Cancer Specialists

Medical Oncology is a subspecialty of internal medicine.  Doctors who specialize in internal medicine treat a wide range of medical problems.  Medical oncologists treat cancer and manage the patient’s course of treatment.  A medical oncologist might also consult with other physicians about the patient’s care or refer the patient to other specialists.  Most physicians who treat people with cancer are medical doctors and they have an M.D. degree, or osteopathic doctors who have a D.O. degree.  The basic training for both types of physicians includes 4 years of premedical education at a college or university, 4 years of either medical school to earn an M.D. or D.O. degree, and postgraduate medical education through internships and residences. This training usually lasts 3 to 7 years.  Physicians must pass an exam to become licensed to practice medicine in their state.  Each state has its own procedures and general standards for licensing physicians.  When choosing a doctor for your cancer care, you will probably find it helpful to know some of the terms used to describe a doctor’s training and credentials.
Hematology is also a subspecialty of internal medicine.  Hematologists focus on diseases of the blood and related tissues.
Radiation Oncology is a subspecialty of radiology.  Radiation oncologists specialize in the use of radiation to treat cancer.
Surgery is a specialty that pertains to the treatment of disease by surgical operation.  General surgeons perform operations on almost any area of the body.   Physicians can also choose to specialize in a certain type of surgery.
Specialists are physicians who have completed their residency training in a specific area.  Independent specialty boards certify physicians after they have fulfilled certain requirements.  These requirements include meeting specific education and training criteria, being licensed to practice medicine, and passing an examination given by the specialty board.  Doctors who have met all of the requirements are given the status of “Diplomate” and are board certified as specialists.  Doctors who are board eligible have obtained the required education and training but have not completed the specialty board examination.After being trained and certified as a specialist, a physician may choose to become a subspecialist. A subspecialist has at least one additional year of full-time education in a particular area of a specialty. This training is designed to increase the physician’s expertise in a specific field.  Specialists can be board certified in their subspecialty as well.Almost all board-certified specialists are members of their medical specialty society.  Physicians can attain Fellowship status in a specialty society, such as the American College of Surgeons (ACS) if they demonstrate outstanding achievement in their profession.  Criteria for Fellowship status may include the number of years of membership in the specialty society, years practicing in the specialty, and professional recognition by peers.

Chemo Brain and More Chemo Brain

Research has proven that breast cancer survivors can experience problems with certain mental abilities several years after treatment, regardless of whether they were treated with chemotherapy plus radiation or radiation only.   In fact, there are indications that there may be common and treatment-specific ways that cancer therapies negatively affect cancer survivors’ mental abilities.
To compare the effects of different types of cancer treatment on such mental abilities, a study examined 62 breast cancer patients treated with chemotherapy plus radiation, 67 patients treated with radiation only, and 184 women with no history of cancer.  Study participants completed neuropsychological assessments six months after completing treatment and again 36 months later, which is further out from the end of treatment than most previous studies of this type.
The study confirmed that chemotherapy can cause cognitive problems in breast cancer survivors that persist for three years after they finish treatment. In addition, the investigators found that breast cancer survivors, who had been treated with radiation and not chemotherapy, often experienced problems similar to those in breast cancer survivors treated with both chemotherapy and radiation.  (They did not find that hormonal therapy, such as tamoxifen, caused cognitive difficulties.)
These findings suggest that the problems some breast cancer survivors have with their mental abilities are not due just to the administration of chemotherapy. The findings also provide a more complete picture of the impact of cancer treatment on mental abilities than studies that did not follow patients as long or look at mental abilities in breast cancer survivors who had not been treated with chemotherapy.  This study gives voice to the many women who believe that they suffer from chemo brain.

Accelerated Partial Radiation

Have you heard of accelerated partial radiation before?
Women who are diagnosed with early-stage breast cancer often choose to have the cancer removed by lumpectomy, and they usually have radiation therapy after surgery as well.   Radiation therapy after lumpectomy lowers the risk of the cancer recurring and it makes lumpectomy as effective as mastectomy.  Radiation can be delivered to the entire breast, whole-breast radiation, or to just the area of the breast where the cancer was located, partial-breast radiation.  Traditional whole-breast radiation typically lasts 5 days a week for 4 to 6 weeks; and the unintentional exposure of nearby healthy tissue (lungs or heart, for example) to is a factor to consider as well.
One of the newer ways to deliver radiation is accelerated partial-breast radiation.   This is a new technique that delivers a more focused and intense  therapy over a shorter period of time.
3-D conformal external beam radiation (3DCRT) is one type of accelerated partial-breast radiation.  3DCRT starts with a planning session.   A special MRI or CAT scan of the breast is done and is used to map out small treatment fields for the area at risk.  The type and distribution of radiation is designed to maximize the dose to the area that needs to be treated and avoid or minimize radiation to tissue near the area.  The radiation is delivered with a linear accelerator, the same machine used in traditional whole-breast radiation, twice a day for 1 week.
A study has found that women diagnosed with early-stage breast cancer and had 3DCRT after lumpectomy had worse cosmetic results than women who got traditional whole-breast radiation after lumpectomy.  The study was published online on July 8, 2013 by the Journal of Clinical Oncology.
In the RAPID trial, researchers randomly assigned 2,135 women diagnosed with either early-stage breast cancer or DCIS to get either 3DCRT (1,070 women) or whole-breast radiation (1,065 women) after lumpectomy.  Before they received any radiation therapy, all the women were assessed by a trained nurse using a cosmetic rating system for breast cancer.  After radiation therapy, the women were again assessed by a trained nurse at 2 weeks, 3 months, 6 months, 12 months, and then once a year.
The rating system compared the treated and untreated breast for:

• size and shape
• location of the nipple and areola
• how the surgical scar looked
• whether or not there was an enlargement of small blood vessels on the skin
• overall appearance of the breasts

The researchers then compared cosmetic results and side effects between the two types of radiation.
The researchers found that women who had 3DCRT had worse cosmetic results than women who had whole-breast radiation:

• Before radiation, 18.9% of women who would get 3DCRT had fair or poor cosmetic results compared to 17% of women who would get whole-breast radiation.
• Three years after radiation, 29% of women who had 3DCRT had fair or poor cosmetic results compared to 16.5% of women who got whole-breast radiation.
• Five years after radiation, 32.8% of women who had 3DCRT had fair or poor cosmetic results compared to 13.4% of women who got whole-breast radiation.

Looking at side effects, the researchers found that women who had 3DCRT were more likely to have telangiectasia and breast induration (hardening or thickening of the skin) than women who had whole-breast radiation.  About a quarter of the women in both groups had mild to moderate pain after radiation.  Very few women in either group had severe pain.
While other ongoing studies have suggested that accelerated partial-breast irradiation is safe, none of these other studies have reported on cosmetic results.  Since the cosmetic results and side effects were worse with 3DCRT than whole-breast radiation, the researchers recommended that 3DCRT not be routinely used unless it’s part of a clinical trial.  More research with long-term follow-up is needed so doctors know for sure that accelerated partial-breast irradiation is a good alternative to whole-breast radiation.
If you’ve been diagnosed with early-stage breast cancer and lumpectomy followed by radiation therapy will be part of your treatment, ask your doctor about the radiation therapy options that make the most sense for your unique situation, including:

• the characteristics of the cancer (size, location, lymph node involvement)
• your personal preferences
• the experience level and results of the doctors who will administer your radiation therapy

Deciding between Lumpectomy and Mastectomy

When a woman is faced with breast cancer, there are two choices available: lumpectomy and mastectomy.
Lumpectomy is less invasive than mastectomy and it allows a woman to save her breast. Mastectomy involves removal of the entire breast.
Most women, when offered the choice between the two, prefer the less invasive lumpectomy Generally, lumpectomy results in a good cosmetic look. And, if you want to keep your breast, you may decide to have lumpectomy followed by radiation.  However, in rare cases, when a larger area of tissue needs to be removed, lumpectomy can cause the breast to look smaller or distorted.  There are types of reconstructive surgery available for both lumpectomy and mastectomy.  If you need to have a large area of tissue removed and two breasts of matching size are very important to you, you and your doctor will need to decide which surgery is best for your situation.
Research shows that women who live in the United States are more likely to have mastectomies than women who live in other countries.  In the Midwestern and southern parts of the U.S., mastectomies are very common.
Lumpectomy followed by radiation is likely to be equally as effective as mastectomy for women with only one site of cancer in the breast and a tumor under 4 centimeters.  Clear margins are also a requirement (no cancer cells in the tissue surrounding the tumor).
Lumpectomy has a few potential disadvantages:
Radiation therapy is likely to be scheduled for 5 to 7 weeks of radiation therapy– 5 days per week after lumpectomy surgery to make sure the cancer is gone.
Radiation therapy may affect the timing of reconstruction and possibly your reconstruction options after surgery.  Radiation therapy also may affect your options for later surgery to lift or balance your breasts.
There is a somewhat higher risk of developing a local recurrence of the cancer after lumpectomy than after mastectomy.  However, local recurrence can be treated successfully with mastectomy.
The breast cannot safely tolerate additional radiation if there is a recurrence in the same breast after lumpectomy.  This is true for either a recurrence of the same cancer, or for a new cancer.  If you have a second cancer in the same breast, your doctor will usually recommend that you have a mastectomy.
One or more additional surgeries may be needed after your initial lumpectomy.  During lumpectomy, the surgeon removes the cancer tumor and some of the normal tissue around it (called the margins).  A pathologist looks to see if cancer cells are in the margins.  If there are cancer cells, more tissue needs to be removed until the margins are free of cancer. Ideally, this is all done during the lumpectomy, but analyzing the margins can take about a week.  So sometimes after the pathology report is done, the margins are found to contain cancer cells and more surgery (called a re-excision) is needed.
Some women may want the entire breast removed because it provides a greater peace of mind regarding the recurrence of breast cancer.  Radiation therapy may still be needed, depending on the results of the pathology.
Mastectomy means that the woman will have a permanent loss of her breast and that she will have to have additional surgeries if she chooses to have her breast reconstructed. A mastectomy takes longer than a lumpectomy and is more extensive. It also has more post-surgery side effects and a longer recuperation time.
The choices are personal so be sure to weigh your decision carefully after you’ve talked with your doctor.

When a woman is faced with breast cancer, there are two choices available: lumpectomy and mastectomy.
Lumpectomy is less invasive than mastectomy and it allows a woman to save her breast. Mastectomy involves removal of the entire breast.
Most women, when offered the choice between the two, prefer the less invasive lumpectomy Generally, lumpectomy results in a good cosmetic look. And, if you want to keep your breast, you may decide to have lumpectomy followed by radiation.  However, in rare cases, when a larger area of tissue needs to be removed, lumpectomy can cause the breast to look smaller or distorted.  There are types of reconstructive surgery available for both lumpectomy and mastectomy.  If you need to have a large area of tissue removed and two breasts of matching size are very important to you, you and your doctor will need to decide which surgery is best for your situation.
Research shows that women who live in the United States are more likely to have mastectomies than women who live in other countries.  In the Midwestern and southern parts of the U.S., mastectomies are very common.
Lumpectomy followed by radiation is likely to be equally as effective as mastectomy for women with only one site of cancer in the breast and a tumor under 4 centimeters.  Clear margins are also a requirement (no cancer cells in the tissue surrounding the tumor).
Lumpectomy has a few potential disadvantages:
Radiation therapy is likely to be scheduled for 5 to 7 weeks of radiation therapy– 5 days per week after lumpectomy surgery to make sure the cancer is gone.
Radiation therapy may affect the timing of reconstruction and possibly your reconstruction options after surgery.  Radiation therapy also may affect your options for later surgery to lift or balance your breasts.
There is a somewhat higher risk of developing a local recurrence of the cancer after lumpectomy than after mastectomy.  However, local recurrence can be treated successfully with mastectomy.
The breast cannot safely tolerate additional radiation if there is a recurrence in the same breast after lumpectomy.  This is true for either a recurrence of the same cancer, or for a new cancer.  If you have a second cancer in the same breast, your doctor will usually recommend that you have a mastectomy.
One or more additional surgeries may be needed after your initial lumpectomy.  During lumpectomy, the surgeon removes the cancer tumor and some of the normal tissue around it (called the margins).  A pathologist looks to see if cancer cells are in the margins.  If there are cancer cells, more tissue needs to be removed until the margins are free of cancer. Ideally, this is all done during the lumpectomy, but analyzing the margins can take about a week.  So sometimes after the pathology report is done, the margins are found to contain cancer cells and more surgery (called a re-excision) is needed.
Some women may want the entire breast removed because it provides a greater peace of mind regarding the recurrence of breast cancer.  Radiation therapy may still be needed, depending on the results of the pathology.
Mastectomy means that the woman will have a permanent loss of her breast and that she will have to have additional surgeries if she chooses to have her breast reconstructed. A mastectomy takes longer than a lumpectomy and is more extensive. It also has more post-surgery side effects and a longer recuperation time.
The choices are personal so be sure to weigh your decision carefully after you’ve talked with your doctor.

Hormone-Sensitive Breast Cancer

Hormones are substances that function as chemical messengers in the body.  The hormones, estrogen and progesterone, can stimulate the growth of some breast cancers.   These breast cancers are called hormone-sensitive (or hormone-dependent) breast cancers.
Hormone-sensitive breast cancer cells contain proteins known as hormone receptors that become activated when hormones bind to them. The activated receptors cause changes in the expression of specific genes, which can lead to the stimulation of cell growth.
Breast cancers that lack estrogen receptors are called estrogen receptor-negative (ER-negative). These tumors are estrogen-insensitive, meaning that they do not use estrogen to grow. Breast tumors that lack progesterone receptors are called progesterone receptor-negative (PR-negative).
Hormone therapy is used to stop or slow the growth of these tumors.  Therapy is used to treat both early and advanced breast cancer, and to prevent breast cancer in women who are at high risk of developing the disease.
Hormone therapy slows or stops the growth of hormone-sensitive tumors by blocking the body’s ability to produce hormones or by interfering with hormone action.  With that said, tumors that are hormone-insensitive do not respond to hormone therapy.
Hormone therapy for breast cancer is not the same as menopausal hormone therapy, in which hormones are given to reduce the symptoms of menopause.
Several strategies have been developed to treat hormone-sensitive breast cancer, including blocking ovarian function, ovarian ablation, and temporarily suppressing ovarian function by treatment with drugs.  These medicines interfere with signals from the pituitary gland that stimulate the ovaries to produce estrogen.
Drugs called aromatase inhibitors are used to block the activity of an enzyme named aromatase, which the body uses to make estrogen in the ovaries and in other tissues.  Aromatase inhibitors are used primarily in postmenopausal women because the ovaries in premenopausal women produce too much aromatase for the inhibitors to block effectively.   However, these drugs can be used in premenopausal women if they are given together with a drug that suppresses ovarian function.
Several types of drugs interfere with estrogen’s ability to stimulate the growth of breast cancer cells.  Tamoxifen is one of them and has been approved by the FDA.   Tamoxifen has been used for over 30 years to treat hormone receptor-positive breast cancer.
There are three main ways that hormone therapy is used to treat hormone-sensitive breast cancer.   Research has shown that women treated for early-stage ER-positive breast cancer benefit from receiving at least 5 years of adjuvant hormone therapy.
Adjuvant therapy may include radiation therapy, a combination of chemotherapy, and targeted therapy.
Until recently, most women who received adjuvant hormone therapy to reduce the chance of a breast cancer recurrence took tamoxifen every day for 5 years.  However, with the advent of newer hormone therapies, some of which have been compared with tamoxifen in clinical trials, additional approaches to hormone therapy have become common.  For example, some women may take an aromatase inhibitor every day for 5 years, instead of tamoxifen. Other women may receive additional treatment with an aromatase inhibitor after 5 years of tamoxifen.   And, some women may switch to an aromatase inhibitor after 2 or 3 years of tamoxifen, for a total of 5 or more years of hormone therapy.