What’s Your Stage?-Notes on biologic factors in the 8th Edition Cancer Staging Manual
Read on as our Director of Education, Martha McCormick, explains the 8th Edition Cancer Staging Manual as it pertains to a breast cancer diagnosis.
A breast cancer diagnosis generates complex feelings, fears and questions. It also brings a whole new language and terminology to learn. The vocabulary of Breast Cancer includes words such as Oncotype, Bilateral, Lymphedema, and acronyms like DCIS, LCIS, HER2, and BRCA. Another word that becomes important is “Stage”. You learn that you don’t just have Breast Cancer. You have Stage 0, I, II, or higher Breast Cancer.
Classification by staging of Breast Cancer began in 1959 and is used worldwide. It classifies as TNM based on size of primary tumor (T), lymph node involvement (N), and metastasis to other parts of the body (M). The first Staging Manual for Breast Cancer was published in 1977. It’s purpose was to provide a consistent way for descriptions of particular cancers to be communicated, to assist in treatment decisions and prognosis, and to allow for comparisons.
Today, few would describe their Breast Cancer simply as Stage I, Stage II, etc. They would say “Stage II, Triple Negative” or Stage I, HER2 positive, or Stage I, ER positive, etc. These additional characteristics, known as “biologic factors,” are noted because they are significant for determining treatment and prognosis.
Since the first staging manual was issued, it has been reviewed several times to address scientific and medical progress. The last review in 2010 considered the increasingly utilized biologic factors and prognostic indicators but decided that there was not enough evidence to include them in staging. Years later, in preparation for the 8th edition, it was determined that sufficient research-based evidence existed to warrant inclusion.
Reviewers acknowledged that biologic factors such as grade, hormone receptors, HER2 status and genomic panels have become at least as important as tumor size, lymph node involvement and metastasis in predicting survival. Therefore, in the new edition, adopted in 2018, biologic factors are part of the equation.
So what changes in 2018 and what does not?
The main thing that does not change is that anatomic designations of TNM are still the foundation of the staging framework; indicative that not everyone worldwide has the advantage of genomic testing, tests for hormone receptor status, etc. TNM designation remains an important baseline that can apply anywhere, regardless of the availability of advanced testing and treatment.
The 8th edition classification now incorporates biologic factors as predictors of outcome. These include: Tumor grade, hormone receptor status, and HER2 status; indicators which are known to impact prognosis and treatment options.
Tumor Grade describes the extent to which cancer cells resemble or differ from normal cells in appearance and proliferation (how fast they are dividing, growing and dying). Lower grade cancer cells are more similar to normal cells so they proliferate more slowly than higher grade cells, which are less similar to normal cells and proliferate more rapidly. Tumor grade can be an indication of how aggressive a particular cancer is and influence how it is treated.
Hormone receptor status indicates the extent to which the individual cancer is affected by Estrogen and Progesterone in the body. Breast cancer that is hormone receptor positive can be treated by therapies that remove or block the hormones. There are different treatment options available for Breast Cancer that is hormone receptor negative.
Another important receptor is the Human Epidermal growth factor Receptor 2 (HER2). HER2 is a protein that promotes growth of cancer cells. Patients who are HER2 positive may have the option of targeted treatments that are often effective; whereas HER2 negative status patients are not eligible for these same treatments. When a negative HER2 status is added to a negative estrogen and a negative progesterone status, that is considered Triple Negative Breast Cancer, for which there are fewer treatments available currently.
Genomic tests such as the Oncotype DX can be incorporated into evaluation and treatment as appropriate. The Oncotype DX tests Breast Cancer tissue from women whose cancer is estrogen receptor positive. For those estrogen receptor positive cancers of TNM stage 1 - IIIa, the Oncotype DX test can help determine whether chemotherapy would be of benefit and the likelihood of the cancer recurring. For estrogen receptor positive DCIS, stage 0, the test can help determine the likelihood of local (same breast) recurrence and determine the appropriate course of treatment.
Utilization of Genomic Tests, particularly the Oncotype DX, has become increasingly common and evidence as to the value of such tests for managing disease has progressed to the point where results are being factored into guidelines.
Will the staging classification change?
Breast Cancer has been identified as TNM Stage 0 – Stage IV for many years and new classifications will continue to stage breast cancer similarly. However, with the incorporation of biologic factors to TNM staging, some Breast Cancers could be staged higher or lower. Some cancers, where TNM alone indicates a certain stage, may be upstaged or downstaged based on biologic factors that indicate it is more or less aggressive than others.
It is important to note that it is the classification of the staging that is changed - NOT the treatments. If you were previously a stage IIb you would have received a specific course of treatment based on the TNM factors and on the status of other biologic factors - such as grade, hormone receptor and HER2 status. Treatment with the old staging and the new would likely be identical. Accordingly if you are a long-term survivor, diagnosed and treated before the biologic factors were recognized, your treatment would simply have been based on the what was known and the standard of care at that time.
What if I was diagnosed before 2018 but I am still in treatment? Will my cancer be restaged now?
No, your cancer will not be restaged. The 8th edition goes into practice in 2018. It does not look back.
Could my cancer actually be a higher or lower stage with the new criteria? Does that make a difference?
Some breast cancers might be staged higher or lower in some specific instances. Cancers with certain biologic factors that are known to be more aggressive and/or currently have fewer treatment options such as Triple Negative Breast Cancer may now be staged higher to better reflect the impact of the Triple Negative status. Cancers that might be larger but are hormone positive indicating effective treatment options, and/or less aggressive, may be staged lower than previously, also to reflect the impact of those biologic factors and associated treatment options.
If you are told that your Breast Cancer is Stage II, for example, that number itself is less important than understanding why it is that stage and the possible treatment options. Your treatment and prognosis are based on anatomic TNM and known (at the time) biologic factors. That has not changed. Only the staging classification is changed to account for mounting evidence of biologic and other factors on the many variations and progression of this disease. Up until now, the biologic factors have not been classified – just added on as descriptors. Now that their impact is recognized as significant in measurable and predictable ways, they are part of the classification and add to its usefulness.
Are there other changes in the Eighth Edition?
There are a number of incremental changes in measurements and definitions that reflect ongoing knowledge, evidence and specificity in how the staging system is utilized, and how various breast cancers are treated.
Earlier TNM staging reflected characteristics that could be seen and measured at the time. In recent years, additional characteristics have come to light concerning predictable aggressiveness and response to treatment of different types of breast cancer and these are being factored into the classification when evidence warrants.
-Martha M. McCormick, MS, EdS
Director of Education, To Life!
2017 Women’s Health Conference - In case you missed it….
Women's Health Conference
November 14, 2017
Overview of the day's presentations
Genomics today: What the Research Tells Us
Douglas Conklin, PhD
SUNY Cancer Research Center
Our 7th annual Women’s Health Conference began with an engaging lecture by Dr. Douglas Conklin of the SUNY Cancer Research Center. Dr. Conklin explained that there are four molecular subtypes of breast cancer tumors-luminal A, luminal B, Basal-like and HER2ex, all caused by different DNA mutations in breast cells that can happen over time. He then went on to introduce biochemist Dr. Otto Warburg who hypothesized that cancer growth is caused by cells that use glucose for energy through fermentation, instead of using oxygen through respiration, which occurs in normal body cells. In other words, sugar is a major source of nutrients for cancer cells. This hypothesis has led to the creation of new anti-cancer therapies, which revolve around inhibiting cell intake of glucose, thus interrupting and slowing cancer metabolism. This research also supports the idea that standard recommendations such as maintaining a healthy weight, regulating sugar and alcohol intake, exercising and not smoking have an even bigger impact on preventing cancer or recurrence - great news for many of the survivors in the room!
Advances in the Local Treatment of Breast Cancer
Duncan Savage, MD
Radiation Oncologist at St. Peter’s Hospital, SPHP
Our second speaker was board certified radiation oncologist Dr. Duncan Savage, of St. Peter’s Hospital. Dr. Savage spoke to our audience about the many advances that have occurred in the localized treatment of breast cancer, including radiation therapy, lumpectomy, Oncotype Dx testing, and targeted therapy based on the molecular subtype of breast cancer. We have learned that in many cases of breast cancer, a total mastectomy may not be needed. Instead hormonal therapy, a lumpectomy with a course of radiation, or just radiation could be equally effective in eliminating the cancer and preventing recurrence. In addition, advances in radiation have made it easier to administer effective doses without damaging internal organs, such as the heart. All in all it was a fascinating talk that reminds us of the wealth of treatment options available for breast cancer patients AND how important it is to make shared medical decisions with your oncologist regarding treatment.
Breast Surgery: Then and Now & Breast Cancer Staging
B. Marie Ward, M.D., F.A.C.S.
Division of Breast Surgery, Albany Medical Center
Our third talk of the day was given by Dr. B. Marie Ward, Director of Breast Surgery at Albany Medical Center. Dr. Ward began by taking the audience through a brief history of breast surgery and all of the progress we have made towards localized treatment. In the 21st century, surgeons have adopted a breast conservation approach, which has resulted in the near extinction of radical mastectomies and has increased the instances of lumpectomies, followed by a course of radiation. In addition, oncologists have discovered that chemotherapy is not right for everyone. Oncotype DX testing can tell us a patient’s risk for recurrence and overall survival, as well as the magnitude of chemotherapy response. If a tumor is not likely to respond effectively to chemotherapy than an oncologist can easily spare that patient the process of having to go through chemo. Dr. Ward also touched on the new 8th edition AJCC Breast Cancer Staging system which reflects the many advances made in breast cancer research. The new staging system will still include the old TNM staging (tumor size, lymph node involvement, metastasis), but will also incorporate a tumor’s biological markers, such as whether it is hormone positive or negative.
Break Out Sessions
When Legal Problems Become Health Issues
Alexis Kutski, Esq
Legal Aid Society of Northeastern NY
Alexis Kutski is a staff attorney with the Legal Aid Society of Northeastern New York who spoke to the audience about Legal Aid’s Medical Legal Partnership (MLP) program with St. Peter’s Health Partners and Albany Law School. Ms. Kutski explained that a MLP is defined as collaboration between legal and medical services to address health harming legal problems. Through Legal Aid’s MLP, Ms. Kutski provides free legal services to low-income patients concerning legal issues that relate to and affect the patient’s health. Some of the legal areas addressed through an MLP are housing, legal status, health insurance, disability benefits, personal and family stability, estate planning and power of attorney. The talk contained great information for both breast cancer patients, as well as clinical professionals who may be in need of Legal Aid’s services.
Psychological Issues in Breast Cancer
Edward S. Dick, LCSW
Edward S. Dick is a Clinical Social Worker Specialist in Cambridge, NY who has a wealth of experience helping cancer patients work through the psychological impacts of their diagnoses. In an intimate interview with an audience member, Mr. Dick was able to explain how a cancer diagnosis can often make patients feel alienated, due to the fact that patients each have their own, unique cancer journey that family members and friends may not understand. He also provided great insight into breast cancer diagnoses in particular- that many new breast cancer patients feel guilty, as if somehow they made a mistake or were careless in their health. This feeling is caused by a variety of different factors, such as forgetting to go to an annual mammogram, ignoring a lump, or simply “life getting in the way” of making a doctor’s appointment. Nevertheless, Mr. Dick assured audience members that it is never the patient’s fault and that cancer is often a random occurrence over which the patient has very little control. There are also ways in which patients can combat these feelings of alienation and guilt, such as attending support groups, keeping family and friends updated via email or letters, or writing in a gratitude journal.
Trauma Informed Breast Cancer Treatment and Care
DVHRT/Communications Coordinator, YWCA Northeastern NY
Wendy Gapczynski is the Advocacy Coordinator at YWCA NENY, as well as a licensed EMT. She works with Domestic Violence programs and counseling with the YWCA. Through her professional experience working with domestic violence survivors, Wendy was able to explain to the group of clinical professionals how to recognize potential domestic violence cases. Often those suffering in a domestic violence situation may not outright tell you what is going on and it is important to listen carefully and if you suspect violence, ask the patient. In providing resources to a patient in a domestic violence situation it is important to allow him or her autonomy in decision making. As a clinical provider, you can never know exactly what is going on in the patient’s home and it is unwise to make decisions for him or her. Often listening, providing contacts to the nearest YWCA or domestic violence association in the area, and practicing confidentiality best practices are the best courses of action.
Research in Lymphedema Diagnosis & Treatment
Geraldine Pfeiffer, PT CLT-LANA
Geraldine Pfeiffer provided an informative and well researched talk on lymphedema. She began by outlining and defining the stages of lymphedema, focusing on the subtle signs that can lead to an early diagnosis and emphasizing the importance of having baseline measurements for later reference. Further into the talk, Geraldine reviewed known risk factors and steps that can be taken by the patient to reduce incidence and severity of the condition.
Understanding Clinical Trials
Amy Zuchelkowski, RN, MS Clinical Research Manager
New York Oncology Hematology
With feedback from previous Conference participants, we have received numerous requests to present on the topic of clinical trials. Amy Zuchelkowski, the Clinical Research Manager for New York Oncology Hematology is an excellent local resource for information related to ongoing clinical trials. Her talk started out by addressing the four phases of clinical trials, offering a detailed overview of the process from the perspective of the research sponsor. Then Amy addressed patient concerns; prior to starting in the trial and during the trial, then a detailed review of patient risks/benefits and protections.
Discussion of the book Radical Remission – The Nine Key Factors That Can Make A Real Difference, by Dr. Kelly Turner
The book is based on Dr. Turner’s 10 years of research analyzing 1,500 cases of radical remission and looking for commonalities. This led to her doctoral dissertation, a peer-reviewed scientific journal article and then the New York Time’s best-selling book, Radical Remission, which is now in 20 languages.
Dr. Kelly uncovered 75 healing factors – 9 of which were common among all her research subjects. These 9 healing factors uncovered in the research are HYPOTHESES only. There is no guarantee that following these 9 factors will heal cancer. However, separate scientific studies have shown these factors significantly strengthen the immune system. The one factor that should be practiced under the guidance of a health care professional to ensure safety is “Taking Herbs and Supplements”.
I’m So Glad You Asked That Question!- Boutique Q & A’s
In this edition of I'm So Glad You Asked That Question!, we answer questions from the To Life! Mastectomy Boutique Mailbox. If you have had or may have a mastectomy, these answers are very informative and will explain how To Life!'s mastectomy boutique can help you on your cancer journey.
Dear friends at To Life!,
I had my mastectomy ten years ago and I got a prosthesis from your boutique. It doesn’t seem to be fitting well anymore and now I’m old enough to be on Medicare. What should I do?
Dear Not Fitting,
I’m so glad you asked that question! First of all, most insurances cover replacement prostheses and bras every two years. Also, To Life! is a Medicare Certified provider so we will take that insurance. Second, and another reason to stay in touch is that all of our bodies change as we age (gravity and all that) so a prosthesis that was perfect back then, may not fit as well ten years later. We always encourage women to come in for a fitting and to see what’s new. There’s no obligation to purchase. We have boutiques in Delmar and Saratoga. We can only see one person at a time and we schedule about one and one half hours for a fitting. Please call for an appointment (518) 439-5975. We’ll be glad to hear from you!
Dear To Life!,
I will be having a mastectomy on one side and don’t want any further surgery. I was planning to get a breast prosthesis but my sister in law is saying that they are so heavy and I won’t like it. I just want to look good and be comfortable.
Not Sure What To Do
Dear Not Sure,
You raise some important concerns. It’s true that a breast form may seem heavy. But that’s for a reason. They are designed to match the weight of an actual breast. Having a single mastectomy and not reconstructing or using a breast prosthesis, can actually be bad for your spine because of the imbalance. Many women develop backaches and discomfort that goes away when they are properly fitted with a breast prosthesis that matches their other breast in size and weight.
While many women opt for reconstruction, others do not want the additional surgery and find prostheses to be a good solution. Also, with some kinds of reconstruction, it can be several months before the process is completed. We can help with solutions or suggestions for looking balanced during that period. Women are more than welcome to visit us BEFORE their surgery to see what is available and learn how the process works. Just give us a call!
Can I Stay Emotionally Healthy During Cancer Treatment?
In this informative and fascinating article, our director of education, Martha McCormick, explains how positive psychology can help patients stay emotionally healthy during cancer treatment. Using research from the University of Pennsylvania, Martha helps identify specific characteristics that are found in people who are "thriving," and how these characteristics can help us to stay positive in the face of great trial.
According to researchers at the University of Pennsylvania, Positive Psychology is the scientific study of the strengths that enable individuals and communities to thrive. It is founded on the belief that people want to lead meaningful and fulfilling lives, to cultivate what is best within themselves, and to enhance their experiences of love, work, and play. One outcome from this is a model of resilience based on the assumption that these same strengths which help us to thrive can also make us resilient during difficult times such as breast cancer treatment, when reserves of endurance and confidence can be severely taxed.
This is taking a “strength-based” approach to resilience. Rather than having to learn new behaviors and attitudes, a strength-based approach highlights existing strengths and capabilities that may become personal assets during hard times. You could list many strengths that help us to live good lives. But research identifies five characteristics likely found in people who are “thriving” in life. With initials that create an acronym “PERMA,” the characteristics are: Positive emotion, Engagement, Relationships, Meaning and Accomplishment. Positive Emotion can be linked to two other terms – optimism and enjoyment. Optimism means viewing life overall in a positive way. It means recognizing that usually both good and bad things may happen in life but believing overall that things trend toward the positive. It doesn’t mean that you have to feel good about bad things or feel happy all the time. Enjoyment usually comes from some sort of focused activity, intellectual stimulation or creativity. Engagement means having activities in your life that pull you in so that when you are involved in that activity, you are entirely absorbed in what you are doing. Most likely, whatever you are doing is challenging enough that you have to pay attention. Mindless activities such as zoning out in front of the TV, surfing the internet or taking a stroll aren’t usually ways to be engaged. But trying to learn something new, figure something out, or challenge yourself in some capacity are all ways to be absorbed in something. Relationships concern people in your life whom you look forward to seeing; who add to your life in a good way. Time spent with others who stimulate you, make you laugh, make you think and make you feel connected is time that enhances your sense of well being. Meaning pertains to things that feel more important than just yourself and your own happiness. Religious observance, or other faith-related activities can add meaning to life and give a structure of values that makes sense of life. Other kinds of meaning-based activities might include community organizations, volunteering or specific work-related meaning. Some people structure their lives around meaning while others seek it outside of daily activities.
Accomplishment is about doing things, and knowing that you can. The dictionary may imply that accomplishment and achievement mean the same thing but that’s not usually the case here. Achievement usually implies some sort of judgement or contest. Accomplishment might or might not be that and often it implies things that might not be trophy material. “I grew enough tomatoes last year to make sauce for two dinners.” That’s not a lot of tomatoes but may be quite an accomplishment. Or, “I got the lawn mowed this weekend.” That’s in spite of the rain and the soccer tournament. Yes, an accomplishment!
What can watching our PERMA do for us? First, just being aware of the components means that we start to notice and value them. Most of us have PERMA to some degree, but maybe not in balance. It can be easy to cultivate in good times – great family and friends, community involvement, interesting work, time for hobbies, etc. But life events, like serious illness, moving, changing jobs, losing a family member, can let us loose sight of PERMA.
Some may have PERMA all tied up in the same package. It might be a job or parenting or a great neighborhood. But if something disrupts that package, much can be lost. Having cancer may be all-consuming. Many speak of breast cancer treatment as a part-time, if not a full-time job, that also affects the lives of family members. If activities that provided meaning and relationships are cut off, this can add insult to the injury of treatment. Inability to participate in athletics or schooling, feeling “out of the loop” socially, or experiencing anxiety and uncertainty due to health worries are all common side effects of cancer treatment.
Keeping PERMA in mind can support a sense of wholeness through treatment and survivor issues. Much is written about “life balance” for women who usually have many roles as employee, mother, caregiver, etc. But, it is almost impossible to balance anything consistently over time. The PERMA model better lends itself to the idea of good nutrition where each food group has its place on the plate; varying from day to day or week to week, but all represented.
In the case of breast cancer, we know that many women add to their sense of meaning and their relationships through the treatment process. Prevailing through a challenging course of treatment can be life-changing and add to the sense of mastery and accomplishment. Many find sustained meaning in spirituality as a result of that experience.
Like Breast Cancer, one’s sense of thriving is an individual matter. We all get to decide what defines positive emotions, relationships, engagement, meaning and accomplishment for ourselves. Still we can be confident from the evidence that a good mix of positive emotion, engaging activities, good relationships, sense of meaning in life and personal accomplishments all contribute to resilience and ability to thrive, regardless of health concerns.
Martha McCormick MS, EdS
Director of Education, To Life!
Learn more at http://ppc.sas.upenn.edu/
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What’s the Latest News About Breast Cancer?
An Update from the Miami International Breast Conference.
Conference notes from Dr. Richard MacDowell, Albany Medical Center
Breast Cancer conferences are filled with talks about chemotherapies and protocols. Also discussed this year were current issues relating to treatment options. Many were discussed in detail and deserve some further explanation.
(Published in the To Life! Spring 2016 Newsletter)
Lumpectomy or Mastectomy? Currently, breast conserving surgery (lumpectomy followed by radiation therapy), is the more common approach to treating breast cancers. But, requests for mastectomy, including bilateral mastectomy have been increasing, especially among younger women. Some describe this as the “Angelina Jolie effect” due to her much publicized bilateral mastectomy and reconstruction surgery. This treatment is indicated in some patients, particularly those with increased risk of breast cancer because of gene mutations. But most patients opting to have the second breast removed do not fall into this high risk category. Instead, many patients indicate the wish to avoid years of follow-up by mammogram and possible future biopsies. Some note that the cancer risk is lessened following mastectomy, though with close follow-up, these cancers are rarely fatal. There is no clear answer but this decision is significant and not to be made without a thorough understanding of the pros and cons of both surgical techniques. Consensus is emerging that we are misdirected in doing more mastectomies and prophylactic mastectomies. We know that, absent a markedly elevated genetic risk, there is minimal, if any, surgical advantage to removal of the second breast. It should also be noted that there is now data to suggest a survival advantage to breast conserving therapy (lumpectomy plus radiation) over mastectomy.
Do we overtreat DCIS? Much is written about noninvasive breast cancers such as DCIS (ductal carcinoma in situ). Historically, this was seen as a definite precursor to invasive cancer and treated aggressively. Some now claim that we treat DCIS too aggressively given that many of these cancers are unlikely to spread thus not needing aggressive therapy. A technique called genomic profiling is available to identify DCIS patients who can be monitored, rather than
aggressively treated. Genomic profiling is analysis of biopsied breast tissue to predict which tumors are likely to be aggressive and which are likely to be indolent. Studies show that many such tumors can be treated with minimal therapy and close follow-up. It is likely that this will lead to fewer patients receiving radiation therapy, particularly older patients. Breast Density Many patients having mammograms recently have gotten letters from the radiologist about the density of their breasts. This is new in the last few years and has caused confusion. For many years, radiologists in New York State have been required to notify patients if their mammograms indicated any problems. Now radiologists must also indicate if the scan indicated significant breast density. Breasts are considered “dense” when they have more fibroglandular tissue than fatty tissue. In that case, it can be harder to see a mass or a lump on the mammogram, meaning that it might be missed. It is left to the physician and patient to determine what to do with this information. Some medical practices routinely recommend screening ultrasounds for patients with dense breast tissue while others use 3-D mammography, or rely on close observation. The number of additional breast cancers found due to this change is small but significant. Breast density is a finding that many women will need to consider. It is important to talk to your physician about the significance of dense tissue and what follow-up is needed.
To Screen or Not to Screen? There has been much discussion and debate about mammography timing and frequency of late. This largely concerns patients with no obvious risk factors for breast cancer. Those with abnormal gene mutations or a strong family history likely need to start having mammograms sooner, more often, and for a longer time. We know that 75-80% of breast cancers occur in individuals who do NOT have abnormal genes, a strong family history or other significant risk factors. This average person sees a variety of very different recommendations, causing understandable confusion. The American Cancer Society now recommends screening to begin at age 45 with annual screening thereafter. However, the United States Preventative Services Task Force recommends starting screening at age 50 and continuing every two years. Both organizations agree that women should have the choice to begin screening as early as age 40. This may
be appropriate for those wanting to take every step in the interest of early detection, but others are concerned about false positive findings generating unnecessary biopsies and radiation exposure. For them, starting screening at age 50 may be appropriate. This is a point to be reviewed with your physician.
A Compelling Account The conference keynote speaker was Amy Robach of Good Morning America. She is the reporter who was persuaded to have her first mammogram at age 40, on live television. She didn’t want to but was convinced that her participation would save lives. Little did she know that the life she saved would be her own. Robach had no risk factors but her live TV mammogram showed an invasive and aggressive breast cancer with positive lymph nodes - potentially fatal without early detection. Over many years I have heard survivors tell their stories, but rarely been so moved as I was listening to this professional commentator and young mother describe her experience. Screening recommendations address the broadest general audience but allow for individual differences. Clearly Robach is an advocate for early mammography but again, this is something that needs to be discussed between physician and patient to determine when best for her to begin her mammography screenings. This should not be determined by governments or others.
Well known breast and general surgeon, Dr. Richard MacDowell practices at Albany Medical Center. He attended the Miami Breast Cancer Conference and shared his impressions with To Life!
FAQs on How to Choose and Buy a Breast Prosthesis and Mastectomy Bra
One of the services offered at To Life! is the proper fitting of breast prostheses (also called breast forms).After breast cancer surgery, a woman can take control of her appearance and boost her self-esteem with the proper fit of a breast prosthesis.This can make a big difference in a woman’s self-image. Read more for some frequently asked questions and answers concerning breast forms:
“Why should I have a ‘proper fit’?”
A properly fitting breast prosthesis will balance your appearance, prevent your bra from moving around, keep your spine in alignment and balance weight on your shoulders. They are designed to mimic the weight and shape of your natural breast.It is our goal at To Life! to find a prosthesis that is the right size and shape for you and your lifestyle.
“When should I have my first fitting?”
After surgery, your surgeon will recommend the appropriate time for you to start wearing a breast prosthesis. This largely depends upon the post-operative healing process and the type of mastectomy that was performed.While we appreciate that many women in the post-mastectomy phase of recovery are quickly ready to get back to normal or at least establish a “new normal”, it is a good idea to wait at least five to six weeks post-surgery to ensure all swelling has gone down.Your measurements will not be accurate if you are swollen.
“What should I wear to a fitting?”
You should wear what you normally wear in your everyday life.Part of the fitting is seeing how your clothes fit and look when you are wearing the prosthesis.A snug-fitting, design-free top will offer you the best idea of how proportional and symmetrical the breast prosthesis is to your body.
“How are prostheses sized?”
Breast prostheses are available in different shapes, sizes and skin tones.You will be fit to a shape that best conforms to your body shape and matches your existing breast (for unilateral patients).The forms are not sized like a bra so you can't count on getting a form that fits by referencing your bra size.Our fitters can help you find a style and size that works best for you.
“What do they look like?”
Some forms are symmetrical, so they can be used on either side, and some forms are designed to be asymmetrical (used only on your right or left side).
“What are they made of?”
Some are made of silicone and some are made of fiberfill. A silicone breast prosthesis is closest to imitating breast tissue in weight and drape.A good prosthesis will also have some movement similar to your real breast.Some silicone breast prostheses are designed to be worn in the pocket of a mastectomy bra and some are designed to adhere directly to the chest wall.
A fiberfill breast form is very light weight, although some do come “weighted.”It is a good idea to ask your fitter about the pros and cons of a fiberfill breast form.These forms may not be the best option for some women because they may be too light.Fiberfill breast forms are designed to be worn in the pocket of a mastectomy bra.
To Life! has a wide variety of breast prostheses and breast forms and our fitters are knowledgeable in what each form has to offer.The fitters will help you find a prosthesis that's the proper shape, size and weight for your lifestyle and your body.
“Is it comfortable to wear a prosthesis?”
Fit and comfort of a prosthesis is very individual.The prosthesis is designed to mimic the weight of the existing breast and the existing breast can be surprisingly heavy.The industry has come a long way in offering silicone prostheses that are lighter weight and cooler.Our fitters can show you the latest in lightweight silicone prostheses.
“How do I take care of my prosthesis?”
Simply washing them with a mild soap, towel drying them and putting them in their box when they are not being worn is all the care and maintenance they need.
“Will my insurance cover the cost of my prosthesis?”
Insurance companies typically provide coverage for one prosthesis every two years for unilateral patients or two prostheses every two years for bilateral patients.Because of that two-year limit, it is very important to be sized correctly.If you are sized incorrectly, you will not be eligible to re-submit for the correctly sized prosthesis for two years.That is why we recommend waiting until all of your swelling has gone down.
“Do I need a prescription?”
Your doctor will need to write a prescription for “mastectomy bras” and a “breast prosthesis” if you plan to submit these products to your insurance company.
“When do I get the mastectomy bra?”
Your fitting for the breast prosthesis will include a mastectomy bra fitting.The fitter will measure you to determine your bra band size and your cup size.If you have had bilateral surgery, you will tell the fitter the cup size you want to be.To Life! offers many options for mastectomy bras including seamed, seamless, molded cup, camisole bras, and sports bras.
Our goal at To Life! is to ensure your breast prosthesis and mastectomy bra needs are met properly and in a stress-free manner.A proper fitting at the right time is the best way to attain that goal.
“How Much Does a Prosthesis Cost?”
Fitting services at To Life! are complimentary, provided by certified mastectomy fitters. There are costs associated with product. We participate with some insurance companies, including Medicare. However, should we not participate with your insurance company, please know that we have options for supporting your needs and will not turn anyone away. Please feel free to contact us for more detailed information on how we may best serve you.
Our goal at To Life! is to ensure your breast prosthesis and mastectomy bra needs are met properly and in a stress-free manner. A proper fitting at the right time is the best way to attain that goal. Please feel free to contact our fitters with any questions you may have.
Please feel free to contact our fitters with any questions you may have.
Delmar Boutique:Ann Rose (518) 439-5975
Saratoga Boutique:Melanie Murphy (518) 587-3820
Radical surgery just one option
Actress Jolie's double mastectomy puts focus on gene tests
Victoria O'Donnell wishes she got tested for a gene that shows an increased risk of breast cancer after her sister, Valerie Grugan, was diagnosed and had a double mastectomy three years ago.
The 46-year-old Greene County resident considered the test at the time, but figured she didn't need it. She got annual mammograms. She felt good.
Quyen Nguyen: Color-Coded Surgery
Surgeons are taught from textbooks which conveniently color-code the types of tissues, but that's not what it looks like in real life -- until now. At TEDMED, Quyen Nguyen demonstrates how a molecular marker can make tumors light up in neon green, showing surgeons exactly where to cut.
For Latinas, Patient Navigation Can Speed Breast Cancer Diagnosis
It’s not uncommon for Latinas who have an abnormal mammogram test to not follow up and get the medical treatment that can need. But a little extra support can make the difference.
SAN ANTONIO, TEXAS — It’s not uncommon for Latinas who have an abnormal mammogram test to not follow up and get the medical treatment that can need. But a little extra support from helpers called “patient navigators” can make the difference.
Facing a possible diagnosis of breast cancer can be tough for anyone to process. But for whatever reason Hispanic women need a little extra help to get them back to the doctor.
“It can be fear, it can be economics, it can be language issues, it can be not knowing the medical system and what are the next steps required to get complete follow-through," said Amelie Ramirez of the University of Texas Health Science Center.
Ramirez is the author of a new study published in the journal Cancer that found assigning a “patient navigator” to Latinas who have abnormal breast cancer scans improves their health care.
“They help them set up their appointments. If the woman says 'I can’t come in because I don’t have anyone to help me with child care, I don’t have transportation,' our patient navigator assists them with these barriers," Ramirez said.
In the study, on average, women received a diagnosis more than 40 days sooner if they worked with a patient navigator.
This can save lives and health care dollars. Ramirez said they are looking for ways to make having a patient navigator on staff as a standard part of a successful health care model.
Vitamin D and Breast Cancer
New Research & Recommendations
Dr. JoEllen Welsh, Professor at University at Albany's Cancer Research Center, presented on the topic of Vitamin D at our recent Beat the Odds event. She answered a number of questions from the audience. The following article highlights her findings (Click for full length presentation PDF)
The recommendations are confusing, partly because there are two things to consider (but they are related):
How much vitamin D do I need (ie, from diet or pills)?
What is the optimal blood level of vitamin D?
The optimal blood levels are determined by measurement of 25-hydroxyvitamin D. This is the test a Dr can/will order, and it will be flagged as “low” if the measurement is below 32ng/ml. It measures both forms of vitamin D (D2 and D3). Some of the data on blood levels and chronic disease is shown in different units (nmole/l), 32ng/ml is equivalent to 80nmole/l. Therefore the minimum level of 80nmole/l is the same as 32ng/ml. From what we know now, this is the level which seems to be associated with best protection against chronic diseases. We do not have evidence that levels higher than this are better.
If the value is found to be low, then a prescription form of vitamin D may be given – this is a very large dose of D2 (50,000 units per pill) and is usually taken once a week for 6-8 weeks, then the blood level is re-tested.
If the blood test is OK, then you can assume your vitamin D pools are sufficient.
The recommended minimum intake is 600 units per day but this is for healthy persons and assumes some sun exposure. Not everyone will have a normal blood test at this level, so it is absolutely essential to have the test done to see where you are. The upper limit has been set at 4000 units per day (although this is conservative).
To Life! offers Reiki and Healing Touch at no charge to patients, survivors, and caregivers by appointment.
Each of these therapies promotes relaxation and healing, and clients leave our doors with a sense of calm and positivity.
As one client stated,
"I really enjoyed my [Healing Touch] experience with Shirley. I left in peace and calm. The feeling continues today. Oddly for me, tears flowed during the session; I wonder where they came from. Hmmmm. I haven't cried in years, but it sure felt good!!
I strongly recommend a session with Shirley for everybody. The healing touch made the rest of my day pleasant and enjoyable; I was able to relax and enjoy the simple wonders of nature that surround me that I don't notice very often, like the smell of flowers in my garden, the birds chirping, the magnificient sky. Truly a magical experience. It dawned on me that I might just be depressed and Shirley's healing hands greatly affected my mind, body and spirit. Amazing!!"
--Ruth, Breast Cancer Survivor
To learn more about how Reiki can help manage chronic pain, visit this article: How can Reiki help you?
Breast Cancer Surgery Rules Are Called Unclear
A recent article published in the New York Times cites a study that indicates guidelines for lumpectomies (the most common breast cancer surgery) are unclear and not necessarily agreed upon...
A recent article published in the New York Times cites a study that indicates guidelines for lumpectomies (the most common breast cancer surgery) are unclear and not necessarily agreed upon. The study, performed by Dr. Laurence E. McCahill of Lacks Cancer Center in Grand Rapids, MI, was published online by The Journal of the American Medical Association.
According to Dr. McCahill, nearly half of women who have undergone lumpectomies had second opertaions that weren't needed, while others are missing out on additional surgery that could benefit them. Ths study found that rates of repeat surgery can vary widely by doctor, from zero percent to 70 percent. This is due to lack of agreement on guidelines amongst the surgeons who perform these surgeries.
Read more here.