Obamacare and Cancer Patients

We have heard so much rhetoric about the Affordable Care Act, or Obamacare, that I would like to once again clarify some of the provisions in the bill.  Gov. Romney has said on multiple occasions that he would repeal the bill, and I think it is essential for all of us who have walked the cancer road to understand what that means. He has said he will keep some of the most popular provisions, but I worry what will happen when this all again becomes a political football.  What gains would we lose? How long will it take to makes changes?  What happens in the meantime?  The key points of the bill as it now stands, especially for those of us who have had cancer:

It outlaws discrimination because of pre-existing conditions. The Big C makes you quite an unpopular risk for Big Insurance. This bill changes that. Starting immediately, individuals without insurance and with a preexisting condition will have access to insurance. Starting in 2014—too long in my estimation—that applies to all individuals with insurance.  

It provides a cushion for those of us with high health costs.

• Beginning immediately, it limits the ability of insurance companies to charge higher rates because of health status.

• In January 2014, it will prohibit individual and group plans from placing annual limits on coverage.

• It prevents insurance companies from canceling your policy for any reason other than fraud.  And it has happened that companies have cancelled the policies of cancer patients.

It helps those over 65 with high prescription medicine expenses by reducing the “doughnut hole,” an odd little Medicare glitch that means that once seniors have spent $2,830 on drugs, they must cover the full cost of their medicines until their out-of-pocket expenses have reached $4,550.

This is not a budget buster. The Congressional Budget Office says the bill will reduce the deficit by reducing overall healthcare costs. This is a non-partisan group that took into account all aspects of the bill.  This is a complex issue, but the bill operates as a whole, cutting costs in things such as Medicare and Medicaid fraud and, yes, relying on everybody to be in the pool through the individual mandate.  The fact is that, without the bill, our healthcare costs are already draining our economy.  Throwing this back into the political arena could be a costly gambit.

For a complete analysis of the bill, check out the Kaiser Family Foundation’s summary.

Weight lifting and stretching best for lymphedema

NEWS RELEASE

COLUMBIA, Mo. –Nearly 40 percent of breast cancer survivors suffer from lymphedema, a chronic condition that causes body limbs to swell from fluid buildup, as a result of lymph node removal and radiation therapy. A cure for lymphedema does not exist, so individuals with the condition must find ways to manage the symptoms throughout their lifetimes. Now, a team of researchers and clinicians working with a University of Missouri lymphedema expert has found that full-body exercise and complete decongestive therapy (CDT) are the best ways for patients to minimize their symptoms and maintain their quality of life.

“There’s a sense of empowerment—of autonomy—that comes from meeting the challenge of living with lymphedema,” said Jane Armer, an MU nursing professor. “Some breast cancer survivors say that they’ve become a new person after cancer because they met a challenge, and they like the stronger person they’ve become. The challenge of lymphedema is similar. It’s something that is pervasive in every part of life. It takes problem solving and persistence to manage the condition without letting it interfere with their goals.”

Armer and her colleagues reviewed published research about lymphedema self-management in order to determine which practices were most effective in managing the condition. The researchers found that full-body exercise, such as weight lifting and stretching, was likely to be effective in minimizing lymphedema symptoms. In addition, the researchers concluded that complete decongestive therapy (CDT), a comprehensive treatment approach that incorporates skin care, exercise, manual lymphatic drainage and bandaging of swollen limbs, also helps patients effectively manage the condition.

“Previous research suggests that, the earlier the interventions, the better the outcomes,” Armer said. “If patients can learn how to successfully manage the condition early on, then they can continue those processes throughout their lives, and their outcomes will be better than those of individuals who resist participating in self-care.”

The research, “Self-Management of Lymphedema,” was published in Nursing Research.

A Low-Fat Cancer-Fighting Salad

My husband whipped up this yummy salad the other day and it’s about as tasty as it is healthy—and it is quite healthy.  

It mixes the ever-nutritious broccoli, a cancer-fighting cruciferous veggie, with chickpeas (aka garbanzo beans), which contain dietary fiber and folate, also good for reducing your risk of cancer.  

Add low-fat yogurt, red bell pepper and feta cheese, and you have a meal in a bowl, with only 122  calories per cup.  

Try it.  You’ll like it.  Find the recipe at Eating Well.

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Pregnancy Hormones Tied to Risk of Hormone-Negative Breast Cancer

Increased concentrations of the pregnancy hormones estradiol and progesterone were associated with an increased risk for hormone receptor-negative breast cancer diagnosed before age 50, according to the results of a nested case-control study presented at the 11th Annual American Association for Cancer Research International Conference on Frontiers in Cancer Prevention Research.  

The research was small—only 640 women, most of them with hormone-positive breast cancer—but the study might encourage continued research on the link between pregnancy and TNBC.  Samples were taken in the first trimester. Interestingly, the association was stronger for PR-negative tumors than for ER-negative.  And stronger for women under 50 than for those over 50.

"Pregnancy influences maternal risk for breast cancer, but the association is complex and the biological mechanisms underlying the associations are unknown," said Annekatrin Lukanova, M.D., Ph.D., associate professor at the German Cancer Research Center in Heidelberg, Germany. "Understanding the mechanisms underlying the protective effect of childbearing on cancer risk can form the basis for primary prevention of breast cancer."

Check out the abstract and more information here.

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Breast Feeding Reduces TNBC Risk

NEWS RELEASE

Breast-feeding reduced the risk for estrogen receptor-negative and progesterone receptor-negative breast cancer, according to results presented at the 11th Annual AACR International Conference on Frontiers in Cancer Prevention Research, held in Anaheim, Calif., Oct. 16-19, 2012.

"We found an increased risk for estrogen receptor- and progesterone receptor- (ER/PR) negative breast cancer in women who do not breast-feed, but in women who have children and breast-feed, there is no increased risk," said Meghan Work, M.P.H., doctoral student in the department of epidemiology at Columbia University's Mailman School of Public Health in New York, N.Y.

Work and colleagues examined the relationship between reproductive risk factors -- such as the number of children a woman delivers, breast-feeding and oral contraceptive use -- and ER/PR-negative breast cancer. ER/PR-negative breast cancer often affects younger women and has a poor prognosis, according to Work.

The researchers used data from three sites of the Breast Cancer Family Registry, which includes women with and without breast cancer from the United States, Canada and Australia. This study included 4,011 women with breast cancer and 2,997 population-based controls.

The results indicated that having three or more children without breast-feeding was associated with an increased risk for ER/PR-negative breast cancer.

"Women who had children but did not breast-feed had about 1.5 times the risk for ER/PR-negative breast cancer when compared with a control population," Work said. "If women breast-fed their children, there was no increased risk for ER/PR-negative cancer."

Further, the researchers found that oral contraceptive use was not associated with ER/PR-negative cancer risk, with the exception of those formulations available before 1975. "These earlier formulations contained higher doses of estrogen and progestin than more recent versions," Work said.

These findings are in line with previous findings that have demonstrated breast-feeding benefit in triple-negative breast cancer. "This is particularly important as breast-feeding is a modifiable factor that can be promoted and supported through health policy," Work said.

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Cruciferous Veggies Like Broccoli Studied For TNBC Treatment

NEW RELEASE

Arlington, Va. — A new compound created from a rich source in vegetables including broccoli and brussel sprouts has been developed to combat triple-negative breast cancer (TNBC). This research is being presented at the 2012 American Association of Pharmaceutical Scientists (AAPS) Annual Meeting and Exposition, the world's largest pharmaceutical sciences meeting, in Chicago, Ill., on Oct. 14 – 18, during Breast Cancer Awareness Month.

TNBC accounts for approximately 15-20 percent of all breast cancer cases in the U.S. It is one of the most aggressive forms of breast cancer; it grows faster, spreads to other parts of the body earlier, is harder to detect on a mammogram and recurs more often. [Pat's note:  Again, TNBC can be aggressive, but this is not always the case.  And, unless it is paired with inflammatory breast cancer or very dense breasts, mammograms can spot it.]

Mandip Sachdeva, Ph.D. and Chandraiah Godugu, P.h.D. from Florida A&M University, in collaboration with Stephen Safe, Ph.D., from Texas A&M University, have evaluated the activity of novel C-substituted diindolylmethane (C-DIM) derivatives and demonstrated that they have superior anticancer activities. Sachdeva's study reveals that these synthetic compounds derived from diindolylmethane (DIM), commonly found in various types of cruciferous vegetables, can be used to treat several types of cancer, including triple-negative breast cancer. C-DIMs are also being investigated for their cancer prevention activity.

"Targeted treatment options for TNBC are limited; current treatments, such as infusions, result in poor patient compliance and increased toxicity," said Sachdeva. "We are confident that the compounds we are currently working with are an effective treatment for triple-negative breast cancer. These compounds are safer for the patient than current treatments available."

In contrast to existing anticancer drugs, the diindolylmethane compounds are orally active, so they could be available to patients in pill form and safe to take daily. When taken in combination with existing anticancer drugs, the diindolylmethane compounds can effectively decrease the number of treatments a patient receives.

PAT'S NOTE:  I always have kale and cabbage as part of my nightly vegetable juice—both are cruciferous vegetables.  Earlier research has pointed to these veggies as being helpful in fighting TNBC.  And they are good for us in general, so it seems an easy step to take.

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PARP Inhibitors Plus EGFR May Slow TNBC Growth

Researchers have successfully slowed the growth of triple-negative breast cancer tumors in lab research that combined PARP inhibitors with EGRF inhibitors.  In the past PARP, or Poly (ADP-ribose) polymerase, inhibitors  have shown mixed results for TNBC.  The difference here might be the effects of EGFR (epidermal growth factor receptor).   The  research was published in PLOS One (The Public Library of Science).  In the summary to the article, the researchers, note,  "Our intriguing and novel results point to the potential broader utility of PARP inhibitors in breast cancer beyond hereditary BRCA1-and BRCA2-deficient tumors by combining it with EGFR inhibitors such as lapatinib. Moreover, the discovery of the novel EGFR-BRCA1 interaction may lead to other therapeutic targets for the highly aggressive TNBC."

The full release, with my inevitable editorial comments about language:

Researchers at the University of Alabama at Birmingham (UAB) reported new discoveries that can slow the growth and metastasis of triple negative breast cancer in the peer reviewed open access journal Public Library of Science on October 11, 2011. Triple negative breast cancer is one of the most lethal forms of breast cancer due to a high rate of spread by metastasis. [NOTE:  IT CAN BE LETHAL BUT IS NOT ALWAYS. MOST WOMEN SURVIVE. WHY DO I HAVE TO REPEAT THIS OVER AND OVER AND OVER?]

The researchers reported a slowed rate of growth of triple negative breast cancer both in the breast and in metastasized tissues by using ABT-888 and lapatinib. Both drugs are known as Poly (ADP-ribose) polymerase (PARP) and act to repair breaks in DNA and also function in programmed cell death.

Combined EGFR and PARP inhibition delays the growth of orthotopic breast tumor xenografts in mice.Photo credit:  doi:10.1371/journal.pone.0046614.g007 Yang et. al. open access

The scientists found that the PARP drugs combine with EGFR (epidermal growth factor receptor) to produce cancer cell death both in the affected breast and metastasized tissues.

Breast cancer type 1 susceptibility protein (BRCA1) and EGFR were found to exist in the same protein complex for the first time. The researchers conclude that this factor is one of the major contributors to the susceptibility of triple negative breast cancer to PARP type drugs.

The scientists also found that cancer reduction through cancer cell death was not dependent on the concentration of EGFR but did require this factor's presence.

The study also suggests that there are six distinct groups of triple negative breast cancers based on gene expression profiles: basal-like 1, basal-like 2, immunomodulatory, mesenchymal, mesenchymal stem-like, and luminal androgen receptor.

All types of triple negative breast cancer are susceptible to the synthetic cancer cell death methodology developed at UAB.

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On the Importance of Hope for TNBC

I have a series of videos on You Tube.  This is my favorite. 

Small Pox Vaccine May Kill TNBC Cells

A vaccine that has been given to millions of people worldwide without serious side effects may end up being a non-toxic treatment for triple-negative breast cancer, according to research presented at the 2012 Annual Clinical Congress of the American College of Surgeons.

In lab research on mice, a new smallpox vaccine,  GLV-1h164, was successful in killing more than 90 percent of the TNBC tumor cells within four days.

According to researchers, the virus infects and breaks down cancer cells and also inhibits tumor blood vessel growth. According to Sepideh Gholami, MD, lead study author and surgical resident at Stanford University Medical Center, Palo Alto, CA, in a news release:

“We performed ultrasound imaging of the tumors and we saw a significant reduction in blood flow supplied to treated tumors with our new virus. More specifically, when we looked at the stained vasculature of the tumors, the treated tumors showed at least one half of what control mice did." 

These findings will allow the researchers to take the next step toward designing a clinical trial and evaluating the safety of this new virus in patients with TNBC, she concluded.

See the full release here.    Warning:  It contains exaggerated language that assumes all TNBC is deadly, which is not accurate.  Some forms can be aggressive, most are much less so.

Quit Talking Smack About TNBC

[NOTE: I originally wrote this post, with a more refined title, for the Oxford University Press blog.]

The big news this week comes from the Cancer Genome Atlas program, which has announced a strong molecular connection between basal-like breast cancer tumors and ovarian cancer. The news stories I have read on the topic provide a great deal of hope for women with basal-like cancers. But the hope is, unfortunately, buried in a greater deal of confusion.

Here’s the hope: We’re getting closer and closer to understanding what makes breast cancer tick on a molecular level, and that means we could ultimately have treatments that target specific molecular anomalies, making the treatment more effective, efficient, and possibly less toxic. Most important, it would be clearer to doctors which patients need chemo and which don’t, saving thousands of people from unnecessary and dangerous treatment. And making chemo for those who need it more precise.

Among those who could benefit most from this research are the women and men with triple-negative breast cancer (TNBC), which is currently treated with anthracylines — chemotherapy drugs such as Epirubicin and Adriamycin — that can cause long-term side effects including heart disease and increased risk of leukemia. Moreover, metastatic TNBC — cancer that has spread beyond to distant organs — can be resistant even to current forms of chemo.

The research on the genome project, published in the 23 September 2012 online edition of the journal Nature, ties basal-like breast cancers to ovarian cancers on a molecular level, suggesting that ultimately TNBC could be treated with the less-toxic chemotherapy used for ovarian cancer, including a mix of a carboplatin (Paraplatin) or cisplatin with a taxane such as paclitaxel (Taxol) or docetaxel (Taxotere).

That’s the hope. Now the confusion. The biggest confusion revolves around our understanding of triple-negative breast cancer (TNBC).

Some news stories I have read equate TNBC with basal-like tumors, as though the two were synonymous, which is not accurate. There is a correlation between TNBC and basal-like cancers, but not all TNBC tumors are basal-like, and not all basal-like tumors are TNBC. In fact, some researchers break TNBC into three subtypes, including basal-like and non-basal-like.

The other, and bigger, problem, come in the terms journalists and researchers use for TNBC: “particularly deadly,” “especially aggressive,” and “lethal.”

I understand why these words are used; it makes the research appear more significant. But these terms can frighten and depress those with TNBC and their families, and the research is significant enough to stand on its own without hyperbole.

Lost in the hyperbole is the fact that most women survive TNBC. The rates depend on too many factors to offer a generalization, but multiple studies have shown from 70 to 90% of patients with TNBC with no recurrence after five years. And rates for TNBC recurrence drop significantly after three years, so TNBC patients who have reached five years without recurrence often face better long-term odds than those with other forms of breast cancer.

It is a disease to take seriously, but who doesn’t take cancer seriously? Patients and survivors don’t need frightening words for effect. They are frightened enough.

Triple-negative breast cancer gets its name because tumors of this subtype lack receptors for estrogen, progesterone, and the human growth hormone Her2/neu. The significance of being negative for these receptors is that TNBC lacks a targeted therapy, such as tamoxifen, which blocks the effects of estrogen, Arimidex, which prevents the production of estrogen, and Herceptin, which treats her/2-positive tumors.

So, TNBC is a disease defined by what it lacks. But, thanks to research on the human genome, it may soon be defined by its specific molecular characteristics. And treating something you can define is a whole lot easier than treating what you can’t.