Chicago by Thomas Jefferson University Hospital researchers.

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In another abstract, the researchers report that women with estrogen negative tumors were 91 percent more likely to die from breast cancer if they did not receive radiation therapy after a lumpectomy.

Given the relatively recent developments in radiation therapy (i.e., an increased use of brachytherapy and external beams) and data supporting the idea that radiation isn't necessary for women with estrogen positive tumors, researchers wanted to see how actual practice patterns were impacted.

Researchers found that there was a modest increase in the percentage of women with estrogen receptor positive cancers who did not get radiation therapy starting around 2004, and increasing use of radioactive implants, such the MammoSite, Contura, Savi or similar devices, since 2002.

There was also a corresponding drop in women who received external beam radiation, according to Xinglei Shen, M.D., a resident in the Department of Radiation Oncology at Thomas Jefferson University Hospital. "Among women with estrogen receptor negative cancers, there was not the same increase in frequency of women who did not get radiation, but there was an increased use of radioactive implants," he said.

The consequence of those findings was determining what impact omitting radiation has on survival. While there is data that the omission of radiation therapy in women with estrogen receptor positive tumors who receive endocrine therapy, such as Tamoxifen, is not associated with a survival difference, limited data exists for estrogen receptor negative tumors in older women who undergo breast conservation.

"From the randomized trial data, we know that women with estrogen receptor positive stage I breast cancer have no detriment to survival by avoiding radiation, as long as they took Tamoxifen," Dr. Shen said. "However, it is unknown if this would be the case in women with estrogen receptor negative cancer."

Dr. Shen worked with Jefferson Medical College student Andrzej Wojcieszynski to examine survival in these women, and found that they were 91 percent more likely to die from breast cancer if they did not receive radiation therapy after a lumpectomy. (Abstract #1037).

"We have to be cautious when interpreting survival data from the SEER because of potential confounding variables, such as the health of the patients and use of chemotherapy," Dr. Shen said. "However, these data do raise hypotheses for future study."

"Our conclusion is that adjuvant radiation therapy after lumpectomy reduces breast cancer mortality in women over 70 with stage I, estrogen receptor negative breast cancers, and that radiation is currently underutilized in these women," said Wojcieszynski.

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Losing more than 15 percent of body weight significantly boosts vitamin D levels in overweight women

ScienceDaily (May 25, 2011) — Overweight or obese women with less-than-optimal levels of vitamin D who lose more than 15 percent of their body weight experience significant increases in circulating levels of this fat-soluble nutrient, according to a new study by researchers at Fred Hutchinson Cancer Research Center.

See Also:Health & MedicineVitamin DVitaminDiet and Weight LossObesityDietary SupplementFitnessLiving WellReferenceB vitaminsNutrition and pregnancyEssential nutrientGeneral fitness training

"Since vitamin D is generally lower in persons with obesity, it is possible that low vitamin D could account, in part, for the link between obesity and diseases such as cancer, heart disease and diabetes," said Caitlin Mason, Ph.D., lead author of the paper, published online May 25 in the American Journal of Clinical Nutrition. "Determining whether weight loss helps change vitamin D status is important for understanding potential avenues for disease prevention," said Mason, a postdoctoral research fellow in the Hutchinson Center's Public Health Sciences Division.

According to the National Institutes of Health, vitamin D plays many important roles in the body. It promotes calcium absorption and is needed for bone growth and bone healing. Along with calcium, vitamin D helps protect older adults from osteoporosis. The nutrient also influences cell growth, neuromuscular and immune function, and reduces inflammation. Many gene-encoding proteins that regulate cell proliferation, differentiation, and apoptosis (programmed cell death) are modulated in part by the vitamin.

The year-long study -- one of the largest ever conducted to assess the effect of weight loss on vitamin D -- involved 439 overweight-to-obese, sedentary, postmenopausal Seattle-area women, ages 50 to 75, who were randomly assigned to one of four groups: exercise only, diet only, exercise plus diet and no intervention.

Those who lost 5 percent to 10 percent of their body weight -- equivalent to approximately 10 to 20 pounds for most of the women in the study -- through diet and/or exercise saw a relatively small increase in blood levels of vitamin D (about 2.7 nanograms per milliliter, or ng/mL), whereas women who lost more than 15 percent of their weight experienced a nearly threefold increase in vitamin D (about 7.7 ng/mL), independent of dietary intake of the nutrient.

"We were surprised at the effect of weight loss greater than 15 percent on blood vitamin D levels," said senior author Anne McTiernan, M.D., Ph.D., director of the Hutchinson Center's Prevention Center and principal investigator of the study. "It appears that the relationship between weight loss and blood vitamin D is not linear but goes up dramatically with more weight loss. While weight loss of 5 percent to 10 percent is generally recommended to improve risk factors such as blood pressure, cholesterol and blood sugars, our findings suggest that more weight loss might be necessary to meaningfully raise blood vitamin D levels."

About 70 percent of the participants had less-than-optimal levels of vitamin D when the study began; at baseline, the mean blood level of vitamin D among the study participants was 22.5 ng/mL. In addition, 12 percent of the women were at risk of vitamin D deficiency (blood levels of less than 12 ng/mL).

The optimal circulating range of vitamin D is thought to be between 20 and 50 ng/mL, according to a recent data review conducted by the Institute of Medicine, which found that blood levels under 20 ng/mL are inadequate for bone health and levels over 50 ng/mL are associated with potential adverse effects, such as an increased risk of developing kidney stones.

Vitamin D is naturally found in some foods, such as fatty fish, and is produced within the body when skin is exposed to sunlight. According to the Institute of Medicine, just 10 minutes of sun a day is enough to trigger adequate vitamin D production. The estimated average requirement via diet or supplementation is 400 international units per day for most adults.

"It is always best to discuss supplementation with your doctor, because circulating levels can vary a lot depending on factors such as age, weight, where you live, and how much time you spend outdoors," Mason said. Vitamin D levels tend to decrease as people age and are generally lower among those with dark skin.

It is thought that obese and overweight people have lower levels of vitamin D because the nutrient is stored in fat deposits. During weight loss, it is suspected that the vitamin D that is trapped in the fat tissue is released into the blood and available for use throughout the body.

"Vitamin D is found in several different forms in the body and its pathways of action are very complex, so the degree to which vitamin D becomes available to the body as a result of weight loss is not well understood," Mason cautioned.

A possible link between vitamin D deficiency and chronic diseases, including cancer and heart disease, is also not well established. "More targeted research ongoing at the Hutchinson Center and elsewhere aims to better understand whether vitamin D plays a specific role in the prevention of these chronic diseases," McTiernan said. To that end, McTiernan is recruiting Seattle-area obese and overweight postmenopausal women for a separate new study to assess the impact of vitamin D on weight loss and breast cancer risk factors.

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Yoga improves quality of life in women with breast cancer undergoing radiation therapy, study finds

ScienceDaily (May 18, 2011) — For women with breast cancer undergoing radiation therapy, yoga offers unique benefits beyond fighting fatigue, according to new research from The University of Texas MD Anderson Cancer Center.

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While simple stretching exercises improved fatigue, patients who participated in yoga that incorporated yogic breathing, postures, meditation and relaxation techniques into their treatment plan experienced improved physical functioning, better general health and lower cortisol (stress hormone) levels. They also were better able to find meaning in their cancer experience.

The findings, to be presented next month in an oral session at the 47th annual meeting of the American Society of Clinical Oncology by Lorenzo Cohen, Ph.D., professor and director of the Integrative Medicine Program at MD Anderson, are the latest in an ongoing effort to scientifically validate the age-old belief that mind-body interventions have a beneficial impact on the health of cancer patients. The research was conducted in collaboration with India's largest yoga research institution, Swami Vivekananda Yoga Anusandhana Samsthana in Bangalore, India.

The study assessed, for the first time, yoga benefits to cancer patients by comparing their experience with patients in an active control group who integrated simple, generic stretching exercises into their lives. "The combination of mind and body practices that are part of yoga clearly have tremendous potential to help patients manage the psychosocial and physical distress associated with treatment and life after cancer, beyond the benefits of simple stretching," said Cohen.

To conduct the study, 163 women with breast cancer (stage 0-3) averaging 52 years of age were randomized to one of three groups: 1) yoga; 2) simple stretching; or 3) no instruction in yoga or stretching. Participants in the yoga and stretching groups attended sessions specifically tailored to breast cancer patients for one hour three days a week throughout their six weeks of radiation treatment.

Participants were asked to report on their quality of life, including fatigue, daily functioning, benefit finding, depression and spirituality. Saliva samples were collected and electrocardiogram tests were administered at baseline, end of treatment, and at one, three and six months post-treatment.

After completing radiation treatment, only the women in the yoga and stretching groups reported a reduction in fatigue. At one, three and six months after radiation therapy, women who practiced yoga during the treatment period reported greater benefits to physical functioning and general health. They were more likely to perceive positive life changes from their cancer experience than either other group.

Women who practiced yoga also had the steepest decline in their cortisol across the day, indicating that yoga had the ability to regulate this stress hormone. This is particularly important because higher stress hormone levels throughout the day, known as a blunted circadian cortisol rhythm, have been linked to worse outcomes in breast cancer.

According to Cohen, developing a yoga practice also helps patients after completing cancer treatment. "The transition from active therapy back to everyday life can be very stressful as patients no longer receive the same level of medical care and attention. Teaching patients a mind-body technique like yoga as a coping skill can make the transition less difficult."

Through a grant from the National Cancer Institute -- the largest ever awarded for the study of yoga in cancer -- Cohen and his team will next conduct a Phase III clinical trial in women with breast cancer to further determine the mechanisms of yoga that lead to improvement in physical functioning, quality of life, and biological outcomes during and after radiation treatment. A secondary aim of the trial, but one of great importance, stressed Cohen, is assessing cost efficiency analysis for the hospital, health care usage costs in general, and examining work productivity of patients.

MD Anderson recognizes the growing body of research indicating that relaxation-based interventions can contribute to the well-being of people with cancer. Through the Integrative Medicine Program, complementary therapies, such as yoga, are offered at MD Anderson's Integrative Medicine Center, and are used in concert with mainstream care to manage symptoms, relieve stress, enhance quality of life, and improve outcomes for patients and their caregivers. MD Anderson's Integrative Medicine faculty also conduct research in the biological and behavioral effects of mind-body based interventions; the anti-cancer potential of natural compounds; and, acupuncture to treat common cancer treatment-related side effects.

In addition to Cohen, other MD Anderson researchers contributing to this study include: Kavita Chandwani, M.D., former senior research coordinator and yoga teacher; Robin Haddad, M.P.H. , research coordinator, George Perkins, M.D. in the Department of Radiation Oncology; Amy Spelman, Ph.D., Kayla Johnson, B.S. and Adoneca Fortier, B.S., all staff in the Integrative Medicine Program; Banu Arun, M.D., in the Department of Breast Medical Oncology; and Qi Wei, M.S., Sr. Statistical Analyst. Clemens Kirschbaum, Ph.D. contributed from the Technical University of Dresden, Dresden, Germany. Collaborators from SVYASA include NV Raghuram, B.E.; R. Nagarathna, M.D., and HR Nagendra, Ph.D., founder.

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Recurring cancers in women with a history of breast cancer differ from the original tumors

ScienceDaily (May 18, 2011) — When women with a history of breast cancer learn they have breast cancer again, one of the first questions they and their doctors ask is: Has my cancer come back, or is this a new case? Now, new data from Fox Chase Cancer Center suggest that both new and recurring cancers will differ significantly from the original tumors, regardless of how many months or years women spent cancer-free, and doctors should tailor treatment to the specific qualities of the second tumor, regardless of whether it's old or new.

See Also:Health & MedicineBrain TumorCancerBreast CancerOvarian CancerLung CancerWomen's HealthReferenceMetastasisTumor suppressor geneTumorMammography

Anita Patt, MD, surgical oncology fellow at Fox Chase and lead author on the study, will be presenting the findings at the 2011 Annual Meeting of the American Society of Clinical Oncology on Monday, June 6.

"There tends to be a stigma and a lot of anxiety about the word 'recurrence,'" says Richard J. Bleicher, MD, FACS, attending surgeon at Fox Chase and senior author on the study. "Sometimes women will worry more if they believe their original cancer is back, meaning they didn't 'beat it' the first time around. These findings suggest they should not get hung up on that idea, because any subsequent diagnosis -- whether it's a recurrence or a new tumor -- will look significantly different from their first cancer."

In women with a history of breast cancer, doctors often approach new tumors differently depending on whether they believe it's a recurrence of the first tumor, or a totally new one, Bleicher explains. But there are no official ways to distinguish between the two types, so doctors typically rely on a few criteria, then form their own opinion based on an "overall gestalt," he says.

One of the criteria doctors have used to distinguish between new and recurring cancers is the amount of time women spent cancer-free, reasoning that the longer the time between the two tumors, the more likely the second one is to be an entirely new case.

To investigate if this and other criteria indeed distinguish new and recurring tumors, Bleicher, Patt, and their colleagues looked at data collected from 4,420 women with a history of breast cancer. Two-hundred and thirty five women were eventually diagnosed with another tumor in the same breast, suggesting it could be a recurrence.

However, when the researchers compared the first and second tumors, they saw that 89% differed in at least one key characteristic that could potentially affect treatment or prognosis, regardless of whether the second tumors were new cases or a recurrence of the original cancer. Sixty percent of the second tumors differed from the first by at least 2 or more criteria, including whether or not it would respond to hormones, how it was diagnosed, and whether at least 25 percent of the tumor was confined to the ducts, and therefore less able to spread throughout the body.

Half of the women experienced a second tumor within 60.5 months of their first. And, importantly, the amount of time they spent cancer-free appeared to have no bearing on whether the two tumors differed in any key characteristics.

The findings suggest that patients and doctors shouldn't spend much time determining if the second tumor is a recurrence of the first, or a totally new entity, says Bleicher, and should instead tailor treatment to the specific qualities of the second tumor, regardless of whether it's old or new.

"When a patient comes back with a relapse, whether it's a new tumor or a recurrence, it really doesn't make a difference," he says. "We treat them both as potentially curable."

Co-authors on the study include Tianyu Li, Massimo Cristofanilli, and Elin Sigurdson, from Fox Chase and Gary Freedman from the Hospital of the University of Pennsylvania.

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