52 Breast Cancer and Listener Question.mp3: Audio automatically transcribed by Sonix
52 Breast Cancer and Listener Question.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.
Speaker1:
Hi and welcome to the Cancer Secrets podcast. I am your host and guide, Dr. Jonathan Stegall. Cancer is like a thief who has come to steal, kill and destroy. I have personally seen it wreak havoc on patients, friends and even my own family. But I am on a mission to change the cancer paradigm. Who? The practice of integrative oncology cancer treatment that integrates the best of conventional medicine with the best of alternative therapies backed by science and personalized to each patient. You need a positive voice you can trust. This podcast will share valuable information to give you practical hope for a better outcome. So I invite you to join me on this journey as we seek to change the cancer paradigm together. Hello and welcome back to the Cancer Secrets podcast. I'm your host, Doctor Jonathan Seagal. This is season four and episode number 52. In today's episode, I will be discussing breast cancer in the context of an excellent question I received from one of our listeners. As always, I encourage you to listen with a family member or friend. Let's get started. Our question is from Angela from San Diego, California. Angela was recently diagnosed with breast cancer and underwent surgery and radiation. Her cancer was found to be estrogen and progesterone receptor positive and her two new negative. She'll be starting Tamoxifen shortly. Her question is, are there any interactions between Tamoxifen and supplements, especially dim turmeric, vitamin C, Vitamin E and ashwagandha? She asks for guidance regarding implementing a supplement protocol that will be safe.
Speaker2:
Hi, Dr. Segal. My name is Angela and I'm calling from San Diego, California. First of all, I want to thank you for your Cancer Secrets podcast. There is so much valuable information in each and every one of the episodes. I was diagnosed with breast cancer about three months ago and underwent surgery and radiation. I had estrogen, progesterone positive, cancer, HER2 negative. So I will start Tamoxifen here shortly. My question is regarding drug interactions with supplements, and I know there are some great supplements out there, but I am concerned about the interaction that they may have with the Tamoxifen, specifically damn turmeric, possibly vitamin C, vitamin E, ashwagandha, and some others. So if you could maybe give a little insight regarding those interactions and possibly if there are any problems taking any of those supplements with Tamoxifen. Thanks again.
Speaker1:
Angela. Thank you so much for your question. This is a very important topic, so important that I decided to devote an entire episode to it. So today we'll be discussing breast cancer, the ins and outs of diagnosis and treatment, and finally, interactions between drugs and supplements. Before we jump into the details of the interactions, I'd like to back up and discuss some of specifics of Angela's diagnosis. For those of you who may be curious, when a breast cancer diagnosis is made, it is based upon in-depth analysis of the breast tissue. This is typically obtained via biopsy. There are several questions that biopsy attempts to answer. First, is it malignant or benign? If it's malignant? In other words, cancerous. What type of cancer is it? With a breast biopsy, we want to know if it's ductal or lobular in origin. This tells us where the cancer came from. We also want to know if it's inflammatory or invasive. All of these details matter. More specifically, there are four main components that must be investigated. These are the estrogen receptor, progesterone receptor, HER2 new status and k 67. As we know, both estrogen and progesterone or hormones, which can be drivers of growth in breast cancer. It's important to know if a patient's breast cancer uses estrogen and or progesterone as fuel for growth, because if so, we can block those hormones in order to significantly slow cancer growth. Angel's breast cancer was found to be both estrogen receptor positive and progesterone receptor positive.
Speaker1:
Determining her two new status is also important, as cancer found to be HER2 positive can be treated with immunotherapy directed toward the HER2 new receptor. There are several agents available which do this, the most commonly known being Herceptin. Generic name trastuzumab. This is an excellent therapy when indicated as it utilizes the body's immune system to attack cancer cells expressing the HER2 new receptor. Angela is HER2 new negative, so this is not an option for her. Now women who don't have the estrogen progesterone or HER2 new receptor being positive are termed triple negative. And this is important because triple negative breast cancer has fewer options for treatment and is thus a little bit more aggressive and typically has a worse prognosis. Now, I will add, however, that triple negative breast cancer is still very treatable. We still have many treatment options, especially in the integrative oncology world. And it's not a condition where women should lack any sort of hope or optimism for a good outcome. Now, the last component I mentioned above was K 67 and 67 can be thought of as a measurement of the metabolic activity of the cancer. So K 67 is a score as a percentage, which is from 0 to 100. And the lower the chi 67, the less metabolically active those cancer cells appear to be. And the higher the 67, the more metabolically active they are. So k 67 When we talk about the metabolic activity, you can think of that as being partly related to aggressiveness.
Speaker1:
So if you look at a K 67 scale, anything from 0 to 10 is considered less metabolically active. Between ten and 20 is considered moderate on the scale, and anything over 20 is considered more metabolically active. So if you have a cancer with a K 67 above 20, you can know that that cancer is more metabolically active. That means it's growing and dividing at a faster rate. And that's important because not only do we want to know generally how aggressive the cancer is, but we also want to know if we do proceed with some sort of chemotherapy based treatment, how well do we think it's going to work? And so the advantage we have with a cancer that has a higher Chi 67 is it's going to typically be more responsive to chemotherapy. And that's not to say a lower K 67 won't be responsive because it will be cancer in general is going to be responsive to chemotherapy because that's just how we've developed chemotherapy. It's going to harm those cancer cells that are going through cell replication and division. But the advantage we have with a a more metabolically active cancer is that chemo is going to typically work especially well on those. So it's not always a negative to have a higher 67. So moving along, the next important factor after determining the specific type of cancer and those details with your cancer is the staging.
Speaker1:
Now we stage cancer using the TNM system, which stands for tumor nodes and metastasis. Tumor characteristics evaluated include tumor size as well as the degree of tumor invasion into surrounding tissue, if any. When we evaluate lymph nodes, we look at whether cancer has spread into nearby lymph nodes and if so, how many. Evaluating metastasis looks at cancer spread to distant sites, including various organs and bone. When it comes to breast cancer, we can describe its involvement as local or regional or distant. Local spread means that cancer is confined within the breast. Regional spread means that cancer has spread outside the breast into nearby lymph nodes such as the axilla, otherwise known as the armpit. Distance spread means that cancer has spread beyond the breast region and is found in other parts of the body. Using the TNM system. Stage one is the lowest stage of breast cancer and is subdivided into stage one A and stage one B. Stage one A breast cancer includes a tumor up to two centimeters in size with no evidence of spread outside of the breast, including low lymph node involvement. Stage one B breast cancer includes a tumor up to two centimeters in size, but with very small groups of cancer cells found in lymph nodes. Stage one. B Breast cancer can also include cancer where no tumor is found in the breast, but instead as small groups of cancer found in nearby lymph nodes.
Speaker1:
Stage two Breast cancer is subdivided into stage two A and stage two B. Stage two A can either be a tumor smaller than two centimetres with spread to axillary lymph nodes, or a tumor larger than two centimeters, which is not spread to the axillary lymph nodes. Stage two A also includes a situation where no tumor can be found in the breast. But 1 to 3 axillary lymph nodes or internal memory nodes are involved. Stage two B Breast cancer is when the tumor is larger than two centimeters, but no larger than five centimeters. And no more than 1 to 3 lymph nodes are involved. Stage two B can also be diagnosed when the breast tumor is larger than five centimeters, but there is no spread to axillary lymph nodes. Stage three, breast cancer is subdivided into stage three A, three B and three C in stage three A breast cancer. The tumor is larger than five centimetres and has spread to up to three lymph nodes. Stage three A can also include no discernible mass in the breast itself, but evidence of spread to 4 to 9 lymph nodes can be seen. Stage three B Breast cancer can include a tumor of any size with spread to the chest wall and or the skin of the breast with spread up to nine lymph nodes. Stage three C Breast cancer has spread to ten or more lymph nodes or the lymph nodes above the collarbone.
Speaker1:
Stage three C can also be diagnosed when no discernible mass is seen in the breast but spread to the chest wall or the skin overlying the breast is seen. Stage four. Breast cancer has spread beyond the breast and nearby lymph nodes to include other organs of the body, such as the lungs, liver, bones, brain or skin. Descriptors such as advanced or metastatic, are often used to describe stage four breast cancer. Now, you might have also heard of something called stage zero breast cancer. This is something called ductal carcinoma in situ or DCIS. This is considered a precancerous stage according to most classification systems, so I did not include that here. Typically, only stage one through four is considered cancer and stage zero is sort of a grey area, pre-cancerous type situation where there are abnormal cells found and they do need to be treated, but they're not a full blown cancer yet. So as you'll see with stage zero cancer, it's typically still going to include some surgery and possibly even some additional treatment beyond that. But it does not require things like chemotherapy and radiation. So there are two important aspects to staging imaging findings as well as surgical findings. So imaging is often the first step when we try to determine the stage of a cancer. And this can include various imaging modalities, including breast dry, a chest CT scan, which is also called a CAT scan or a PET CT scan, which is the CT scan, plus the pet portion, which gives us additional information.
Speaker1:
One or more of these imaging modalities is often conducted prior to surgery, although this is not always necessary. Sometimes imaging occurs after surgery if needed, especially if some questions remain after surgery regarding the specific stage. Information obtained during surgery is also very helpful for staging, especially since lymph nodes sampled during surgery can turn out to be positive even if they did not seem to be so on imaging. I realize that was a lot of detail I just went through, but I wanted to illustrate for you how complex a breast cancer diagnosis is, and this complexity is really there regardless of the type of cancer we're discussing. And as you can see, these details are all important not only for establishing the correct diagnosis, but also in guiding our treatment decisions. I know some of you might be hesitant to obtain a biopsy or undergo imaging in order to establish the diagnosis due to a variety of concerns such as radiation exposure or being worried about possibly spreading the cancer. But I can tell you these concerns are insignificant in relation to the importance of getting the correct diagnosis. It's simply not possible to treat a patient optimally without having this information. As we often say, knowledge is power. Angela's case seems to be stage one or stage two based on the fact that she had surgery first and will be having radiation as well.
Speaker1:
A stage three or four breast cancer will typically require treatment with chemotherapy and possibly other agents as well prior to surgery. Since radiation is being incorporated, I'm assuming that Angela had a lumpectomy rather than a mastectomy. Mastectomy, which is a complete removal of the breast, does offer a greater reduction in risk of cancer recurrence compared to lumpectomy. But studies have found that adding radiation on to lumpectomy, which is just a simple removal of the tumor itself, reduces the risk further to approximate that of mastectomy. So when we look at risk of cancer recurrence, mastectomy is basically equivalent to lumpectomy plus radiation. Angela is taking Tamoxifen to address the hormonal component of her cancer since she's estrogen receptor positive. Now we know that we must block estrogen to reduce the risk that any remaining cancer cells will be fueled by estrogen in the body. Tamoxifen is in a class of drugs known as selective estrogen receptor modulators or sperms for short. Tamoxifen blocks estrogen in breast cells, but not in other types of cells. This is important because we want to block estrogen in breast cells since that is the cell type where the cancer is present. However, allowing estrogen to still exert its beneficial effects on other cell types, including bone, mean that the risk of osteoporosis and osteopenia with Tamoxifen is no greater than for someone not taking tamoxifen. However, since Tamoxifen allows estrogen to continue to affect cells in the female organs, there is a slightly increased risk of endometrial cancer in women taking Tamoxifen.
Speaker1:
As you may know, endometrial cancer is our scientific term for uterine cancer. Now, in contrast, there's another class of medications sometimes used in cases of estrogen receptor positive breast cancer. These are known as aromatase inhibitors. In examples include Anastrozole, brand name or Imitrex, Letrozole, brand name, Femara and exemestane brand name, aroma, sin. These medications block estrogen everywhere throughout the body. So in addition to blocking estrogen in breast cells, they also block estrogen in bone and in the female organs. These drugs do not have an increased risk of endometrial cancer, but they do increase their risk of bone loss, causing osteopenia and osteoporosis, since the beneficial effects of estrogen on bone are blocked. The decision regarding which of these estrogen blocking agents to take is an individual one. I typically prefer tamoxifen since osteoporosis is a very real problem in our society and can be especially concerning in women who have spread of their breast cancer to bone. In addition, Tamoxifen has the added advantage of blocking what is known as IGF one. Igf one stands for insulin like growth factor one and is our surrogate marker for growth hormone. Virtually all cancers, including breast cancer, utilize growth hormone for fuel. Aromatase inhibitors such as a remedy, do not have this benefit of blocking IGF one. Now, this is not to say that aromatase inhibitors are bad because there are certainly situations where they have their advantages, such as in women who have a strong family history of endometrial cancer or who prefer to take the risk of osteoporosis instead of their risk of endometrial cancer, regardless of which hormone blocking agent is chosen.
Speaker1:
The current guidelines are for ten years of therapy. The recommendation used to be for five years, but research within the last few years found an additional decrease in risk of cancer recurrence with ten years of treatment. Because these agents block estrogen, they can cause menopausal type symptoms such as hot flashes, night sweats and joint aches. They seem to be fairly consistent between the two classes of drugs. I will say that I typically use Tamoxifen with my patients and rarely see side effects from its use. One aspect of treatment of hormone positive breast cancer we've not discussed yet is the difference between premenopausal and postmenopausal breast cancer. The above scenario I discussed, which also seems to be the case for Angela, is of postmenopausal breast cancer. This means that menopause has already occurred and there is no longer a menstrual cycle. However, there are many cases of women diagnosed with breast cancer in the pre menopausal setting, meaning that they have not reached menopause and are still having a menstrual cycle. The treatment principles are the same. However, the traditional method has been to suppress the menstrual cycle and create a chemical menopause using a medication known as liberalised. Once the menstrual cycle is suppressed, we would use an estrogen blocking agent such as an aromatase inhibitor or Tamoxifen.
Speaker1:
However, in recent years, Tamoxifen alone is being used in pre-menopausal breast cancer when the patient is low stage. And of course, there's always a surgical option as well, even in pre-menopausal breast cancer, where the patient can undergo a hysterectomy to remove the ovaries, the fallopian tubes and the uterus. So this is another option for women who are still having a cycle, but who no longer want to have children and would rather just do the surgical approach rather than undergoing the the routine injections of something like a looper line. Now you may be wondering why we've not discussed chemotherapy. In some cases of stage one or stage two breast cancer, chemotherapy actually is not needed. I suspect this is the case for Angela. Research has shown that some cases of early stage breast cancer only require surgery, radiation therapy and endocrine therapy and do not need chemotherapy. One test which can help clarify this is the ONCO type D test. This is a genomic test which evaluates the activity of specific genes within a tumor. Based on these results, a recurrence score between zero and 100 is generated. A lower score on this test suggests a low risk of recurrence. Assuming the aforementioned treatments such as surgery, radiation and hormone therapy are utilized when indicated in these cases, suggesting a low risk of recurrence. Chemotherapy is not thought to provide additional benefit.
Speaker1:
However, patients with higher scores on this test have a greater risk of cancer recurrence and are thought to benefit from chemotherapy. It's important to note that the archetype test is only for women with early stage estrogen receptor positive and her two new negative breast cancer. Okay, so we've talked about the ins and outs of breast cancer diagnosis as well as the main elements of the standard of care treatment for breast cancer. Now let's get to the heart of Angela's question regarding interactions. She had surgery to remove the cancer with clear margins, which was an excellent first step. She'll be having radiation therapy to further reduce her risk of cancer recurrence, which I'm glad to hear. And she will be taking Tamoxifen, which I'm thrilled about as well. She's interested in augmenting these therapies with appropriate nutritional supplements, which I think is a great strategy. Angela, I want to thank you for thinking about what we refer to as drug supplement interactions, because it is a very important concept. The temptation many people have is to think that supplements such as herbs, vitamins and other natural products are harmless simply because they're, quote, natural. This is a dangerous assumption to make. We must keep in mind that any substance which has an ability to have an effect in the body also has a potential to cause a reaction. Do not fall into the trap of thinking that only pharmaceuticals have side effects.
Speaker1:
Supplements can also have side effects. If you take too much of a supplement, you can have a wide range of side effects. As we often say, the dose makes the poison substances themselves are not toxic, but rather too much of a given substance is toxic. So if we acknowledge that there are nutritional supplements which are capable of having a beneficial effect in the body, then we also must acknowledge that they are that they are capable of causing harm. The key to using them is the same as with pharmaceutical agents, which is to use them in their appropriate doses and to use them only with other substances which are compatible. My first piece of advice is to ask your oncologists about any natural products you're interested in using. Unfortunately, if you ask most doctors, nurses, PAs and dietitians, they are unaware of potential interactions between drugs and supplements. The default recommendation is simply not to take supplements because they might interact with drugs. I find this to be a wimpy approach. It's just lazy ignorance should not be an excuse for failing to take action. I realize that training in herbs and nutraceuticals is severely lacking in most health professions today. However, there are resources available. One resource I can recommend, which is easy for anyone to access, is Memorial Sloan-Kettering is about Herbs Database. The About Herbs Database provides in-depth information on various herbs and other dietary supplements, including details regarding how they are used and with which substances they might interact.
Speaker1:
The database was designed with both patients and health care professionals in mind. If you just Google Sloan-Kettering about herbs, you'll see the link pop up in an Internet search. Angela is concerned with several nutraceuticals possibly interacting with Tamoxifen. I can tell you that Dimm, which stands for DNA, will methane possibly interact with Tamoxifen by reducing the amount of one of Tamoxifen metabolites in the body? For this reason, I do not use dimm in women who are on tamoxifen, as I do not want to risk compromising tamoxifen effect in the body. This interaction makes sense because dim affects the metabolism or breakdown of estrogen. There is also a concern about vitamin E and its interaction with Tamoxifen. A study from about 15 years ago suggested that Vitamin E might inhibit the effect of Tamoxifen. For this reason, I typically don't include vitamin E in my protocols for patients who are taking Tamoxifen. I'm not aware of any known interactions between Tamoxifen and the others. You mentioned Angela, including turmeric, vitamin C and ashwagandha. The disclaimer here is that there could be interactions that we don't yet know about. This is especially true of less common and more obscure herbs and supplements. But turmeric, vitamin C and ashwagandha have all been around a while. They're pretty well known and they have been studied pretty significantly. So any interactions that exist should be should be known at this point. As always, this podcast is for informational and educational purposes only, and this does not replace medical advice from your oncologist.
Speaker1:
I'm a firm believer in open communication between doctor and patient, so my recommendation for anyone listening is to discuss your desire to incorporate nutritional supplements in your regimen with your oncologist. If you're met with resistance, then it might be time to find another oncologist. Look for an integrative oncologist, as we are knowledgeable about many supplements, including how they work and how they might interact with other aspects of a treatment protocol. Angela, I hope you found this information helpful. Thank you again for your excellent question and for being a faithful listener of the podcast. I'm praying for you that your treatments will be successful and that you will have tremendous peace along the way. As a reminder, if you would like to submit a question, please go to Cancer Secrets dot com forward slash podcast. You'll see a tab on the right hand side of the page that says Send voice mail. If you click on that, it'll allow you to leave a voicemail message to us with your question. It's that easy. I also want to thank our many listeners from around the world. It is truly humbling to see how many people we have reached through this podcast. We have listeners from 124 countries around the globe and have reached nearly 100,000 downloads. I am truly honored to be able to share my knowledge, research and clinical experience with you.
Speaker1:
On that note, I'd like to highlight two excellent reviews we recently received. The first said Great podcast, well produced and informative. It is not about controversy. It's about looking into the latest research. Many of the things presented here have helped me personally. Another was entitled Infinite Information, and it said My mom got diagnosed with stage two B pancreatic cancer. And to be honest, I never really educated myself about cancer until now. I still feel a little lost about the situation because I'm constantly thinking about how I can help my mom beat this. I've been listening to this podcast every day. I have a better understanding about her cancer and ways to change her and my lifestyle to beat it and prevent it in the future. I am so happy I found this. Definitely recommend. Thank you so much for those wonderful reviews. And if you're enjoying these podcasts, please take a minute and provide your own review on iTunes, Spotify or wherever you listen to podcasts. As a reminder, please subscribe to the Cancer Secrets podcast to be notified when new episodes are released. We have some great shows planned and I can't wait to share them with you. As always, please share this podcast with your family and friends. All previous episodes are available for free on our website Cancer Secrets dot com. I look forward to many great episodes coming up later this season. Until next time. Bye bye. Oh.
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