Download Frances- Jan 2011 a) Avoid port if possible b) Had 17 nodes

Frances- Jan 2011
a) Avoid port if possible
b) Had 17 nodes removed, no lymphedema
c) See Carlson @stanford
d) Likes the drugs in the clinical trials.
e) Avoid taxol because of neuralgia
f) Smoke pot for nausea.
Ujwala
Do Pet CT.
Add Vitamin D to bloodtest
Laurie Frakes, oncologist, January 27, 2011.
She had a phone conversation wih UCSD pathologist, cancer in both places, Grade 3 invasive
(on a scale of 1-3, scale is 1 = slow, 2= intermediate, 3=faster growing). Cancer can be lobular or
ductal, RG’s is ductal (goes through the ducts). It is probably also DCIS. Invasive really means
cancer has gone to the lymph nodes.
Grading different from staging, latter is on a 1-4 scale depending on size of tumor and number
of lymph nodes, ours probably 2 said Wallace earlier.
Should view this as a puzzle of which only 1/3 of the pieces are in place so far.
1. Adriamycin usually requires a port because it is toxic on the vein, RG most likely needs
it.
2. Taxol is iffy because of neuropathy, she does taxatere (sp) but it is more about oncologist
tastes.
3. There is a BRCA-1 and BRCA-2 to test for mutations of a cancer gene, $4K to do, worth
it because of mummy. Its value is that it informs us about likelihood of recurrence and if
positive should take out ovaries etc. Also $300 on sibs if RG is positive, usually done on
the one with C.
4. Receptors are proteins and estrogen and progesterone, Herceptin. There is a Fish test,
results are expressed as a percentage, will know from the biopsy report which is us.
If we are triple negative, then only chemo and nothing else is done. Usually not clear
which combo of positive/negative is better, generally being positive for estrogen (ER)
and progesterone (PR?) is better, then tamoxifen given later, chemo puts you into
menopause).
ER+ and PR+ with HER- is very different from triple negative. Mamma print may be
done for some version of the former. HER+ in about 20% is a little more aggressive.
Parp inhibitors have been around, close to being approved for ER and PR positive?
people.
SGB: Trial docs say one of the investigating agents is a PARP inhibitor given to
HER-ve patients. Google says PARP inhibitor Olaparib in trials (2009) given to
metastatic triple negatives.
Shouldn’t Dr. Wallace want a BRCA test? See below for more.
There is one trial with our drugs on Pfizer site for ErbB-2 positives called
NEFERTT (no mention of ISPY-2).
ABT-888 is our PARP, also in an MGH trial for BRCA-1 and 2, is Phase 2,
metastatic only?
5. Generally chemo given if tumor over 1cm and lymph positive in a region. Chemo presurgery is neo-adjuvant. Basically, stats on chemo pre- or post- surgery are the same.
Former means easier to assess the value of chemo on tumor. Can abandon ship and do
surgery if neo-adjuvant does not work.
6. UCSD is big on neo-adjuvant, on taxol, on trials (all esp Wallace). More traditional may
say surgery first to take out.
7. This trial seems innovative.
8. Lymph node dissection is anatomical (in a region), so not clear how many will come out
until surgery is done (only then can see how many there are near the one that is currently
positive).
9. Overall, remember to ask the important questions, Do not worry too much about side
effects and toxicity (people do, but medicine has a pretty good fix for side effects).
Dr. Schwab, February 1, 2011 (alternative is Dr Helsten, didn’t do as Tomoko).
Very nice, competent, knowledgeable, like Frank, doesn’t need to have an ego.
Doesn’t think ER, PR-ve is so bad.
Herceptin didn’t work well with AC, that is why it is with Taxol in the trial (reversed from
std. of care.
If her-2 neg then trial gives 40% chance of getting to a parp inhibitor which we need., (here
is the luck!).
There are also Her 1, 2,3 and 4, WTF!
Bone scan needed because of node positive). thinks metastatic not likely, but pet CT and
bone scan needed for staging. Pet CT does fewer false positives than MRI.
BRCA-1 has no implications for study or port. This is an expensive gene test, can do later
post surgery, costs will come down, test will get better. Its purpose is LR anyway, RG less
likely to have it, more for Ashkenazi.
CHEMO makes you possibly neutropenic, no immune system. Even if mild fever(100.5 or
less for RG as she never gets any) or feeling shitty go to em room.
Chemo around the 20th is a good target.
Taxol=> 2% get severe and painful neuropathy (nerves tingling), happens right away if so.
Else goes away in few months to few years This is why Frakes does Taxetere (expense?)
Immune system comes back in 3 weeks post chemo, also says Thommy. SRS had WBC
count stay lower for longer.
May get transient diabetes with chemo.
Go for walks, sun in the morning for light exposure, wake up at the same time.
AC can do heart failure, (1 in 800 get it 5-7 years later), 0.5% get leukemia.
Talk to Wallace about lymph node dissection later, palpable, sentinel etc, some room to play,
studies not conclusive, Dr, Wallace has lower lymphedema rates,
Longer-term weight loss is key. Joke that teen pregs with 1 mth of breast feeding least likely
to get BC.
Sridhar Ganesan, Monday 1-31-11
Works on triple negatives with BRCA mutations (what luck?)
Her 2+ are treated with parp inhibitors
Her 2- are treated with iniparib etc.
TNBC also responds to AC and T chemos like the others. TNBC or Her-2 amplified are similar?
ISPY is particularly good if 2-neg holds.
Find other trials that are more at TNBC, (Schwab says none around, SG couldn’t find on
clinicaltrials.gov.)
BRCA (bracca) test for sure, if the mutation exists then treatments like parp are good,
There is also a subset of TNBC without the mutation that behaves as if they had BRCA-1
mutations anyway.
But Schwab says BRCA tests are really LT only, prices will come down later in 6ths to 1 yr.
Shridar has a hunch that er-neg may actually benefit from neo-adj therapy but hasn’t look at the
data closely. Note that there are 6 combos of c –cells (I assume 3C2 of the 3 hormone sensitives
conbos).
Random tidbits.
Statins reduce cancer growth (probably why Frakes did something with Avastin.
Exercise for RG, even gentle walking, will help says a study.
At surgery time, seems established that margins around tumor are removed. How much depends
on surgeon, but is preserving breast tissue the dominating variable? If so, RG should have some
input into how this decision is made.
Chemo: AC = Adriamycin (doxorubicin) and Cytoxan (cyclophosphamide) and Taxol
(paclitaxel) or Taxotere (docetaxel), is usually AC-TH.
Estrogen stimulates the growth of B-cancer cells, tamoxifen is a hormone that blocks the uptake
of estrogen by tumor cells. How long to take it is debatable, SRS ?
S-phase fraction and Ki-67 tests to measure rate of cell growth, not reliable.
Also necrosis, rate of cell death is also an indication of speed of growth since tumor cells die
because not enough blood to feed them (is this also calcification?)
ER+ => tamoxifen works
NCI’s understanding cancer series is a nice set of slides!
HER may work regardless of ER and PR.
Aromatase inhibitors (AI) reduce the amount of estrogen produced, while tamoxifen blocks the
ability of the tumor to use estrogen. Aromatase is a substance the ovaries and tissues use to make
estrogen, so the AI inhibitor reduces its production.
Why not neulasta (side effects on spleen and lung, asthma?) 1 day after chemo starts?
How do margins at surgery affect recurrence?
All drug names ending in “mab” are monoclonal antibodies”
Idea is that a mab will bind to a cancer cell and trigger a response.
Receptors are protein molecules at the end of cells that tell the cell to grow and divide, too many
receptors implies too many signals and too much growth. So a HER2 positive is a cancer cells
with too many receptors. Herceptin perhaps attaches to the receptors and tells them to stop
growing or at least to slow it down.
Vitamins C and D as antioxidatns are treated as good but they affect the ability of chemo to do
what it does, hence the objection to naturopathic treatments in the medical community.
Nakamura, Feb 10, 2011
Mitaki mushrooms rather than pushpa;s reichi master
Beets and spinach to combat chemo liver damage.
Tomato juice.
Other dietary tips
Complex carbs, not SG-type simple ones, basically because of relationship with insulin.
TNBC investigations:
Ixempra vs Taxol and the TITAN trial, see link
Androgen receptors implies less response to chemo, see +/-.
Avastin (Frakes trial, also bevacizumab) appears to have helped TNBC if taken along with
chemo. FDA moving to revoke its approval, because it increases the risk of heart failure, LBBC
has one comment from a user that it is helping many. It costs $8K per month, capped at $57K per
year.