Customized treatments enhance breast cancer care

Editor's Note: This article originally appeared in the September/October 2011 issue of Vital Signs.

Not all breast cancers are the same, and tailoring treatments for different types is becoming increasingly common in cancer care. This approach has improved cure rates in some patients and allowed others to avoid unnecessary treatments.

At Providence Regional Cancer Center, medical oncologists utilize various methods to customize therapies. Gene analysis is one technique, which may be used when it’s not clear if a patient’s particular form of breast cancer will benefit from chemotherapy.

“The gene analysis test we use looks at 21 genes and gives us an idea of whether the patient has a low, intermediate or high likelihood of recurrence,” said Maury Blitman, MD, medical oncologist at Providence Regional Cancer Center (pictured left.) “Patients with a high recurrence score will typically benefit from chemotherapy, while those with an intermediate or low recurrence score will not gain additional benefit over the hormonal therapy they have already been prescribed.”

For other breast cancer patients, including the 20 to 25 percent who have what’s known as HER2-positive cancer, “targeted” therapies have shown success. This type of breast cancer occurs when the HER2/neu gene mutates, which can result in cancer that is often less responsive to chemotherapy.

However, says Dr. Blitman, physicians now know that combining chemotherapy with Herceptin®, a drug that specifically targets a protein created by the HER2/neu gene, can improve treatment response and increase cure rates.

As cancer physicians and researchers continue to discover new ways of tailoring treatments, the possibility of curing breast cancer – or at least managing it as a chronic medical condition – is becoming reality.

Advice from Bob: A patient's top tips

Editor’s Note: The following article was developed by a Providence Regional Cancer System patient, Robert R. Largen and his wife/editor Rosemary Shold. Bob received a diagnosis of “stage four, non-smoking, Agent Orange induced, lung cancer on October 31, 2001.” Below are some of his top tips for how he personally manages his cancer. The views reflected below are his own. If you’d like add your own tips, please leave a note in the comments.

1. Have someone accompany you to any doctor’s appointments or consultations. This person will help you absorb all the information that comes at you. Take notes.
2. Repeat back to the nurse or doctor any instructions that are given to you. Follow the instructions as closely as you can.
3. If possible, have a health professional other than the treating doctors and nurses guide you through the process. (Editor’s Note: Bob has a daughter Catherine, who is also an RN. There are many resources like this in our community, please don’t be afraid to ask if you’d like to be directed to one).
4. Keep a daily log of your health. It is a helpful resource when the nurse and doctors ask, “How is the patient doing?” And, “When did the symptoms start?” We found that the combination of happiness for making it through the day and fearfulness for what tomorrow may bring made for very poor long term memory.
5. Do something each day to better the future for the family, e.g., estate planning, distribute possessions, contact your pastor, open or close bank accounts, etc.
6. Make each day count. Achieving what is essentially a positive attitude is difficult as it is easy to be drawn down in the morass of the situation. This activity requires extreme mental discipline.
7. Take advantage of any counseling offered by the hospital or clinic.
8. Develop a network of support. We sent out 45-50 letters informing people of my diagnosis. As a result, each day’s mail brought something for me to look forward to. (Editor’s Note: This is an excellent example of where an electronic network like Caring Bridge would be helpful, Providence is currently in the process of linking up with this resource.)
9. Try to keep as near normal routine as possible in a situation in which everything has changed. We celebrated my 75^th birthday with a card party. I received over 100 cards in the mail. Once again, each day’s mail brought something to look forward to.

Have your own tips? Leave us a note in the comments!

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Introducing Jan Crawford, Breast Cancer Survivor

Photo Caption: Jan Crawford, and her daughter Cortney Crawford stand with James Lechner, MD, medical director of the Providence Regional Cancer System, following his lecture at the Cancer Survivor Event in June of 2011.

I've had the honor of meeting Jan Crawford three separate times in the past month. When we met most recently, she was excited to share the news about her latest accomplishment. She had just been credentialed as a Certified Cancer Exercise Specialist. This meant she could officially start turning her passion into a profession. She wants to use her exercise expertise and her personal experience with cancer to help others figure out how activity can help them get through cancer, too.

Jan's path towards this goal started three years ago. In October 2007, she had a mammogram that revealed lumps in her breasts. She wasn't overly worried, though. Ever since high school, she had dealt with an unusual number of benign breast lumps. However, this time was a little different. She decided she wanted to end the underlying stress she felt whenever she found a lump. Her solution: to undergo a prophylactic (preventive) double mastectomy.

Her surgery took place on December 19, 2007. Expecting a routine recovery and a little downtime to enjoy the holidays, she was devastated to learn instead that she had breast cancer -- including aggressive cancer on her right side. Her surgeon told her she needed more surgery as soon as possible, and she was back in the operating room the next day.

In January she started chemotherapy treatments. And in May she underwent reconstructive breast surgery. All of this left her unable to work for 10 months; not surprising due to her on-the-feet job as a flight attendant. She finally went back to work, but then learned that surgery was not quite finished for her. Possible side effects of her chemotherapy drugs included uterine or endometrial cancers, so she decided to have a hysterectomy. She says she doesn't regret that decision because her physician found suspicious areas during surgery that may have led to cancer in the not-so-distant future.

Today Jan talks easily about her cancer, treatment and the many emotional and psychological issues that have accompanied her experience. She emphasizes how much exercise helped her cope with what she was going through, including the "fog of cancer" that she felt stuck in frequently. Now she wants to help other people with cancer discover how activity can improve the quality of their lives, too. She's currently exploring the practical side of how she can make this happen, and hopes to have a place available soon where she can offer guided exercise sessions for other cancer survivors.

In future blog entries that Jan is planning on writing, she'll talk more about her experiences as a breast cancer survivor and her dream of sharing the benefits of exercise with other survivors.

Please, welcome Jan to the blog.

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Your treatment is over? ... but we're still here

A diagnosis of cancer and the subsequent treatment can feel overwhelming. The expectation is that when treatment ends, life will get back to “normal.” The days wind down and it is finally the last radiation treatment and/or chemotherapy infusion. You and your loved ones may expect that you will be immediately ready to jump back into your pre-cancer activities at 100%.

Surprisingly for some, ending active treatment is not the end of the cancer journey. Indeed, when treatment ends you may finally have the physical and emotional energy to start processing information and feelings that were too threatening to contemplate while rushing from doctor appointments to phone calls with the insurance company. You may feel abandoned and unsure of what to feel and do next. The transition from cancer patient to cancer survivor can be very challenging.

Some cancer survivors report that ending treatment is more stressful than the initial diagnosis. Although surgery, chemo and radiation are not pleasant, they feel like very powerful weapons. When they end, you may wonder how successfully you will be able to keep the cancer at bay. Furthermore, you may still be experiencing symptoms from the treatment such as fatigue and neuropathy; they do not end the moment you walk out of the cancer center on the last day of treatment.

You may feel inundated with a mountain of tasks that were put off while the treatment was ongoing. Unfortunately, the supportive folks who gathered round during the acute phase of your illness usually retreat during this transition time, thinking you do not need help anymore. You may even be told, “What are you worrying about? You’re done!”

You are not “done.” I would argue that the time when treatment ends is just the beginning; the beginning of processing one’s experience and starting to heal physically, emotionally and spiritually. And even if you are not cured of the cancer, healing is possible.

For those of you who have finished treatment, what challenges have you faced in making the transition from patient to survivor? Do you have any coping strategies you have found helpful?

Providence Regional Cancer System has resources and support to help you navigate through this transition.

• Combating end of treatment stress
• Free resources

How to make the most out of every patient visit

Editors Note: We met with Susan Covey and Pam Clay, Certified Medical Assistants who serve as Clinical Staff at the Providence Regional Cancer System Clinic in Lacey, WA to ask them, “How can patients make the most out of their visit?” Here are their top 6 …

1. Bring a list of your medications. See “I take one blue pill and three pink pills twice a day.”
2. Write your questions down. We find that it’s helpful for our patients and their support partners to keep a journal beginning the day they leave their last visit to the day of your next one.
3. Bring a support partner. It’s not only helpful to have a second set of ears listening to your care team’s instructions; it’s also beneficial to have a second person’s questions while the doctor is present.
4. Let us know if you’ve been to another doctor, or had tests done somewhere else. This information helps us to ensure the treatment plan we are creating for you is the most appropriate and complete.
5. Be a good patient. This means, don’t be afraid to give us the full picture.
   - Tell your doctor everything you tell your nurse. Often patients will share openly with their care team up until the point they see their doctor. Not wanting to look like they are “complaining to their doctor” they stop sharing and simply answer the doctor’s questions, painting an incomplete picture of their treatment.
   - Don’t ignore your side-effects! Every day we make more progress managing the side-effects that cancer treatment often brings … but we can’t address them if you don’t tell us about them. See “Cancer and pain: It’s okay to ask for help.”
6. Be yourself. We think our patients and those who support them are some of the bravest people we know … but we also know that you are feeling scared, confused, frustrated … the list goes on. When you come to see us don’t be afraid to tell us how you really feel. We’re here to help.

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