Breast Cancer Survivors

Chemo Secrets From a Breast Cancer Survivor

Undergoing chemotherapy can be one of the most terrifying things that you go through in your life. One of the most frightening things about chemotherapy is the lack of real information that most people have about it, and the unknown makes it so much more frightening as a result. This eBook, written by a young cancer survivor gives you the real story about what chemo is all about. The most valuable information you can get about chemotherapy is from someone that has already experienced it. This PDF eBook allows you to download and read it as soon as your order it. You can begin your journey of reassurance as soon as you want! Because that's what this is about: chemo does not have to be a terrifying unknown! Other people have gone through it before, and want to help you through it as well! This eBook is the guide through chemo that many people wish they could have had, and now you can have it yourself!

Chemo Secrets From a Breast Cancer Survivor Summary


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Author: Nalie Augustin
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The Rising Incidence of Breast Cancer

Breast cancer is a serious, potentially lethal disease. Its incidence has been rising steadily since 1950, most significantly in postmenopausal women. Approximately 183,000 new cases are diagnosed in the United States each year, comprising 31 percent of all cancers. Of these cases, over 40,000 will die. In fact, breast cancer is the leading cause of death in women forty to fifty-nine years old. An American woman today has a one in eight (12.5 percent) cumulative risk of developing breast cancer in her lifetime1 (table 1.1). Many theories have been proposed to explain the increased incidence of breast cancer in modern times. Some of the data may reflect the increase in life expectancy. The increase in reported cases may also reflect the increase in awareness and in screening programs for early cancers. However, these explanations do not fully account for the increased incidence. Researchers and clinicians agree only that breast cancer is a complex disease that reflects the interplay of...

Sporadic vs Inherited Breast Cancer

In approximately 70 percent of cases, there is no family history of breast cancer. Those cancers are sporadic. The remaining 30 percent have a close family member (mother, sister, aunt) who also has the disease, suggesting that their susceptibility to developing the disease is inherited. However, a patient may have a close family member who is also affected and yet she may have sporadic disease. Only 5 10 percent of all breast cancer patients carry a known mutation that greatly enhances their chance of developing the disease. Sporadic breast cancers may also involve defective genes that enhance susceptibility, but to date these gene defects have not been clearly identified, nor are they known to be inherited. Although only some cancers are inherited, all involve damage to genes, as I will describe in chapter 2. Therefore, all cancers are genetic diseases.

Chemotherapy in Prostate Cancer

Prostate cancer is now most frequently diagnosed malignancy and the second leading cause of cancer-related death 1 . Death rates have increased over the past 20 years and mortality may approach that of lung cancer within 15 years 2 . For patients with advanced disease, the response rate to hormonal therapy is about 80 , but this is not durable, and all patients will eventually develop hormone-refractory prostate cancer (HRPC) 3 . Chemotherapy has been shown to have palliative benefit in symptomatic HRPC, but has not yet been demonstrated to prolong survival. Median life expectancy for patients with HRPC is only 12 to 18 months, underscoring the urgent need for new therapeutic approaches 4 . Historically, the role of aggressive systemic chemotherapy in HRPC had been questioned because elderly patients with poor marrow reserve, concomitant illnesses, and poor performance status tolerated it poorly. Coupled with this, chemotherapy trials before 1991 reported response rates of only 5 . In...

Neoadjuvant Chemotherapy

The use of systemic chemotherapy earlier in the course of treatment, an effective strategy in some malignancies, has been explored to a small degree in prostate cancer. The objectives of neoadjuvant chemotherapy are to downstage the cancer, decrease the incidence of positive surgical margins, and eliminate micrometastases. In addition, chemotherapy may eradicate both androgen-independent clones and androgen-sensitive clones, the latter by synergizing with hormonal ablation. Several pilot neoadjuvant chemotherapy trials have now been reported, and suggest that from a surgical standpoint this is a feasible approach (Table 9.4). Pettaway et al. 38 treated patients with high-risk localized disease with 12 weeks of ketoconazole and doxorubicin alternating with vinblastine and estramustine (KAVE) and androgen ablation followed by radical prostatectomy (RP). The primary end point, a 20 pathological complete response (pCR), was not achieved, but there were fewer positive margins. Clark et al....

Intravesical Chemotherapy and Recurrence Progression Rates

Intravesical chemotherapy agents were traditionally administered as delayed bladder instillations initiated at least 1 week following transurethral resection of the tumor and continued for up to 6 weeks. Such regimes were originally intended as prophylaxis against new occurrences, and had been demonstrated in many series to effect significant reductions in the short-term tumor recurrence rates. Early recurrence rates (within 1 year) for low-grade (G1 or G2), low-stage (pTa) superficial tumors can be reduced by up to 33 using anthracyclines 41 and 33 to 50 using MMC 42 , although these rates are adversely affected by increasing tumor stage and grade 43 .Unfortunately,good initial responses have proven less durable with prolonged tumor surveillance. In a review of 2861 patients enrolled in controlled studies up to 1992 42 , the long-term reduction in tumor recurrence averaged only 17 . Indeed, in those followed 5 years or more, the recurrence rate increased to that achieved using...

The Search for the Breast Cancer Gene

Unlike retinoblastoma or AT, which are caused by a defect in a single gene, breast cancer is multifactorial it is caused by the interaction of genes and the environment. Most cases are sporadic, occurring in women who have no family history of the disease and no obvious risk factors. At least 30 percent of patients have some family history, however, and 5 10 percent of patients have close relatives with the disease. Clusters of breast cancer cases within an immediate family have been observed for many years. A large study by the National Centers for Disease Control helped identify specific characteristics of inherited breast cancers Most are diagnosed at an early age (less than forty years old). Many are bilateral, that is, they occur in both breasts. The risk to an individual appears to rise with the number of affected first-degree relatives (mother, daughter, sister). Some patients, or their close relatives, also suffer from ovarian cancer.

Chemotherapy for Bladder Cancer

Transitional cell carcinoma (TCC) of the urinary bladder is the second most common genitourinary malignancy. Each year, over 73,000 new cases are reported in Europe and over 56,000 new cases in the United States. A substantial percentage of these patients develop metastases despite initial management for presumed localized disease, whereas others have metastases at the time of presentation. Once metastasis occurs, the median survival for patients with TCC is approximately 1 year. To improve this poor survival rate, intense efforts over the past two decades have focused on the development of active chemotherapeutic regimens for use in this disease, both in the perioperative setting and in the setting of advanced disease. Chemotherapy for advanced disease is discussed here first because of its impact on the management of early-stage disease.

Postchemotherapy Surgery in Metastatic Transitional Cell Carcinoma

The importance of postchemotherapy surgery in the setting of minimal residual disease after achieving a near complete response to chemotherapy has been highlighted in several analyses 45-47 . In a series of 203 patients treated on five trials with MVAC, 50 patients underwent postchemotherapy surgery for suspected or known residual disease 45 . Seventeen patients had no viable tumor found at postchemotherapy surgery. In three patients, the residual disease was unresectable. In the remaining 30, residual TCC was completely resected, resulting in a complete response to chemotherapy plus surgery. Of these 30 patients, 10 (33 ) remained alive at 5 years, similar to results attained for patients achieving a complete response to chemotherapy alone. Optimal candidates for postchemotherapy resection of residual disease had prechemotherapy disease limited to the primary site or lymph nodes.

Adjuvant Chemotherapy

As with neoadjuvant chemotherapy, administration of chemotherapy after surgery is associated with potential advantages and disadvantages. Foremost, an adjuvant approach allows the administration of chemotherapy to be based on pathologic stage. Given the inaccuracies in clinical staging, this avoids overtreatment of patients who are estimated to have a reasonable outcome from surgery alone. Administration of chemotherapy after surgery also prevents delays in carrying out potentially curative surgery. The major disadvantages associated with adjuvant chemotherapy are the potential difficulties of tolerating treatment postoperatively and the lack of an objective means to assess response after the primary tumor is removed. At least six randomized trials have evaluated the use of adjuvant chemotherapy following cys tectomy for muscle-invasive TCC (Table 14.3) 59-63 . Although all of these trials used cis-platin-based chemotherapy and had surgery as a control arm, two trials primarily...

Hereditary vs Sporadic Breast Cancer Further Considerations

Although familial breast cancer tends to occur earlier than sporadic and differs histologically, the biology of the two diseases is similar. This observation might suggest that sporadic breast cancer involves random mutations in the same genes that control familial breast cancer. To date, this has not been observed. Statistically, an individual at higher risk of breast cancer due to a known genetic mutation would also be at risk for sporadic breast cancer due to random mutations at another genetic locus. DNA microarray analysis of hereditary and sporadic breast cancer cells may shed light on differences in the two entities. This information could be helpful in determining prognosis and designing therapeutic interventions.

Current Treatments for Breast Cancer

If the lesion proves to be malignant, there is now a wide variety of treatment options. This book is intended to be a general guide, but new treatment protocols are constantly being developed. Different medical centers use different experimental and standard treatment protocols. Remember that every breast cancer is unique. The best option for a given patient is a matter for the patient and the health care provider. Today, patients are usually informed of their options and are given choices. Although it is important not to delay, they are usually given some time to think about the options and to arrive at decisions with which they and their loved ones are comfortable. In major medical centers, patients are often treated by a multidiscipli-nary team that may include a surgeon, radiation oncologist, medical oncologist, radiologist, pathologist, nurse practitioner, and social worker. Most traditional treatments for breast cancer involve some combination of surgery, chemotherapy, and or...

Chemotherapy for Testicular Cancer

The last 30 years have seen extraordinary advances in the management of metastatic germ cell cancer of the testis. Prior to the advent of cisplatin-containing chemotherapy in the mid-1970s, chemotherapy was highly toxic, and gave poor results, with cure unusual in those with advanced disease. Following the introduction of cisplatin, and subsequently etoposide, progress has been rapid, not least in the development of ancillary drugs (e.g., 5-hydroxytryptamine 5-HT3 antagonists and growth factors). Modern therapy is now usually curative, tolerable, and has few long-term side effects. Indeed, the current dearth of randomized trials for most subgroups of these patients is largely a testimony to the advances taking place during this period. In most modern studies, patients with semi-noma requiring chemotherapy (a minority group) are combined with those with nonsemi-noma. Patients with seminoma are a median of 10 years older than patients with nonseminoma, which may have important...

Postchemotherapy RPLND

After an intensive course of platinum-based chemotherapy for stage II to IV NSGCT of the testis, a residual mass will be apparent within the retroperitoneum on computed tomography (CT) or MRI scans (Fig. 21.2) in 25 or more cases 26 . It is now established practice to excise such residual masses in order to increase the chance of cure 27 . However, when the mass is 95 chance of cure, provided that all residual tissue has been removed. Malignant tissue within the PC-RPLND specimen confers a worse prognosis. The majority of these patients are best treated with further chemotherapy, sometimes a high-dose regimen including Taxol with autologous bone marrow transplantation. When a further recurrence occurs after a second course of chemotherapy, then desperation RPLND can be considered and is likely to be of benefit in up to 50 31 . All

The Role of the Media in Breast Cancer Education

Increased advocacy for breast cancer funding has led to increased media coverage of the disease. In Denver, at least one local TV station is a major supporter of the annual Race for the Cure, and encourages a buddy-check system to remind women to do monthly self-exams. Feature stories of breast cancer patients, especially survivors, appear regularly on TV and in the newspapers. Unfortunately, the media is often motivated to report the news that sells the newspapers or increases ratings, and often sacrifices accuracy in the process. Reports of clinical studies often do not distinguish between those that are well controlled and those that are not. Observational studies may point to correlations between events or conditions, but do not determine cause and effect despite media reports to the contrary. Desperately ill patients and their families are given false hopes when the media convey promises of a new cure, only to retract the information several days later. The information is often...

Common Cancers Breast Cancer

A woman's lifetime risk of breast cancer is approximately 1 in 8. Breast cancer clusters in families the risk of breast cancer doubles for a woman with one affected first-degree relative (e.g., mother, sister, or daughter). The risk increases further if there are multiple affected relatives or if the relatives developed early-onset breast cancer. About 5 of breast cancer cases are inherited in autosomal dominant fashion, and most of these cases are the result of mutations in either the BRCA1 gene (chromosome 17) or the BRCA2 gene (chromosome 13). Women who inherit one of these mutations have an approximately 60 chance of developing a breast tumor. Women with a BRCA1 mutation also have at least a 20 chance of developing ovarian cancer. Both BRCA1 and BRCA2 are involved in the DNA repair process. Faulty DNA repair leads to an accumulation of harmful mutations in cells, ultimately causing a tumor to form. A small proportion of breast cancer cases are the result of mutations in the p53...

Node Positive Early Breast Cancer

Breast-conserving therapy with a wide excision (lumpectomy), axillary dissection (or sentinel node biopsy), and radiation therapy is considered the preferred treatment for most patients with stage I or II breast cancer. In patients at moderate or high risk of developing systemic metastasis, it is preferable to give adjuvant therapy, beginning with chemotherapy followed with radiation therapy. This patient has a high risk of recurrence because of the presence of lymph node metastasis, and it would be inappropriate to withhold further therapy. Another high risk factor that this patient has is that the tumor is larger than 1 cm. Recommended adjuvant treatment for patients with node-positive breast cancer is explained in the table below. A large number of prospective randomized trials, as well as recent overviews and meta-analysis of adjuvant systemic therapy, have determined that both chemotherapy and tamoxifen therapy reduce the odds of recurrence in breast cancer patients....

Expression of Specific Genes Associated with Breast Cancer Progression

Pieces (called oligomers) of DNA derived from cDNA sequences for known genes are embedded onto microchips and incubated with extracts from tumors. Tumor mRNAs hybridize with their cDNA counterparts and can be detected and identified. Since the cDNA sequences embedded on the chips are known, those that hybridize indicate which genes are being expressed in the tumor at that time. Microchips containing sequences of more than 30,000 genes are now commercially available. Tumor extracts can be assessed to determine which of all known genes are turned on and which turned off. The pattern reveals specific molecular pathways utilized by the cancer cells. These profiles give valuable information as to the biology of the tumor. Patterns may differ in different breast cancers and may help distinguish whether the cancer is sporadic or is due to BRCA1 or BRCA2 mutations. The profiles may also be useful in predicting how individual tumors might respond to different therapeutic interventions. To...

Biology of Sporadic vs Hereditary Breast Cancer

Recent studies have demonstrated that hereditary breast cancers often present different histological characteristics from those that occur sporadically. However, the biological behavior of tumors is often the same. In fact, younger women with hereditary breast cancer often do better than those whose tumors arise sporadically. Women who have two or more first degree relatives (mother, sister) with breast cancer have a greatly increased chance of developing the disease at a younger age, but the disease itself is not necessarily more aggressive. Overall mortality rates are similar between patients with hereditary breast cancer and those whose tumors arise spontaneously.

Breast Cancer Prognosis

A 65-year-old patient visits the gynecologist with a solid 2-cm mass in the upper outer corner of the left breast. A biopsy of the lesion is done, which is consistent with infiltrating ductal breast cancer. Epidemiology. Breast cancer continues to be the most common cancer diagnosed in women of western industrialized countries. An estimated 182,000 new cases of invasive breast cancer were expected to occur among women in the United States during 2000. After increasing by approximately 4 per year in the 1980s, breast cancer incidence rates in women have leveled off in the 1990s to approximately 110 cases per 100,000 women. Management. The preferred treatment for most patients with stage I or II breast cancer is considered to be breast-conserving therapy with a wide excision, axillary lymph node dissection or sentinel lymph node biopsy, and radiotherapy. Lymphatic mancipg and sentinel lymph node biopsy are new procedures that offer the ability to avoid axillary lvmph node dissection and...

Treatment of Breast Cancer

Surgery is usually followed by an additional (adjuvant) therapy. A lumpectomy is usually followed by a course of radiation to destroy undetected cancer cells that may have been left behind in the breast, chest wall, or lymph nodes and that have the potential to metastasize. Some lumpectomy and most mastectomy patients also receive chemotherapy in which toxic drugs are given orally or by IV to block DNA synthesis or division of cancer cells (table 5.3). Although the drugs target tumor cells, they are not specific and affect all rapidly dividing cells such as those in hair follicles, intestinal lining, and bone marrow. That is why chemotherapy causes such unpleasant side effects as hair loss, vomiting, and low blood cell counts. Chemotherapy may also cause premature menopause and infertility. Chemotherapy is usually given in cycles, with each period of treatment followed by a period of recovery. The total course of treatment can span three to six months. Side effects usually vary with...

How Does Breast Cancer Kill

Once a cancer has spread, it is difficult to control. Treatments such as surgery, chemotherapy, or radiation may reduce the mass of the tumor, but metastatic cells may remain in lymph nodes or elsewhere and eventually resume their rampage. Some cells develop resistance to chemotherapy or radiation. Those cells have a selective advantage and will continue to grow. Eventually, vital organs are destroyed and the patient dies of organ failure or hemorrhage. Cancer patients often develop fatal infections. White blood cells, which are critical for fighting infections, are made in the bone marrow. As mentioned above, chemotherapy destroys all fast-dividing cells including those in the marrow. The patients are left immunosuppressed and are susceptible to a variety of infections that people with intact immune systems normally overcome. The marrow may also be destroyed by direct invasion by the tumor cells. It is therefore extremely important for breast cancer or any fast-growing cancer to be...

Implications for Current Breast Cancer Investigations

Clinical and epidemiological studies have revealed a close association between breast-cancer risk and the cyclical exposure of the mammary gland to ovarian sex steroids that occurs during the premenopausal years (reviewed in 151). This correlation is further substantiated by the fact that inhibition or reduction of such steroidal exposure, (e.g., after oophorectomy, and in late menarche and early menopause), has been demonstrated to markedly reduce breast-cancer risk (152-155). The increase in breast cancer observed with advancing age (Fig. 10) is currently hypothesized to arise from ovarian sex-steroid-induced proliferation of the mammary epithelial cell, which allows for the occurrence and aggregation of genetic changes throughout the reproductive years that result in breast cancer in later life (156). With a primary correlate of breast-cancer risk linked with the cyclical exposure of the mammary epithelial cell to ovarian sex steroids, breast-cancer prevention treatments based on...

The Role of Sex Age Hormonal Status and Ethnicity on the Biology of Breast Cancer

As noted in chapter 1, men are also susceptible to breast cancer, and it can be just as deadly. The disease follows a similar course, but since men are often unaware that they can get breast cancer they may delay seeing a doctor when they find a suspicious lump, and therefore may be diagnosed too late for effective treatment. Age is the greatest risk factor for developing breast cancer, but tumors in post-menopausal women are sometimes less aggressive than in those who are pre-menopausal. A role for female sex hormones in breast cancer has long been suspected because women are far more susceptible than men. Early menarche and late menopause, which lengthen the period of exposure to sex hormones, increase the risk for breast cancer. The age at which a woman has her first child, the number of pregnancies, and whether she breast feeds may also be risk factors and are related to hormonal status. The amount of breast tissue available may be a factor, but small-breasted women are at similar...

Role of Diet in Preventing Breast Cancer

Most physicians today recommend well-balanced diets that are low in fat and calories and high in fiber, complex carbohydrates, fruits, and vegetables. These foods contain ingredients including antioxidants that may protect DNA from damage by absorbing and inactivating dangerous free radicals that are generated during normal metabolism. They also recommend physical exercise and weight management. Physicians may caution against excessive ingestion of alcohol since there is evidence that alcohol may increase breast cancer risk, especially in women who have no other risk factors. There is no question that physicians will recommend that their patients not smoke, and that they exercise regularly. These recommendations are for an overall healthy lifestyle, not just for prevention of breast cancer. The sale of these products, however, is driven by economics, not health. The likelihood of diet supplements and modifications in preventing breast cancer is probably small, and they will not cure a...

Can Breast Cancer Be Prevented

Although researchers and clinicians are continuing to learn more about the nature of genetic defects and environmental interactions that may lead to development of breast cancer, no magic bullet is currently available for prevention of the disease. In chapter 6 I discuss some of the state-of-the-art research relating to prevention and therapy for the disease. For example, studies have shown that women at high risk can benefit from prophylactic tamoxifen therapy, but there is increased risk of endometrial cancer and potentially fatal blood clots. For now, it will suffice to say that for women of average risk, there are probably no specific options for prevention other than leading an active, healthy lifestyle including exercise and a healthy, well-balanced diet. Some risk factors can be avoided, but involve conscious lifestyle choices. For example, a menopausal woman should carefully weigh the potential risks of classic HRT (breast cancer and cardiovascular disease) versus the benefits...


Side effects of chemotherapy include loss of appetite, changes in taste and smell, mouth tenderness or sores, nausea, vomiting, changes in bowel habits, fatigue, leukopenia, and weight gain. Many side effects of chemotherapy dissipate quickly. Their frequency and severity depend on initial nutritional status, type and dosage of chemotherapy, and other drugs and treatments given simultaneously.


The lack of cross-resistance, nonoverlapping toxicity, and potential synergy between chemotherapy and biological therapy has led to several trials combining cytokines and chemotherapeutic agents (so-called biochemotherapy) in metastatic renal cell carcinoma. One rationale for this approach is that by causing cyto-toxicity chemotherapy will release tumor antigens, which are processed by IFN-a-stimulated antigen-presenting cells that in turn activate IL-2-stimulated CTLs. The counterargument would be that chemotherapy may downregulate immunological responses. (PVI). Protracted venous infusion 5-FU- containing regimens have given high response rates in neoadjuvant treatment of breast cancer 66 and relapsed ovarian cancer 67 . Our study using IFN-a, IL-2, and 5-FU (PVI) showed an overall response rate of 31 in 55 patients (CR three patients PR 14 patients) 68 . Interestingly, there was a trend toward higher response rates and longer survival in the poorer prognosis group, although this...

Breast cancer

Breast cancer survivors are at increased risk for endometrial carcinoma. This maybe related in part to coexistent risk factors of obesity and higher circulating estrogen levels. Additionally, women who have been treated with tamoxifen for prevention of breast cancer recurrence experience an increased risk of endometrial hyperplasia and carcinoma related directly to the duration of tamoxifen therapy, with risk peaking for women taking tamoxifen as adjuvant therapy at two to five years of therapy in long-term population-based studies (odds ratio 5.1, 95 CI 2.1-13).15 The risk increases from four to nine times in women who use tamoxifen for longer than five years.16 Fewer data are available on other anti-breast-cancer drugs. Toremifene stimulates uterine tissues similarly to tamoxifen, whereas raloxifene has not been demonstrated to have any effect upon the endometrium in a randomized, double-blind trial.17

The Roles of Age Sex and Ethnicity

Although breast cancer can strike women in their twenties, it is primarily a disease of older age (table 1.2). At least 78 percent of patients are age fifty or older, and the incidence rate is increasing most rapidly in post-menopausal women. However, the incidence of breast cancer in women under age forty is also increasing. This is significant because the hormonal status of the female patient seems to play a role in the behavior of the disease. In younger women the tumors tend to be more aggressive, and the patients may have a less favorable prognosis. Table 1.1 Cumulative risk of developing sporadic breast cancer by age Risk of Developing Breast Cancer Pregnant or lactating (nursing) women are not immune from breast cancer. It is, in fact, the most common cancer among this group of women, occurring in approximately one per 3000 pregnancies in women ages thirty-two to thirty-eight. The diagnosis of breast cancer during pregnancy is often complicated by the need to avoid certain...

Interplay of Genetics and Environment

Inheritance of susceptibility accounts for only a small percentage of breast cancers. In order for a cell to become cancerous, changes must occur in the genetic information that regulates its growth and relationship to nearby cells. These changes are most likely initiated by environmental events. However, even though most people in a geographic area are exposed to the same environmental insults, only a fraction will develop breast cancer. In the majority of the population, the triggering of cancer may be pure chance. An older person accumulates more environmental insults and eventually may sustain enough critical events to trigger the disease. However, if one has inherited a susceptibility to develop cancer, the same environmental insults may trigger the disease process sooner. Thus, although the greatest risks for developing breast cancer are being female, aging, and inheriting predisposing genes, environmental factors appear to be critically important in initiating the disease...

An Introduction to Cancer Biology

In chapter 1, I introduced the concept of inherited versus sporadic breast cancer. In order to understand the role heredity plays in the development of the disease, it is important to understand what cancer is. Cancer is actually a catch-all term for many different diseases that share a fundamental defect a loss of regulation of cell division and differentiation. This loss is generally due to the alteration of certain regulatory genes known as oncogenes and tumor suppressor genes. Cancer may therefore be considered a genetic disorder, even if the genetic alterations involved are not inherited.

Derangements of the Cell Cycle and the Rise of Malignant Cells

Malignant cells that spread have acquired the ability to break free of their surroundings and invade blood and lymphatic vessels. This activity requires that the cells activate genes for enzymes that can break down the extracellular matrix that holds the cells in place in a tissue. Alternatively, changes may occur in the surrounding stroma to allow the altered cells to escape. This latter theory is currently the subject of experimental inquiry. If the cancer cells can successfully escape into the circulation and survive there, they may then travel to distant sites and invade other tissues and organs. This process of invasion and acquiring the ability to survive in a foreign environment is known as metastasis. Certain cancers have a pattern for metastasizing to specific sites that cannot be explained simply by the distribution of blood vessels and lymphatics that drain the tumors. For example, breast cancer often metastasizes to underarm lymph nodes and then to brain, lung, ovaries,...

The Nature of Breast Abnormalities Benign and Malignant Lesions

Breast cancers vary in biological behavior (for example, their growth rate) and tendency to metastasize. The least dangerous are those that arise in the lobule itself and do not spread. They are often found in both breasts (bilateral), but may never cause the patient any problems other than worry. This form of breast cancer is known as LCIS, or lobular carcinoma in situ. Some question whether they are true malignancies or markers of a potential Tumors that arise in the epithelium of the ducts can remain within the duct and are known as DCIS, or ductal carcinoma in situ. DCIS can acquire the ability to invade beyond the duct into the stroma. The most common breast cancer (80 percent of all breast cancers) is invasive ductal carcinoma. It may grow and invade locally, or it may travel through the lymphatics to other parts of the body. It is the danger of metastasis that makes this form of cancer such a concern. Other, less common breast cancers include medullary, colloid, tubular, and...

Special Genes Involved in Cancer Oncogenes and Tumor Suppressor Genes

Several tumor suppressor genes are associated with specific cancers including breast cancer. These include BRCA1, BRCA2 (breast cancer genes 1 and 2), and p53 (a protein product of a tumor suppressor gene). I will discuss these in greater detail in the following chapter. For now, it is sufficient to understand that these genes are part of the normal human genome and play a role in regulating cell division. If these genes are disrupted and do not function properly, the consequences may include the development of cancer. Some genes expressed by cancer cells prevent the induction of apoptosis, which would normally destroy a genetically damaged cell. An example of such a gene is BCL2. Some types of chemotherapy damage a cell's DNA and trigger cell death by apoptosis. A cancer cell expressing BCL2 is often resistant to apoptosis induced by chemotherapy. This is clearly a selective advantage to the cancer cell, but harmful to the patient.

Localization of BRCA1 and BRCA2

The hunt for the putative breast cancer genes in the 1980s and early 1990s was far more difficult given the limits of technology available at the time. For example, in the early 1980s, Mary-Claire King worked with a group of twenty-three breast-cancer families (i.e., families who had a number of individuals with breast cancer that were diagnosed before age forty-five). Seventeen showed evidence of genetic linkage to a specific marker on the long arm of chromosome 17, with a lod score of 5.98. This suggests that the likelihood of linkage to a predisposing cancer gene occurring by chance was nearly a million to one. (The other cancer families in this group did not show this linkage, suggesting that they either had a different gene that was responsible for their disease or were exposed to a common environmental agent that caused it.) And yet, the putative cancer gene was still ten cM from the marker, a distance that could encompass as many as five genes. There are many known mutations of...

Lowprevalence Risk Genes

In addition to p53 and AT, other genes may contribute to the development of breast cancer. Several low-prevalence risk genes are considered to be candidates for BRCA3, to account for the incidence of familial breast cancer not attributable to BRCA1 or BRCA2 mutations. These risk genes include rare alleles of common genes such as those regulating estrogen or androgen (male hormone) receptors. They also include rare alleles of genes coding for enzymes that are normally involved in detoxifying environmental carcinogens, such as cytochrome P-450, N-acetyl transferase, and gluathione-S-transferase. Abnormalities in these genes, which are normally expressed in breast tissue, may prevent normal detoxification of potentially dangerous substances, resulting in tumor initiation. It is increasingly apparent that breast cancer is a multifactorial disease, where the interplay of inherited susceptibilities and environmental factors determines who will ultimately develop the disease.

Genetic Testing for BRCA1 and BRCA2 Benefits and Consequences

A woman with a family history of breast cancer and or ovarian cancer may be facing more difficult questions. Tests are now available for the presence of mutated BRCA1 and BRCA2 genes, but there are many pros and cons to be weighed. There is no correct answer. What works for one woman may not work for another. The emotional consequences of testing are extremely difficult. Not every woman can handle the knowledge that she has a high probability of developing a potentially deadly disease at an early age. Once a woman learns that she is positive for BRCA1 or BRCA2 mutations, what does she do with that knowledge Although she is at much higher risk for disease, there is no guarantee that she will actually develop breast or ovarian cancer since the genes are not 100 percent penetrant. These women are still at risk for spontaneous breast cancer (although at a lower risk), as are women with family histories who test negative for the mutated genes. It is strongly suggested that women who...

What Happens If You Find a Lump Diagnostic Procedures

Occasionally a man will discover a lump in his chest in the area of the nipple. He too should have a medical consultation, even though breast cancer in men is rare. If diagnosed late, it can be as deadly as in women. The risk in males is higher if they have a family history of BRCA2-associated disease. A male may also be referred for mammography.

Potentials for Gene Therapy

The protocols for treating breast cancer do not differ between patients with hereditary or spontaneous disease, since the diseases are not different. Much attention has been placed on Human Genome Project discoveries and the possibilities of gene therapy. Patients with known BRCA1 or BRCA2 mutations wonder whether these defective genes can be corrected by such treatment. While gene therapy is perceived as a treatment of the future, current experience is a mixed bag. It is especially difficult to address issues of germ-line mutations (which BRCA mutations are) given the current controversy and restrictions on embryonic stem cell or fetal tissue research. I address this issue in greater detail in chapter 6.

The Need for Emotional Support

Physicians and others who care for breast cancer patients are becoming more sensitive to quality-of-life issues. An important part of breast cancer therapy is emotional support both for the patient and for the family. Many women feel a deep sense of loss following mastectomy and even lumpectomy, and need the support that can be provided by professional counselors. Chemotherapy often causes hair loss, induces premature menopause, and may cause serious mood swings that affect not only the patient but also her loved ones. Many medical centers now provide integrated services including physicians, surgeons, nutritionists, and social workers as part of a team. Patients often have supportive family members and friends, or may be part of a religious group or other organization that provides support sessions and religious healing services. A diagnosis of cancer is a life-altering event even if the prognosis for long-term survival is excellent.

The Search for More Predisposing Genes

The discovery of BRCA1 and BRCA2 has launched a new era in the quest to understand the causes of breast cancer. Now that the human genome has been mapped, the focus of molecular biologists will be on understanding the role of the approximately 35,000 genes that define a human being. A new field of proteomics is being developed in which the role of gene-encoded proteins is studied. Already, the dogma that one gene encodes a single protein is not certain. The gene encodes the primary backbone of the protein, but other factors control the processing that makes the three-dimensional, functional molecule and regulates how the molecule functions in the cell. There are many questions concerning genetic intervention in multifactorial diseases such as breast cancer. We already know that BRCA1 and BRCA2 do not account for all the cases of hereditary breast cancer, and that the disease is influenced by other genes and environmental factors. It is likely that, in coming years, other predisposing...

Focus on Prevention and Control If Not Cure

As mentioned earlier, a major current focus of breast cancer research is on prevention and control. Understanding the complex interaction of susceptibility genes and environmental stimuli including dietary factors may lead to drugs and even vaccines that may help prevent the disease in high-risk people. Further understanding of the role of epigenetic interactions, may enable control of the disease, even if a cure is not feasible.

Cancers Related to Specific Mutations eg Retinoblastoma Ataxia Telangiectasia

Some cancers are associated with specific gene mutations. I have already mentioned retinoblastoma, which occurs when the tumor suppressing the RB gene is lost or altered. Another disease, ataxia telangiectasia (AT), is caused by a recessive gene. AT patients have increased sensitivity to ionizing radiation and often develop leukemia or lymphoma. Their heterozygous relatives have an increased incidence of breast cancer. There are other cancers associated with inherited defects of specific genes, and some patients with these defective genes also have higher risks of developing breast cancer. These conditions are extremely rare.

Modification of Genetic Risk Caused by Environmental Factors

The question arises whether a woman can modify her risk of breast cancer by altering environmental factors that may induce its development. This thinking can apply equally to those who have inherited a faulty gene or to those who are at average risk, since, in either case, environmental factors most likely provide the necessary genetic damage to initiate the onset of disease. Although female sex hormones are believed to increase the risk for breast cancer, the data is not completely clear. Overall, there appears to be some increased risk if a women begins to menstruate before age twelve, does not have children or has her first child after age thirty, does not breastfeed her children, or undergoes menopause after age fifty-five. The correlation appears to be with the number of ovulatory cycles the woman undergoes in her lifetime. The period between menarche and first pregnancy, during which time the breast tissue is developing, appears to be most sensitive to environmental insults,...

Considerations for Alternative Medicine

Some patients choose to obtain care from practitioners of alternative medicine. They may consult naturopaths, homeopaths, or herbologists, and are treated with assorted diets and herbal therapies. None of these, however, has ever been tested on breast cancer in a clinical trial, nor is there any credible evidence of their effectiveness. Furthermore, some unproven treatments can interfere with standard medical treatments or may cause serious side effects. Nevertheless, alternative medicine is becoming so popular in the United States that some medical schools are beginning to discuss its use as adjuncts to evidence-based treatments. Co-treatments by practitioners of alternative medicine may offer some comfort to patients who are

The Role of Crosstalk Between Malignant Cells and Their Surroundings

A focus of current research is to understand how a malignant cell's environment modifies its behavior. This approach is called epi-genetic, because the target is not the gene itself but rather factors that regulate the expression of the gene. A gene may be damaged, but its expression may be controlled so that its altered product may not be produced. In other words, cancer may be preventable if we can change the environment the gene acts on rather than changing the genetically altered cell. For example, researchers have focused on the role of genetic damage in the ductal cells in initiating breast cancer, but the role of the surrounding stromal cells has been more or less ignored. It is now increasingly apparent that there is crosstalk between the ductal cells, where breast cancer usually begins, and surrounding cells, and that the stroma may play a role in preventing carcinoma in situ from breaking through into an invasive cancer. It has also been postulated that specialized...

Importance of Early Detection

Although the incidence of breast cancer is increasing, its death rate has been steady since 1990 and may even be dropping. Much of this increased survival can be attributed to increased awareness leading to early detection of the disease, and treating it before it has had a chance to spread. The importance of early detection cannot be stressed enough, whether or not a woman has a family history of the disease. Although there have been reports of new diagnostic tests, mammography remains the best screening technology available today. The newest mammography machines deliver minimal X-ray radiation and permit the trained radiologist to detect lesions as small as 0.5 centimeters (0.2 inches) (fig. 5.1). New digital imaging technology is further improving the detection of tiny lesions, especially in the presence of dense breast tissue. The American Cancer Society guidelines currently recommend that a baseline mammogram be done at forty years of age, then repeated every two years until age...

Role of Environment

Epidemiologists have noted that Japanese women, who normally have a low risk for developing breast cancer, eventually acquire the same risk as other Americans if they move to the United States. This observation and others suggest a role for environmental factors in the development of the disease. Scientists have studied the effects of exposure to many environmental and dietary factors that might contribute to the increasing incidence of breast cancer in Western countries. They have examined the effects of dietary fat, air and water pollutants, pesticides, radiation, alcohol, stress, oral contraceptives, hormone replacement therapy, and even abortions. They have also studied the effects of chemicals known as xenoestrogens, environmental chemicals that behave like estrogens. Organochlorines, for example, are common pollutants that exhibit estrogenic activity. These chemicals include PCBs, organic components of industrial waste that may leak into the water table. To date, none of the...

Risk Factors

While the link between environment and breast cancer remains unclear, a number of factors that increase the risk of developing the disease have been identified. The most important risk factor is age (table 1.1). A woman younger than fifty years, with no other risk factors, has only a 2 percent risk of developing the disease. In contrast, if she lives beyond eighty-five years, her risk is 12.5 percent. Other major risk factors include the age of menarche (first menstrual period), parity (number of pregnancies), whether she breast-fed her children, and age at menopause. These factors suggest a strong role for hormones, especially estrogens, in developing breast cancer. Use of hormone replacement therapy (HRT) over many years also increases risk, as may obesity and heavy ingestion of alcohol. Women who inherit susceptibility to breast cancer (altered BRCA1 and BRCA2 genes, chapter 4) have a greater probability of developing the disease at a younger age. Their risk of contracting breast...

Understanding Risk

Many women find breast cancer statistics frightening. They often see the one in eight statistic in women's magazines and assume they will inevitably get breast cancer. It is no longer considered a matter of if but rather when. Almost everyone knows someone who has been struck by the disease. Ashkenazi Jewish women fear that they have inherited the dreaded breast cancer genes and wonder if they will pass it on to their offspring. Women who know they carry a mutated form of BRCA1 or BRCA2 wrestle with how to prevent what they deem is an inevitable outcome. I have explained earlier that although the incidence of breast cancer is rising, the statistic one in eight reflects a cumulative or additive risk throughout an individual's lifetime. This type of risk is calculated across the general population, without taking into account ethnic or genetic differences or specific environmental factors that may alter the risk, and is called an absolute risk. Absolute risk is expressed as the number...


Recent five-year clinical trials of the anti-estrogen compound tamoxifen indicated that chemoprevention may be an effective method of preventing breast cancer in high-risk individuals (including lobular carcinoma in situ, and those with mutated BRCA1 or BRCA2 genes). However, as I indicated above, tamoxifen is not without its own risk. It may lead to endometrial hyperplasia or cancer or cause thromboses. It also causes temporary premature menopause, with all the associated discomforts, and some patients develop resistance to the drug. New studies are under way comparing tamoxifen to a similar drug, raloxifene (Evista ), that may have similar beneficial effects with fewer side effects.


Cancer therapy, including that for breast cancer, has traditionally taken a slash, poison, and burn, approach where the tumor is subjected to surgical eradication, followed by chemotherapy and radiation to remove any malignant cells that may remain. Although this aggressive approach is still used, efforts are made to use the most conservative surgery possible (including options for breast reconstruction where possible), chemotherapy protocols based on increased knowledge of the biology of the disease, and radiation that targets the tumor but as little normal tissue as possible. Chemotherapy for cancer generally employs chemicals that poison all rapidly growing cells. New knowledge of the molecular and genetic bases for cancer is enabling the development of drugs that target cancer cells more specifically, thereby eliminating some of the side effects. An example of molecular based therapy is Herceptin, the new antibody against the Her2 neu receptor. Her2 neu is expressed in 70 percent...

Gene Therapy

Elucidation of the genes involved in breast cancer is prompting continued research in gene therapy. The goal of gene therapy is to replace the defective gene with a normal one or to counteract its expression, and thereby prevent the inherited disease from occurring. Other gene therapy approaches target cancer cells with a lethal gene that will kill just the malignant cells but not normal surrounding cells. There have been some success stories with this approach in conditions caused by single gene defect. There have also been failures, including a well-publicized case in which a young man died during experimental gene therapy that was not clinically necessary. Many of the problems of gene therapy involve the delivery of the target genes to the site in which they must act. The gene is carried in a vector that must seek out only the correct target. This is especially difficult to achieve in a heterogeneous, metastatic cancer. A recent study targeted elements in the stroma of a tumor...

Political Issues

Biomedical research is expensive, and is subject to political posturing as advocates lobby for funds for their pet diseases. Although efforts to secure funds for breast cancer research are now extremely visible, it is only in recent years that the disease entered national consciousness. As recently as forty years ago, breast cancer was considered a shameful disease, one that was kept in the closet. Patients who had suspected breast tumors signed consents for breast surgery. If the biopsy proved to be positive, they were treated immediately with disfiguring radical mastectomies. They did not learn if they still had a breast or if they had cancer until they awoke from the anesthetic. They generally had little emotional support from their physicians or even from their families. The American Cancer Society initiated the Reach to Recovery program in 1952, in which breast cancer survivors would visit newly diagnosed (and treated) patients and reassure them that there really is life after a...

Hope for the Future

Breast cancer remains a serious illness in the early twenty-first century, but like many diseases of earlier eras it is slowly revealing its molecular secrets. The mapping of the human genome is paving the way for extensive research as to how genes work, how they are regulated, and what their protein products do in normal cells and in disease. Discoveries will lead to the development of better drugs and new methods of treatment that may ultimately prevent the disease. The cloning of BRCA1 and BRCA2 in the past decade was a major breakthrough, but it was just a beginning in the molecular battle against breast cancer. While researchers have learned that defects in these genes (and in other cell-cycle regulators) often lead to breast and or ovarian cancer, it has not been easy to extrapolate this knowledge to cases of sporadic breast cancer. Although we know that genetic damage is necessary for cancer to occur, BRCA1 and BRCA2 are not usually the site of damage in sporadic cases. The...

National Programs

Advocacy for breast cancer information and to prevent genetics-based insurance discrimination. Living Beyond Breast Cancer A Philadelphia-based organization whose mission is to empower all women affected by breast cancer to live as long as possible with the best quality of life. National Alliance of Breast Cancer Organizations (NABCO) Membership organization providing information about breast cancer. National Breast Cancer Coalition 1707 L Street, NW Suite 1060 Coalition of cancer patients focused on changing public policy as it relates to progress against breast cancer. A network of major cancer research and treatment institutions including City of Hope National Medical Center, Dana-Farber Cancer Institute, Fox Chase Cancer Center, Fred Hutchinson Cancer Research Center, H. Lee Moffitt Cancer Center and Research Institute at the University of South Florida, Huntsman Cancer Institute at the University of Utah, James Cancer Hospital and Solove Research Institute at the Ohio State...


Diagnostic imaging techniques are intended to identify tumors at the earliest possible stages. Ultimately, the goal is to distinguish between dense tissue, benign lumps, and cancer. To date, mammo-grams still offer the best imaging available for early diagnosis of breast cancer. However, they are not foolproof, and miss perhaps 10 percent of cancers. In younger women with dense breast tissue, mammograms may not distinguish a small tumor from surrounding tissue, although digital enhancing may enhance the sensitivity. They often cannot detect lobular carcinoma in situ in early stages. They are not reliable in women who have breast implants, nor do they distinguish fluid-filled cysts from solid fibroadenomas as well as does ultrasound. Current research is focused on better imaging with the least possible radiation.

Rxr Functional Activities

The first application of rexinoids in clinical studies took advantage of their efficacy in triggering apoptosis, in contrast to cell differentiation seen with retinoids (Mehta et al., 1996 Nagy et al., 1995). This led to their successful use since the 1980s in the treatment of refractory or persistent early-stage cutaneous T-cell lymphoma. Presently, a number of cancer types and cell types are being tested for their possible responsiveness to rexinoids, such as acute myeloid leukemia (Altucci et al., 2005), aerodigestive tract cancer (Dragnev et al., 2005), human breast cancer cells (Toma et al., 1998), or pancreatic cancer cells (Balasubramanian et al., 2004). Along the same line, chemopreventive n-3 fatty acids in colon were shown to activate RXR in colonocytes (Fan et al., 2003).

Concurrent Malignancy

DVT is more common in patients with a malignant tumour, an observation made for the first time by Trousseau 47 in 1865. DVT can be the first sign of cancer and is taken as a warning sign for malignant disease. The thrombogenic effect of cancer arises from the production of humoral factors (procoagulants), mechanical factors (vein compression or local infiltration) and general factors indicated by the presence and increased levels of acute phase reactants 5 . Indirectly, thrombosis may also be induced by reduced patient mobility and diminished uptake of vitamins such as folates. Finally, thrombosis may be promoted by the treatment received by the patient including radiotherapy and chemotherapy 31, 49 , and may also be triggered by postsurgery fibrosis.

Evidence for the Genetic Etiology of Prostate Cancer

So far, genotyping data have been reported in over 1600 families. There are numerous conflicting reports supporting or refuting linkage within many areas in the genome. This challenges our understanding of the genetic basis of this disease. This search is distinct from the search for a familial breast cancer predisposition gene, in which analysis of linkage in select regions revealed a site where the BRCA1 gene was situated 14 . This work shows that the

Impaired Wound Healing

Malnutrition has long been observed to profoundly influence wound healing at multiple points in the phases of wound repair. Protein malnutrition or vitamin C deficiency directly inhibits collagen synthesis and deposition, leading to a retardation of the healing process (2-5). Patients with malignancies frequently have impaired nutrient intake and potentially tumor-induced altered substrate utilization. Various antitumor treatments such as chemotherapy and radiation

Candidate Gene Analysis Evidence BRCA2 NBS and CHEK2 Genes

The candidate gene approach is used to search for genetic markers of disease susceptibility, where a gene is targeted based on the characteristics of its protein product. PCa cases were noted, in the early 1990s, to be clustered within breast cancer families 52,53 . The RR of PCa in male carriers of mutations in the breast cancer predisposition genes BRCA1 and BRCA2 is increased. The RR with respect to BRCA1 was found to be 3.33 54 and 1.82 in a further study by the Breast Cancer Linkage Consortium (BCLC) 55 .

Necrotizing Enterocolitis

Me was diagnosed as neutropenic (due to aggressive cytotoxic chemotherapy) a few days ago. Neutropenic enterocolitis is a fulminant form of necrotizing enteritis that occurs in neutropenic patients neutropenia is often related to cyclic neutropenia, leukemia, aplastic anemia, or chemotherapy. In postmortem exams of patients who have died of leukemia, infections of the cecal area ( TYPHLITIS) are frequently found C. septicum is the most common organism isolated from the blood of such patients.

Cancer Treatment and Research

Gradishar, WJ., Wood, W.C. (eds) Advances in Breast Cancer Management. 2000. ISBN 0-7923-7890-3. Sparano, Joseph A. (ed.) HIV & HTLV-I Associated Malignancies. 2001. ISBN 0-7923-7220-4. Ettinger, David S. (ed.) Thoracic Oncology. 2001. ISBN 0-7923-7248-4. Bergan, Raymond C. (ed.) Cancer Chemoprevention. 2001. ISBN 0-7923-7259-X. Raza, A., Mundle, S.D. (eds) Myelodysplastic Syndromes & Secondary Acute Myelogenous Leukemia 2001. ISBN 0-7923-7396. ISBN 0-7923-7523-8. Stack, M.S., Fishman, D.A. (eds) Ovarian Cancer. 2001. ISBN 0-7923-7530-0. Bashey, A., Ball, E.D. (eds) Non-Myeloablative Allogeneic Transplantation. 2002. ISBN 0-7923-7646-3. Leong, Stanley P.L. (ed.) Atlas of Selective Sentinel Lymphadenectomy for Melanoma, Breast Cancer and Colon Cancer. 2002. ISBN 1-4020-7013-6. Andersson , B., Murray D. (eds) Clinically Relevant Resistance in Cancer Chemotherapy. 2002. ISBN 1-4020-7200-7.

Studies in Seventh Day Adventists

These studies are reviewed below. However, as early as 1958, Wynder and Lemon examined cancer and heart disease in SDA hospital patients compared with non-SDA patients.18 In this early study, based on 564 SDA and 8128 non-SDA patients admitted to eight SDA hospitals throughout the U.S., lower risk of epidermoid lung, mouth, esophagus, larynx, and bladder cancer were found in the SDAs than in the non-SDAs. Colon and rectum cancer, however, were not found less frequently in the SDA than the non-SDA comparison group, while prostate and breast cancer were found somewhat more frequently in the SDA patient series. Interviews with study subjects indicated that only 41 of the SDA patients consumed any meat, whereas 95 of the general population consumed meat. A further follow-up of this population was completed through 1976 and Standardized Mortality Ratios were reported comparing age-adjusted mortality rates in California SDAs to the U.S. white...

Dietary Fiber and Cancer Risk

There are few studies on the relationship between dietary fiber intake and cancer risk for cancers other than colon rectum. Studies on breast cancer show mixed results for fiber,56-58 but a more consistent, protective role for fiber appears evident in regard to pancreas cancer.59

Mitoxantrone and Prednisone

A Canadian study led by Tannock et al. 17 randomized 161 symptomatic patients with HRPC to receive either mitoxantrone every 3 weeks with daily prednisone or prednisone alone. The primary end point of this study was palliative response, which was defined as a significant improvement in either pain or analgesic usage or both (neither could get worse). In the mitox-antrone arm, a statistically significant improvement in pain relief (29 vs. 12 , p .01) and a prolonged duration of this palliative response (43 weeks vs. 18 weeks, p .0001) was demonstrated. These patients also reported improvements in physical and social functioning, global quality of life, anorexia, drowsiness, constipation, and other symptoms 18 . The use of mitoxantrone was also associated with a higher PSA response rate and time to progression. There was no survival benefit of chemotherapy, although a crossover to mitoxantrone in patients who progressed on prednisone was allowed and may have impacted on the survival...

Nuclear transport receptors

70-90 of tumor cells in a population of invasive ductal and lobular breast carcinomas 6 . The functional yeast homologue of CAS is a protein called Cselp, which was originally isolated in a screen for yeast mutants with defects in chromosome segregation 113 . It is possible that CAS Cselp serves as a critical regulator of growth control that when altered can cause uncontrolled cell growth or cancer. It seems likely that other transport receptors may also be implicated in tumorigenesis in the future. Consistent with this notion, a recent study identified a translocation of a novel human karyopherin, RanBP17, in acute lymphoblastic leukemia 39 . In addition, a truncated form of the NLS receptor, importin a, has been identified in the human breast cancer cell line, ZR-75-1 59 .

Maturation Of Immune Responses And Antimicrobial Immunity

Although it was speculated for some time that there might be a subset of regulatory T cells (TR), it was not until these cells could be identified by cell surface markers that definitive studies could be performed. In both mice and humans, the major population of TR is CD25+, CD4+. CD25 is the a-chain of the high affinity IL-2 receptor. TR have rearranged T cell receptors and are antigen specific many of them react with host antigens. Once activated, the TR secretes IL-10 and TGF-0 and suppresses the immune response nonspecifically. The importance of TR has been shown in mice and humans. Mice that are depleted of CD25+, CD4+ lymphocytes rapidly develop autoimmune disease and in humans genetic deficiency of Foxp3 transcription factor, which is downstream of CD25 signaling, is associated with IPEX (immune dysregulation, polyendocrinopathy, enteropathy, and X-linked syndrome).55 In normal subjects, lymphocytes reacting with self-antigens with high affinity are eliminated in the thymus....

Alternative Explanations for Low Cancer Risk in Vegetarians

Data have suggested that colon cancer may be associated with cigarette smoking (but only after a long latency period).64-65 The more relevant question today may be which cancer sites are not associated with tobacco the list appears to be quite short and currently includes prostate, endometrium, and breast cancer.

Genetic Characterization

Few as 1 leukemic cell in 104-106 normal cells and therefore is very useful for the detection of MRD after cytoreductive therapy. A problem is the risk of false-positive results owing to contamination of reagents. New opportunities are emerging with the development of quantitative PCR. With techniques called real-time PCR, quantification of PCR products is more easily and more accurately reached than before, allowing one to determine the kinetics of leukemic cells during and after chemotherapy.

Intermittent Hormonal Therapy

To cause devastating destruction of cell cultures rather akin to the effects of chemotherapy. transient response, and this is seen in 20 to 40 of patients 8 . Upon further progression, treatment with low-dose steroids leads to a transient response in 10 to 20 of patients. It is very doubtful whether there is any benefit from other agents, such as ketoconazole, tamoxifen, or a progestogen. Platelet-derived growth factor receptor (PDGFR) positivity is reported in 10 to 70 of patients' biopsy specimens. For this reason, inhibitors of PDGFR action have been investigated in prostate cancer. Agents inhibiting PDGFR may do so through a number of routes, varying from direct blockade of the receptor itself to inhibition of downstream effector mechanisms. There is no evidence to date that these agents have activity in prostate cancer, though there has been interest recently in the combination of such agents with cytotoxic chemotherapy, and in one such study docetaxel in combination with...

The Side Effects of Hormonal Therapy

Iologically is osteoporosis, with a loss of bone mass of nearly 10 per annum. Although bis-phosphonates have been shown to be of little effect in prostate cancer in terms of limiting pain and tumor progression, which are the main benefits of their use in breast cancer and myeloma, this group of agents is of significant use in limiting osteoporosis in prostate cancer 11 .

Hormone Refractory Prostate Cancer

Hormone-refractory prostate cancer is defined as disease that progresses despite castrate testosterone levels, and is refractory to all hormonal manipulations including withdrawal of antian-drogen therapy. Until recently, there had been no standard chemotherapeutic approach for HRPC. Several agents had been evaluated in clinical trials, but many older studies suffered from methodological deficits such as small numbers of patients, heterogeneity of enrolled patients, and lack uniform response criteria 5 . Overall there have been very few recent phase III trials completed in HRPC (Table 9.1) making it difficult to draw firm conclusions about the efficacy of many regimens. However, it would appear that chemotherapy at a minimum does provide a palliative benefit. Non-chemotherapy-based approaches to palliation also exist. External beam radiotherapy, for example, remains the mainstay of treatment for patients with bone pain, spinal cord compression, or painful urinary obstructive symptoms....

Estramustine TaxaneBased Therapy

Chemotherapy in Prostate Cancer By combining mitoxantrone, docetaxel, and low-dose prednisone in a phase II multicenter trial, Freeman 33 showed a PSA response rate of 69 and a trend toward improvement in quality of life end points after two cycles of chemotherapy. This is another regimen that will be investigated further.

Combinations of Targeted and Cytotoxic Therapy

Targeted therapy in combination with chemotherapy is another area of active research. Several trials have assessed the combination of targeted therapies such as thalidomide, cal-citriol, and exisulind with docetaxel. Thalidomide glutarimide is a synthetic glutamic acid Taken together, targeted therapies either alone or in combination with chemotherapy are an area of active research that shows promising PSA responses and tolerability.

Geographical Distribution

Leprosy occurs throughout the world but predominates in tropical and subtropical regions. The problem is greatest in Central Africa and Southeast Asia. Worldwide there are about 5.5 million cases of leprosy, but it is estimated that the total number of cases is actually 11.5 million of which 4 million are in India. In the Americas there are 400,000 cases of which 70 are in Brazil with a prevalence of 1.7 per 1000 inhabitants. The Unites States has more than 7,000 cases, most of them from immigrants. According to WHO the prevalence of leprosy has been modified because the patients that have undergone a course of chemotherapy are not considered active. For the first time the number of reported cases has declined from 5.37 million in 1985 to 3.1 million in 1992. In Mexico, of 16,694 reported cases in 1989 there were only 6,106 active patients, and 7,946 were successfully treated. This gives a prevalence rate of 0.6 per 10,000 inhabitants.

Incompetent Terminal Patients Right To Refuse Upheld In One Case Overridden In Another

Salkewicz (Mass. 1977), the court authorized the withholding of chemotherapy for 67-year old Joseph Salkewicz, a profoundly retarded man. It was felt that he would not have understood the pain resulting from chemotherapy, and would have had to be held down physically for doctors to give him the necessary drugs and blood transfusions. The court summed up its decision as follows. To presume that the incompetent person must always be subjected to what many rational and intelligent persons may decline is to downgrade the status of the incompetent person by placing a lesser value on his intrinsic human worth and vitality, it is of interest to note that, like John Storar, Salkewicz was a mentally retarded person who had never been competent. Yet, in the Storar case (held 4 years later in New York) the court did not allow the terminally ill and incompetent Storar patient to refuse blood transfusions. Observes medical ethicist Ruth Macklin Cases that are...

Intravesical Therapy and Dose Scheduling

The traditional induction regimen of six weekly instillations of chemotherapy,initiated a week after resection, was based on original work using BCG immunotherapy. Delayed bladder instillation was intended as a prophylactic therapy for a secondary new occurrence, presuming that all previous tumors have been eradicated. It is now increasingly apparent that intravesical chemotherapy is best intended as an ablative therapy to mop up loose cells released at the time of extirpation and to prevent tumor reimplantation. Longitudinal studies have shown that tumor recurrences occur in two time-dependent peaks. The groups with early recurrence peaks are sensitive to chemotherapy, whereas those with delayed recurrences are generally resistant 35 . It is not surprising, therefore, that the influential study of the MRC demonstrated that immediate instillation of MMC within 24 hours of transurethral resection was as effective as conventional 6-week courses 61 . Indeed, more recent studies have...

Insertion of Central Catheters

The technique of internal jugular and subclavian vein catheterization is indispensable to the clinician. The placement of central venous catheters is necessary for the administration of parenteral nutrition, long term antibiotics, central pressure monitoring, vasopressor therapy, chemotherapy and, in some circumstances, large volume resuscitation. The placement of these catheters is not without risk, and several investigators have studied the role of ultrasound guidance in decreasing this risk. This chapter will summarize the literature on the use of ultrasound as an aid to central venous cannulation and attempt to come to a conclusion on the role of this technology.

Chemically Induced Diabetes Mellitus

The advantages of using these agents are that the technique is easy and it produces an insulin-dependent form of diabetes mellitus. Healing studies have demonstrated many forms of tissue-healing impairment that are at least partially reversible by insulin treatment (9-14). The applicability of these models is illustrated by the great number of studies that use this technique. The disadvantages include the use of a chemotherapy agent that may have more systemic effects than desired. The weight loss, as described earlier, suggests that other, less specific effects are also induced.

Infiltrating Ductal Breast Carcinoma

Chemotherapy and radiotherapy, hormone therapy poor prognosis. Breast cancer with angiolymphatic spread characterized by a malignant course with early and widespread metastases. Perform skin biopsy in patients diagnosed with breast infection who do not respond promptly to antibiotic treatment.

Gemcitabine and Cisplatin A New Standard of Care

And cisplatin in metastatic TCC were initiated. Several phase II studies reported OR rates of 42 to 57 and CR rates of 18 to 22 11-13 . Subsequently, a multicenter, randomized phase III trial was performed to compare gemcitabine and cisplatin (GC) with MVAC (Table 6.1) 14 , in which 405 chemotherapy-naive patients were randomized to GC or standard MVAC. The CR, OR, and median survival rates were similar in both arms. Although GC was associated with more grade 3 anemia and thrombocytopenia, MVAC was associated with a greater incidence of neutropenic fever (14 compared to 2 ), neutropenic sepsis (12 compared to 1 ), grade 3 mucositis (22 compared to 1 ), and treatment-related deaths (3 compared to 1 ).

The Menopausal Transition

Menopause signals the end of child-bearing capacity, and is also associated with changes in susceptibility to various chronic diseases, including breast cancer, heart disease, and osteoporosis.66 Differences in age at menopause between vegetarian and omnivorous women, should they exist, could be associated with differences in chronic disease patterns between these groups. Furthermore, some women experience unpleasant symptoms during menopause (vasomotor symptoms such as night sweats and hot flushes, mood swings, insomnia, weight gain, headaches, and fatigue),67 and these symptoms have been observed to differ among women in different cultures.67,68 Whether dietary variables contribute to these differences in symptom experiences has not been clearly established, but there is speculation that they could.68-70 Some of these dietary differences may also exist between vegetarian and omnivorous women. Accordingly, after defining and describing the menopausal transition, available research on...

Role of Bacille Calmette Gurin in the Treatment of Carcinoma in Situ

To date, BCG remains the treatment of choice for CIS disease. Although cytotoxic chemotherapy agents have shown initial response rates as good as 48 using anthracyclines and 53 for MMC, most series have demonstrated that this response is time limited, with fewer than 20 remaining disease free at 5 years 72 . This apparent chemoresistance may well reflect the high grade of CIS disease, whereas higher grade may imply greater antigenicity and therefore susceptibility to BCG immunotherapy. Bacille Calmette-Guerin therapy gives complete response rates of 60 to 70 with a median duration beyond 3 years and projected 5-year responses of 45 . Nevertheless, 30 to 40 of patients with CIS disease do not respond to a single induction course of BCG 72 . The response rates and the durability of response may be improved with maintenance therapy. Advocates of long-term maintenance refer to the SWOG 8507 study (see above) 69 ,although this was not specific for CIS. Further credence to maintenance BCG...

Nonplatinum Combinations

In an alternate attempt to improve the efficacy and tolerability of combination chemotherapy in advanced TCC, regimens devoid of platinum analogues have been developed. These regimens include paclitaxel plus ifosfamide 37 , paclitaxel plus gemc-itabine 38,39 , and docetaxel plus gemcitabine 40 . Several of these trials were performed in patients who had previously received cisplatin-based therapy. Overall, these regimens were well tolerated. However, hematologic toxicity was prominent, particularly in the pretreated population. Noteworthy activity was seen with these regimens, including varying rates of complete responses, but the role of these regimens in the treatment of patients with metastatic TCC has not been defined.

Novel Therapeutic Strategies in Metastatic Transitional Cell Carcinoma

Despite the promising activity of the newer combination regimens in TCC, the majority of patients still succumb to their disease, necessitating further exploration in approaches to treatment. One novel approach is the administration of sequential dose-dense chemotherapy based on the Norton-Simon hypothesis, a mathematical prediction model of chemotherapy sensitivity derived from the Gompertzian growth rates of tumors 41 . Other studies are exploring novel targeted therapies. Chemotherapy regimens that include new agents targeting the epidermal growth factor receptor (EGFR) pathway are also under study. The Southwest Oncology Group is evaluating trastuzumab given in combination with paclitaxel, carboplatin, and gemc-itabine 44 . The selective EGFR tyrosine kinase inhibitor ZD1839, in combination with either gemcitabine cisplatin or gemcitabine carboplatin, is being explored as first-line therapy in two Cancer and Leukemia Group B (CALGB) trials.

Technologies to Investigate Mammary Gland Development

Transplantation techniques developed by DeOme et al. rely on the ability of MEC to repopulate a host fat pad that has been surgically cleared of its endogenous epithelium (13). A schematic of the transplantation protocol is presented in Fig. 1. Following removal of the host's endogenous epithelium, small portions (1 x 1mm) of donor mammary tissue, averaging approx 4600 MEC (10), are inserted into a pocket created within the host fat pad. After a period of outgrowth, typically 6-8 wk posttransplantation, the ductal network has reorganized, growing away from the site of the transplant to the edges of the fat pad (Fig. 1). Serial transplantation is usually possible for up to five generations from tissue that has regenerated from the original transplanted graft (14). In 1988, Sheffield et al. described successful transplantation of human breast epithelium into cleared fat pads of athymic nude mice, providing another application of transplantation to breast-cancer research (15).

Recommendations for Treatment of Locally Advanced Transitional Cell Carcinoma

Two large randomized trials and a meta-analysis support the concept that neoadjuvant chemotherapy for patients with muscle-invasive bladder cancer imparts a survival benefit over surgery alone. This approach should be considered for patients who are candidates for cisplatin-based combination chemotherapy and radical cystectomy. For patients who have not received neoadju-vant chemotherapy and who have extravesicular or node-positive disease following cystectomy, enrollment in a clinical trial should be encouraged. If a patient is not protocol- eligible, adjuvant cisplatin-based combination chemotherapy is a reasonable consideration.

Gene Therapy of Urothelial Malignancy

Low- to medium-risk superficial disease, currently managed with cystoscopic surveillance and intravesical chemotherapy 3. Invasive, nonmetastatic disease suitable for attempted curative treatment by radical cystec-tomy or radiotherapy overall cure rates are unsatisfactory at approximately 50 adjuvant chemotherapy may improve outcome There is certainly scope for improvement in groups 2 to 4. Intravesical administration of gene therapy is the most commonly utilized method of delivery, and it is hoped that this will improve upon BCG in reducing progression of high-risk superficial disease. Adjuvant gene therapy prior to attempted curative treatment of muscle invasive disease is likely to be used in conjunction with chemotherapy. Intratumoral injection, intravesical therapy, and systemic administration could be used. It is in patients with metasta-tic disease that initial clinical trials are likely to take place, and there is already phase I data from other cancer types. Clearly in this...

Hormone replacement therapy a preventive therapy that has fallen from favor

The next major and even more significant blow to the use of combined HRT for CHD prevention came when the Women's Health Initiative (WHI) was stopped early, at just over five years rather than after the planned 8.5 years. The WHI showed that in healthy women without vascular disease, treatment with combined HRT actually increased the risk of heart disease and breast cancer.59 Even though the increased risk was small, women on HRT had more MIs, strokes, and blood clots. The WHI is continuing to investigate the effects of estrogen alone used for women who have had a hysterectomy. Experts now feel that there is no basis for the use of combined estrogen and progesterone to prevent CHD in either primary or secondary prevention.

Restoration Overexpression of Tumor Suppressor Genes

Phase II and III trials, when they occur, are likely to assess the effects of p53 gene transfer in conjunction with chemotherapy regimens. There has been experimental work that suggests this is a promising strategy. When mice with subcutaneous tumors were injected intra-tumorally with adenoviral p53 and also administered intravenous cisplatin, the reduction in tumor growth was greater than with either agent alone 23 (Fig. 15.1). Subsequent work in vitro has shown statistically, using the combination index, that this additional effect is synergistic rather than just additive, implying that gene therapy such as this may target chemoresistant cells 24 . This idea is further supported by work on bladder cancer cell lines known to be cis-platin-resistant, which are more susceptible to p53 gene therapy than those that are cisplatin-sensitive 25 .

Surgery at the Skull Base

Radiation causes fibrosis in and around the nerve which may interfere with blood supply, compress the nerve, or otherwise compromise axonal flow. Cases of vocal fold paralysis have been documented following radiation treatment of nasopharyngeal carcinoma (along with other cranial neuropathies) 63-65 and mediastinal irradiation for the treatment of mediastinal tumors or breast cancer 66, 67 . Vocal fold paralysis has also been related to radioactive iodine treatment of thyroid malignancy 68-70 . A unique feature of vocal fold paralysis in this scenario is its latency it may occur from 12 months to 34 years following radiation.

Cytokine and Angiogenesis Inhibitors

Renal cell carcinoma is an inherently chemoresistant tumor. There have been many trials of single agent and combination chemotherapy regimens however, response rates are low and characteristically of short duration. Yagoda and colleagues 4 , in a review of 4093 adequately treated patients in 83 phase II chemotherapy trials published between 1983 and 1993, showed an overall response rate of only 6 . Thus, there is no role for chemotherapy alone in the treatment of renal cell carcinoma, but there have been improvements in survival as a result of the development of cytokine therapy.

The answers are 312b 313h 314d 315b e f 316g

(Goldman, 21 e, pp 751, 1039-1042.) Tumor markers should not be used to diagnose cancer, but may be helpful in following patients for whom a diagnosis has already been made. CEA is associated with colon and breast cancer. CA-125 is associated with ovarian cancer. Lactate dehydrogenase (LDH) is an important prognostic factor for Hodgkin's disease p2-microglobulin is the most important prognostic factor for multiple myeloma. LDH, AFP, and hCG are associated with testicular cancer, and 5-HIAA is associated with carcinoid syndrome (facial flushing and diarrhea from a tumor usually located in the lung or ileum). AFP is also associated

Further investigation of antimalarial plants

Considering the international trend in malaria chemotherapy research, we have proposed in this paper two antimalarial screening targets, the erythrocytic and the hepatic stages of malaria parasites. However, unlike the tight selection of drug candidates for development in the pharmaceutical industry, the results should be handled with flexibility, taking into account the holistic approach of traditional medicine. There cannot be a rigid framework with defined decision points. The stages in the process of decision making toward a final product (efficacy evaluation, safety evaluation, standardisation, galenical formulation, clinical observation, and clinical trials) will be different for each plant that is investigated, and it is necessary to spend more time on the study of individual plants that have strong ethnobotanical evidence of usefulness in the treatment or prevention of malaria. Particularly, the high frequency of indications of a certain plant must encourage further insight...

Conventional Cytotoxics

Define a stable point for building a chemotherapy-based approach to renal cancer. Key determinants of renal cancer resistance to conventional cytotoxic drugs remain to be identified and circumvented. Teleologically, the kidney is an organ that must resist and expel toxic substances, and this may be part of the basis for the recalcitrance of renal cancer to conventional cytotoxic treatment. Drugs directed at the adenosine triphosphate (ATP)-binding cassette (ABC) transporter drugs, such as P-glycoprotein (Pgp), multidrug resistance-related protein (MRP), and breast cancer resistance protein (BCRP) are another category of compounds that may ultimately have relevance for improving the outcomes for conventional cyto-toxic drugs in renal cancer.

Concluding Remarks of Chapter

Quite a revolution in the biomedical sciences. Their signals are mostly of chemical nature. Their characterization, however, may not be an easy task. The chapter is closed with a brief description of the signals produced by an image, perhaps the most powerful form to transmit information. The thermic signal was not described. Its use is mostly limited in the detection of breast cancer using infrared sensors. Unfortunately, it is also used in war to locate enemies in dark or foggy environments.

Of Immunophenotyping In

The lack of standardized criteria in the past for the classification of immunophenotypic subgroups, the paucity of controlled prospective studies on the treatment outcome of precursor B- and T-cell ALL subsets, and the different treatment strategies administered complicate the assessment of the prognostic impact of immunophenotyping studies in ALL. In addition, the strong correlation between certain immunophen-otypic subgroups and cytogenetic or clinical features (see above) has called into question the value of immuno-phenotyping as an independent predictor of treatment outcome. Finally, several studies have shown that the prognostic impact of immunophenotypic subgroups as well as chromosomal abnormalities is diminished by the improved efficacy of chemotherapy hence, prognostic factors must be evaluated in the context of the therapy delivered (270,299,316-319).

Information by Conflation

The rhetoric of the gene as code and information, so familiar now as to resemble common sense, turns on, I will argue, a conflation of two distinctly different meanings of the gene. When scientists and clinicians speak of genes for breast cancer, genes for cystic fibrosis, or genes for blue eyes, they are referring to a sense of the gene defined by its relationship to a phenotype (i.e., the characteristics of the person or organism) and not to a molecular sequence. The condition for having a gene for blue eyes or a gene for cystic fibrosis does not entail having a specific nucleic acid (DNA) sequence but rather an ability to predict, within certain contextual limits, the likelihood of some phenotypic trait. What molecular studies have revealed is that these phenotypic differences are Thus far Gene-P sounds purely classical, that is, Mendelian as opposed to molecular. But a molecular entity can be treated as a Gene-P as well. BRCA1, the gene for breast cancer, is a Gene-P, as is the...