Doctors Are Slow To Adopt Changes In Breast Cancer Treatment

Cancer doctors want the best, most effective treatment for their patients. But it turns out many aren't paying attention to evidence that older women with early stage breast cancer may be enduring the pain, fatigue and cost of radiation treatment although it doesn't increase life expectancy.

Researchers from Duke University Medical Center analyzed the impact of a large randomized trial published in 2004 that compared treatment options for women over the age of 70 with early-stage breast cancer. That study compared cancer recurrence and survival rates among women who had surgery, chemotherapy and radiation to that of women who had surgery and chemotherapy only.

While there was a slight decrease in recurrence of cancer in the group who had radiation, there was no difference in survival, thus raising the question of whether radiation treatment for this group of patients is worthwhile.

According to Dr. Rachel Blitzblau, a radiation oncologist at Duke University Medical Center and lead author of the study, which was published Monday in the journal Cancer, "we should consider omitting radiation for these women, because the small observed benefits might not be worth the side effects and costs."

Short-term side effects of radiation include skin blistering and fatigue. Long-term effects can include nerve damage and lymphedema, or swelling of the hand and arm.

Blitzblau and colleagues looked at practice patterns among cancer doctors, comparing the number of women who received radiation therapy prior to the 2004 findings and after. There was little difference, just a 7 percent drop in the number of women receiving radiation.

About 69 percent of patients treated between 2000 and 2004 got some form of radiation, compared with 62 percent 2005 and 2009.

"The publication of the trial had only a very small impact on practice patterns," she says, "our findings demonstrate the potential difficulty of incorporating clinical trial data that involves omitting a treatment that has been considered the standard of care." The study was published Monday in the journal Cancer,

It may be that doctors are simply uncomfortable suggesting that patients forego treatment even when high quality studies show little advantage, Blitzblau says, adding that it's important to improve "evidence-based medical practice in all medical specialties."

Breast cancer prevention drug gives lasting protection, study finds

Taking the cancer drug tamoxifen for five years drives down the incidence of breast cancer in women at high risk for the disease by close to 30%, researchers have found. And the medication's protective effects against breast cancer appear to last, unabated, for as long as 16 years after a woman stops taking it, a new study says.

The long-awaited IBIS-I trial (short for International Breast Cancer Intervention Study-I) found that tamoxifen was even more effective in preventing breast cancer in women who did not take hormone replacement medications. Women who took tamoxifen and did not take concurrent replacement hormones had a 38% decline in breast cancer diagnoses of any genetic variety over roughly 16 years of follow-up. And new diagnoses of estrogen-sensitive breast cancers -- the most common kind -- dropped by 45% among these women.

That means that for every 22 women who took tamoxifen for five years, there would be one fewer diagnosis of estrogen-sensitive breast cancer over a 20-year period. In an editorial published alongside the IBIS study, Rowan T. Chlebowski, a leading breast cancer researcher at Los Angeles BioMedical Research Institute, called that a "very favorable number."

This may be good news for the estimated 15% of women between the ages of 35 and 75 who have a roughly 20% lifetime risk of developing breast cancer (double the average woman's risk). While public attention has focused on prophylactic mastectomies, medications such as tamoxifen offer women at elevated breast cancer risk a vastly less drastic way to drive down the odds of developing such malignancies.

For young women with a family history of the disease, or who carry genetic variations such as BRCA-1 and BRCA-2, the findings are especially reassuring, said Jack Cuzick, an epidemiologist at Queens College London who is one the study's principal investigators.

Premenopausal women who take tamoxifen now can be assured that their five-year stint on the drug will confer substantial protection from developing breast cancer well into midlife -- and possibly beyond, said Cuzick.

Cuzick cautioned that it would take longer studies still to determine whether breast cancer "chemoprevention" actually drives down breast cancer deaths.

Only 5% of the 7,154 IBIS subjects -- who were between 35 and 70 at the study's start -- have died. The reduction in new cancer diagnoses during the study's roughly 16-year follow-up was "striking" among those who took tamoxifen, said Cuzick. But the possibility remains that the medication has merely delayed the appearance of breast tumors, and that those will rear up and claim the lives of tamoxifen-treated women at rates similar to their peers who never took the medication.

That's a possibility hinted at in the IBIS-I findings. Among the 3,579 women who took tamoxifen, there were 31 breast cancer deaths, compared with 26 among the 3,575 taking placebo. Whether that slightly higher breast cancer death rate is a fluke or stems from treatment "needs to be addressed," Chlebowski wrote in his Lancet editorial.

Tamoxifen has been prescribed for decades to prevent recurrence of breast cancer in women who have been treated for an initial case. It's thought to reduce first instances of breast cancers, and repeat cases as well, by blocking the action of the female hormone estrogen throughout the body.

Despite consistent evidence that the medication is effective in warding off first breast cancer diagnoses among women at high risk, very few such women take it while they are still healthy.

Women's widespread fears about side effects is partly to blame: in some, tamoxifen intensifies menopausal symptoms such as hot flashes and vaginal dryness. In the IBIS-I trial, as in everyday clinical practice, many women have sought out hormone-replacement therapy as an antidote to those side effects.

"Our trial shows pretty clearly that it's not a good idea" for women at high risk of breast cancer to take hormone-replacement medication, even if they're on tamoxifen, Cuzick said.

In recent years, researchers have shown that another class of medication that blunts estrogen's effects -- aromatase inhibitors such as exemestane, anastrozole and letrozole (marketed as Aromasin, Arimidex and Femara) -- drive down rates of breast cancer in older women, whose ovaries are producing little to no estrogen. A second medication that works in the same way that tamoxifen does -- the osteoporosis drug raloxifene (marketed as Evista) -- also drives down breast cancer incidence in women after menopause.

Those medications are better choices for postmenopausal women, said Cuzick, as they appear to be more effective and have fewer side effects than tamoxifen.

"But for premenopausal women, tamoxifen remains the only choice, and it is a good one," he said.

The IBIS-I study was published Thursday in the journal Lancet Oncology. The findings are also to be presented in San Antonio this week at the American Assn. for Cancer Research's Breast Cancer Symposium.

The IBIS-I trial did turn up a worrisome finding, although investigators are unsure of its significance. Women taking tamoxifen are at slightly greater risk of developing endometrial cancers while they are on the drug -- a long-recognized trend that has raised few concerns because such cancers tend to be slow-growing and readily treatable.

But in the tamoxifen arm of the IBIS-I trial, five women died of endometrial cancers (compared with no such deaths in those taking placebo), and all the deaths occurred after tamoxifen treatment had ended. While IBIS-I investigators said the finding could be due to chance, they warned that tamoxifen's links to endometrial cancers bear continued watching.

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Olli Maatta set to return after thyroid surgery

Pittsburgh Penguins defenceman Olli Maatta will play Tuesday night against Montreal, two weeks after undergoing surgery to remove a cancerous tumour from his thyroid.

The 20-year-old Maatta underwent surgery earlier this month at the urging of doctors, who detected it during a pre-season physical.

Maatta returned to the ice a few days after the procedure, and coach Mike Johnston says Maatta could have come back over the weekend but the team wanted to give him a few extra days to get his legs back.

Maatta says he just wanted to get the surgery over with so he could focus on hockey. Maatta has one goal and five assists in 10 games for the Penguins.

Vitamin D Deficiency Associated With Colorectal Cancer

A Scottish study of 1,598 patients diagnosed with stage I to III colorectal cancer (CRC) found an association between plasma concentrations of 25-hydroxyvitamin D (25-OHD) and CRC survival. 

The study (J Clin Oncol 2014;32[23]:2430-2439, PMID: 25002714) involved patients who were part of a larger national study identifying genetic and environmental factors in CRC. Blood was drawn after definitive surgical treatment (median time to sampling, 105 days), and samples were standardized to a single month (May) to adjust for seasonal differences in vitamin D. Total 25-OHD was measured by liquid chromatography/mass spectrometry, and blood leukocyte DNA was genotyped for polymorphisms at the vitamin D receptor (VDR) gene locus. 

The researchers reported that 49.7% of patients met the criteria for vitamin D deficiency (25-OHD <10 ng/mL) and 26.8% were at high risk for deficiency (10-16 ng/mL), thought to be the result of increasingly indoor lifestyles, as well as Scotland’s northern latitude.

Plasma 25-OHD levels were significantly associated with CRC-specific (P=0.008) and all-cause (P=0.003) mortality. Comparing CRC mortality between the one-third of patients with the highest 25-OHD levels and patients in the lowest tertile, the adjusted hazard ratio was 0.68 (95% confidence interval, 0.50-0.90; P=0.004). CRC-specific mortality reached 10% after 2.5 years for patients in the lowest vitamin D tertile and 6.6 years for patients in the highest tertile. These trends were similar for all-cause mortality.

A gene–environment interaction was found between increased 25-OHD levels and the presence of VDR variant rs11568820. The authors speculated that this variant might serve as a prognostic biomarker.

EXPERT INSIGHT

Celina Ang, MD 

Assistant Professor of Medicine, Hematology and Medical Oncology

Mount Sinai Health System

New York, New York

Although seemingly less sophisticated than contemporary molecularly targeted agents, vitamin D boasts an expansive and versatile repertoire of biologic activities. Typically known for its role in maintaining bone health and calcium homeostasis, vitamin D also has been shown to have antiproliferative, pro-apoptotic, pro-differentiative, anti-inflammatory and antiangiogenic properties, which have generated interest in its utility as an antineoplastic agent.  

In this observational study, investigators reported a significant inverse relationship between 25-OHD concentrations and CRC mortality, with a 32% reduction in risk for death among patients with the highest compared with the lowest 25-OHD concentrations. Of note, the relationship was most pronounced among patients with stage II CRC and those who did not receive chemotherapy. The findings are even more remarkable considering that the differences were seen at concentrations that would be considered deficient (<20 ng/mL), as well as the relatively small differential (6 ng/mL) separating the highest and lowest concentration categories. This suggests that even greater benefits may be achieved with vitamin D sufficiency. 

The study adds to the growing body of data suggesting that vitamin D plays a protective role against CRC, although it remains to be determined if there is a true cause-and-effect relationship between vitamin D status and CRC outcomes. Several questions deserve further evaluation. First, will correcting vitamin D deficiency improve survival and lower the CRC mortality in this patient population? Second, given the observation that the protective effects of high 25-OHD were greater in those who did not receive chemotherapy than in those who did, is there a negative interaction between chemotherapy and vitamin D, and can this be overcome by supplementation? Third, do current guidelines for vitamin D supplementation in the general population apply to patients with CRC? Fourth, given the strong prognostic effect of vitamin D status in the stage II subset, should 25-OHD concentrations be considered in risk-stratifying these patients to determine whether adjuvant chemotherapy should be given? Finally, what is the role of VDR polymorphisms in modulating response to vitamin D supplementation and chemotherapy?  

In summary, vitamin D supplementation appears promising as a relatively low-risk therapeutic adjunct for CRC with broader health benefits. However, additional studies are needed to ascertain its precise role in the management of this disease.

A medical student develops an illness she has been studying

We had just finished our endocrine unit when I noticed a lump in my neck. Perhaps school had made me more vigilant, or perhaps I merely fell into the realm of hypochondriac medical student, but I couldn’t ignore this lump.

I set up an appointment with my doctor, fully expecting a diagnosis of what’s sometimes called medical student neuroticism. Instead, she agreed that it was a peculiar lump, and though she believed that it would ultimately prove to be nothing, she was ordering some tests just to be conservative and careful. I approached the tests as an educational experience, something that would make for a good story.

And then one day as I was studying in the library, I found I was having a hard time focusing on anything but the lump. I felt an overwhelming need to check the results of the ultrasound that had been done, so I shakily typed in my password to access the test results; I scanned the radiologist’s note until I landed upon the words “biopsy recommended.” I guess I hadn’t realized just how much I had compartmentalized the experience until I read those words over and over again. With my face red from crying (and embarrassment over my public display of emotion), I quickly gathered my things and ran home. Do I tell my father? Do I tell my friends? It could still be nothing.

I just wanted it to be nothing.

A patient’s worst nightmare

The first two years of medical school, the preclinical years, teach students about disease in the abstract, as testable material. We detach ourselves from reality as we memorize a constellation of symptoms and treatments presented from a podium or a textbook. I have been guilty of occasionally forgetting that what I am studying may be a patient’s worst nightmare.

“We ask patients to take on risks in order to heal,” Cherie Fathy writes, “but we should never forget how overwhelming it is to hear those risks or to play those odds.” (Courtesy of Cherie Fathy)

As students on the wards, we see mere snapshots of our patients’ illnesses. We are there as patients receive a diagnosis in the clinic or a treatment in the hospital. What we don’t see is a patient at home deciding whether that lump is even worth checking on or a mother dreading when to tell her children what she has, or how to even begin telling them.

A full two months after my initial doctor’s visit, time that was filled with scans and biopsies, I received a phone call that confirmed my worst fear. I had thyroid cancer. The news shattered my sense of invincibility that, as a 20-something, I had taken for granted.

Almost 63,000 people will be diagnosed with thyroid cancer in 2014, according to the National Cancer Institute. As a student, I had seen its gross pathology, studied its microscopic appearance and even constructed mnemonics to commit the signs of the disease to memory. I quickly learned that the 10-minute lecture we had on thyroid cancer left out quite a bit of detail, and now those details were personal.

When I sat in front of my surgical oncologist for the first time, I had just experienced one of the most radical shifts in my life. He told me that my treatment would include removing my thyroid gland and any affected lymph nodes, and this would be followed by a radioactive iodine treatment. The radiation was in the form of a pill that directed radiation to my thyroid cells, destroying any that may have spread to other parts of my body. The only stipulation was to stay away from others for at least a week while I was radioactive.

How do I do this?

In that moment, my fears transformed from prepping for my next exam to wondering, “How do I even begin to balance school with doctor’s appointments, surgery and radiation, and how do I stay strong for my family members, while internally processing this diagnosis?”

My type of thyroid cancer has around a 95 percent long-term survival rate. Knowing that did little to quell the emotional haze that set over me. Ironically, I still remember the first time I heard this number. Our professor held up a thyroid specimen and pointed to the cancer, stating, “If you ever get a cancer, this is the one you want.” At the time, I found that tremendous. Almost everyone lives! Now, I struggled to find solace in those words.

You see, patients will play odds and measure risk in very different ways than we may expect them to as physicians. In my mind, I was already the one person out of 10 who did not have a benign thyroid nodule. That I was the one person out of 10 made me look at almost every situation through a lens of “what if’s.” I constantly feared that any rare side effect would become a reality for me. Who’s to say I wouldn’t acquire a rare complication such as chronic swelling and tenderness of my salivary glads or the rumored increased risk of a secondary blood cancer from radiation exposure? What if I lose my voice because of the surgery? As a medical community, we ask patients to take on risks in order to heal, but we should never forget how overwhelming it is to hear those risks or to play those odds.

‘At least it’s thyroid cancer’

Perhaps one of the most isolating experiences came from the number of times I heard “at least it’s thyroid cancer”or “it’s so treatable” from my classmates and professors. And yes, even during my short time on the wards, I had seen patients undertake much bigger battles against cancer or other illnesses, but any illness can be a trial of a patient’s will, courage or sense of safety.

The day after Christmas a year ago, I was scheduled for a whole-body tumor scan. It was about two months after my surgery and two weeks after finishing my radioactive iodine therapy; I was ready to be done with this chapter of my life. As I braced myself against the cold metal table, the radiology tech explained that the process would take about a half-hour. If they found anything irregular or concerning, they would set up the machine for more imaging.

I gave a quick wink to my dad, who was sitting beside me, hoping to reassure him (and myself) that all would be fine. As the machine rumbled, a pixelated image of my body showed up on a screen above my head. The erratic twinkling of lights caught my attention. As parts of my body lit up, I prayed under my breath that the cancer hadn’t spread. I shut my eyes and avoided the screen until I heard the tech reenter the room.

“We think we’re going to go ahead with the second set of imaging.” I felt gutted and incredibly vulnerable at that moment. Any sense of control I thought had over this tumor, this saga, dissipated with that statement. I didn’t have the strength to look at my father before the second go-round. I just shut my eyes and dreamed about anything. Anything but cancer.

Several months have passed since I was lying under that CT scanner. I had spent the rest of that day furiously checking and rechecking my medical records to find the results of the scan. Eventually, I retreated from my efforts, realizing that there wasn’t much I could do even if I had those results. It wasn’t until I received a letter from my physician a couple of days later stating that the scan had been fine and detailing plans to reassess in a year that I started to feel as though I could begin to put this story behind me. That was a powerful feeling.

Moving on

I’ve returned to my life as a medical student, spending most of my days with patients facing diagnoses that range from a simple cold to terminal cancer. I’ve also had the honor of scrubbing into and assisting with thyroid cancer surgeries to see how they are done. I wish I could say that my experience last year has revolutionized how I speak with sick patients, that I always know exactly what to say or when to say it. But I don’t.

My brush with cancer has, however, humbled me in my interactions with patients. I try never to assume that just because I know the medical facts, I understand how a patient is going to interpret them. Especially with a disease such as thyroid cancer, in which there is a high survivorship, there is a fine line between reassuring patients about their prognosis and unintentionally minimizing their concerns about a cancer diagnosis.

As medical students, we undergo this rapid and major transition from textbook learners to active participants in patient care, from learning about illness to dealing with it in real life. In a textbook, the workup of a patient’s illness looks swift and sequential. In reality, it can take weeks or months from the first time a pathology is noted to when a patient receives an actual diagnosis. And that time of uncertainty can be debilitating. Despite knowing the incredibly high percentage of people who survive thyroid cancer, I still experienced all the fear, anger and dread that can accompany any illness. Because, ultimately, learning about a disease is incredibly different from living it.

Fathy is a third-year medical student at the Vanderbilt University School of Medicine in Nashville. A version of this article was published by KevinMD.com.

6 self-help tips for hemorrhoid flare-ups

Getting older has its benefits—and its drawbacks. Included in the latter are hemorrhoids. These swollen blood vessels on the outer rectum and anus can turn bowel movements into intensely painful experiences. Classic symptoms include rectal pain, itching, bleeding, and possibly prolapse (protrusion of hemorrhoids into the anal canal). Although hemorrhoids are rarely dangerous, they can be a painful recurrent bother.

Hemorrhoids come in two varieties. The internal type sprout from within the rectum. External hemorrhoids develop on the anus itself. Either way, stools passing by them can cause pain and bleeding.

But simple self-help measures can ease the ordeal of most hemorrhoids and allow healing. In this month’s Harvard Men’s Health Watch, I asked Dr. Jacqueline Wolf, a gastroenterologist and associate professor of medicine at Harvard-affiliated Beth Israel Deaconess Medical Center, about effective steps you can take to care for hemorrhoids—and when it’s time to seek out a procedure to remove them.

Here are six self-help tips:

Step up the fiber. “The most important thing is to add fiber to your diet,” Dr. Wolf says. This is best done with food, but some people find they need to take a fiber supplement to get 20 to 30 grams of fiber per day. To start, try a psyllium husk fiber supplement, such as Metamucil or a generic equivalent. If psyllium causes gas or bloating, try a supplement containing wheat dextrin or methylcellulose.

Lubricate the process. Mixing a tablespoon of mineral oil with applesauce or yogurt and eating it at breakfast or lunch allows stool to slide by the hemorrhoid more easily. But don’t do this for a long period, cautions Dr. Wolf. (if you try this, you may want to place a liner in your undergarments to absorb any oil leakage.)

Don’t delay. When you feel the urge, go to the bathroom immediately; don’t wait for a more convenient time. Putting off bowel movements can worsen constipation, which then aggravates hemorrhoids.

Try elevation. Elevating your feet a bit with a step stool as you sit on the toilet changes the position of the rectum in a way that may allow for easier passage of stools.

Off-the-shelf remedies. Over-the-counter products are available for hemorrhoids. These include witch hazel infused pads and soothing creams, like the iconic brand Preparation H and its generic equivalents. If these don’t work, ask your doctor about prescription preparations.

Sit in a sitz. Don’t overlook the relief offered by sitz baths. Using a basin that fits under the toilet seat, soak the inflamed area in warm water for 10 to 15 minutes, two to three times a day.

Time for hemorrhoid removal?

If hemorrhoids persist no matter what steps you take to make them go away, or they begin to bleed, interfere with bowel movements, or make life difficult, ask your doctor about medical procedures to remove or reduce hemorrhoids. Two minimally invasive techniques—rubber-band ligation and laser, infrared, or bipolar coagulation—shrink internal hemorrhoids. Some people need surgery (hemorrhoidectomy) to take care of the problem.

She says breast cancer was like ‘a normal sickness’

Jennifer Cook’s breast cancer episode has earned her Pied Piper status.

“I can’t believe how many (friends and associates) have come to me and said they’re getting their mammograms, now, ‘because of what I’ve learned from you,’” said Cook, 43, of St. Louis.

Cook recently finished her last round of radiation therapy for stage 2 breast cancer discovered in July. After surgery in August, she was back in church a couple of weeks later.

The ordeal wasn’t easy, but it wasn’t so difficult as it used to be, she said.

She had her annual mammogram in July. It indicated tumors in her left breast.

Her mother and aunt had breast cancer, so with that family risk, she had been having checkups every year for about five years, she said.

This year, she put it off for about three months. The widespread cancer already at stage 2 surprised her a bit, but she took it in stride, she said. With her family history, it wasn’t unexpected.

Dr. Julie Margenthaler, Cook’s surgeon, said that in younger women — the 40-year-old range — small tumors may be difficult to see in a mammogram, a specialized imaging machine that picks up cancer by measuring contrasts in tissues. “It can be like finding a snowball in a snowstorm,” Margenthaler said.

After some long discussions about her condition, Cook weighed the options, she said. She decided on a double mastectomy to remove the worry for the rest of her life.

“I had too many friends and friends of friends, who’d had similar situations,” she said. “I didn’t want that looming over me. I just thought as a woman, I wanted to eliminate even possibility.”

Margenthaler said Cook’s cancer was common. How women react emotionally and physically, “… is very individual,” she said. Treatment can be a few weeks or up to a year depending on a lot of elements, she said.

For Cook, “It was like this was a normal sickness; we’ll take care of it,” she said. “It wasn’t easy, but there was no feeling like this was a death sentence.”

This wasn’t her mother’s breast cancer episode, she said. Her mother wrestled with physical and emotional problems with her breast cancer decades ago.

“She has never been happy with the results of her treatment,” Cook said.

Cook said she didn’t face those problems.

What helped was she had the cancer surgery and reconstructive surgery at the same time, she said. “I never had time to have the fear; with doing it all at the same time I’d never even notice too much of a difference.”

Still, she said, she would have had the cancer surgery even if reconstruction hadn’t been an option.

The cancer also wasn’t scary because, “so much is out there, so many people are out there recovering or going through it, tackling it day by day; you don’t really have a choice,” she said.

At-home test could help detect colon cancer earlier

KUSA – There's a simple test that you can do at home to prevent one of the most common cancers in the country.

The Cologuard is the first and only FDA-approved noninvasive stool DNA screening test for colorectal cancer.

After it is prescribed to a patient, it is mailed to their home. The patient collects a sample in the provided container, and sends it back to a lab for analysis.

The patient's doctor gets the results in as little as two weeks.

The test costs $599 out of pocket, but is covered by Medicare.

American Cancer Society screening guidelines call for men and women at risk for the disease to get a screen when they turn 50. Nevertheless, 23 million Americans over that age do not get screened for colorectal cancer.

The five-year survival rate for colon cancer caught early is 12 percent, as compared to more than 90 percent for those who catch it early.

9NEWS reporter Taylor Temby spoke with Dr. Christopher Lieu, the director of Colorectal Medical Oncology at the University of Colorado Hospital, about the procedure.

Watch the video above for her interview.

To learn more, visit http://www.businesswire.com/news/home/20141125006043/en/Exact-Sciences-Announces-Final-Payment-Decision-Cologuard%C2%AE#.VISs1zHF98H

(KUSA-TV © 2014 Multimedia Holdings Corporation)

New test to diagnose thyroid cancer

FRESNO, Calif. (KFSN) --

Thyroid cancer is the most rapidly increasing type of cancer in the U.S, with 63,000 new cases diagnosed in the past year. Traditionally, doctors diagnose thyroid cancer with a fine needle biopsy -- a painful procedure that is only accurate 50 percent of the time -- meaning additional surgery for some patients. Researchers have developed a new test that improves diagnosis -- the first time around.

Kris Provence, 38, is an avid outdoorsman. But when Kris discovered a lump in his neck earlier this year, it stopped him in his tracks.

"The first word I thought of was cancer. And that scared me to death," Kris Provence told ABC30.

Kris tested positive -- but the numbers were on his side. Thyroid cancer has a 97 percent five-year survival rate. Also in his favor -- a new diagnostic tool.

Dr. Linwah Yip has studied the use of a molecular testing panel researchers say improves diagnosis by 30 percent.

"We take the cells from the biopsy and we actually put them through genetic testing -- looking for mutations or gene changes that are often found in thyroid cancer," Linwah Yip, M.D., Associate Professor of Surgery, Surgical Oncologist and Endocrinologist at UPMC told ABC30.

Before molecular testing, patients who had unclear results after a biopsy needed surgery to remove half the thyroid. Then if doctors found cancer, a second surgery would be necessary

Doctors say the molecular panel reduces that burden.

"It saves them time off of work. It saves them trips to the hospital -- additional testing if we need it," said Dr. Yip.

One surgery, and months later, Kris is cancer-free.

"I feel like a million dollars," Provence said.

Doctor Yip says surgeons don't automatically remove the entire thyroid unless cancer is confirmed because the patient would then become dependent upon thyroid medication for the rest of his life. While the molecular testing is not the gold standard for diagnosis, yet, the American Thyroid Association has changed its guidelines to add that doctors may consider using the molecular "markers" when the initial biopsy is inconclusive.

For more information on this report, please contact:

Allison Hydzik
UPMC
412-647-9975
hydzikam@upmc.edu

Thyroid cancer in kids

PHILADELPHIA, Pa. (Ivanhoe Newswire) – Thyroid cancer is the fastest growing cancer in the United States, and it's being diagnosed more often in younger patients. Previous data found the age group seeing the largest increase was white, teenage girls. But the most recent study shows it crosses all genders and races. Since this is a cancer that has few early symptoms, experts say it's especially important that parents know what to look out for.

The McCarthy kids are always moving, especially four-year old Chloe. That's why her parents never suspected something was wrong until two years ago.

“Well actually, my husband was playing with her, like you do a normal one and a half year old. Dip them upside down, bring them back, and when he pulled her up, her head was back and he saw the lump in her neck,” Chloe's mother, Lauren McCarthy told Ivanhoe.

Images showed Chloe's one thyroid gland was three times its normal size. It was cancer. Doctors removed all of the thyroid tissue.

Doctor Andrew Bauer says thyroid cancer in kids under 10 is rare, about five cases per every million, but at age 15, those numbers jump to 18 per million.

“In adolescents, it's actually quite similar to non-Hodgkin's lymphoma, which many people have heard of before,” Andrew Bauer, M.D., Pediatric Endocrinologist and Medical Director of the Thyroid Center at the Children's Hospital of Philadelphia explained to Ivanhoe.

Experts say most parents aren't aware that thyroid cancer can and does strike kids.

“They don't have any pain. They don't have weight loss,” said Dr. Bauer.

Doctors say parents should check kids for swelling or lumps in the neck. Don't skip routine check-ups, where doctors will examine neck glands.

Chloe McCarthy is cancer-free. Her parents are happy they can put this behind them.

“It's not something that we thought to look for,” McCarthy said, “It's nice to keep an eye on everything on your child.”

Doctor says with early diagnosis and treatment kids have a 95-percent chance of surviving thyroid cancer. Experts aren't sure why there has been an increase in thyroid cancers, but they say previous exposure to radiation is a risk factor.

Blood tests or ultrasound can sometimes detect changes in the thyroid, but experts say those are not recommended unless the physical exam is abnormal or a patient is at high risk, possibly because another family member has had thyroid cancer.

BACKGROUND: Thyroid cancer is the third most common solid tumor malignancy and the most common endocrine malignancy in children. The two most common types of pediatric thyroid cancer are differentiated thyroid cancer, which includes papillary and follicular thyroid cancer and their variants. Papillary thyroid cancer is the most common type in both children and adults. The second is medullary thyroid cancer in which approximately 30-percent to 35-percent are familial tumors transmitted by a gene from either the mother or father. Risk factors that can cause pediatric cancer can include occurrences in family history, radiation treatment, or radiation fallout, as discovered in increased thyroid cancer rates after the 1986 Chernobyl disaster. Although not fully understood, females tend to develop thyroid cancer more than males after puberty; the risk is equal for children, male and female, under the age of 10. (Source: http://www.entnet.org/content/pediatric-thyroid-cancer, http://www.thyca.org/pediatric/about/, http://www.everydayhealth.com/thyroid-cancer/pediatric-thyroid-cancer.aspx)

TREATMENT: Because children have a much greater chance of having thyroid cancer spread to other parts of the body, a removal of the thyroid, or total thyroidectomy, is the standard-of-care. If there is suspicion that the cancer has spread to the lymph nodes in the neck, these may be removed surgically as well. If there are any cancerous cells remaining after surgery, radioactive iodine therapy may be utilized. Thyroid hormone therapy may also be needed to replace normal hormones needed for a child's growth. These hormones include: thyroxine and triiodothyroxine, which help with growth and metabolism, and calcitonin which decreases calcium in the blood and increases it in the bones. Chemotherapy and radiation are also options depending on the type of thyroid cancer, or may be used as treatments to shrink tumors.(Source: http://www.entnet.org/content/pediatric-thyroid-cancer)

FOR MORE INFORMATION ON THIS REPORT, PLEASE CONTACT:
Ashley Moore
(267) 426-6071
Moorea1@email.chop.edu

If this story or any other Ivanhoe story has impacted your life or prompted you or someone you know to seek or change treatments, please let us know by contacting Marjorie Bekaert Thomas at mthomas@ivanhoe.com

Andrew Bauer, M.D., Pediatric Endocrinologist and Medical Director of the Thyroid Center at the Children's Hospital of Philadelphia (CHOP), talks about thyroid cancer in kids.

Interview conducted by Ivanhoe Broadcast News in September 2014.

Tell me a little bit about the increase that doctors are seeing in thyroid diseases, and specifically a thyroid cancer in children. Has there been a sharp increase over the last 5 years, 10 years?

Dr. Bauer: Over the last 10 years there's been an increase rate of diagnosis for both thyroid nodules and thyroid cancer, specifically differentiated thyroid cancer, in both adult and pediatric patients. For the majority of patients we do not reason for this increase has not been determined, however, we do not know why either develops, however, there are several risk factors that explain some of the increased rate. We know that exposure to radiation is a predisposing factor, most commonly for the treatment of a previous, non-thyroid related cancer, and we know that there are an increasing number of familial disorders where thyroid cancer can be part of the tumor predisposition syndrome. However, for the remainder of patients that do not have these risk factors, parents need to understand that there isn't anything that could have done to prevent these tumors from developing. In addition, the most important point is that no matter how a patient is diagnosed with a thyroid nodule, whether my physical exam or as an incidental finding on an unrelated radiology study of the head and neck, they need to go to a center where they can obtain a complete evaluation to determine if the thyroid nodule is a benign lesion or something that's more concerning that needs further evaluation and management.

Are you able to give me some statistics just to give us some context? Just how many pediatric cancer-thyroid cancer patients are there in the United States?

Dr. Bauer: The incidence of thyroid nodules in pediatrics has not been well studied. If you look at age distribution by the time we're 60 years old about 50% of us will have some type of thyroid lesion, a thyroid nodule a thyroid cyst. Fortunately for adults only 5-10% of these will be thyroid cancer. In addition to an age predisposition there is also a gender predisposition; females are more at risk of being diagnosed with a thyroid nodule than men are. Within pediatrics (patients < 19 years of age) the incidence of thyroid nodules is not as clearly defined. The most informative study to date looked at about 1200 head and neck ultrasound studies from patients < 19 years of age and found that 15% had a thyroid abnormality (cyst, nodule, thymic tissue…) of which 17% were thyroid nodules; a total of 9 out of 1228 studies, or 0.7%. This may not sound like a lot, however, if you consider that there are 319 million people in the United States, 27% of which are less than 20 years old, then up to 600,000 patients less than 20 years may have a thyroid nodule. In contrast, only 1 to 2% of patients will be found to have a thyroid nodule detected by physical exam. So, as I mentioned before, it turns out that no matter how you find a thyroid nodule, it is more important to determine what the nodule feels like on exam, and what it looks like on ultrasound imaging, then how the nodule was discovered in regard to deciding if the nodule should undergo fine needle aspiration biopsy (FNA). A complete and accurate evaluation when a nodule is found in a child or adolescent is critical as up to 20% of nodules may be thyroid cancer (4-5x risk compared to adults). Within this group, for both adults and pediatrics there has been some discussion of whether small, incidentally or serendipitously discovered nodules may be ‘subclinical'; a cancer that was not going to growth or spread, a cancer that the patient could have lived a full life with and died of old age rather than from the cancer. Unfortunately, it is hard to predict how the cancer is going to behave, so, we often approach care conservatively, not trying to put patients through too much as far as evaluation and treatment but also balancing that they have a long life ahead of them and treating it now may be associated with a better outcome and less anxiousness than leaving it in place. On a national basis, the National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results Program (SEER) database reports that about 63,000 adults, about 130 per million adults, will be diagnosed with thyroid cancer in 2014. Within pediatrics about two to five per million children under age 10 years and up to 18 per million adolescents will be diagnosed with thyroid cancer. That sounds like a relatively small number but I try to steer away from calling this a ‘rare' cancer because it isn't rare if you're the person with the diagnosis. To put the number in context, the number of adolescent patients diagnosed with thyroid cancer is similar to the number diagnosed with non-Hodgkin and Hodgkin's lymphoma, cancers that many people have heard of before. A recent report published by the American Academy of Pediatrics reports that between 2001 to 2009 there was a 5% annual rate of increase in incidence for thyroid cancer, the cancer with the second greatest increase in the rate of diagnosis.

Give me some indication of symptoms, or what parents could watch out for?

The majority of patients are asymptomatic at the time of diagnosis, even patients where the cancer has spread to lymph nodes in the neck, which happens in about 50 to 70-percent of pediatric thyroid cancer patients. This is in contrast to other cancers where patients often have had weeks or months of not feeling well and then they discover the diagnosis as an explanation for why they felt so terrible. For both, the news is difficult, but for our thyroid cancer patients, the patients and families are a bit blind-sided and it is one of the hardest parts of the discussion; ‘how can I have cancer and still feel so well'? Even for our patients that have ‘bulky' disease, where the spread to the lymph nodes in the lateral neck can be seen on physical exam, most of the patients don't feel a lump when they're swallowing, they don't have any pain, they don't have weight loss, they don't have any symptoms, it's just that somebody a parent, another provider, a teacher, a friend or themselves discover that when they looked up or they look to the side there is a lump in the front of the neck or lymph nodes that are persistent and not going away. Swollen glands are a very common finding in children, most are secondary to an upper respiratory infection, but for patients with lymph nodes that are not going away, thyroid cancer should be considered as a potential cause.

Let's talk a little bit about prognosis. Is thyroid cancer in pediatric patients a slow growing cancer?

Dr. Bauer: What I usually try to explain to patients and their families is that the good and the bad part of (differentiated) thyroid cancer is that it is usually a slow growing cancer. This is a good thing because the slow growth is typically associated with a high likelihood of being able to surgically remove the cancer and an excellent prognosis. In fact, surgery is the most important part of treatment (and outcome) but one needs to ensure that the ‘right' surgery is performed by the ‘right surgeon. An endocrinologist that regularly manages pediatric patients with thyroid cancer serves as the ‘gatekeeper', the manager of care, ensuring accurate pre-operative staging is completed, that patients are referred to a high-volume thyroid surgeon, and that post-surgery staging and surveillance be put in place to ensure the appropriate use of medical treatment, to include if and/or when patients may benefit from radioactive iodine treatment. Regionalization of care, especially for pediatric thyroid cancer is critical to ensure that > 95% of pediatric patients with thyroid cancer go on to live happy, healthy and productive lives with the lowest risk of complications from therapy.

How do you give radioactive iodine?

Dr. Bauer: It's a pill given as a single dose. For young patients, a liquid preparation can be special ordered. The radioiodine (RAI) is absorbed by the cancer cells and the unabsorbed amount of radioactive iodine is removed through the gastrointestinal and urinary system. We use two tests to determine if a patient may benefit from receiving RAI; a blood test to look determine the level of a thyroid specific protein thyroglobulin (abbreviated Tg) and a imaging study called a diagnostic whole body scan. These tests allow us to determine if there is any thyroid cancer left after surgery and, based on the amount and location, if and how much radioiodine to administer. Two weeks prior to these tests patients stop their thyroid hormone replacement and start a special low-iodine diet in order to optimize the evaluation and potential treatment. RAI is colorless and odorless and is cleared from the body over 2 to 5 days after a dose. So patients and family members are educated and provided directions in order to increase clearance from non-thyroid tissue and to avoid exposure to other family members. Patients are considered for repeat RAI if there is evidence of persistent disease that is growing and cannot be removed surgically. This is usually 12 or more months after a previous RAI dose. This is the touch part of treatment that I mentioned earlier, the ‘bad' or difficult part is to be patient in an effort to determine if and/or when additional therapy is needed even when the blood test (Tg) suggests that all the cancer many not have been eliminated. Our patients and families need to be lifelong partners with us and to be patient. We wait as long as possible between treatments in an effort to see how much we get from each surgery and/or dose of RAI. People want immediate resolution of the cancer, to achieve cure as fast as possible. This may happen in 3 months for some, but 18 months or longer for others. For a cancer that grows slowly, and is not associated with high mortality, we work to balance and individualize how and/when additional treatment would be beneficial.

You mentioned that you are not sure why children and adolescents develop this kind of cancer, why it seems to happen more in adolescent girls, and why the increase in the number of children being diagnosed; could it be hormone related?

Dr. Bauer: That's a reasonable guess and a research area of interest that I have as far as trying to figure out why females are diagnosed more than men and girls more than boys in the pediatric age. Saying that estrogen must be related seems to be pretty obvious but the reality is that we don't have the data to say that estrogen is an absolute and/or how it may be related to allowing a cell to become cancerous and behave in regard to treatment. As an example, there are data that thyroid cancer is more aggressive, less responsive to therapy, in older patients and in men. So, we really need to increase how much time and money we are investing into figuring out why thyroid cancer develops during the pediatric age, if there are things we could change in our environment to decrease the risk of it developing it, and to find markers to predict how the cancer will behave and respond to therapy in an individual patient.

Is there anything I didn't ask you that you think is important to know?

Dr. Bauer: I think we've touched on a lot of the important aspects. The only other recent item that is of interest is the recent movie that is based on two teenagers with cancer, the boy with bone cancer and the girl with thyroid cancer that spread to her lungs.

Is the movie increasing awareness for pediatric thyroid cancer?

Dr. Bauer: I haven't seen the movie yet so I'm at a disadvantage, but my daughter and several of our patients that have seen it describe that it is based on a patient that had thyroid cancer and then developed ‘lung cancer'. The reality is that the movie is based on the true story of a strong, independent and very engaging girl that had papillary thyroid cancer that had spread to her lungs, a site for metastases that happens in about 15 percent of our patients that have significant spread to lymph nodes in the neck. So, it is not ‘lung cancer' it's thyroid cancer in the lungs. For the majority of pediatric patients when the cancer spreads to the lungs it continues to absorb iodine so that we can use radioactive iodine to treat the cancer. About 20-30% of patients develop stable lung disease that does not grow but we can't get rid of it, and less than 5% develop disease that no longer absorbs iodine. So, overall, even for patients with metastasis to their lungs, the long-term outcome is excellent. Sadly, Esther (Grace Earl), the patient that the movie is based on, developed progressive lung metastasis that did not absorb radioactive iodine and despite excellent care and amazing strength it continued to grow and she died from thyroid cancer. So, the wonderful part of the movie is that it is based on the life of someone all of us would be proud and humbled to have known and cared for. The difficult aspect of the movie is that it reminds us that cancer is cancer and we don't have all of the answers. The movie helps raise awareness that there are no good cancers, that even patients that enter remission after one surgery and one treatment of RAI still had cancer and we have an obligation to figure out why it developed and what we can do to improve diagnosis, improve our ability to predict prognosis, and to ensure patients are cared for in centers with expertise in an effort to reduce complications.

Have you found that with establishing a thyroid center, how it helps to have that expertise when you're dealing with something like this? You mentioned it's a partnership.

Dr. Bauer: Having the Children's Hospital of Philadelphia invest in creating a thyroid center has been very rewarding. The center includes about 7 different divisions but with only 1-2 providers from each division. This affords improved communication and improved care, from diagnosis to treatment. To provide appropriate care, you need expert endocrinology, oncology, surgical care, radiology, pathology, ophthalmology and behavioral health all in the setting of a pediatric hospital. The endocrinologist has to be able to identify patients at risk, to perform an accurate exam, and to review the ultrasound images in order to decide who may need to have a biopsy. You need to set up a system where the biopsy is performed in an environment where the patient is comfortable and that the likelihood of an adequate sample and accurate diagnosis is ensured. You have to have a pathology that can examine the cells and decide if they look like cancer cells or whether they look benign (not cancer). You need to have 1 to 2 surgeons that perform thyroid surgery regularly to ensure that as much of the cancer is removed as possible with the least risk of complications. Ideally, thyroid surgery should only be performed by a surgeon that is performing 30 or more thyroid surgeries per year. After surgery, your pathologist needs to determine what type of cancer it was, whether papillary thyroid cancer (the most common), follicular thyroid cancer, their variants or medullary thyroid cancer. Then the endocrinologist has to work with the nuclear medicine physician to decide if RAI would be beneficial, and, last the endocrinologist also needs to manage the surveillance plan to determine when a patient is in remission, to follow normal physical growth and development, and to decide if and/or when additional treatment is necessary. Oncology is a nice addition to help screen high-risk populations and to help manage patients that develop disease that may benefit from targeted chemotherapy that is not responding to the standard approach to care. So, the advantage of having a thyroid center that is organized around this structure, that ensures regular communication between team members across divisions, cannot be over stated or overemphasized. In addition to our monthly tumor board we are in constant communication. Our nurse coordinators ensure a single path to access care and to ensure timely response to calls and we arrange our endocrine clinic to coincide with the clinics of our two surgeons, Dr. N. Scott Adzick and Dr. Ken Kazahaya. For patients that travel from out of town, we can coordinate evaluation and surgical treatment for the same week. Most endocrinologists have experience with medical treatment of Graves' disease (hyperthyroidism), congenital hypothyroidism and acquired hypothyroidism. But, with a higher volume, and providers that have been afforded an opportunity to focus their clinic time and research on thyroid disease, the center provides greater expertise to evaluate and manage typical thyroid disorders and to determine and care for patients that don't follow the plan, don't follow the what our textbooks describe as the usual course.

About the patient we're going to see tonight can you tell us about her condition? Is she four years old?

That's really young isn't it? I mean teenagers are young to me too, but to have somebody in that age, under ten years?

Dr. Bauer: Yes, you're right. For children that are prepubertal, and even preschool age, the likelihood of having the most common thyroid disorder, congenital hypothyroidism is about one in 2,000. Every State in the United States screens newborns for this disorder. However, this is the least common age group for patients to be diagnosed with thyroid nodules and thyroid cancer. There are some tumor syndromes that can present in this age group, the most common being multiple endocrine neoplasia type 2 (MEN 2) where there is a very high risk of developing a form of thyroid cancer that does not absorb radioiodine called medullary thyroid cancer (MTC). There are also some patients that are referred for evaluation of a thyroid nodule and it ends up that they have a variation of development where a piece of thymic tissue is located within their thyroid gland, in addition to the remainder of the thymic gland being in the chest cavity, the normal location. But, although less common, patients in this age can develop true thyroid nodules and thyroid cancer, at times cancer that is very invasive. Chloe had follicular thyroid cancer (FTC) which is another form of differentiated thyroid cancer. It is much less common across all ages and within a prepubertal child it's really very uncommon. She had a large nodule, four centimeters in size that was initially discovered by her pediatrician. It was a good pick up by someone doing a thorough exam. Her initial surgery was not performed at CHOP and was limited to only removing ½ of the thyroid gland. When the family came to us the question they asked was what should we do now that we've found thyroid cancer, should we have another surgery to remove the remaining thyroid tissue and does she need reactive iodine? We talked to the family and decided that a completion thyroidectomy, doing the second surgery, was important as it would allow use to use the lab tests, the thyroglobulin (Tg) level to follow her and then decide if radioactive iodine may be of benefit. So, while none of us were excited about the second surgery, we were comforted that the complication rate was low as one of our two thyroid surgeons was performing the surgery in a pediatric hospital with the expertise to care for a 4yr undergoing surgery. Dr. Adzick completed the surgery and performed an oncologic thyroidectomy, removing all of the remaining thyroid tissue. Her Tg level post-surgery has been undetectable, so, as of now, it appears that we have achieved surgical remission without needing to use radioactive iodine, a huge benefit to Chloe. So, that's one example of the advantages of going to someplace that sees patient with less common disease more frequently and another reason to support creating regional centers for care. It's the only way you can increase the expertise and optimize caring for patients with less common diseases. As far as other patients Chloe's age, we care for patients with all forms of thyroid disease, from congenital hypothyroidism, to hyperthyroidism, thymic tissue in the thyroid, thyroid nodules, and several patients with thyroid cancer that has spread to lymph nodes in the neck and to their lungs. Less common than in adults, less common than in teenagers, but, it really does happen in this young age group, and it reinforces the advantage of having a pediatric thyroid center.

With the statistics we talked about, the 5 per million under age 10, 15 to 18 per million in 15-18 year olds, is that a specific type?

Dr. Bauer: Yes, these numbers refer to differentiated thyroid cancer, to include papillary and follicular; papillary thyroid carcinoma (PTC) is about 90 percent of the cases, follicular thyroid carcinoma (FTC) is about 5%, and the rest mixed PTC and FTC, or, medullary thyroid carcinoma (MTC).

Follicular is the most common?

Dr. Bauer: No, Papillary thyroid carcinoma, PTC, is the most common.

Are those are the most recent statistics across all pediatric ages?

Dr. Bauer: Yes, the most recent data is from the NCI SEER database is through 2011 and the numbers above cover the least to the most frequent in patients < 19 years of age.

When you say 2 to 5 per million children under age 10 years is that an increase or just a range? Do you know what the statistics were 10 years ago?

Dr. Bauer: Within the prepubertal that incidence has been pretty stable. It's just within the adolescents age group that the rate has gone up from let's say 8 to 10 per million to about 18 per million over the last two decades. This data is only referring to patients with a confirmed diagnosis of thyroid cancer, the number of patients with thyroid nodules has increased well beyond that, but outside of the data I mentioned earlier in the interview there isn't a national registry to track pediatric patients with a diagnosis of a thyroid nodule. This is another limitation of having patients undergo evaluation at non-thyroid center, there is less that is known about the number of patients undergoing evaluation. We continue to see patients that were referred from their primary provider directly to a local ENT or surgeon and the patient diagnosis, typically thyroid cancer, is never entered into the State reporting system that is mandated at all pediatric tertiary care hospitals. Endocrinology, both adult and pediatric, should be the first place a patient is referred if a nodule is found on exam. They are in the best position to ensure an adequate and appropriate evaluation is completed and to ensure that if a patient would benefit from surgery, that the patient is sent to a high-volume thyroid surgeon. Having fewer, but regional centers of care, is the ideal path to ensuring stratification and individualization of care, of decreasing complications and for setting up a system to better track the incidence of a disease as well as outcomes of therapy.

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