V.A. and Brest Cancer: Are their treatments up to snuff?
While we hear tell of improvements in breast cancer treatments, it seem the V.A. health care system has not caught up with the latest teast and treatments, or are just unwilling to pay for state of the art tests and treatments. The result is that the V.A. may be sending women with Breast Cancer to an early grave.
Women Vets and Breast Cancer Treatment
For women, the personal seems to always be political. Perhaps one of the most offensive realities is how women's health care can be driven more by politics and/or profit than by good science. We all know that politics has interfered w/ women's reproductive health care. We know that patriarchal control over politics and science has effected research and treatment of women's health issues.
But, what about cancer, breast cancer. How might politics and profit play into Breast Cancer treatment?
The following is a story in the making. It is not something that has happened; it is something that is happening. To me; and to many other women.
In March I agreed to have a mammogram as I was approaching 50. Now I had a baseline done at 40 and it seemed a little rough, so I expressed my concerns and the Roseburg V.A. facilitator assured me that the new machines were not bad and I could get a state of the art, no pain monogram in Roseburg.
Boy did I feel betrayed. This idiot tortured me for over an hour while she failed time after time to get a good image. Likely due to the fact that she was overcompressing, and each time she failed to get a viable image she just came back and clamped down harder. I was ready to b slap the woman. This was much worse than anything I remembered a decade ago. How could this be better; my breast was red and swollen when she was finished. Well the images were no good and the whole thing had to be repeated; this time in Portland at OHSU. What a difference!!!! No pain, little compression. Now I knew this woman who tortured me either did not know what she was doing or needed to be incarcerated to protect the general public. I complained to the Roseburg V.A.. The reply was that is the only imaging place in Roseburg. Hell man, tell these women the truth; I am sure they will not mind going to Portland to avoid useless tortured.
OHSU asked if there were any earlier images available for a bass line. I called Eugene were images were taken 10 years ago, only to find out they had been destroyed. Why did I have that "baseline" again?
After the new images were in; it was suggested that I have a core biopsy. It was done; the results came back. Invasive ductile carcinoma.
Now it was time to do research, so I thought. But, as it turns out, I should have done the research before the mammography. What? Research a condition before you know you have it? That is what you would have to do, it turns out, if you want to protect yourself from the medical establishment and their killer breast cancer tests and treatments.
What killer treatments? What do you mean?
Well, I found research, then more research, then more and more, indicating that trauma inducing mammography, biopsy, and surgery, chemo all may increase the rate of cancer growth. Now metastasis is the most dangerous feature of cancer. Yet, cancer treatment it seems can often induce metastases.
A few of many sources are:
"Excisional surgery for cancer cure: therapy at a cost, the Lancet Oncology, Coffey..... at http://www.sciencedirect.com
"Does the act of surgery provoke activation of "latent" metastasis in early breast cancer?" at http:/www.pubmedcentral.nih.gov/ariclerender.fcgi?artid=468671
"Trauma-associated growth of suspected dormant micrometastasis", BMC Cancer, 2005;9/4 on line at http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1190165
"Treatment-induced growth factor causes cancer progression", Vanderbilt, at http://www.brightsurf.com
"Wounding from biopsy and breast-cancer progression, Lancet, 2001 Mar 31;357(9261):1048
"Does surgery unfavorably perturb the natural history of early breast cancer..." Baum, Eur J Cancer2005, Mar:41 (4):508-15
"Wound-healing genes promote cancer progression, Lancet Oncol. 2004;5:138.
Now I was freaked! A cancer that I could have had for years, and could have grown slowly for many years more, may now kill me in a matter of a few years. Why was I not told of this risk? Why was nothing done to hedge against such a risk? The science on the risk was enough to justify warning and response. What the hell happened to "informed consent"? The lack of communication on the issue breached all trust; I would no longer consent to anything I have not checked out for myself.
Of course one might argue that it may be better not to know, that is that it could be that there no good reason to warn about what cannot be helped and will only cause anxiety. Core biopsy is the best way to distinguish cancer from benign tissue, and there is no known means to offset the rate of growth. "NO other way" is usually a logical fallacy; "No better way", is as I found highly suspect if not simply wrong,
It may be that a core biopsy is the best way to find cancer; but in many cases there are known means to offset the treatment induced stimulation of growth. In my case where 90% of my cancer cells test ER+ that is dependent upon estrogen for growth, something known within 3 days after the core biopsy. It seems logical that neoadjuvant (pre-surgery) hormone suppression starting right after the ER status is known to be + might be a good means to offset treatment/trauma induced growth. There are several ways this can be done including for premenopausal women like myself removal of the ovaries, radiation of the ovaries, or chemical suppression. "New opportunities in premenopausal breast cancer? goserelin (Zoladex) plus Aromatase inhibition" Jakesz, Breast Cancer Online, Cambridge Univ. Press 2006,
After that rough roseburg mammography and the core biopsy, I have repeatedly asked for immediate therapy in the form of tamoxifen, hormone suppression, oophorectomy, something to offset this risk of treatment induced growth. No help, just condensation and patronizing B.S. Yes, I am afraid, anyone but a fool would be; not just afraid of the cancer, but afraid of all the fools coming out of the woodwork to do harm in the name of health. It may be that some are helped, but others are harmed, they know this is true, but rather than spend the money on appropriate tests and treatment, for some reason, economic/political I suspect, the V.A. Drs. are holding by an out dated standard of care when it comes to premenopausal ER+ breast cancer treatment.
Also, being somewhat concerned about long term side effects including cervical cancer, of tamoxifen, I asked about surgical oophorectomy at the time of breast surgery or before, a treatment of choice in Italy.
"Ovarian oblation "Vs. goserelin with or without tamoxifen in pre-premenopausal patients with advanced breast cancer..." http://annonc.oxfordjournals.org/cgi/content/abstract/5/4/337 also see. "Breast Cancer Growth and Surgical oophorectomy", Love and Neiderhuber, Ann Surg Oncol Vol.11 No 9 2004, 818-828
When I showed this study to the oncologist he pointed to the words "a trend did favour oophorectomy" emphasis the word "trend" and never looked to see that everyone in the study rec'd ovarian irradiation of some sort, surgical or goserelin, neither of which I am being offered. The idea that something should be done to offset surgical stimulation of growth was not in question but now assumed knowledge. Oophorectomy is "comparable in efficacy to ususal chemotherapy programs", what matters is tumor genetics in determination of appropriate therapy. certainly what we knew about my tumor thus far suggested further investigation into this line of thinking, that is in using hormone suppression as indicated by the ER+ status but not using chemo until testing proves effectiveness. Yet again, without further examination, my suggestion was refused. Oophorectomy would take two surgeons I was told, not practical. I asked about testing for chemo effectiveness, and was ignored, No 21 gene test, no neoadjuvant test, just the old fashioned if it is outside the breast you get radiation/chemo regardless. What happened to "do not harm"? Medical induced harm may have already been done and is currently being done, and they are determined to risk more, all with no hedge. Most people on wall street would not accept the odds without a hedge, why should breast cancer patients with their very lives in the balance?
In fact research supports this reasoning.
Baum and others have suggested that hormone suppression and COX2 inhibitors might, "in part suppress the activation of dormant metastases by the act of surgery. If this is the case, IQAs should be initiated at (or even before) surgery in order to optimize this effect. Furthermore, this benefit might be enhanced by the concomitant use of a COX2 inhibit."
"An exploration of relapse data by hazard rate as a means of developing biological insights into the natural history and treatment of breast cancer..." JCO 2005, v23 no 16S 612, at http://meeting.jco.org/cgi/content/abstract/23/16_suppl/612
"...the next leap forward would depend on "stabilizing" these latent metastases...before letting a surgeon near a patient" (Baum, Breast Cancer Res, 2004 6/4: 160-161)
Vanderbuilt is experimenting w/ TGF-beta inhibitors.
others are experimenting w/ Bisphosphonates....
I asked about using Goserelin and an IA, and quoted the recent guidelines by the "American Society of Clinical Oncology and the National Comprehensive Cancer Network that "tamoxifen therapy (what I was being told I would be given sometime after surgery, perhaps after radiation and chemo (a delay in hormone suppression which research has shown could further harm my chances) should no longer be considered optimal therapy, and that all adjuvant treatment regimes should now include an A I, in combination with goserelin for premenopausal women. See.
"Breast Cancer Growth and Surgical oophorectomy", Love and Neiderhuber, Ann Surg Oncol Vol.11 No 9 2004, 818-828-
"Management of premenopausal women with early-stage breast cancer: is there a role for ovarian suppression?" Clinical Journal of Breast Cancer 2002; 3(4):260-267
I pointed to UK research concluding that, while, "no obvious survival benefit (quality of life, number of surgeries, treatment side effects... are not considered) to women with breast cancer...it does allow avoidance of surgery in some cases..." 14% in this small sample, and can allow for the testing effectiveness of systemic therapy. http://www.springerlink.com/content/h2064j420p241v25/
His comment simply contradicted the study pointing to the small sample, ignoring the fact that the numbers were amazing. 14% of the women who underwent pre-breast surgery oophorectomy of some kind did not have to have breast surgery after 4 months of treatment. Now this was the most significant scientific discovery I could imagine. Take the ovaries first and in many cases then save the breast? Hmmm.
Again I was refused the up to date treatment and told I would get the best of care as was determined 25 years ago.
Which brings me to chemo and radiation which have proved only effective in a sub population of cancer patients, but continues to be applied to a larger population, potentially doing more harm than good. Sandra M Swain of the National Cancer Institute using Recurrence scores claims that patients w/ a low RS do not benefit from chemotherapy and ER+ tumors have a small benefit from chemotherapy."A step in the right direction:" Journal of Clinical Oncology Vol 24, no23, aug 10, 2006. Why do this harm again? Are there not test to narrow treatment down to the appropriate subgroup? There are ways. Yet none are being employed in my case, inspire of repeated request.
"Gene Expression and Benefit of Chemotherapy in Women with Node-Negative, Estrogen Receptor-Positive Breast Cancer" Journal of Clinical Oncology at " http://jco.ascopubs.org/cgi/content/abstract/JCO.2005.04.7985v1
"Genomic Test Improve Prediction of Breast Cancer Response to Chemotherapy, Hormonal Therapy" Univ. of Tx, MD Anderson Cancer Center, 12/14/06, at " http://www.mdanderson.org
Radiation not unlike other treatments is also only effective in the case of some tumors. "Predicting Recurrence by Beth W. Orenstein, Radiology Today Vol 8 No. 1 p20.
Despite the fact that hormone suppression is the best thing that we know can be done in my case, one has to wonder why two months after discovery, after biopsy may have increased the growth rate of my cancer, to months after status and type of cancer was known, no therapy has been administered. In fact not only have I been refused any type of hormone suppression in spite of my repeated requests, but they insist I must move forward with surgery, and accept that hormone suppression may be further delayed for radiation and chemo if there are any signs of metastasis or lymph positive status is discovered, and no plans of a test to ensure the chemo or radiation will even be effective.
Now some Drs. may claim these treatments are not approved. But, off label use of drugs and phase III experimental treatments are employed often, and insurance companies often do not have the choice not to cover such treatments. In fact, treatments can become standards of care prior to FDA approval.
The U.S. Congress passed a law in 1993 requiring Medicare ( http://www.medicare.gov/), the federally funded health care program for elderly and disabled people, to cover off-label drugs used in cancer treatment when the use is supported by:
a citation in at least one of the following authoritative drug reference books.
The American Society of Health-System Pharmacists' American Hospital Formulary Service (AHFS). There is a regularly updated online version.
U.S. Pharmacopeia Drug Information
two or more peer-reviewed articles published in respected medical journals.
The drug reference books are not available online to us layfolk, but I have provided the V.A. oncologists with an abundance of peer-reviewed articles published in respected medical journals. However, while Drs. can help a patient in seeking insurance coverage for treatment, the V.A. is my Dr. and insurance coverage. Are the Drs. told what treatments they can offer and what treatments they cannot based on economic factors overriding health concerns? What is going on with breast cancer care and the V.A.? I can remember when the V.A. did no women's medicine referring us to private Drs. Did they take us on only to provide us with substandard care?
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