DICTIONARYThis dictionary contains terminology that is commonly used in the field of medicine, specifically in the area of breast disease and osteoporosis. It will help to bring a more thorough understanding. While it could be expanded to thousands of subjects and not be complete, I think those included herein are of paramount importance to us. Additionally, I have tried to insert my own thinking as a surgeon on these definitions and the interplay of how we actually use them in real life. The decisions we doctors make are of the utmost importance since the patient’s life many times hangs in the balance. If you will, the team has to play the Super Bowl every day and win. Much of this is more information than you may want to know, but if the time comes when you or a friend need this information, it will be at your fingertips as well as other resources at VBC like the mentor program.

ADENINE – Adenine is a nucleobase derived from purine metabolism and is involved with complex cellular interactions like cellular respiration, energy production in mitochondria via ATP- NAD pathways and importantly for us adenine is a critical component in DNA (deoxyribonucleic acid). Our DNA is what makes us human and determines everything about us, from skin color to allergies to rare diseases. There are only four nucleotides in human DNA and they are Adenine, Guanine, Thymine and Cytosine. In the DNA molecule the four nucleotides attach to each other, usually A-T and G-C go together making the double helix of DNA. See (DNA). The InterGenetics company has discovered that abnormal combinations of these nucleotides which are age specific actually confer risk for breast cancer that can be detected in their saliva DNA test. In other words, we can not only tell a woman’s risk for breast cancer but when that risk is likely to manifest within ten years during her lifetime (it’s like a crystal ball). Dr. Bretz was one of the principal investigators for their FDA clearance study. Many people think DNA was discovered by Watson and Crick back in about 1968. Actually it was discovered in the 1860s by the Swiss scientist Friedrich Miescher but he didn’t call it DNA. However, Watson and Crick where the ones who figured out (in 1953) the exact manner in which DNA is structured (the double helix spiral). There was a fortuitist meeting between an American chemist named Jerry Donohue who pointed out to Watson the bonding of hydrogen allows A to be paired with T and C with G. Then a guy named Wilkins showed Watson a picture of the B form of DNA and everything fell into place. Watson, Crick and Wilkins shared a Nobel Prize in 1962. They toured the world in 1968 lecturing about DNA. I was actually fortunate enough to hear Watson lecture at Northwestern University.

ANATOMY – With any discussion of anatomy a purest would insist on starting with the embryology of the organ/gland. Embryology tells us how that particular organ/gland came to be and why it is in a particular position in the body. As early as six weeks in a developing fetus, the breasts begin to develop along a ‘milk line’ which extends from the shoulder area to and through the groin. At first there are multiple spots along that milk line where breasts can develop.

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However, in humans they usually all regress, except two. In dogs and cats for example, their breasts develop along the same milk line but don’t regress which is the reason they have multiple breasts. During this evolutionary process things can go wrong or not quite right.

For example, amastia can occur (no breast formation), athelia – no nipple development, polythelia – multiple nipples or polymastia – multiple breasts along the milk line. About ten percent of women have some indication of polythelia. Tissue called ectoderm is responsible for the formation of the ducts and lobules and tissue called mesenchymeal is responsible for development of the fat and vessels otherwise known as stroma.

As the breast matures under the influence of female hormones, it takes on its adult appearance. The breast isn’t like a water balloon. It’s full of glands (whose purpose it is to produce milk). They are called lobes and there about 15, sometimes less sometimes more. You can think of them like grapes where the stems are the ducts that carry the milk and the grapes are the lobules that produce the milk. Together each is a lobe. Throughout a woman’s life, those cells (hundreds of millions of them in each breast) respond daily to changes in hormone levels. Another way to think of the breast is like a fruit tree. Stop and look at a fruit tree sometime. You’ll see that on a limb of healthy looking lemons sits a shriveled one right next to them, how can that be? That’s Mother Nature. It’s the same way with the breast. One wonders how most of those cells can function for decades and decades normally, yet some just don’t and develop say a fibroadenoma. Surrounding all those lobes is fat. There are no muscles in the breast, only behind it. The two major muscles on the chest are the pectoralis major and minor.

The breast also contains a rich blood supply from about four different arteries that in many instances form what’s called an anastomosis. That is where they hook up with each other. The four arteries are the internal thoracic which runs just under the sternum and alongside of it. That artery is actually used for coronary bypass surgery as well. The three others are the thoracoacromial, long thoracic and the intercostal arterial supply. The lymphatics of the breast are extremely important because of potential tumor spread. The lymphatic supply of the breast starts with Sappey’s plexus, a bud of tissue behind the nipple. It forms an extensive network just like a women’s hair net. There are superficial lymphatics in the dermis and they grow larger in the subcutaneous tissue. About 80% or more of the lymph drainage goes to the axilla through the lateral pectoral nodes, then to the central nodes and then subclavian nodes before they are out of reach of the surgeon. There are also perforating lymphatics alongside the internal thoracic artery that drain to the substernal area and opposite breast.

Some authors notably Turner and Warwick back in 1959 studied lymphatic drainage of the breast and found that unlike Sappey’s model where all lymph flowed to the plexus under the nipple ,that there was direct flow to the axilla mostly without going through Sappey’s Plexus. See (nipple).

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ANESTHESIA – This is the process whereby we numb the tissue so the patient doesn’t feel any pain. This can be divided into general, regional and local anesthesia. General anesthesia is reserved for an operating room setting with an actual anesthesiologist in attendance. The anesthesiologist may place a mask on the face to provide a few moments of 100% oxygen before the patient goes to sleep.

This is followed by medication delivered through the vein (IV) which puts the patient to sleep and relaxes all the muscles. That drug is usually Propofol. Another name for it is ‘milk of amnesia’ since one of the side effects besides inducing sleep is it causes total loss of memory about the surgery. Interestingly, one of the only things patients remember is my holding their hand and reassuring them while the anesthesiologist works. Once the patient is put to sleep, the anesthesiologist puts a breathing tube down into the trachea (wind pipe). That tube goes through the vocal cords and may cause temporary irritation of the patient’s throat immediately after surgery. This is normal. Throughout the procedure, the patient’s vital signs are constantly monitored by the anesthesiologist (and surgeon) to ensure safety. Upon completion of the procedure depending on the response of the patient, the intubation tube is removed while in the OR or may remain until the patient is more aware and able to breathe on their own. Factors that enter into this are for example, smoking history, diabetes, obesity, etc. Hyperthemia is a condition that can develop during general anesthesia that dramatically increases the patient’s core body temperature. This can be inherited and generally the patient knows this but sometimes they don’t. There are specific protocols to follow. In more than thirty years of operating, I have never seen a case.

Regional anesthesia is reserved, for instance, to block the nerves leading to the arm so the entire arm goes numb. This is usually carried out in the OR. Local anesthesia can be carried out both in the OR and in the doctor’s office. I generally use lidocaine 1%, probably the same drug your dentist uses to do a nerve block on a tooth. In the office I generally use ethyl chloride before I introduce a needle into the skin. Ethyl chloride is a spray the briefly numbs the skin so the patient doesn’t really feel the needle stick. The first syringe I use is an insulin syringe which the patient can’t feel. This is followed by a 10cc syringe using an 18ga needle. I infuse enough lidocaine to get the job done, usually around 10-15ccs for The Lavender Procedure. During the infusion no matter what, the lidocaine going in will feel like a burning sensation but that quickly passes.

Then during the procedure the patient should only feel pressure of my working. If the patient does feel pain, more lidocaine is infused. You can have too much lidocaine causing side effects. For example, it can cause respiratory depression and irregular heartbeats and in extreme cases death. The decision to even contemplate using lidocaine depends on just what type of procedure the surgeon is doing. Is the procedure too big to be done under local in the office? That calls on the experience of the surgeon. The answer for our cryoablation patients is no, it is very safe and allows me to get the job done. The patient should tell the doctor if they are allergic to lidocaine or any local anesthesia. There is also a rare blood disorder called methemoglobinemia, an inherited familial enzyme deficiency.

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Patients usually know these things and tell the doctor BEFOREHAND which decreases the potential for an adverse reaction. There are two broad classes of local anesthetics, ester type like benzocaine or procaine and amide type like lidocaine. Allergies to local anesthesia are rare (about 1%). If the patient suspects a potential allergy, skin testing can be done. That’s enough about anesthesia, I’m going to sleep.

APBI – Accelerated Partial Breast Irradiation or APBR (radiation) depending on what paper you read was a major advance coming on line around 2002. Dr. Mantik will deal with this topic in detail in the radiation options section. However, since I have published data of my personal experience, I will explain.

The APBI catheters cost around $3,000 which the surgeon pays for and theoretically insurance reimburses the surgeon. The catheters have been modified over the years but essentially they mimic a Foley catheter that we use to canulate (insert into) the urinary bladder. When the balloon is activated by the high dose radiation machine (HDR) it radiates circumferentially, that is, 360 degrees to a distance around the balloon of about 1cm. This then is targeted radiation and outside this 1cm area the breast doesn’t receive any radiation. The 1cm is important because 90% of the local recurrences occur within that 1cm and the theory was that this device would take care of that problem of local recurrence. So the surgeon is tasked with getting the margins from the balloon surface to the skin of at least 1cm. If it’s less, the skin can potentially be in jeopardy.

That caused me to ponder the problem since many times surgeons are faced with close skin margins to get the tumor out with normal tissue around it. In my surgical residency at Loyola University in Chicago, we did a study back then on servicemen returning from Vietnam on whether or not they were exposed to dioxin (Agent Orange). To determine this we removed about an Oreo cookie size piece of fat from the abdomen and had it analyzed. Well, I thought why couldn’t I just do the same thing for these women, except the fat pad would be transferred under the thin wall at the lumpectomy site and act as a buttress. This procedure would make thousands of women candidates for APBI as without that fat pad they would be relegated to six weeks of radiation instead of APBIs 5 days. I have now done over thirty of these autologous (from the person’s body) abdominal free fat patches. I have followed them for over six years and since 2002 when I started to implant the APBI balloon catheters, I have personally not had a recurrence at the lumpectomy site. This data is published along with Dr. Mantik in ASTRO (see published results) proceedings. The paper was selected for a poster presentation 2009. ASTRO is the largest radiation group in the world.

However, as revolutionary as this breakthrough was back in 2002, it is basically obsolete. Why? Because now we have IORT (intraoperative radiation). Here the theory goes the patient has a lumpectomy and then about 20 minutes of radiation via a special machine with a ball attached to it simulating the balloon of APBI. So when the patient awakes in the recovery room she is done with surgery and radiation.

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The problem is this technology is only available currently at a few places in Southern California. Fortunately, I know the surgeon at Hoag Hospital and have sent over about five patients for that procedure. All have done very well. Of course, before the patients go over there they have an opportunity to visit radiation facilities here in the desert, and, of course, there is never a mention of IORT. If the patient brings it up the radiation therapists at the facilities in the desert are likely to denounce it as experimental, since they don’t have the machine. Yes IORT is experimental but now we have in the literature clinical trials of longer term analysis of 2 days of APBI instead of five and that works just fine. Where will it end? I am happy to see IORT coming along since it almost uses the same rational as cryoablation targeted kill of the cancer, we just use different means to kill it while at the same time saving thousands of dollars. But IORT is an advance for sure. It’s another example of treating breast cancer where less is more, meaning that as far as the breast is concerned, everything we’ve done less, i.e., from mastectomy to lumpectomy, from axillary node dissection to sentinel node, from six weeks of external beam radiation to APBI and now IORT, they all have the same result as far as the breast is concerned. I’m convinced just from my own 30 plus years of experience that either IORT or cryoablation will work just fine to prevent a local recurrence given proper patient selection. Another example is, we say that with The Lavender procedure the women feel like going right over to Lavender Bistro immediately after the procedure. After all the stories we have all heard about breast cancer, how can this be possible? The following story shows we are spot on. The City of Hope has done cases now with Zoft (one of the makers of the IORT machine). To tout the advance with this technology, of course, they had a patient that says she was puttering in her garden at home the same day!! Yeah I can see it very clearly how that patient was able to work in her garden, but VBC patients can go to Lavender Bistro. Change has come for sure.

ATYPIA – Atypia are cells that are judged to be not typical under the microscope. For example, suppose you had an audience and all the people were wearing blue hats except one who was wearing a red hat. The red hat would be atypical. I personally think that every invasive cancer starts out with atypical cells. It falls in a spectrum of change (in the cells that comprise the breast ducts) from mild, moderate and severe. Atypia can be divided into ADH and ALH meaning atypical ductal hyperplasia and atypical lobular hyperplasia. As the pathologists say, there is an increased nuclear to cytoplasmic ratio and increased desmoplastic response. This then leads to DCIS (ductal carcinoma in situ). At this time the more atypical cells begin to dissociate themselves from one another. The next step is invasive carcinoma. This generally takes years to progress. While we think all invasive cancers start out with progressive changes from atypia to DCIS, not all atypical cell changes or for that matter DCIS goes on to develop invasive carcinoma. If you have paid attention recently, there were headlines about how much doctors are over treating DCIS which may never amount to anything and thus the patient’s breast should not be subjected to an invasive procedure like mastectomy or bilateral prophylactic mastectomies. How can you tell? There is a new genetic test for this also. It will give a score for the atypia to tell if this is likely to proceed to DCIS and invasive carcinoma.

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Like all these new genetic tests, insurance companies judge many of them to be just experimental and therefore not cover them. That’s part of the problem with research findings. If there are some significant findings that can truly help people, it takes a long time before they are recognized as a mainstream test that should be covered.

There has been discovered a new bio-marker for atypia that has about an 80% accuracy in predicting whether a given woman’s atypia will eventually evolve into a breast cancer. It is developed by Benign Diagnostics (BDX) and is performed using (IHC) Immunohistochemistry on paraffin embedded biopsy tissue obtained at the time of biopsy. Nothing special needs to be done. They can go back to anybody’s tissue block to obtain the needed sample.

BENIGN - This refers to tissue that is not malignant (cancer). Like anything else there are shades of gray. For instance, of three different pathologists independently looking at the slides, one may call the tissue DCIS and the others severe atypia.

BIOPSY – This is the act of removing tissue from the breast for pathologic examination. It can include FNA (FINE NEEDLE ASPIRATION), core biopsy or open biopsy (generally in the OR). FNA is a cytology sample (like a PAP smear) and the core biopsy is actually multiple core samples (like coring an apple but much smaller – straw size).

Each can be done free hand in the office or with ultrasound, stereotactic guidance using a mammogram machine or MRI. The other way to obtain a biopsy is through open biopsy technique. This involves an incision made by the surgeon on the breast. I always try to use a circumareolar incision around the nipple as it hides the incision the best. I use a self-taught technique which eliminates or minimizes any indentation so it looks like we weren’t there. There are some 5-700,000 open biopsies done yearly in the United States and about 80% of them are benign. By using needle biopsy techniques, I have cut down on these open biopsies.

BONDING – Bonding is the chemical attraction between two atoms that forms chemical substances like water that shares two hydrogen atoms with a molecule of oxygen – H2O. The two molecules of hydrogen bond with the molecule of oxygen because of electromagnetic forces of the atom. An atom is like a miniature solar system with the nucleus (like our sun) surrounded by electrons (our planets) like the rings of Saturn. All nuclei are positively charged because the nucleus is made up of neutrons and protons which themselves are made up of a number of different quarks held together by gluons (complicated particle physics). The electrons (which are always negatively charged) are attracted to the nucleus and circle it in various orbits that have distinct energy levels or shells. So when two molecules come close together, the outer most electrons are attracted to both nuclei and thus a bond is formed that is very strong. A new substance is formed then by the mutual attraction of the electron to each atom. This is called covalent bonding where electrons are shared between atoms. There is also ionic bonding where electrons aren’t shared but attracted to another atom because there is an empty space in the outer most orbits where electrons should be but aren’t so electrons from one atom are drawn to another positively charged nucleus of another atom. How is all this held together?

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Just for general information there are four fundamental forces in nature, the strong and weak nuclear force, electromagnetic force and lastly gravity. The strong nuclear force is responsible for holding the nucleus of all atoms together. Without these forces acting just so every second of every day since the Big Bang, you would not be reading this.

So our DNA double helix is held together by covalent bonding between the pentose sugar molecule and the phosphate group and the sugar binding to the phosphate group of each nucleotide makes up the backbone (support) of the DNA strands. Without this bonding the nucleo bases like Adenine would just float independently. No life would exist.

BRETZ DIET (LIFESTYLE)- Yes, it’s a lifestyle not just a diet. I remain convinced six years later after I laid down the first Bretz Diet that with a lifelong proper diet and exercise program (lifestyle change), it’s likely you’ll live well into your nineties or reach a 100+ and still be independent, active and know where and who you are. Further, that most of the diseases (i.e. diabetes, heart disease, arthritis, etc.,) that plague us can be avoided or at least minimized so we don’t all end up taking 20 pills a day to try to control these problems. What most people think of as a diet is severely cutting back on the amount of food you consume (so it feels like you’re starving). That never works and you end up like a yo-yo, drop twenty pounds, and gain 25 pounds.

Starving yourself doesn’t work because the body senses this lack of food and goes into a survival mode and slows down metabolism so it becomes hard to lose weight. It’s not that at all. Diet refers to not starving yourself but whatever you put in your mouth from now until the day you die. It’s eating low glycemic index foods, anti-inflammatory nutrient rich foods, supplements as needed and avoiding meat and dairy as much as possible. Having an ongoing moderate exercise program including aerobics (not necessarily a gym, I bike ride and swim) and weight lifting is critical.

Trust me. I grew up in Chicago (during the tail end of the stockyard days) and we always had and loved meat and a lot of it with potatoes and gravy. I can still remember my mother’s fried chicken, biscuits and gravy. She ate things like that daily and lived into her nineties and knew who she was.

You bet genetics plays an important part in all this. But for those with a less than stellar genetic family background, don’t think it’s hopeless. With epigenomics (see epigenomics), we can tweak those bad genes by proper diet. As you may know Joan and I have been married for 45 years and for most of those years (up until about eight years ago) when I came home for dinner, the roast had a nice crispy covering and the gravy was warmed and it all smelled so good. Now except for Thanksgiving, Christmas and a few times during the year all that roast and gravy is long gone. What makes it tolerable and usually enjoyable for me is that Joan has figured out a way to eat mostly vegetarian but make it so a meat lover (me) can stick with the vegetarian lifestyle. I’m still after her to do the cook book.

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It’s more than just trying to eat a plate full of peas and carrots every day for a meat lover, it’s fooling me into thinking I’m really getting something like meat, that tastes like meat and is tasty but it’s not meat. Yes, we do eat fish and a lot of it. The fish is all wild and cold water, salmon, trout, cod, sardines, etc.

Before we get into what to eat let’s back up a little and tell my story of how I changed my lifestyle. I was a jock in high school and college playing football, swimming and track. Back then I could eat as much as I wanted as I was probably burning about 3000 plus calories a day. As time went on and I entered my five year surgical residency (every other night in the hospital), we never knew when we would be able to eat again so I got used to eating two full meals. When we came to Eisenhower (in 1979), I was busy from day one which didn’t leave much time for exercise. At that time we were still on the meat wagon. As the years went by, I gradually gained weight and at the max I was over 235.

One day I just looked in the mirror and said, “you either have to do something about this or just lie on the couch and enjoy the nachos and cheese.” So I just locked the door that evening, left the car in the parking lot and I wanted to see if I could walk home, 6 miles. I did and for the next four months I walked to and from work (took an hour and 45 minutes). It became a running joke at the hospital with people honking their horns as they passed me. At the end of four months, I had dropped 20 pounds and we were still eating all the meat we could. Then in 2005, I got a chance to ride with Lance Armstrong in the ‘Tour of Hope’ 50 miles. That event changed everything. Back then I (like a growing number) was really into the Tour de France. As I prepared to ride the fifty miles with Lance, it really hit me how out of shape I was. So I made the decision to buy a road bike and began to ride a little more each weekend.

At the same time I began to look at nutrition, and supplements. I had also read ‘The China Study.’ At the time it was the largest nutritional study carried out by T. Colin Campbell, PhD., who ran the nutritional programs/studies for the National Institutes of Health. From then on Joan and I decided we would try to eat free of animal products. I continue to lift weights (as does Joan) almost every day, as heavy as I can lift, and we include about ten minutes of stretching beforehand. When I’m out on the bike I’m gone for three to four hours. So it’s not that I want you to go to a ‘spinning class’ at the gym and see how fast you can pedal the stationary bike for ten minutes. It’s the longevity of the exercise that counts and it’s a life style change instead of doing other things or just sitting around. It’s a conscious effort, all the way, every day.

There are four books I would recommend if you want to get deep into this. The China Study by T. Colin Campbell, PhD, “The China Study Cook Book”, Turn Off the Fat Genes by Dr. Neil Bernard and Dr. Joel Fuhrman’s material which you can find at the PBS store on-line. You need to experiment and find vegetables that you really like and how to prepare them differently to satisfy you not just day in and day out but for a life time. It’s a challenge but well worth it! There are many vegetarian cookbooks out there. Most include dairy products which should be eliminated as you will learn.

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You don’t need any of these weight loss companies sending you boxes of food all the time. Yes, you’ll lose weight but are you going to eat that boxed food your whole life? Another change we made is where we shop for food. Almost exclusively we shop at Trader Joe’s and Sprouts and take in a farmer’s market when we can. Foods that we have cut out altogether: sugar, fast food, sodas, any sugar coated cereal, meat (except fish) and dairy. We use minimal salt. We drink only bottled water or filtered, no tap water. If you’re into soda and want help getting off the juggernaut, drink sparkling mineral water which comes in flavors. That’s how I got off the sugar soda. Carbonated water gives you the rush like you’re getting something. You want to be drinking at least 6-8 glasses of water a day (assuming you don’t have renal failure or congestive heart failure and need to restrict your fluid intake). That’s close to two bottles of Trader Joe’s mineral water or the equivalent. Bottled alkaline water is available at Sprouts if you want to try it. I won’t get into that controversy except to say there is some evidence in the literature that cancer has a hard time growing in an alkaline environment.

Breakfast: This usually revolves around some organic cereal like oat meal, shredded wheat, Cheerios, whole wheat toast and green tea, coffee on the weekends. We start each morning with a glass of water before breakfast. Joan makes her own cereal of raw oat meat, walnuts, chia seeds and cinnamon.

On weekends we usually have pancakes using whole wheat pastry flour and almond milk. We always add fruit of the month. We sometimes have tofu (fake meat sausage). Morning Star is a good brand. The trick is (as you will learn in Dr. Bernard’s book) if you become a vegetarian, in three months your taste buds will change so you will not crave unhealthy foods with empty calories, i.e., calories that go straight to fat and not utilized as energy in the body. The more processed the foods, the emptier are the calories.

That’s why you’re constantly hungry. We also try to keep processed soy products to a minimum as these may be hormone disrupters.

Lunch - Usually we have a salad with salmon or tuna, perhaps a whole grain pasta dish. Yes pasta is ok if you’re exercising. Quinoia or whole wheat pasta is the best choice. If we are out for lunch, it’s still the same. We sprinkle different seeds (chia, sunflower), nuts and fruits on the salads.

Dinner – It always includes a salad (kale or spinach) tomatoes, onions etc. Joan makes her own salad dressing. A few times a week we’ll have fish or she’ll make a pizza with wheat dough, no cheese and mushrooms/green peppers. We will have pasta probably two times a week like clams and linguine or spaghetti with mushrooms, no meat sauce. For certain there are our favorite veggies served with each meal.

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Recently we happened onto Dr. Joel Fuhrman on PBS talking about nutrient-dense foods and G-BOMBS. He has added his own twist to the vegetarian band wagon. The mantra is you can eat as much as you want, exercise properly and you still lose weight and be as healthy as you can be. Nutrient-dense foods are what you’ll be eating (providing every cell in your body with the right energy and environment) instead of foods with empty calories.

G-BOMBS is an acronym for (G) – GREENS, (B) – BEANS, (O) – ONIONS, (M) – MUSHROOMS, (B) – BERRIES and (S) – seeds. These kinds of foods provide everything your body needs to work properly and ward off disease. I think this doc has it right. You just can’t eat anything with a face or a mommy (except fish) or any product of the above. It’s whole foods prepared right not processed foods. For genetically altered foods, I think the jury is still out. It takes decades to know the final outcome like HRT causing uterine cancer wasn’t found out for a good twenty years. It’s good to know that all organic foods are non-GMO (genetically modified organism).

Dessert – If we have it it’s usually non-dairy ice cream with berries or frozen banana with chocolate. Food is great and should be enjoyed.

The idea here is you can eat as much as you want of the right food. Remember you’re eating half the calories every day. Think of your body like a gas tank. We have all seen somebody at a gas station pump gas in until it starts over flowing on the ground. Well, your body acts the same way. Carbohydrates get broken down into storage units called glycogen in the liver. Glycogen is just glucose (sugar) molecules linked together chemically. When you exercise your muscles are put through work which burns calories. If you exercise long enough you begin to sweat. Your blood sugar begins to fall and if you don’t eat, glycogen from the liver is metabolized into glucose to be used as food for the cells. If you just eat the carbs and don’t exercise, the liver storage capacity for glycogen is exceeded and the rest of the carbs are metabolized into fat.

If you exercise, the glycogen isn’t turned into fat. It’s used for work muscles do. Just like the gas tank analogy, we don’t want to overload our livers with simple cards that then get turned into fat. Exercise avoids that scenario. We avoid the simple carbs (like pie, white bread, regular pasta, cake, donuts) complex carbs are ok if you exercise. Complex carbs are like whole wheat pasta, oatmeal, quinoa, wheat bread. Please give the books and other web-sites a try. Remember if you’re out to lose weight DON’T WEIGH YOURSELF AT ALL, PUT THE SCALE AWAY. When someone you haven’t seen for a while sees you and says, “Did you lose weight?” – then go weight yourself. This is a lifelong commitment and we know now that diet refers to anything you put in your mouth, not food restriction. Eating nutrient-dense whole foods and foods with a low glycemic index and that are anti-inflammatory is the diet you want to be on always.

CAD – This is an acronym for Computer Assisted Diagnosis. If you ever get to see your actual mammogram report it will clearly say the radiologist used CAD. It is a machine containing software the can read your mammogram that the radiologist uses as he/she reads your films.

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So it’s all done at once. In essence, it’s a second set of eyes the radiologist and the computer which is programmed to identify calcifications and masses the radiologist may miss. This sounds good but the other side of the coin is if the radiologist misses a target and it’s identified on CAD that’s a problem or if the radiologist sees the CAD unit identifies a problem area that he/she thought to be benign then this might prompt a recommendation for biopsy if the radiologist isn’t sure of himself/herself. Because if he/she doesn’t recommend a biopsy and later it shows the area to be a cancer the attorney for the plaintiff will say, “Doctor your hospital paid for this expensive equipment to help you and it identified the area now known to be a cancer and you ignored it how’s that doctor?” CAD is a double edge sword depending on the experience and expertise of the radiologist. We have seen cases where CAD missed what infrared picked up for three years. Like mammography and ultrasound in experienced hands it usually has a good result. But you have to ask after fifty years of interpreting mammograms are the radiologist so deficient in reading mammograms they have to have a machine do it for them? Reading a mammogram isn’t rocket science and we would all probably improve the outcomes if radiologist and breast surgeons worked together like at VBC in the same location.

CALCIFICATIONS – The calcifications we are concerned with are the ones that show up on mammogram and if they do are they part of a benign or malignant process? They can be divided into whether they are benign or malignant. If they are associated with a malignancy the calcifications themselves are not the cancer just a by-product of its development. Like anything else sometimes it’s easy to tell sometimes it’s not. First off the calcifications we see on mammogram have nothing to do with the calcium you take as a supplement or that’s in your body generally. While rarely calcifications show up on ultrasound (depending on the size) mostly we see them on mammography and that is why mammography has this niche of ferreting out tiny calcifications.

Here is a list of calcification we see on mammogram – 1) calcifications in blood vessels (which have nothing to do with breast physiology except the artery is located in the breast and happens to be imaged), 2) Macrocalcifications, 3) Microcalcifications, 4) Milk of Calcium, 5) Pleomorphic calcifications, 6) dystrophic calcifications and 7) calcifications found in a fibroadenoma and 8) adenosis, 9) clustered calcifications, 10) calcifications associated with deodorant, 11) Calcified capsule around an breast implant.

We will address these one by one. 1) Arterial calcifications seen on mammography may be an indication of kidney disease or heart disease. These calcifications are part of a generalized process and should prompt the doctor if these are extensive to discuss heart and kidney health. The heart may be involved since the coronary arteries (your heart arteries) are about the same size as the tiny arteries in your breast. These calcifications appear in about fifty percent of women over fifty to one extent or another. They are easily seen and you can see how they track with an artery (not vein) in the mammogram. They have nothing to do with cancer but may as I said spark some investigation into heart and kidney health.

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2) Macrocalcifications - these calcifications are easily seen on mammogram and are generally small to large (3mm) or so. We call these pearls and they can be scattered about but not clustered and easily seen. We just document them in the report. 3) Microcalcifications – This is where the difficulty comes in as sometimes we don’t know on a screening mammogram if these calcifications are small pearls and they will just be big pearls when they grow up or if they are part of an evolving cancer not visible on any other modality. So generally the radiologist will request ‘extra or special views.’ These could include compression or more likely magnification views that give us a better look. If the question still isn’t settled then two options are open. One is to repeat the mammogram in about six months and compare them to the last mammogram for changes. The problem with that (which is what radiologist have done in the past since they are treating x-ray films and not the patient) is that cancers can remain unchanged for up to three years on mammogram depending on their individual proliferation or now KI-67 rate. I don’t like this approach because the patient would have to undergo mammography every six months (if there is no change right away) for about three years to determine if they are truly suspicious or not. Then when they did change and cancer is found, you can bet it was cancer on the first mammogram and well before that, so time is lost. In the trade it’s called, ‘failure to diagnose cancer in a timely fashion.’ The other thing we look for is whether or not the difficult calcifications to define are scattered or clustered. Benign calcifications tend to be scattered in the breast while cancers tend to be clustered in one area where the cancer is evolving. 4) Milk of Calcium – these are benign calcium deposits and if they are associated with a cyst the radiologist looks for a phenomenon called ‘layering’ which is generally best seen on the lateral view of the breast or also known as the MLO view. If there is layering present this is a benign finding. If there are punctate calcifications associated with the layering we go to special views again. 5) Pleomorphic calcifications -These are the ones we are most concerned about and would prompt a core biopsy. They prompt biopsy because they are associated with evolving cancers. Unlike round pearls they are irregular in shape with jagged edges and clustered. These are at time really tiny and difficult so see under any circumstances depending on when they started to grow and when we find them. I kind of liken them to snowflakes verses a smooth rubber ball. 6) Dystrophic Calcifications – These calcifications are benign and have a rather distinct look. They are associated with degenerated or necrotic tissue that develops these calcifications as the body heals. Common examples include calcifications below the suture line of a woman who has undergone a breast reduction as some of the tissue that is left from the operation is not viable. Old injury can also cause these. It’s actually the most common cause of abnormal infrared signal that isn’t cancer on biopsy. 7) Calcifications associated with a Fibroadenoma – Just like dystrophic calcifications when a fibroadenoma gets older it degenerates and deposits calcium within its substance. Generally these are easy to tell and we just note them. It doesn’t mean the fibroadenoma is turning to cancer. 8) Adenosis – These are benign calcifications that give radiologist fits. They are benign but there can be thousands of them scattered throughout the breast.

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On mammogram it almost looks like somebody sprinkled salt all over, 9) Clustered Calcifications – Just to reiterate, these are grouped calcifications on mammogram that can be a small group (about 2mm) or a large grouping of calcifications (over 2cm). These are the ones we watch for and where mammography has the edge. Cancers usually develop in this manner from DCIS to Infiltrating so that’s why we go after these with biopsy. These calcifications are usually pleomorphic and punctate (dots) as opposed to course calcifications of pearls, 10) Calcifications associated with deodorant - This is why you are told not to use deodorant prior to your mammogram because the aluminum specks in the deodorant mimic malignant calcifications on mammography, 11) Calcifications associated with a breast implant capsule – For those women who after breast augmentation (implants, a boob job) depending on the extent of capsule formation may develop course calcifications which many times are palpable. These ae not associated with malignancy but bothersome from a cosmetic stand point.

CANCER –What a word to come close to The Bretz Diet since diet plays such a big role here. This one definition could take up multiple books but the basic understanding is all we need. It all starts with the normal cell cycle. Cells are programed genetically to be born, do their function and then die. This process can be divided into three different segments of the normal cell cycle. These are the quiescent (senescent) or resting phase, interphase (where DNA synthesis takes place) and the last phase is actual cell division (mitosis). In the resting phase the cell is just doing its thing. When it goes into the interphase it starts to grow getting ready for cell division (thereby making a duplicate copy of itself to carry on its work). Within the interphase there are again three divisions, G1, S-phase and G2. G1 is analogous to a preflight test a pilot would carry out before taxing unto the runway. It is mostly a check of the DNA to make sure it is undamaged (by something like radiation). If it is damaged cell division is delayed and repair of the DNA is carried out if possible. If there is too much damage then apoptosis (programmed cell death occurs). If all is ok the restriction point comes up. When the restriction point is reached, the cell is committed to proceed with cell division. This is analogous to a pilot running up the engines and putting down the flaps just prior to take off and going down the runway and hitting V2. Usually at these speeds the plane is committed to take off or will run out of runway. Just prior to S – phase there is one last check point called G2. If the cell passes that point, cell division is imminent. The next phase is entered (S-phase). This is where just prior to cell division the DNA is replicated. The DNA double helix unwinds and is immediately duplicated so now there are two identical strands (genetic material), one of which will go to the new daughter cell. At the outset of all this the cell depends on external growth factors and a cascade of extracellular and intracellular interactions to get ready for actual mitosis which is the last step and actual cell division.

This process is highly complex and mitosis is divided generally into a prophase, metaphase, anaphase and telophase and each of these has subsets of critical cellular interactions. There are hundreds and hundreds of these interactions and each must go perfect or else. Or else what? You guessed it - cancer. All cancer is, is unregulated cellular proliferation. Somehow cancer cells are able to ignore the signal for cell death.

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Cancer doesn’t kill like a snake bite with venom. Cancer kills by becoming a space occupying lesion in a vital organ. An old professor of mine back in the 1970s told me cancer depended on three things, genetics, environmental factors (toxins) and factor X. I suppose he wasn’t far off.

The hallmarks of cancer are its ability to proliferate (grow uncontrollably), invade surrounding tissue, develop a new blood supply to feed itself (called angiogenesis) and spread to distant organs (metastasis) in the lymph and vascular systems. That’s why we have to find these cancers at the very earliest point to have an opportunity to destroy it before it can spread. The old model by the “system” is to have a mammogram machine shinny and new and wait for random women to come in (that is if their doctor reminds them).This hasn’t worked. If it did work, no women would be dying but we know that’s not true. This is why we need “the VBC model.” We first do genetic testing to identify actual risk, low moderate or high. Then we set up an individual surveillance program where we can implement our diagnostic modalities without radiation to find these cancers. It’s important for you to understand that currently in the old model of a woman judged to be at high risk, they can’t just keep doing mammography every six months. That will eventually cause cancer itself since radiation is cumulative.

A former director of the NIH (National Institutes of Health) felt that every time a woman came in for a series of mammogram pictures, she raised her risk about 1%. If a woman starts mammography in her thirties and goes in yearly and possibly for extra views each year because ‘they saw something,’ that’s over fifty years of concentrated radiation to each breast. That’s why I’m working with non-radiation modalities. Mammography has its place but I think we can use it much more wisely and avoid a lot of radiation. Using genetics and non-radiation modalities to guide us is the answer I feel in 2014 and beyond.

While cancer is certainly uncontrolled growth of certain cells, it was unknown exactly what cells started all this chaos. In recent years researchers have discovered that not all cells are capable of this transformation but a small number are and they are called CSC (cancer stem cells). Genes that are capable of this change are called protooncogenes. Protooncogenes are genes that have the potential under the right circumstances to start a cancer. They encode or manipulate growth factors that make possible mutated or misregulated genes. There are also usually next to this promoter genes tumor suppressor genes. This means that even though a person may have the genetic tendency or capability to develop cancer that cancer won’t appear if the suppressor gene is active. Research is directed now into (epigenomics) just what makes the suppressor gene happy as it were. Lastly, proper nutrition meaning an anti-inflammatory diet and keeping the body alkaline are other important factors. See the Bretz Diet.

CDK 4/6 – We know there are multiple pathways that regulate the cell cycle and one or more of those pathways goes awry in cancer. We know that ER+ cancers have a good chance of being controlled by an oral anti-estrogen like Tamoxifen or Femara.

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However, there are some ER+ breast cancers that eventually don’t respond or become resistant to anti-estrogen therapy. Research has now discovered signaling pathways of CDK (Cyclin Dependent Kinases). In ER+ tumors, estrogen leads to activation of Cyclin D-1. Activated Cyclin D -1 then joins with CDK4/6 and causes a chemical reaction named phosphorylation and inactivation of the retinoblastoma protein (RB). This allows the production of E2F which causes gene transcription and drives cell growth. Current research is being carried out of blocking this CDK pathway.

CLEAR/NEGATIVE MARGINS – Since 90% of breast cancer local recurrences occur within 1cm (about dime size) of the original lumpectomy site/walls, the surgeon makes every effort to remove the tumor with a rim of normal tissue. There is debate in the literature as to just, what constitutes clear or negative margins. It can be technically negative/clear at 1mm however, most surgeons would probably agree that as close as the surgeon can get to 1cm negative margins the better. The surgeon can use blue dye and make the margins with suture so the pathologist knows exactly how that lump of tissue was situated in the breast. Then if the margins are involved with tumor, the surgeon can re-operate with a definite idea as to where he/she needs to remove more tissue. What is very nice about The Lavender Procedure is the kill zone extends about a full 2cm (almost an inch) on either side circumferentially around the tumor. Therefore, the old problem of clear margins doesn’t enter into the discussion. Also what needs to be remembered about The Lavender Procedure is that the tumor is not removed, it remains in place. It eventually gets absorbed over the months after the procedure. Interestingly, there is preliminary evidence that leaving the dead tumor cells in place will produce anti-bodies against that tumor as it gets absorbed, similar to a dead virus vaccine.

COMPRESSION FRACTURE – This is a fracture that occurs in the spinal column where the vertebral body just collapses when it becomes so osteoporotic. There are about 700,000 per year (probably much more that don’t get documented). The problem is once you have one it’s highly likely that you’re in for another one because the initiating process (osteoporosis ) affects every bone in the body. The other problem is once one vertebra collapses (like a flat tire), it throws off the alignment of the rest of the vertebral column. The vertebras are more prone to fracture because they’re made of ‘spongy bone,” not cortical bone like the long bones of the leg. The best treatment is prevention but once you have one, a procedure called a Kyphoplasty can be done to help reestablish the individual vertebra and relieve pain. (See Kyphoplasty). On the prevention side if your doctor does a DXA test (bone mineral density) and sees developing osteopenia (weak bone but not enough to call it osteoporosis), we can institute proper preventive treatment. See osteopenia.

CORE BIOPSY – This is one of two methods to obtain tissue via needle biopsy. The other is FNA (fine needle aspiration). A core biopsy is just what it implies. The needle used is about the size of a straw so it actually takes a core of tissue. Just like coring an apple except on a much smaller scale. FNA on the other hand only uses a needle that takes cells called a cytology specimen.

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It’s like taking a sample of a tree. An FNA sample would be like taking a leaf of the tree. You could tell what kind of tree it came from and generally the condition of the tree or some specific condition if it shows up in the leaf. The core biopsy could be thought of as taking a limb of the tree where much more information is available for identification. Core biopsies are usually done under local anesthesia and can be done free hand in the office or used for ultrasound and stereotactic guided needle biopsies.

CT – A CT scan is a diagnostic modality that uses computer generated images of x-rays in a tomographic fashion or (slices of tissue). A good analogy is a block of Swiss cheese. Suppose you can’t see any of the holes but with a CT scan, you can see individual holes. A CT scan lets the doctor see inside the body in a 3 dimensional fashion.

Obviously this sounds great but I am not a big fan of CT. Why? Usually we don’t need it in breast surgery. Often the oncologist will use it to look for tumors. However, it’s a lot of radiation, a lot. Some estimates are that there were about 72 million CTs ordered in 2007. There are estimates that CT scans alone account for about .4% of all cancers we see and at 2007 usage it will climb to 2% or more in the coming years.

The radiation dose for a full body CT is about 500 times that of a conventional x-ray. As we know x-rays are cumulative in the tissue. Nowadays we have combined CT with PET (Positron Emission Tomography) but we want to keep exposure to these intense radiation sources limited.

DCIS (ductal carcinoma in-situ) – Strictly speaking it means cancer in place. That is, it hasn’t yet reached the potential to metastasis, if it ever will. I wish there was a definition everyone agreed to but there isn’t for this one. Perhaps both sides are correct. One side feels DCIS is some form of breast cancer albeit non-invasive. However, the other camp feels that because many of these in-situ conditions don’t progress and may in fact regress, they don’t feel this condition should have the word cancer attached to it. DCIS doesn’t possess any of the attributes generally assigned to cancer like ability to invade surrounding tissue, develop a new blood supply (neoangiogenesis) or metastasis. Because I feel invasive cancers spring from in-situ cancers, I am in the camp that feel this should be called a cancer. It’s the kind of cancer that is found on PAP smears looking for cervical cancers. However, I totally agree that the patient should be counseled that this is not a cancer that spreads and kills. That statement can get the surgeon in trouble since now days most breast cancers are diagnosed on core biopsy. Here’s the problem of the surgeon reporting to the patient she has only DCIS on core biopsy. Remember the core sample only gets what it gets. It’s not an evaluation of the entire lesion as in an open biopsy. About 5% of DCIS lesions harbor an invasive component. How’s that? That is probably because we catch the DCIS at a time when it is turning more aggressive. I had a patient diagnosed with atypical hyperplasia (strictly speaking a benign lesion) yet because of one genetic test, I felt I should do an open biopsy and found a 4mm invasive cancer. That patient is an example of newer genetics tests impacting correctly for the patient. DCIS is also divided broadly into non-comedo and comedo necrosis.

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Non-comedo necrosis can be further divided into micro-papillary, papillary and cribriform depending on how the pathologist views the tissue under the microscope. Comedo necrosis generally referrers to DCIS that is more high-grade (that is more aggressive). As these cancers develop some of the cancer tissue dies off because of lack of blood supply and becomes necrotic tissue seen under the microscope. This condition has a tendency to cause the development of pleomorphic calcifications (irregular calcifications) which is a hallmark of cancer on mammography. If mammography is good for anything, it’s picking up these tiny calcifications before the tumor has a chance to develop potential to spread.

Perhaps the problem is this. In the 1970s DCIS only accounted for about 1% of cancers found since mammography was in its infancy and screening programs and organizations (before the pink ribbons) didn’t exist. Now with mass screening mammography, DCIS is the most diagnosed type of breast cancer. In the 1970s, mastectomy was the treatment of choice and that decision was pretty cut and dried. Why? Because mastectomy removed the entire breast along with the DCIS and bingo you had a 100% cure. Contemplating a lumpectomy was a no, no back then. Remember the “Did you get it all generation?” With the advent of lumpectomy DCIS began to be treated with lumpectomy with and without radiation. But it almost took two decades to catch on where women would be counseled about any options. In the literature there are papers and monographs coming down on both sides of the issue. In large part a lot of that delay was the fear of a lawsuit if the cancer came back in the form of a local re-occurrence. There is one meta-analysis (looking at results from a few of papers) that showed benefit of radiation in DCIS over almost 9 years. There are other papers that looked at retrospective results of over 7000 patients with and without radiation and the recurrence rate for tumors removed with margins of at least 1cm was only 2% with and without radiation. It is also true that there are various groups, all of whom have their definition of clear margins and this has led to more confusion.

Basically my feeling is that you can always remove the breast (if need be) if down the line this cancer recurs. But even this statement now has to be tempered with the advent of APBI and IORT. I have personally performed a re-lumpectomy of six locally recurrent breast cancers using APBI (two were mine about 12 and 14 years after lumpectomy and radiation) and four were from elsewhere. If a local recurrence happens after lumpectomy and radiation, standard of care dictates a mastectomy, pure and simple. However, my familiarity with APBI led me to the conclusion that it would be possible to use APBI instead of doing a mastectomy. All six cases have been followed for over six years and all the patients are alive and without a re-recurrences. So again experience helps if the surgeon is willing to push the envelope to help women, but because a woman who has been diagnosed with breast cancer is then in a different set of circumstances and followed much more closely, this enables APBI in my opinion to be considered to save the breast. This is the kind of problem we are faced with that will probably never be evaluated in a clinical trial because it goes too much against the grain.

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It, too, depends on the size of the DCIS and the size of the breast. With a small DCIS and larger breasts, probably the surgeon can get away with lumpectomy alone with wider margins over 1cm. For large DCIS and smaller breasts and therefore closer margins, radiation should probably be added. Paradoxically radiation is more efficacious in invasive cancers rather than in a less aggressive nature of DCIS. That is true because radiation works best on rapidly dividing cells and in DCIS the cells are not rapidly dividing. Then there is the issue of Tamoxifen or the like. All these considerations are taken into account by all the members of the team (unlike thirty years ago), so usually there is a consensus. Lastly, the entire picture needs to be taken into account and explained clearly to the patient and the patient makes an informed consent. I’m sure in the near future this DCIS issue will be straightened out with the advent of genomic research like the continuous recurrence score from Genomic Health. The deeper question with the ‘continuous score for DCIS’ from Genomic Health is how long will it take the ‘system’ to totally adopt this innovation for every woman? The tragedy is that probably thousands of women will never have this genetic test even brought to their attention, let alone who will pay for it! It’s much easier for the system at a large county hospital for instance to just dictate what the frightened woman will have in the way of treatment then to get into the best treatment. This has to end somehow.

DNA – is deoxyribonucleic acid discovered in about 1869 but it took many years for James Watson and Frances Crick to discover the ‘secret of life’ and the double helix. They actually stumbled onto it trying to put together a puzzle of a protein on the floor. They realized that the only way it would work is to be a double helix with the same information on each side but in reverse.

As the story goes after they discovered the double helix structure, they agreed not to tell anyone as there were many scientists working on the same thing and they wanted to get it published first. But Crick apparently went to a local pub (where academics hung out) and after a couple of beers blurted out they had discovered ‘the secret of life’. DNA is actually composed of a few parts and is biopolymer strands coiled about each other. The strands are made of polynucleotides attached to each other (kind of like connecting different color Legos). The nucleotides are composed of the four nucleobases A,T,G or C (Adenine, Thymine, Guanine and Cytosine), and each has an alternating pentose sugar and phosphate group where they each attach through covalent bonds thereby forming the backbone of the helix. The sugar is called 2-deoxyribose. These long strands are what make up the 46 chromosomes we each have, 23 from dad and 23 from mom. Each DNA strand in each cell is about 3 billion base pairs long. If you stretched the DNA out from a single cell it would reach about 2meters or over 6 ft. long. How does it fit into a cell that’s only 4 microns? A micron is about .00004 of an inch or a millionth of a meter. For comparison, the average human red blood cell is about 4 microns across and human hair is about 75 microns.

If you stretched out the DNA end to end from every cell in your body, it would be twice the distance of our solar system and that’s a long way. How does the DNA fit into the nucleus of the cell?

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Try taking a piece of string and hold it on each end and start twisting it, you will see it coils and the more you twist it the more coils you get. That’s how it fits. Think about this. If the DNA strand is 3 billion base pairs long and each time that cell divides, that molecule divides and replicates itself identically, that is, perfect every time. How many times would a human make a mistake in trying to do a complicated task 3 billion times? Then you add on to the DNA division process age and say consuming pesticide laden food for decades, you begin to see how cancer can start.

DXA – Stands for Dual-energy x-ray absorptiometry previous acronym of DEXA. It is an x-ray but very limited exposure. It’s less than flying from New York to California and back. This is the test we order to determine bone mineral density or how strong or weak the bones are. It is the gold standard and should be done when you and your physician deem it necessary depending on your individual circumstance. Of course, insurance companies don’t want one until about age 65 when we have to play catch up. This is modified if there is a family history or we have a very fragile woman or a previous fracture. Basically though, when you just want to know, then it’s time to get one even if you have to pay for it. Given the fact that a woman not on HRT or other bone support at menopause loses on average about 30% of her bone mass the first three years following the onset of menopause, the recommendation for starting at 65 is hard to understand except to delay and deny care. When DXA first came out (about fifteen years ago), we got them every year to document a change in the bone. If you have a baseline study and we institute treatment, we can perform a DXA once every three years or so. There are other tests out there that also look at bone mineral density like heel ultrasound and quantitative computed tomography (QCT) but I don’t use them. I think the doctor needs to know the real story, not just the heel and QCT is unnecessary radiation in my view.

In DXA results, look at ROIs or regions of interest most importantly the neck of the femur (the long bone in your leg from your hip to the knee). When people say they broke their hip, it usually means they fractured the neck of the femur.

For the test, the patient is positioned (differently for the lumbar spine and hip) on the DXA table and the machine is turned on. Before the first scan of the day is done, there is a quality control test that must be done or the machine will not run. You’ll also notice the operator isn’t behind any lead screen or the like. That’s because DXA radiation can’t reach that far. The basis for the test is that radiation photons are produced under the patient and pass through the patient and hit the detector above the patient. Denser bone deflects the radiation more porous bone permits the radiation to hit the detector. We generally look at two or three areas of interest, the lumbar spine (lower back) and the hip. Unfortunately arthritis in the spine throws the machine off and it reads the arthritis like bone mass and may say you have strong bone when in reality you have very weak bone. Newer DXA machines have the rotating option so the x-rays are taken from the side (lateral position) and don’t include the arthritis spurs on the vertebra. We can also image the wrist.

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The results are of two varieties. We get a T-score and a Z-score. I have to be careful about how I write these scores. The society ICSD (International Society of Clinical Densitometry) has decreed that it’s T-score not T score, not t-score or t score. This nonsense is typical of when people seize control of something; things like this become the important thing, not if the patient is really doing well. Get real. Anyway, the Z-score I discard since it’s an age related comparison. Most women score pretty well in the age related area. My thing is who cares if you are as good as all the other women in this age group and they are all going to break their hip the next day. We want the T-score. That’s how you relate to a thirty year old when you had peak bone mass. A DXA is scored as follows.

Anything on the plus side to -1 is normal bone mineral density, anything from -1 to -2.5 is osteopenia (see osteopenia) and anything that is a more negative number than -2.5 is osteoporosis. I had one patient with a -6 T-score that was a quadriplegic who couldn’t move either her arms or legs. A minus -2.5 indicates osteoporosis but not that you’re going to fracture your hip the next day. There is plenty of time to fix things.

How do we fix things? Your body is like your car. If you just drive it until the engine seizes without preventive maintenance you pay the price of repair and sometimes lose the whole car. Hopefully your DXA will not read osteoporosis if you take care of your body starting early on (like in high school) with proper diet, supplements and exercise. In counseling patients, they can pass vital information onto the next generation so we prevent osteoporosis. How many mothers sit down and discuss bone health with their young daughters? We begin to counsel patients the first time we see them and reinforce the issues each time they come or call for information.

What exercise should we do? Weight bearing is the key. The more weight on the bones, the stronger they become to bear the weight. Pool aerobics and stretching for instance while good for the joints does nothing for bone strength. Walking is good but walking your dog doesn’t count. I’m talking about brisk walking for at least 45 minutes, if possible, otherwise as much as you can as often as you can. You should invest in a small set of free weights. Weights called Power Blocks are good since you can change the weights in seconds rather than traditional dumbbells; you tend not to lose interest and lift more weight each workout. I’m not interested in how fast someone can peddle a stationary bike for ten minutes at the gym in a ‘spinning class’. It’s persistence and the daily program that makes the long term difference. A good place to walk (while using weights) is any high school track which is a quarter mile around. Four times equals a mile.

Many of you know I was a jock in high school and college and since then I got up to over 235 lbs. You also know that Joan and I have been on the Bretz diet for about nine years and I weigh about 175. I lost the weight initially by walking to and from the hospital twelve miles a day without changing my mostly carnivore diet. Now besides the diet, I ride my bike about fifty miles on Saturday and fifty miles on Sunday.

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When I go out on the bike, it’s a conscious decision to do that instead of sitting on the couch watching TV. It’s a lifestyle change for most people. You really don’t want to end up in a nursing home at 80 because you fell and broke a hip. You want to be the 80 year old who comes to the nursing home to see your friend. You can be that person if you take care of your body always. About 50% of women 80 years and older who fracture a hip never get out of a wheelchair EVER. They go in a split second (which they can’t remember) from being independent to someone changing their diaper. “I don’t know what happened?” How many times I’ve heard that. To prevent this scenario it all starts when you’re 20 something with good eating and exercise habits and a doctor that cares enough to steer the ship right.

Supplements are at minimum controversial. The literature is all over the place. However, almost 90% of people in American are Vitamin D deficient. Usually they are way low. The limits are a low of 30 to a high of 100. I’ve seen a lot of women at a level of around 12 or so. This is especially bad if you’re on osteoporotic medication. That medication needs the help of calcium and Vitamin D and good overall nutrition to build the bone. I like our patients to have a Vitamin D blood level and if low start and maintain 5000 IU of Vitamin D daily. This comes in one tablet or in drops. In addition, there are medications taken for other problems (like heartburn) that put the patient at more risk long term bone loss.

Calcium intake should about 1000mg daily in divided doses. A little more one way or the other doesn’t matter as much as getting into the habit of just taking the supplements. Why divided doses? The body only absorbs about 600mg at a time. Take the calcium (and any supplement) with food. Constipation is a real problem for some women and therefore try different calcium tablets, liquid, in chocolate whatever it takes. Calcium carbonate is the cheapest to make and usually comes in large pills which many women find difficult to swallow. Calcium carbonate is also the calcium that causes the more constipation. Calcium citrate is less constipating and more easily absorbed in the small intestine. Often times I’ll just recommend the liquid since it’s easier to swallow and it’s already in a more digestible form.

What if you have osteopenia or osteoporosis on DXA? See osteoporosis treatment.

EPIGENOMICS – It is the ability through diet, exercise, supplements and as yet to be discovered ways to tweak the bad genes in your genome from expressing themselves. We know that there are oncogenes (genes that cause cancer) and usually next to them are suppressor genes that keep them from expressing that cancer. The question (after we discovered and mapped the genome) is what can we do to keep those supressor genes happy? Is it diet, exercise, some yet to be discovered medication? The epigenome is like an interface between the environment and the genome (your genes). We think that the epigenome can be tweaked through a process called methylation or histone modification. That is research that is ongoing now. You must remember that the significant research on nutrition has only become available the last few decades. I can still remember the radio broadcast back in the 1960s when there was the discovery of cholesterol. It takes a long time for research to get done.

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FIBROADENOMAS - These are benign solid tumors (not cancer) that occur in the breast most often in women in their late teens and twenties, although they can occur at any age. Older ones that have not been removed go through a process called ‘evolution’. That is, they develop large calcium deposits within them which are very distinct on mammogram. We just note these as incidental findings. For instance, they would be a BI-RADS 2 on your mammogram report. That is, the radiologist sees the target on mammography but knows because of its characteristics it’s benign and no further intervention if required. They can be very small almost like a pinhead or very large like a grapefruit called a giant fibroadenoma. They are rubbery in consistency and at surgery it is common to see tiny ones next to a larger one. It is not uncommon for these things to seemingly recur when in reality the surgeon just missed a small one growing next to the target fibroadenoma. Sometimes we just can’t see it. While strictly speaking they are benign, they do have malignant potential although rare. In the past we used to remove these with an open biopsy if they were palpable (can feel them) and the patient just didn’t want to feel it anymore.

Now, however, we can freeze them with the cryogenic probe without surgery and they just resorb over time. It goes back to the fruit tree. How come all the millions of cells are humming along just fine and then a fibroadenoma happens? It is just what that tissue does.

FINE NEEDLE ASPIRATION (FNA) – This is a technique usually done in the office that removes cells (like a pap smear) from a target. We use a small needle 18ga and usually a 20ga syringe to apply suction to remove the cells. The cells are placed on a slide and sent to the pathologist for evaluation. Done correctly and with the right target, it’s just as accurate as an open biopsy. Also see core biopsy.

FROZEN SECTION – This is a procedure carried out by the pathologist after he is given tissue by the surgeon and while the patient is usually asleep in the OR. Therefore, there is some urgency to the procedure. Basically the pathologist drops whatever he/she is working on and comes to the surgeon’s/patient’s aid. As we have covered elsewhere, a good surgeon will have identified the margins so the pathologist knows the orientation of the specimen. The reason for all this is the surgeon wants to know a few things like, is it cancer, how close is the cancer to the margins and if it’s cancer, what is its origin? This is valuable information at a moment’s notice (actually takes about 20-30 minutes). Since there are time restraints, the pathologist can’t take as much time with a frozen section as he/she can on the permanent section. This comes into play, for instance, with sentinel node biopsy, (see sentinel lymph node).

An experienced pathologist can (mostly) by palpation and visual inspection of a node tell if there may be pathology inside it. But the truth comes out in the sections of tissue they make. So infrequently a sentinel node will be reported to be negative at surgery and days later the permanent report comes out and there is microscopic cancer in the node at another location in the node they didn’t look at during frozen.

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GENOME – This is all the genetic material of an individual. Actually genome is a composite of the two words gene and chromosome. If we go back to our friend the DNA double helix, it contains over 3 billion base pairs that make up the DNA molecule. Your entire genome, which is unique to you, is in every cell in your body except for red blood cells which just carry oxygen. The double helix is compressed into chromosomes, 23 pairs in all. 22 of these are called autosomes and are the same in male and female but the 23rd pair is the sex chromosomes X and Y that determine the sex of an individual. XX yields a female and XY yields a male. The term Pharmacogenomics refers to the study of the genetics as it relates to the care of human beings and cancer and in our case, breast cancer.

GLANDS OF MONTGOMERY - Named after a Irish obstetrician, each breast has about 5-10 little bumps in the areola that secrete an oil to protect the nipple from drying and that oil comes from the glands. Normally they are not visible but such things like pregnancy or sexual stimulation etc., will make them visible as a small bump under the skin of the areola.

HALO – This is an ingenious test that takes about 5 minutes to do. We don’t use it all the time but when we have indicators like an abnormal infrared or ultrasound or other test, we certainly put it to use. It’s a small device that creates suction starting at the nipple and can extract abnormal cells deep in the ducts. It has what appear to be like tulip petals that close around the nipple. For the first three minutes the petals circulate warm water around the areola which relaxes the entire area and opens the duct at the nipple. Then the last two minutes there is suction applied. The rationale for this is that as abnormal cells develop inside the ducts, instead of a normal single layer, there are multiple layers (hyperplasia). As this situation increases under say hormonal stimulation postmenopausally, the cells inside the ducts that eventually develop into a cancer get more and more abnormal (atypical). Those cells can sit there for years with no way of being diagnosed. One of the hallmarks of cancer that Halo depends on is that as mildly atypical cells become more atypical and on to DCIS, some cells start to dissociate themselves from one another and therefore just sit there isolated in the duct. Halo has the ability of sucking out these cells thus providing us with a cancer diagnosis years ahead of time even below a 1mm.

HETEROGENEITY – Of all the problems in treating any cancer, this is the biggest hurdle/obstacle to overcome. Why? A good analogy is bacteria and antibiotics. Nobel laureate Alexander Fleming discovered penicillin in 1928 and penicillin killed every bacterium known to man, no problem. Why? - because bacteria had never seen an antibiotic before. Now how many antibiotics do we have? Why – because bacteria have the uncanny ability to change their cell walls. It’s a compound called peptidoglycan that grows and develops links thus creating the cell wall. Beta lactam antibiotics like penicillin (which is a fungus) prevent the cross links from forming and the cell wall loses integrity and the cell dies. The same holds true about cancer cells although through a different mechanism which is yet to be elucidated. The cancer cell can become resistant very rapidly to any treatment.

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Further, with the hundreds of millions of cellular divisions of cancer cells (considering what we know about cancer cells), each daughter cell is distinct from its parent just as you are from your parents but different. Each successive generation of daughter cells is more aggressive and resistant to therapy. That’s why even knowing all these hundreds of metabolic pathways, we still can’t develop the magic bullet. In short, that is the rational of our using the cryogenic probe. Kill it when it’s very small (3-5mm) before it has a chance to grow further and metastasis. Yes, small cancers can metastasis but the odds are really in your favor (especially with low recurrence risk on OncoTypeDX genetic survey) if we can diagnose a 4mm tumor that may permit killing it without surgery, chemotherapy or radiation. That’s the goal anyway.

HORMONES – The word hormone has its roots in Greek language meaning ‘in motion’ and this is quite true. Hormones are synthesized (made) in the body by various endocrine glands. Hormones circulate in the blood stream thereby finding their target organs. They are a product of the endocrine system. There are both endocrine and exocrine glands that secrete hormones. Endocrine glands (like the thyroid) secrete their hormone (thyroid hormone) directly into the blood stream in response to a feedback system of TSH (thyroid stimulating hormone) secreted by the pituitary gland located at the base of the brain in the Sella Turcica. Exocrine glands (like the salivary glands, parotid, submaxillary and sublingual) secrete saliva containing digestive enzymes into salivary ducts that open into the mouth. There are two sublingual glands located in the floor of the mouth and the two ducts empty there via the two sublingual gland ducts (you can see the openings under your tongue). Then just when you figured you know this, there are glands that are both endo and excocrine like the pancreas. The endocrine portion of the pancreas produces insulin, somatostatin and glucagon. Insulin produced by the beta cell of the ‘islets to Langerhans’ controls blood sugar, somatostatin (also known as growth hormone inhibiting factor) produced by the delta cells regulates insulin and glucagon and help regulate cell proliferation and neurotransmition. Glucagon (produced by the alpha cells in the pancreas) has an opposite effect of insulin; it raises the level of blood sugar by traveling to the liver to tell it to release glycogen (how the liver stores glucose). Generally the endocrine system relies on a feedback system.

The thyroid is easiest to understand. If your doctor wants to see how your thyroid is functioning, he/she will order a TSH (thyroid stimulating hormone) level and possibly a T4/T3. Here’s how it works. Thyroid hormone is produced in the thyroid and secreted into the blood stream in response to TSH secreted by the pituitary gland (sometimes called the master gland). If the pituitary gland senses (as the blood flows through it) that there is not enough thyroid hormone, it sends out TSH. Normally the thyroid then responds by producing more thyroid hormone. Then the increased output arrives at the pituitary and the pituitary senses the increased thyroid hormone and dials down the TSH and so it goes. If, however, the pituitary senses that in spite of the increased TSH no increase in thyroid hormone is occurring, the TSH level goes up and up. If it’s the fault of the thyroid (hypothyroidism), then your doctor will likely put you on thyroid medication.

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The pituitary doesn’t know if the thyroid hormone is coming from your thyroid or you are taking pills. The anterior pituitary gland contains five different endocrine cells that control various bodily functions. They are somatotropes (GH), prolactins (PRL), gonadotropes (LH AND FSH), corticotropes (ACTH) and thyrotropes (TSH). In turn, the pituitary gland gets its signals for various releasing factors from the hypothalamus directly via the hypothalamic-hypophyseal axis. GH stands for growth hormone, PRL stands for prolactin, LH stands for luteinizing hormone, FSH stands for follicle stimulating hormone and ACTH stands for adrenocorticotropic hormone. Two more common diseases associated with these hormones are Cushing’s Disease as a result of a primary pituitary tumor resulting in elevated ACTH levels and in turn elevated cortisol levels produced by the adrenal glands.

The other disease is Addison’s Disease which is primary adrenal failure (the adrenal glands don’t work) so the blood doesn’t carry any cortisol back to the hypothalamus and pituitary and they pump out more ACTH. JFK had Addison’s Disease and took steroids for it which wasn’t common knowledge until his death.

The hormones we are most concerned about are estrogen, progesterone and testosterone. Pre-menopausal estrogen, progesterone and testosterone (yes, women produce testosterone - the male hormone) are predominately produced in the ovaries. After menopause they are produced still by the ovaries but in drastically reduced amounts. The main source of these sex hormones after menopause is body fat and the adrenal gland (which sits atop each kidney). That is one of the reasons obese women have a higher risk of breast cancer because of the higher level of estrogen in circulation converted from cholesterol and DHEA (dehydroepiandrosterone) from body fat. Side bar for DHEA - In the body DHEA comes from cholesterol (yes the parent molecule for all sex hormones is a steroid and is cholesterol so cholesterol provides a vital function for humans. If one takes a DHEA supplement, the body can convert it to testosterone and estrogen in three simple chemical steps. In the body DHEA comes first from cholesterol which is changed to pregnenolone, then 17 hydroxy pregnenolone and then to DHEA which, in turn, is changed into androstenedione, in turn, changed into testosterone then estradiol (E2) and then into estrone (E1). Pregnenolone from cholesterol can immediately be changed into either progesterone or the 17 hydroxy pregnenolene and that can go into either cortisol (stress hormone a glucocorticoid) or androstenedione then testosterone and so forth. Progesterone can also go into aldosterone (a mineralocorticoid).

Pro athletes, in testifying before Congress about taking steroids, probably correctly say they never took testosterone (a banned substance), but in reality they took a pill containing a chemical that is just one metabolic step away from testosterone and that’s androstenedione. It’s available over the counter. Esterone (E1) and estradiol (E2) can be changed to estriol (E3) in the liver and placenta. Estriol (E3) is seen by many to be a more protective (or safer) estrogen in terms of a causative factor in breast cancer. This notion may in part be due to its being an antagonist to (G-protein coupled estrogen receptor on the cell wall encoded (activated) by the GPER gene).

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G-protein coupled estrogen receptor has a strong affinity for estradiol (E2) but not the other estrogens. G-protein coupled estrogen receptor initiates signaling pathways that lead to cell proliferation and since estriol acts as an antagonist, it probably helps slow or stop proliferation caused by G-protein coupled estrogen receptor. Thus, in the very early stages of cellular proliferation that eventually leads to cancer, estriol (E3) may help in some preventive manor. Easily understood right?

Let’s shift focus and discuss the MENSTRUAL CYCLE and its overall effects that affect the female body. In order to understand this phenomenal event that makes it possible to be born, I think it’s best to think of it as symphony orchestra. As one note is ebbying another comes in and that’s just the way the menstrual cycle works. Two major things are involved, the production of an egg (ovum) and preparation of the uterus for pregnancy.

All the events that led up to preparing the uterus for pregnancy blend into each other and are orchestrated to finite detail to make the cycle happen decade after decade in a woman’s life. A girl’s first cycle is called menarche. There is an old benchmark that says an early menarche increases the risk for breast cancer. It seems that the younger generation is starting their periods earlier and earlier thus increasing the time breasts are exposed to this monthly ebb and flow of hormone stimulation. Menopause is the other end of the spectrum defined as no natural period for one year. As usual with hormones, it all starts in the hypothalamus and pituitary with the release of FSH (follicle stimulating hormone). Remember even though it starts in the pituitary, the pituitary in turn is influenced by diet and exercise. It is well known that young female athletes have markedly delayed onset of their menstrual cycle. One thing affects the other. The menstrual cycle technically starts on day one with bleeding. The bleeding is the sloughing of the uterine lining that has been built up by the hormone interaction of the cycle to prepare for a pregnancy. If there is no pregnancy, the progesterone that produces the secretory phase of the uterine cycle gives out and the uterine lining is flushed out. The uterine lining is chock full of tiny blood vessels that are intended to nurture the developing fertilized egg. There are really two cycles going on at the same time. One is the ovarian cycle drama taking place inside the ovary and the other is the uterine cycle taking place in the uterus. The ovarian cycle prepares an ovum (egg) for implantation in the uterine lining and the uterine cycle prepares the lining to accept the fertilized egg. The ovarian cycle is divided into a follicular, ovulation and luteal phases. The uterine cycle is divided into menstrual, proliferative and secretory phases. The typical cycle lasts about 5 days and recurs about 28 days later but can vary normally.

The ovarian cycle can be described this way. The ovaries are located deep in the pelvis, but can at times be palpated via a bi-manual pelvic exam, (that is one hand in the vagina and the other on the abdominal wall pushing the ovaries down). There are two ovaries on either side of the uterus held in place by a suspensory ligament just under the fallopian tubes. The ovaries are about the size of a walnut, shaped like a small egg, whitish in color and you can see the developing ovum as a dark color beneath the surface. In a woman’s life there are about 3-500,000 potential eggs.

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However only one so-called Graafian follicle each cycle produces the mature ovum and causes ovulation. At the start of the period (follicular phase) estrogen and progesterone are low, there is a rapid fall off and the uterine lining sloughs off causing bleeding. This carries on for a few days but then under the influence of FSH from the pituitary (which senses the very low levels of estrogen) the one Graafian follicle that is destined to contain the mature egg becomes surrounded by granulosa cells which nourish the developing ovum.

There are distinct layers the granulosa cells form to nourish the developing ovum initially called an oocyst. As time goes by estrogen levels rise (stimulating the breast as well) and progesterone late in the follicular phase begin to rise. The granulosa cells also produce LH luteinizing hormone also produced by the pituitary. At a certain level of LH, the follicular phase stops. At mid cycle there is a LH surge triggered by the high estrogen levels partly. On about day 12 or mid cycle the second ovarian phase begins called ovulation. The mature egg ruptures into the abdominal cavity next to part of the fallopian tube called the fimbria and the egg is swept up. You can think of the fimbra like a sea anemone. A woman’s body temperature goes up about a degree or two at ovulation. This is a signal that she is at her most fertile time.

The egg is usually fertilized at this point and generally takes about three days to migrate into the uterus implanting usually on the posterior wall. Sometimes there is abdominal pain associated with this ovary rupture and it’s called ‘mittleschmerz’. Occasionally both ovaries produce a mature ovum and, if fertilized, develops into fraternal twins. After ovulation estrogen falls off. The follicle is now called a corpus luteum whose purpose is to produce progesterone which prepares the uterine lining for the egg fertilized or not. If there is a pregnancy, the progesterone level grows and the placenta develops. If there is no pregnancy, hormone levels can’t be sustained and menstruation begins. During the three phases of uterine cycle changes initiated by the pituitary affecting the ovaries, cause similar changes to take place in the uterus. Shortly before the menstrual phase ends, estrogen levels rise and the uterine endometrium (internal lining) begins to grow course blood vessels.

This is called the proliferation phase and lasts until ovulation which sparks the secretory phase where under the influence of progesterone from the corpus luteum, the vessels become delicate and engorged with blood making the endometrium ready for implantation. So it goes decade after decade until menopause. At peri-menopause (about five years before the actual menopause) sometimes there are irregular heavy periods caused by a fluctuating weakening hormone system. All to this discord of fluctuating hormones for decades directly affects each individual breast cell. Then add to that HRT and possible pesticide contamination in food affecting the billions of breast cellular divisions and no wonder we end up with cancer. When a woman takes HRT at menopause for relief of hot flashes etc., while it certainly help with that it also affects the millions of breast cells that in essence know that that there is no more mild and no more babies and is in a state of retirement as it were, we shake them awake with HRT.

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HORMONE RECEPTORS – Some of these receptors have been known for over thirty years and we analyze every tumor to determine the quantity or not of estrogen and progesterone receptors. These receptors are on the surface of the cancer cell if they are present. They can be quantified from 0 to 100. Good analogies are the dimples on a golf ball versus a rubber ball. The rubber ball has no dimples (or in our case no receptor sites) and the golf ball has many. What goes in those receptors sites? Estrogen and progesterone produced by either a woman’s ovaries or fat and adrenal glands (after menopause) fit into these sites and among other things stimulate multiple signaling pathways in the cancer cell to grow and divide. The more receptor sites there are, the more the cancer cell is stimulated. The receptor sites are actually protein molecules that can bind chemically with estrogen and or progesterone. Receptors are kind of the eyes and ears of a cell. While numbers vary, about 80% of breast cancers are hormone positive. We speak of these tumors as ER+ (ER positive) or if there are no receptors it would be an ER- (estrogen negative) and they can fall in-between so they can be marginally positive.

About 13% are ER+/PR- and only about 2% are ER-/PR+. About 20% or so are what we call ER-/PR- and generally they are associated with the gene Her2 also being negative. This is the so-called TRIPLE NEGATIVE breast cancer. Unfortunately, triple negative breast cancers are many times associated with African American women and at a younger age.

In fact, there was a paper from doctors at Children’s Hospital in Seattle in 2013 that looked at breast cancer in African American women. They found higher rates of metastatic disease in these younger women indicating the need for earlier discovery. However, since states like California have adopted the new Federal guidelines on mammography, it becomes more of a moral issue. California no longer pays for a mammogram (through Medi-Cal) until age 50. Well, that flies in the face of overwhelming data that says we need to discover these breast cancers very early on especially in young African American women. What alternative does the system offer these women?

The current system is not set up to do it. For one thing the current system is set up to take care of random women coming in for mammography. It’s an isolated yearly (often times dreaded) event in a woman’s life. Second, we can’t be doing mammography on these young women every six months because that will give them the cancer we are trying to avoid. Whereas, if an personalized surveillance program based on genetics (so the woman knows her risk) is set up early on and we can discover these cancers without radiation, then I think a program like ours is worthwhile. Then the women become partners in their health care, understand it and feel confident and comfortable about the entire lifelong process because someone cares enough to empower them.

The importance of all this is if we have a ER+/PR+ breast cancer, it will almost certainly respond to some kind of anti-estrogen like the drug Tamoxifen. By responding we mean that a drug like Tamoxifen will essentially block the receptor site from estrogen.

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This will eventually lead to the cells death since early on breast cancers need estrogen and or progesterone to grow. Generally it is known that patients with hormone positive tumors just do better than with hormone negative tumors. Having said that, I’ve seen patients with what looks like an aggressive tumor on paper with a life expectancy of about three years live until well into their 90s and one was 97. She was diagnosed at age 83. She was the oldest patient we ever gave neo-adjuvant chemotherapy to. She was my longest surviving patient and died of old age at 97.

Through clinical trials we now know that a patient with an ER+ tumor should be on some anti-estrogen for ten years and probably longer. A few years ago there was concern about tumor developing resistance to an anti-estrogen. After ten years of one anti-estrogen, we can switch to another one that works through a different mechanism. It’s kind of like if you don’t want your neighbor to build on the vacant lot next to you, you can take away the lumber, when he replaces that you can take away the nails, etc. There are basically two types of anti-estrogens, those that block estrogen production altogether and those that let estrogen be produced but block it at the receptor site. These are drugs like Tamoxifen (nolvadex) and Fareston (toremifene). Tamoxifen is an oral synthetic anti-estrogen that acts as an antagonist against the ER/PR receptor sites on the breast cancer cell via its metabolite 4-hydroxytamoxifen. Tamoxifen itself has no real affinity to the receptors. But once it is metabolized by the liver by the cytochrome P450 system, it is converted to 4-hydroxytamoxifen and works by competitive inhibition against estrogen. We will discuss this in another section since Tamoxifen is near and dear to my heart. Some of you may remember long ago in 1990 Dr. Bretz was the first researcher to submit a large-scale clinical trial to the FDA using Tamoxifen to prevent breast cancer altogether in high risk women. It lowers the risk by 50%.

The other type of anti-estrogen is an aromatase inhibitor. Fareston (toremifene citrate) is much like Tamoxifen except it’s not metabolized in the liver like Tamoxifen. These drugs are called SERMS (selective receptor modulators). They act differently at different target organs that are affected by estrogen/progesterone. There is another drug (widely used now) called Evista (raloxifene). Like Tamoxifen, Evista has been found in a large clinical trial (THE STAR TRIAL– Study of Tamoxifen and Raloxifene) to lower the risk of getting breast cancer by 50%. It also has the additional indication for treatment and prevention of osteoporosis in post-menopausal women. There is another drug called Faslodex (fulvestrant) which is usually reserved for women who have failed on a first line anti-estrogen. Faslodex is an injected drug and is a pure anti-estrogen (not a SERM). Now we come to aromatase inhibitors. These are anti-estrogen drugs that block all estrogen production. That is while the receptor sites on the cancer cell are bare and ready to accept the estrogen there is no estrogen to combine, so one way or the other the cancer cell doesn’t get the use of estrogen which it needs at that stage to grow. Over the last thirty years the development of these drugs has been a major help in curing many patients.

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These are drugs like Arimidex (anastrozole), Femara (letrozole) and Aromasin (exemestane). Arimidex and Femera are non-steroidal aromatase inhibitors that irreversibly binds with an enzyme called aromatase that is critical in the production of estrogen from fat and adrenal glands in post-menopausal women. Therefore, much less estrogen is produced and consequently the tumor is deprived of the estrogen it needs to grow and eventually dies off. Aromasin, on the other hand, is a steroidal aromatase inhibitor but essentially in the end does the same thing as the other two.

HOT FLASHES – Some of the symptoms of menopause include but are not limited to mood swings, night sweats, dry vagina, dry skin, hair falling out, urinary incontinence, crying for no apparent reason, loss of a sense of wellbeing and depression, did I leave anything out? These symptoms may occur not at all in some women and be suicidal in others. At one point I gave Premarin (one of my least favorite drugs) to a woman who had ER/positive breast cancer because she just couldn’t tolerate the hot flashes anymore and we had tried everything else. The old saying, ‘Sometimes a man’s gotta do what man’s gotta do’ is in order. Well, just change ‘man’ for ‘woman’ and there you have it. To put HRT in some perspective about its necessity or not, I often say that the reason your reading this is that every woman from Eve on down to current day never had true HRT (hormone replacement therapy) until the late 1950s. Of course that doesn’t make it any easier. Some women say, ‘What are they talking about? I never had a hot flash.’ Others need real help. The exact cause of these symptoms, besides the lack of estrogen, is not really known. Possibly the cause is that the hypothalamus reacts to an ebb in estrogen causing the vascular system to dilate which blows off heat through sweating. There are various relief measures we can employ to help different symptoms.

The big elephant in the room is whether or not to take HRT and what kind? How dangerous is it? Will it cause cancer? These are all valid questions. First, with regard to how dangerous HRT is, we can now employ genetics to partially answer that question for each woman, before she goes on HRT. In my way of thinking every woman who contemplates going on HRT should be studied genetically to actually know the risk. If the genetic risk is low, no family history and mammograms, etc., are negative, then I think there is minimal risk with certain HRT for shorter periods. If on the other hand you have a strong family of breast cancer or high genetic risk or have had breast cancer, then the risk escalates accordingly. Then, knowing the risk, if the patient must have HRT we can accelerate the surveillance without using radiation. I hope this makes sense to you instead of just getting a prescription from your doctor and taking the HRT without knowing all this. There are consequences to taking HRT decade after decade (as many women do) without knowing the genetics to make an informed decision.

The thing to remember about HRT is nothing is written in stone and you’re not going to get cancer if you take HRT for three months and see how the ship floats. There is sometimes fierce disagreement among doctors about the pros and cons of HRT. One thing I think we can all agree on is whatever HRT a woman takes, it should be at the lowest dose that does the trick (relieving symptoms) and taken for the shortest period of time necessary.

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Just anecdotally, some patients I’ve seen that get breast cancer who are on HRT are the ones who have taken high doses for a long period, like decades. Their doctor just continues to write an Rx for HRT because the patient feels well and it’s almost automatic without having a heart to heart talk about HRTs necessity or not at some point. Of course, if a woman is diagnosed with a hormone positive tumor and is on HRT that’s the last day she takes it. The reason is that in essence she is feeding that tumor that needs estrogen to grow at that stage. Another concern is osteoporosis which is another reason women are placed on HRT. During the first three years following menopause a woman can lose up to 30% of her total bone mass which isn’t good. She should have been on calcium about a 1000mg in divided doses taken with meals and vitamin D 5000IU daily. That vitamin D dose is my personal recommendation just because I think there is mounting evidence in the literature that high systemic levels of vitamin D are associated with lower risk of certain cancer among other benefits. The FDA removed estrogen replacement as a treatment for osteoporosis years ago. However, there are studies that do show it helps maintain bone density. Now there may be better options, see osteoporosis. What is the safest estrogen? There is no estrogen that’s absolutely safe.

Here’s the issue with breast cancer. At menopause (this may sound simplistic) the breasts know there are no more babies and no more milk because the hormones are depleted. At a time when they want to go to sleep by taking HRT you’re essentially shaking them up and saying, ‘get back to work.’ Some of you recall the teaching mammograms I have. A couple of them show a ductogram – a dye test that highlights the ductal system in the breast when we look for the cause of nipple drainage. If you don’t recall, ask to see them the next time you’re in. We also now have nice illustrations of how those ducts look under the microscope. The milk ducts are hollow and carry milk from the glands (lobules) that make the milk to the baby’s mouth. They are normally lined by a single layer of cells. Here comes the hormone double edged sword. Initially at menarche besides making the ovaries function, estrogen also accounts for growth of the breasts. But even though the breasts grow under the influence of estrogen, if we give a truck load of estrogen, your breasts won’t get so big you can’t walk out the door. They are predisposed genetically to stop growing at a predetermined point. So when we give a woman HRT after menopause the breast don’t ‘grow’ anymore, the only thing they can do is the normally single layer of cells lining the ducts begin to multiple which is called hyperplasia. Hyperplasia in some cases leads to atypia (see atypia). Realize there are hundreds of millions of cellular divisions going on at a time when that organ wants to remain dormant and now the patients taking HRT. I said the breasts don’t grow anymore after menopause for women who take HRT, but women usually notice a cup size increase after menopause, why? It’s not from actual growth of the glands, it’s that for women not on HRT after menopause, the glands shrink from no use and the body replaces that loss with fat and she gains a cup size.

To reiterated, if a woman takes estrogen (especially higher doses for prolonged periods like 30 years), that’s when we usually get into cancer being caused by that constant stimulation of aging breast tissue; if indeed that was the cause.

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My personal opinion is this is especially true if a woman is taking an estrogen from another species like a horse which some HRT is made from (pregnant mare urine). That’s why thee FDA has a warning about HRT. You have to ask yourself why humans are the only species that take another species hormones. Does it make sense for a 120lb woman to take an estrogen that’s so much stronger than her own from an animal as large as a horse? Sure the horse estrogen is strong and makes most women feel very good by taking away all the post-menopausal symptoms, they just plain feel better, no question. The question is though at what eventual price? To be simplistic again, I think there’s a reason why women get breast cancer so often and men don’t. We breathe the same air, get frustrated in heavy traffic jams, eat the same food, but men don’t get breast cancer very often. What then could be the cause in women? We just went over that besides genetic risk. That is the rational (supposed less risk but still symptom relieving) for so-called bio-identical hormones. Bio-identical means that chemically the molecular structure of the estrogen you take (cream or pill form) is identical to the estrogen your ovaries make. Pharmaceutical companies aren’t really interested in making bio-identical HRT because it’s tough to patent.

If you mention bio-identical hormones to a GYN, they will probably denounce it as witchcraft akin to infrared. Part of it stems from long standing visits from drug reps over the years that their way is the only way to go because it comes from the big pharma system. Bio-identical hormones must be created by a compound pharmacy by prescription from your doctor. Each hormone can come in different forms and strengths depending the desire of the patient to take a pill, use cream or a patch and how she responds.

It’s not as simple as drawing blood and seeing a low estrogen level and Rxing estrogen like you’re filling up your tank at the gas station. Every woman is different and responds differently. If there is one thing that the ‘system’ and I agree on, it’s this. Start and stay with the lowest dose that alleviates the symptoms and use it for the shortest period of time. Don’t be on HRT for decades and decades of high doses of estrogen being prescribed automatically by your doctor because you feel good. In the horse, the major estrogen is estrone (about 50%) and equilin, a unique horse estrogen (about 25%). The estrone is sulfated (chemically) and changed into estradiol in the body. That’s why they are called CEEs (conjugated equine estrogen).

The question of any HRT is, does it act the same as your own estrogen? It’s not just taking an ‘estrogen pill’. What’s really in play here are the numerous metabolites and their various individual effect on the breast cells. Some reports say there are dozens of different estrogens in CEEs. In addition, what may help explain the effect of estrogen on breast cells are two different metabolites, one is 2-hydroxyestrone and the other is 16-alpha-hydroxyestrone. There are two estrogen receptors on the breast cells alpha and beta. Stimulation of the alpha receptor stimulates cellular proliferation and the beta receptors decrease cell division.

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2-hydroxyestrone doesn’t stimulate cells as much as the 16-hydroxy metabolite. Estrone and estradiol preferentially attach to the alpha receptor and estriol (E3) binds to the beta receptor. That may explain why some scientists think estriol is a protective estrogen.

While alpha and beta receptors are the primary receptors in the breast cells, there is another receptor of great importance called GPR 30. It drives cellular proliferation and has strong affinity for estrone and estadiol while again estriol is an antagonist toward GPR 30 thus again dialing down the proliferation rate. Remember, cancers still have the alpha and beta receptors and this is why if a woman has an ER+ tumor, we stop her estrogen because it’s driving the tumor. Also, Tamoxifen blocks the alpha and beta receptors and not necessarily the GPR 30 receptor so that may help explain the appearance of cancer after women have been on an anti-estrogen for a prolonged time.

A little history of CEEs is in order. They first came out for general use in the fifties but it wasn’t like every woman was on it since advertising wasn’t near what it is like today and ‘Big Pharma’ wasn’t in existence. It was just after WWII. It began to gain ground since it did what it was supposed to do - relieve hot flashes. Then in the 1970s there began to be noticed an increase in uterine cancer in women on estrogen alone. Clinical trials then showed that effect could be blocked by adding progesterone and then that combination took off. For a long time, the reader has to know that women were basically neglected in clinical trials in the early days. Even today only about 1% of cancer patients enter some form of clinical trial, but in the past, women have been basically summarily ignored in clinical trials, thus the lack of data.

It wasn’t until the results of the Women’s Health Initiative (WHI) which showed that the combination of estrogen and progesterone actually caused more heart disease and breast cancer and after those findings, HRT prescriptions took a nose dive. Now like in any large study, statisticians dissect every large trial and find numerous reasons why a certain finding isn’t reflective of the study and how it was conducted. The WHI began in 1991 and enrolled over 160,000 women aged 50-79 and results were published in January 2010. We won’t get into that except when the WHI came out; it wasn’t a stellar endorsement of HRT. Then prescriptions went down.

That caused some increased attention to bio-identical HRT because it mimicked the biochemical formula of a woman’s own estrogen. Another desirable thing about bio-identical HRT is that the ratios of estrogen to one another can be changed. Generally the horse urine pill has more estrone and estradiol and minor amounts of estriol in addition to equilin. Equilin is not present in bio-identical estrogen because it’s not from a horse. In writing a prescription for bio-identical HRT, we can in essence flip the ratios to a dominant amount of estriol and less estrone and estradiol. This discussion can go on and on. The main thing which I said at the onset is it’s of vital importance to know your genetic risk for breast cancer and then let that guide us for your personalized surveillance program.

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Just the general hint – stay on the lowest dose of whatever you’ve chosen (that does the trick) for the shortest period of time. Now we come to an even darker side, herbs/phytoestrogens. Nothing makes a straight laced GYN cringe more. These are plant estrogens and are much weaker than either CEE or bio-identical HRT but in some women that’s all they need.

Let’s face it, one of the reasons you’re here is that your grandmother’s generation, and extending all the way back to EVE, never had HRT yet somehow survived. You just have to ask yourself, why are you taking HRT? Is it solely for you heart and bones? If so, we have much better ways to manage those two issues. Or is it mood swings, night sweats, dry vagina, dry skin, hair falling out, incontinence and sense of wellbeing? It all depends on how much those symptoms are affecting you.

Remember I mentioned the one patient who had an ER+ breast cancer and we tried everything but nothing helped her except the horse urine pill. I prescribed it to her since she was literally suicidal. In all this discussion our job (as doctors I think) is not to say at the end, “There lies Mary, you know she never got breast cancer but every day she spent was miserable.” It’s a tradeoff. If a woman (knowing her risk) still wants HRT of whatever variety, we do it and provide accelerated imaging without radiation. Make sense?

Let’s look at phytoestrogens (coming from plants). If you go to any vitamin store, you’ll see them, Black Cohosh (Actaea Racemosa), Chaste Berry, Red Clover Tea, Primrose Oil, etc. You can purchase these things over the counter individually or in combination. There are probably twenty or so different products out there. The draw (hope) here is that because these mimic estrogen and are much weaker than your estrogen (and, therefore, won’t stimulate cellular proliferation), taking them alone or in combination will relieve the post-menopausal symptoms. Who might opt for these - perhaps a symptomatic woman with a strong family history of breast cancer, a personal history of breast cancer or genetically high risk women are candidates. My experience is that once you decide to give these a try, you should try a few to see which one works best if at all. Some women swear by Black Cohosh, some think it’s a waste of time.

Black Cohosh is a flowering plant that grows in Missouri and Arkansas. It is also called by other names, among them, black snake root which is probably why gynecologists are horrified.

Chaste Berry is again a flowering plant and its history for helping women dates back to about AD77 in the Naturalis Historia (Natural History) by Pliny the Elder. It is thought to be the oldest encyclopedia type books and one of the few to survive the Roman Empire. He reports that women of the day used to sleep on Chaste Berry to calm them. See, even back then women had these problems. Like Gilda Radner said, “It’s always something.”

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Lastly, over the years I’ve had some good luck with Zoloft (an anti-depressant). This drug helps elevate the mood and relieve hot flashes. Again, if we have gone for help elsewhere and not getting it and the symptoms are impacting your life then I think it’s worth a try. Behind all this is your diet and exercise program and how you’ve navigated life’s journey, that is, if you’re content and satisfied with your personal journey or are beside yourself with disillusionment. Diet is extremely important long term. We should all be on a low glycemic, anti-inflammatory, nutrient dense diet which means mostly cruciferous vegetables - the more organic vegetarian the better. See the Bretz Diet.

I am very annoyed by the incessant TV commercials about anti-depressants, that if you’re taking one anti-depressant and it’s not helping, the answer from ‘Big Pharma’ is take another. Then in the same breath it’s watch out for suicidal thoughts, diarrhea, allergic reaction, throat closing and death or the like. Then with all these medications, we just have to wait about five years after approval when the attorney commercials come out.

Instead of saying in the first place that maybe drugs aren’t the answer at all, maybe it’s just a matter of finding one’s self and examining one’s life and then trying to correct it without having to load up on pills. Some of you know I worked as a family physician over the past few years and I can say with some authority that resorting to ‘pills’ for the answer to every little thing isn’t the answer. Usually they just deaden the patient’s senses until they are almost like zombies. Because it doesn’t stop with an antidepressant, it generally includes an anti-anxiety medication and, of course, by that time in their lives they have either had chronic low back pain, a failed back surgery or pain in the knees requiring strong chronic narcotic pain pills. One person in the U.S. dies every nineteen minutes from an overdose of prescribed pain pills. It’s just not the road to go down. I think it’s important early on for people to adapt a course in life what will mean something when you look in the mirror.

IMPLANTS - There are different types of fillers but all the sacs are made out of a next generation medical grade silicone. The purpose is to augment (enlarge) the breast. Since they were invented, there has been a seemingly never ending journey to find the ideal implant, one that wouldn’t cause local or distant problems. There are basically two types available in the U.S., saline (salt water) and next generation silicone. Silicone was banned in the U.S. for several years because of the perceived side effects of the implants causing some types of immune disorder, everything from lupus to arthritis to difficulty swallowing. I believe it was alleged that babies were also affected. Those lawsuits basically did in Dow Chemical. Now the FDA allows placement of silicone implants. What are the merits of silicone vs. saline? Silicone has the feel of a natural breast. I have run across a few saline implants that feel like that but the majority of the saline implants ‘crinkle’ like the indentation you see on those 2 liter plastic bottles of soda when you pour the liquid out. Capsule formation is another thing that plagues implants. After spending a good deal of money one her implants, about a year or so later the breast begins to get very firm, sometimes like a league baseball. This can be a disaster of not only a hard breast but the capsule adheres to the muscles and pulls causing discomfort at times.

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There was a particular set of implants that I always felt had the best results and that was the double lumen. Those implants had a bag of silicone at the center surrounded by saline. They seemed to always feel natural and had less capsule formation. The only place to put implants as far as I’m concerned is behind the chest wall muscle. Why? Simple, not only can we see the breast tissue better with mammography but I think they’re stabilized better.

If the patient needs a biopsy down the line, implants behind the muscle are a safer bet in terms of possible injury during a stereotactic or open biopsy. Another issue is rupture of the implant or leak. If it’s saline, no harm no foul (the body just absorbs it). The patient just wakes up with a flat breast and just gets it replaced, no emergency. If it’s silicone, then it’s really tough to get all the free silicone out of there. It’s just impossible.

The other issue with capsule formation and the movement of the implant causing breast asymmetry (not hanging the same) is where the surgeon places the implants; that is either ahead of the pectorals muscle (pre-pectoral) or behind (retro glandular). Plastic surgeons like the pre-pectoral approach because it’s quicker and less painful. I much prefer they’re placed behind the muscle. There are several options available to actually get the implant placed. The first is the inframammary fold (where the bottom of the breast meets the skin from the upper abdomen. This incision can be fairly large allowing easier access for the surgeon and at the same time hidden.

Another place is an infra-areolar incision in the areola. While it can be seen, the areola is erectile tissue and usually hides it quite well. That is why I always try and go through the areola for any open biopsy. Two other places are through the axilla (armpit) and through the umbilicus (belly button) using a scope. Every surgeon has his favorite. I might add that in the decades I’ve handled these implant problems, I’ve only had one, perhaps two, patients who claimed to have some immune response to the silicone. I care for a number of patients who just didn’t sustain a leak of silicone but had hundreds of CCs of free silicone injected in their breasts in the 1960s (it was a fad for show girls). None of those patients has had any problems with their immune system. At the other end of the spectrum I’ve seen silicone bleed. That is, transmigration of the silicone through the sac wall (there is no gaping hole). The sacs are semi-permeable and small amounts (droplets) can migrate over time out of the sac into surrounding tissue. It’s not uncommon to have an intramammary lymph node (an errant node in the breast) have silicone in it from a silicone bleed. I suppose it’s like anything else. Some women are more allergic to silicone than others. There is no evidence in the literature that I’m aware of that implicates silicone or saline implants with the consistent development of cancer. Lastly, if you decide implants are for you, get them for the right reason and get at least two opinions.

INFRARED – Infrared is part of the electromagnetic spectrum going from radio waves to gamma rays. They are all different wave lengths and each wave pattern is made up of photons which are mass-less particles that travel at the speed of light in all directions.

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The spectrum ranges from radio waves to microwaves to infrared to the visible spectrum (what we see) to ultraviolet to x-rays and finally gamma rays. You can get a visual of different wave lengths when you look through a prism and see the different colors. On either side of the visual spectrum are the other wavelengths. Each range is subdivided into several shorter ranges like UHF or VHF. The different regions in the electromagnetic spectrum are defined by the amount of energy in each photon. Radio waves have the lowest and gamma rays have the most energy. X-rays and gamma rays are examples of ionizing radiation that can in harmful amounts kill or cause cancer. We are all familiar with microwave ovens. That electromagnetic energy applied to food excites and rotates the atoms in the food causing thermal heat and cooking. Infrared was discovered in 1800 by William Hershel who noted that temperatures varied in the visible spectrum and that beyond (color red) the temperature kept going up.

There are many uses for infrared ranging from military to medical to space telescopes. The technology in our infrared camera is modified military technology (declassified by President GW Bush). It is digital and is used in the military in night vision goggles, to infrared onboard F-16 to the THEL (tactical high energy laser).

I think that it is important for me to explain why I believe in this technology as part of the solution to the breast cancer problem. There was just a paper put out that looked at the rate of early breast cancer diagnosis and the cost involved from about 2002 to 2007. There was no difference in the rate of early diagnosis with newer technology and the cost to Medicare costs went from 666 million to over 960 million.

Apparently all the money that is being spent on digital mammography and CAD (computer aided diagnosis) isn’t working as planned. It took years to come to that conclusion, and in the face of the paper from Seattle Children’s Hospital last February about the rising incidence of metastatic breast cancer in younger women, isn’t it time the system looked at other possible technology? I think the answer is “yes”. Now ask any doctor (perhaps yours) about infrared (IR) and most likely they will either not know anything about it or they will say, “We tried that in the 70s and it didn’t work.” Virtually every one of them will not have seen our unit with the modified military application and the artificial intelligence combined. The only paper done on our unit (besides mine) is from Cornell University in New York that did the FDA clearance study. I don’t think they understood the technology very well and didn’t want to do any more research; they just wanted to do another paper and move on.

There is a very scathing article written by a gentleman named Clifton Leaf, March 22, 2004 in Fortune magazine. It’s about fifteen pages of his in-depth report on ‘Why we are losing the war on cancer.’ One of the things he says is research has become an end in itself and not a means to an end. That is, many researchers tend to go through their careers just doing day to day things and not really looking for a knockout blow. Just Google the paper name and it will come up. I think that’s what happens to many potential ‘cures’ that are on the front burner until the particular paper is completed and then they move onto the next topic, not stopping to see the big picture. I think that’s what happened to our technology.

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Further, since IR doesn’t fit into the big picture of surgery, radiation and chemotherapy, nobody wants to work with it. I’ll tell you, the military isn’t using IR because it doesn’t work. It works very, very well.

Our unit currently operates with a FLIR A40 IR camera. FLIR is a fortune 500 company that supplies virtually all the IR equipment for the military. The test doesn’t require any compression like a mammogram, doesn’t give you anything like radiation and lasts about four minutes. The unit has an 8000 BTU air conditioner that the patient sits about four feet from disrobed on top. Cool air is poured over the breast for four minutes giving time for the breast to get cold. Hot molecules try to go to cold molecules in an attempt to equilibrate the temperature that is, making everything the same temperature. Basically anything that produces heat like production of calcium, hormone flare, an inflamed cyst or developing cancer will show up. Everything has a heat signature from a piece of ice (that’s why it melts) to a developing cancer. The results are available immediately and the patient gets two scores, a personal score and a score compared to 500 patients that are in the computer that have cancer and an abnormal IR. It learns from itself with each study.

The machine can register heat coming from a developing cancer at 1.5mm in size. The smallest we have found is 4mm, probably because we are not doing thousands of scans. Please refer to the paper for specifics on our first 500 patients and why this technology should be pursued.

KYPHOPLASTY – This is a procedure performed to correct a compression fracture in the spine. It’s usually done in the radiology department of the hospital where the radiologist injects (under local anesthesia) a cement like substance after a balloon is placed in the compressed vertebra to restore its shape. The cement is actually a compound called polymethylmethacrylate (or PMMA), (drop that at a cocktail party and you’ll be a hit.) It’s akin to fixing a flat tire. They just pump the collapsed vertebral body up with the balloon and then place the cement to maintain the vertebra long term. To achieve the best results it must be done as soon as possible after the compression fracture. It won’t help chronic back pain from an old fracture. When a compression fracture happens a women can usually feel the crunch and then pain. Then it’s time to call the doctor. See osteoporosis.

LAVENDER PROCEDURE – Together with genetics, I believe The Lavender Procedure (today) is the culmination of millennia of trying to defeat breast cancer. During my career I have seen the evolution of treatment from very aggressive to now The Lavender Procedure unfold before my eyes. In my opinion The Lavender Procedure is about as good as it’s going to get. What is The Lavender Procedure? It is a twenty minute procedure done in the office setting not the hospital and done under local anesthesia using a cryogenic probe. The idea is to totally kill the breast cancer at this moment in time using liquid nitrogen. The probe allows liquid nitrogen to flow and when activated the probe produces a liquid nitrogen freeze ball.

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Liquid nitrogen (at -180C, -292F) is the second coldest thing in the universe, the coldest being liquid helium (-452F) which is used for instance at CERN to cool the magnets (the world’s largest particle accelerator in Geneva, Switzerland.) We control the size of the freeze ball. A good analogy is if you think of an umbrella with a golf ball under it and the tumor is the golf ball. The freeze ball totally engulfs the tumor for about 2cm (about an inch) on all sides. The probe is placed piercing the tumor (so the tip goes about 2cm beyond), under real time ultrasound guidance. Once properly placed the probe is activated and we can see the freeze ball grow. It goes through three cycles, a freeze, thaw, freeze each lasting about 6-8 minutes depending on how we want it. The thaw cycle is interposed because it changes the ECM (extra cellular matrix) and adds an additional killing power. Once the procedure is complete the probe is removed and not even a stitch is required. I have been putting a small dab of antibiotic gel at the entrance site of the probe but that’s it. The patient is done and resumes normal activity and I mean normal. And for some that includes a walk across the street to Lavender Bistro for a glass of wine or dinner, (thus the name Lavender Procedure).

The first time I performed this procedure I felt like I was walking on hallowed ground of what is to come globally. It was truly awe inspiring and even I (at first) had a hard time swallowing the concept (that I was actually killing the cancer), as it actually occurred before my eyes contrasting that to the years of aggressive surgery, chemotherapy and radiation.

The trick to all this is finding the cancer ultra-early at about 5mm or so and having the OncotypeDX render a low recurrence score. Then after in-depth consultation those patients who chose to undergo the Lavender Procedure should be home free, without surgery, chemotherapy or radiation. How’s that? It all depends on finding these cancers small with a low recurrence score (before it spreads/metastasizes) through the use of genetics, infrared or mammography etc.

Actually the procedure has been a family affair of sorts. One patient’s daughter who wanted to see the procedure couldn’t be there because of work and the patient gave her a description of what was happening step by step via her cell phone. Another patient’s husband I allowed in (after the probe was placed) to see the procedure and hold his wife’s hand. How cool is that? How does this make me feel? Personally I really like to have the upper hand on breast cancer for once and I like kicking it in the --- (sorry but that’s how I feel), before it can harm my patients. It’s a real rush to know we are doing this and the patient can just resume normal activity without a stitch. Now cryoablation (not with liquid nitrogen), has been around for decades but not used like this and our technique makes all the difference.

Contrast that to pre-op visits to the hospital, laborious interviews, endless forms, invasion of privacy, general anesthesia, and perhaps waking up in a cold recovery room with a tube in your throat, a big incision with possibly drains, and an arm and shoulder that hurt. As you try to awake from anesthesia your mind is swirling about what happened and the doctor isn’t there. It’s all over with The Lavender Procedure.

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You are referred to testimonials in the web-site of patients who have selflessly told their individual stories about their experiences with breast cancer and the Lavender Procedure. Also please see Surgical Options section at the web-site. Additionally, I am gratified to see the onset of IORT (Intraoperative Radiation). This is a procedure developed in Italy where the patient receives about 20 minutes of targeted radiation to the breast immediately following her lumpectomy during the same procedure. How can 20 minutes of radiation equate to the 6 weeks of radiation we traditionally were taught was the only way to do it? Almost like every other thing in breast cancer treatment from aggressive surgery to IORT the results are basically all the same. We were wrong to say that only aggressive therapies could save the patient. It just takes the cancer community decades to adapt if ever a new technology. Couple The Lavender Procedure with genetics any you begin to realize why I have the name Visionary Breast Center.

LESION – It refers to anything we are after on mammography, ultrasound needle biopsy or the like. Another word we use is target. The word lesion is sometimes used in radiology reports and scares people but it really means the target we are after.

LYMPHAZURIN DYE – Also known as isosulfan dye, is the dye the surgeon can use to detect the sentinel lymph node. I usually use .4ml (small amount) injected just around the areola. If I do it just before the patient is taken into the operating room, by the time I make the first incision, the dye is up to the sentinel node which looks like a blue ornament on a Christmas Tree. The rest of the fat pad is yellow. The only problem is that dye sometimes stains (or tattoos) a small dot of dye at the injection site which can stay for a long period, a year or more. Using the dye technique is one of two methods surgeons can use.

The other is using radioactive material called Technetium 99m sulfur colloid. This is injected by the radiologist down in nuclear medicine at the hospital. The surgeon uses a kind of Geiger counter in the OR to see which node is hot. Some institutions use both techniques. I only use the dye since it has worked very well for many years and doesn’t expose my patients to unnecessary radioactive material.

LYMPH NODES - Lymph nodes are located throughout the body and more concentrated in some areas like the neck, axilla, groin and abdomen. There are hundreds and hundreds of them. They are part of the Lymphatic System along with the spleen, tonsils and lymphatic vessels. The lymphatic vessels drain into the circulation system at different locations in the body depending on what areas they drain. Lymph from the lower body and abdomen is collected in the thoracic duct also known as Van Hoorne’s duct.

The thoracic duct arises along the second lumbar vertebra and runs along the abdominal aorta (largest blood vessel in the body) and empties into the left subclavian vein. There is also a right lymphatic duct that drains lymph from the right side of the body into the right subclavian vein. It collects lymph all along the way.

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There are three different drainage routes of the breast. Lymphatic drainage and all breast tissue itself originates from Sappey’s plexus, a small bud of tissue that forms embryonically just behind the nipple. There is the so called lateral or pectoral group of vessels and nodes that drain about 85% of breast tissue and along the lateral border of the pectoralis muscle into the pectoral group of axillary nodes of first level that extends to the border of the pectoralis minor muscle. The second way is the internal mammary pathway.

These lymph vessels originate in the medial and lateral parts of the breast and drain in to the internal mammary node chain. This also allows for lymph from either breast to drain into the other. The last pathway is the retromammary that collects lymph from the posterior parts of the breast. See (anatomy).

Lymph nodes can be very small like half the size of a pea or large like a plum if there is tumor in it. Lymph nodes are dotted along lymphatic vessels that collect interstitial fluid on the body and this becomes lymph. The word lymph was taken from the Roman deity of fresh water called Lympha. Mostly nodes are the size of a small lima bean and have an afferent (leading to) and an efferent (leading away) duct so all the lymphatic fluid passes through the nodes. In the nodes the lymphatic fluid is filtered and checked for bacteria, cancer etc. All lymph nodes are part of the immune system and thus produce T and B lymphocytes that are involved with fighting infection and cancer. Antigens that are produced by say a bacteria enter into the lymph system and then to the nodes where the lymphocytes recognize them as foreign and produce antibodies to kill the bacteria or send NK cells (natural killer cells) to kill the cancer. Lymph nodes have long been harvested to help determine staging of the cancer. The more nodes involved, the worse the prognosis generally but not always. There is a recent monograph that showed very low recurrence even for patients with four or more nodes involved. How’s that? It’s genetics, of course.

More research is focusing on this aspect now. The other thing is that tumor spread is not just confined to the lymphatic system. It goes through the blood stream and by direct extension. In my years of practice I’ve seen a number of patients with negative nodes who end up with metastatic disease later on, probably because of the blood stream. That’s why now we look at the entire spectrum from family/personal history, tumor markers, pathology and genetics. This then gives us a very good idea as to whether this tumor has potential to have spread albeit not through the nodes. Lymphedema (swelling of the arm) results from an ALND (axillary lymph node dissection). Sentinel node obviates that problem.

LUMPECTOMY – This is a surgical procedure done in the operating room. There the surgeon makes an incision on the breast skin and removes the breast tumor and a margin of normal tissue around the tumor. It’s basically a glorified breast biopsy. It can be done under general anesthesia or local anesthesia with IV sedation as the situation dictates. Sometimes for tumors that can’t be felt, the surgeon has the patient undergo pre-op needle localization. This is a procedure done immediately before the surgery usually carried out in the mammography center.

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While the name implies a needle, the needle is only there to introduce a localization wire that identifies on mammography the location of an occult lesion. The wire has a hook so the wire doesn’t move, a collar and a tail so the surgeon can know exactly where the target is. Rarely a piece of the wire is retained in the breast for some reason. Nothing really happens to it. It is inert and is just seen on subsequent mammograms.

If that happens, it is usually the hook portion. It could be argued that the piece actually identifies the site of the actual biopsy and therefore serves some purpose. Over the course of thirty years, it has happened to me a couple of times. You can’t see that little tip once it breaks off so we just leave it instead of trying to excavate more and more tissue and damage the cosmetic result. I always do a cosmetic lumpectomy to the best of my ability.

MAMMOGRAPHY – Mammography uses low dose radiation to detect breast cancers and other breast pathology. The first recorded use of radiation to do so was by a German surgeon named Albert Salomon. As usual, it took over fifty years for mammography to catch on. The actual term mammography didn’t come into vogue until the 1970s. There were two large studies here in the 70s, one in the U.S. called the Health Insurance Plan (HIP) and the other was by a Swedish radiologist named Laslo Tabar. They studied over 130,000 women and found that indeed screening mammography did lower mortality rates from breast cancer. The first films were taken on a selenium plate and were blue in color. Those are the ones I cut my teeth on. Then in the mid-1980s, plain film came out. It showed the breast in black and white. Then in the 1990s digital film came out followed by CAD (computer aided diagnosis) and now 3-D (or tomosynthesis) and another technique to look at very dense breasts.

Back when I first got a mammogram machine 1988, there were basically no guidelines. Now multiple agencies, Federal (FDA), state and private (American College of Radiology) make sure through MQSA standards that every facility doing mammography turns out very good films. There are basically two types of mammograms, screening and diagnostic. Screening is meant for asymptomatic women and consist of two views of each breast, a CC view (craino-caudal or up and down) and lateral (taken from the side). A diagnostic mammogram is done when the patient is referred in for a problem, i.e. a lump or the like. During a diagnostic mammogram so-called special views are taken which might include compression or magnification views to get a better look at a particular spot. Of course, each time a film is taken, the breast is absorbing that radiation in a concentrated area.

There is continual debate about the notion that mammography saves lives. You can get support for your chosen stance on either side of the issue in multiple places in the literature. The issue really is not that mammography saves lives, it’s more how many lives does it actually save. In 2013 the Cochrane Collaboration (a non-profit group from the UK) concluded that screening mammography had no effect on breast cancer mortality. They concluded that for every 2000 women invited for screening throughout 10 years, one would be saved and 10 would undergo unnecessary treatment and 200 would have severe psychological impact from the process.

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Further, they say that for women, who are seemingly diagnosed by mammography before there is a lump, feel like (and probably their doctor) that the mammogram saved her life. However, for this scenario the group says it’s not the mammogram that saved her life. It revolves around what the group says are four types of breast cancer found on mammography where mammography hardly makes any difference and they are 1) cancers that are easily treated where a later diagnosis would achieve the same result, 2) cancers that are too aggressive and, therefore, mammography just makes the diagnosis but doesn’t prolong survival, 3) cancers that would have receded on their own or grown so slowly a woman would die from something else and 4) there is a very small number of women whose lives are actually saved by early diagnosis on mammography perhaps 1 out of 2000.

The problem with this is you don’t know if you’re the one out of 2000 assuming they’re right. Those statements by the Cochran Collaboration Group are simplistic in terms of human endeavors and needs. Those doctors who treat cancer are always looking for an edge no matter how small that might make a difference in saving a life. If we as doctors back off the quest to find a lifesaving diagnosis, that essentially one woman out of 2000 doesn’t matter, then we as a society are on a slippery slope to rationed care where we just let people die. Are we there yet? Some say we are with current policies of delayed and denied care. So even in the worst case scenario that mammography doesn’t work all that well, I say it does work, I’ve seen it work thousands of times and I’m not ready to pull the plug. Again assuming the Cochran Group is correct, we don’t know where each individual falls in those four categories so we hedge our bet. That is another reason we use multiple diagnostic modalities without radiation to give us a further edge. When a woman has put her trust in you to make that early diagnosis and you’re the one responsible for a woman’s life, you want to exercise all the options to make sure she’s cancer free.

A problem not covered by the Cochran Group (as is typical of these lay groups that make pronouncements that aren’t doctors or who have doctors that don’t diagnose and treat breast cancer) is that making an ultra-early diagnosis in 2014 makes a huge difference in treatment from the old days of radical mastectomy to a 20 minute cryoablation procedure in the office without a single stitch. Always in these situations you have to take time to look at all the angles, not just the ones the authors want you to read.

Getting back to mammography, generally on mammography we only see two things, white stuff and dark stuff. All the white stuff is breast tissue per say – milk ducts, glands, supporting tissue (Cooper’s ligaments), calcium, blood vessels, lymph nodes all show up as white and all the dark stuff is fat. We also look for asymmetry in the breast tissue that could be a sign of an evolving breast cancer. It’s also very important to review the previous year’s films to look for changes. There is a standard classification called BI-RADS (Breast Imaging Reporting and Data System) that everyone uses. It has 6 categories. BI-RADS 0 - means that the radiologist would like further studies such as extra views or ultrasound etc.

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BI-RADS 1 – negative (very few mammograms come back BI-RADS 1 since there is always something it seems to see, BI-RADS – 2 a benign finding (although technically speaking only a pathologist can make that diagnosis, radiologist do it all the time), and the report says return in a year. BI-RADS – 3 probably benign and warrants a repeat mammogram in six months. I don’t like this last category since breast cancer can just sit there for up to three years on mammography depending on the proliferation rate (how fast it’s dividing).

Then if it proves cancer six months or a year down the line, it was cancer when first seen and before that. So I am in the camp that if there is something that warrants a six month follow up, I would just core biopsy it and put it to bed. BI-RADS 4 a suspicious abnormality is noted and biopsy should be considered. BI-RADS 4 is further divided in a,b, and c if there is low, moderate or high suspicion, next is BI-RADS 5 – highly suspicious of cancer and BI-RADS 6 – is a known cancer like they would see on mammogram after neo-adjuvant chemotherapy to determine the downsizing of the tumor.

Because of new laws the radiologist must include whether the breast is composed mostly of fat, scattered fibroglandular tissue, heterogeneously dense or extremely dense. This is so since the denser the breast tissue is (the white stuff) the more the false negative rate goes up. It is generally quoted at about 10%. However, there is a recent finding from three major centers that did a study for 36,000 diagnostic mammograms read by 123 certified radiologists and the false negative rate was 20%. In my study of infrared on the first 500 patients, the false negative rate for mammography was 24% in keeping with previous results. Another problem is the false positive rate which, until things are sorted out the women think they have breast cancer. The Susan Koman Foundation put out some numbers that over a ten year period the false positive rate is between 50-60% meaning that it’s a flip of the coin if your number is coming up for an extensive workup to determine if a lesion is benign or malignant.

Since these work-up usually take days or weeks to accomplish, until the verdict is in it produces high anxiety. This is so since many of these so-called comprehensive centers, even if they see something on mammography, the patient never actually sees the doctor that can take her to the next step. At Visionary Breast Centers there is no delay. You actually see the doctor who can help you understand your films, make the diagnosis and plan and explain any treatment. That’s part of the reason at Visionary Breast Centers we rely on genetics, infrared, ultrasound and Halo etc. We can individualize care without using radiation to get to the answer quicker. Another issue with mammography as we have noted is radiation is cumulative. Some women have had mammography every six months for three years or more. When does this stop? This is a real problem as radiologists generally don’t see every patient. They don’t necessarily know how much radiation a particular woman has had. They just look at the film and make a call for additional views. It’s a problem that newer technology such as modified military digital infrared could help if given a chance. Infrared has no radiation. It just registers a heat signature coming from the breast.

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When should a woman start mammography? When should she stop? There are new guidelines Federal and State which I ignore since I feel they ae not in the best interest of women. The State of California swiftly adopted the new Federal guidelines established a few years ago. Basically it says that if the Feds or the State is paying for your mammogram (Medi-Cal), you won’t start until age 50 and then every other year. Well, there ensues a moral dilemma. How? If you are a young African American woman, the literature is replete with emphasizing that African American women tend to get breast cancer much earlier and is more aggressive, the so-called triple negative breast cancer. In fact, there was a paper by the American College of Surgeons Oncology group in 2009 that to date was the largest look at African American women and breast cancer. One of the take home messages was that African American women, should consider starting mammography at age 30 because of them getting this aggressive breast cancer. If African American started to do mammography at age 30 with most likely very dense tissue, it would lead to a ton of false positive and false negative results. Again, this is where technology that doesn’t use radiation and could help, including genetics, if it was universally used.

How do the Feds and various states reconcile this issue without finding innovative ways of stopping this killer? Mammography is like anything else, in the right hands and with good equipment, it works very well.

There are two last things that have come to light. A California senator has introduced a Federal bill (July 2014) to make it mandatory that all mammogram reports tell the patient if she has dense tissue or not. The patient should discuss with her physician as to whether she should undergo further testing since dense tissue is associated with both false negative interpretation and a higher risk of breast cancer. I have no problem with that but it’s another area where the doctors have lost control. Even today in 2014 most women undergoing mammography don’t get a chance to see their mammograms or teaching mammograms or have a chance to discuss it right then and there.

That’s why at Visionary Breast Centers, in addition to seeing your own films and having the opportunity to ask questions, we have several teaching films to bring about better understanding. The Federal bill is fine as far as it goes. It’s politics as usual. It leaves the woman to go to her physician (after another month wait for an appointment) who probably doesn’t know the nuances of mammography. In fact since 1988, I have never had a family doctor come in and actually sit down with me so I can explain things. If there is a perceived problem that a woman will have to deal with the rest of her life (like dense tissue requiring endless special views every year), then the comprehensive breast center should sit down with her and outline a surveillance plan. That’s not what happens but it does at VBC.

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Another big problem with the bill is it heaps more paper work on the doctors but leaves out the insurance companies who don’t alter their recommendations for reimbursement. The bill should go on to read, ‘and insurance companies are required to cover additional testing (i.e. ultrasound and or MRI) for women deemed to have dense tissue on mammogram and reimburse the doctors for the extra time required. Neither of those occurred or will occur. If the woman is rightly concerned and wants another test, then that leaves the doctor with the task of arguing with the insurance company to get the test approved. From personal experience that takes another 20 minutes on the phone, usually with a negative result. It seems at first glance, ‘Well that’s his job.’ But if you multiple that 20 minutes by perhaps three or four patients a day, you begin to see why doctors are just burned out not being able to provide the care they deem necessary.

Now comes another disturbing part of the ‘system.’ Yale University researchers just published in July 2014 research into changes in early detection of breast cancer implementing new technologies like CAD and digital screening. They also looked at the cost burden of all these. Since 2002 they found NO increase in early detection of breast cancer while the cost has skyrocketed for Medicare from 666 million to 962 million dollars. This is another reason why I feel VBC is on the right track using multiple, low cost modalities without radiation as an adjunct to mammography. See, it just isn’t coming in for a mammogram, is it?

With womens’ lives hanging in the balance, how come this hasn’t been worked out years ago for optimal treatment? Thus the reason for VBC.

MASS – This is a lump that the patient may or may not feel (visible only on mammogram/ ultrasound/MRI or the like) that requires investigation and perhaps some sort of biopsy.

MASTECTOMY – It is basically the surgical removal of the entire breast. There are various types - extended radical mastectomy (includes removal of the breast, all chest muscles, all lymph nodes including intermammary below the sternum (breast bone) and nodes above the clavicle (collarbone), radical mastectomy (removal of the entire breast and chest wall muscles with less extensive lymph node removal), modified radical mastectomy (removal of the breast and axillary lymph nodes leaving the chest wall muscles intact), simple mastectomy (removal of just the breast, no muscles and theoretically no nodes), skin sparing mastectomy (it’s really a subcutaneous mastectomy where most of the breast tissue is removed leaving the skin, areola and nipple), oncoplastic mastectomy (a relatively new procedure dreamed up by general surgeons to do breast reconstruction (without the plastic surgeon) doing tissue expanders, reductions and implants

MENOPAUSE – Technically it’s the secession of any menstrual cycles for a period of a year. This can occur in women in their late thirties, not necessarily just women around 50 years of age. The time before that involves irregular occurring cycles is called peri-menopause. (See hot flashes!) The question is how bad are the symptoms, what detrimental physiologic effects are in play as a result, what do we do about it and what risk does that impose? See Hot Flashes.

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METASTASIS - This is the process by which cancers spreads to distant organs. There are about seven steps a developing cancer must go through to be able to spread (metastasize). These were dealt with in some detail on page three of ‘surgical options’ section. Metastasis is one of the hallmarks of cancer along with its uncontrolled cell proliferation, ability to invade surrounding tissue and develop angiogenesis (new blood vessel formation).

MONOCLONIAL ABIOBODY – The immune system in general can be so complicated that only the people actually working day to day in the lab really understand the intricacies associated with anti-body production. We will try and keep it to an understandable level here. First, antibodies (a name coined by Paul Ehrlich around 1908) are part of our immune system. They are produced by specialized white blood cells called plasma cells and are of two types, B and T cell antibodies. The B-cell antibody is bound to the surface of the plasma cell designed to recognize antigens (produced by invading bacteria or viruses). B cells are also responsible at recognizing antigens from a long ago infection so you carry some immunity to recurrent infections. T-cells are antibodies that are produced in the Thymus gland. Antibodies are Y shaped proteins. At the end of the Y is a specialized structure called a paratope. This can be thought of as a kind of lock. The antigen has a specific focus on it called an epitope which is like a key that fits into the lock (paratope) and the harmful bacteria is then killed off. Antibodies are part of the humeral immune response. The other immune response is called cell mediated. The humeral response creates antibodies and the cell mediated has cells like phagocytes and NKcells (natural killer cells) that don’t need antibody activation to kill an invader.

Monoclonal antibodies are manmade. They are commonly made from taking a myloma cell that can’t produce an antibody and taking cells from an infected mouse spleen. Monoclonal antibodies are called that because they are all made from the same parent cell. For our purpose the most recognizable monoclonal antibody is Trastuzumab (Herceptin). Herceptin recognizes the HER2/NEU receptor on the cancer cell and binds to it.

The HER2 receptor occurs in about 20-30% of all breast cancers. The HER2 protein is like a signaling center for the cancer cell. It can communicate with growth factors outside the cell like EGF (epidermal growth factor) and also it communicates to genes inside the cell to regulate proliferation (cell division). That’s important because the consequence of Herceptin is it binds with p27, a protein that shuts down cancer cell proliferation and the cells die. This is the so called, ‘magic bullet’ because unlike regular chemotherapy that kills off good and bad cells, Herceptin only targets the HER2 protein on the cancer cell making in turn the side effects much, much less. We have to be careful with patients who have heart disease since Herceptin adversely affects the heart in about 5% of cases. Herceptin is an infusion into the vein about every three weeks and is generally taken for about a year. Recent research is combining Herceptin with another drug (Emtansine), a situation called a conjugate, to achieve better results.

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MRI – Magnetic Resonance Imaging came into being in the 1970s for actual use in hospitals. While it uses no ionizing radiation as in mammography, it still poses potential threats to the patient with cochlear implants, pacemakers and shrapnel. Since MRI depends on a super magnet, any potential metal objects that could fly through the air during the exam are prohibited. The units are very expensive. Just to construct an MRI room is over $200,000 and typically they cost about 1.5-2 million with lifetime about the same. The basis for the exam is that it depends on detecting different radio frequency emitted from excited hydrogen atoms in the body as a result of oscillating magnetic fields which turn on and off at different frequencies.

A problem with MRI is the false positives. It is very sensitive and can routinely pick up lesions at about 4-5mm. However, if one of those small masses at 4mm doesn’t have a blood supply, MRI has a hard time differentiating a benign from a malignant lesion. What I don’t like then is the usual sentence at the end of the report saying to repeat the study in six months. It’s hard to do with insurance companies. Thirty years ago I could just order an MRI. No more. MRIs have also contributed to an increase in mastectomies because of suspected multifocal disease. The NCI (National Cancer Institute) conducted a trial called ACRIN 6666 and it looked at ultrasound and mammography with the addition of MRI. While the addition of MRI found more cancers, all the cancers found via mammography and ultrasound were node negative so there was a question as to the MRI being worth it. The false positive rate in a University of Vermont study approached 20%.

By using contrast, usually a substance called gadolinium, there is better imaging of targets and whether the lesion is malignant or not. The problem is that gadolinium adversely affects the kidneys and may cause renal failure. There are several hundred lawsuits for this very reason. Before every MRI where contrast is needed, a patient’s BUN and creatinine should be measured to document normal kidney function.

A few years ago there was a push that every woman who has breast cancer should have MRI to look at the opposite breast as well. My question has always been before we were using MRI like water, where are all these contralateral cancers or for that matter where is all this multifocal disease that should have cropped up before the push for MRI began?

How is it that we don’t have an epidemic of contralateral cancers and cancers growing all over in the same breast? This is especially true with treatment modalities like APBI, IORT or cryoablation. I just don’t see all these cancers materializing. As with mammography when used properly, MRI is a very good tool. With these more sophisticated modalities, it really requires a radiologist who just reads MRIs. Also, MRI is very good at looking at implants as to whether they have leaked or not.

MULTICENTRIC BREAST CANCER – Cancer occurring in two separate areas in different quadrants of the breast. (See below for multifocal disease.) Interestingly, I had a patient years ago who had multicentric disease, one in the inferior aspect of the breast and another cancer in the superior aspect. Both tumors were about 1.5cm.

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I was able to save her breast via two separate lumpectomies. She did very well and had no further problems with the breast. As years went by, however, she developed Alzheimer’s and couldn’t remember my name. It’s always something.

MULTIFOCAL BREAST CANCER – This term is used a lot especially with MRI along with the term multicentric. Each has a different meaning. Multifocal breast cancer is breast cancer occurring at two different locations in the same breast quadrant. Multicentric breast cancer is cancer that occurs in two different locations in different breast quadrants. Remember, the breast can be divided by drawing cross-hairs into an upper inner, upper outer, lower inner and lower outer quadrants. The upper outer quadrant is where about 50% of all cancers occur, but we look at all of them closely every time!

NEEDLE LOCALIZATION – This is a procedure done just before surgery to identify a small target in the breast that is to be removed. It is done in the mammography unit and under local anesthesia and it’s actually a wire that is left in place as close to the target as possible. The wire has a hook (which stabilizes it) a collar and a tail. For malignant tumors, the surgeon really doesn’t want to see the tumor at all. So when they come upon the wire, they know exactly where the tumor is in relation to either the hook, collar or tail and are able to go around it in a manner to remove the tumor on the first attempt with normal tissue around it as in clear or negative margins. Very rarely, because of one thing or another, the hook breaks off and is left in the breast. It’s almost impossible to remove without another surgery and it doesn’t cause any harm. It could be argued that leaving that little piece of hook in there identifies the biopsy site which may help prevent another biopsy down the line.

NIPPLE – This is the part of the breast where the baby latches onto to receive milk produced by the lobules in the breast. It is the raised portion in the center of the areola. It receives the ducts from each lobe amounting to about 15 or more so the opening in the nipple is like a sieve. Each duct dilates just before it enters the nipple in what is called a lactiferous duct. They are normally not visible but can become so if there is a tumor developing causing nipple discharge. The nipples have small smooth muscle that causes the nipple to become erect. The nipple can normally be different colors from pink to brown. The nipple is also the sight of a particular kind of breast cancer called Paget’s Disease. This is where the nipple becomes involved, inflamed and retracted.

NIPPLE DISCHARGE – This refers to any fluid coming out of the nipple when it shouldn’t. It is normal obviously to have milk (preceded by colostrum) just post-partum. However, nipple discharge without a pregnancy should be investigated. It can be innocent from fibrocystic changes in the breast to being caused by drugs of which marijuana is an example. If the nipple discharge is bilateral we look elsewhere for the cause such as a pituitary tumor. This is called a pituitary adenoma and if symptomatic can be dealt with surgically. For bilateral discharge we run lab tests, like serum prolactin.

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Prolactin is one of two hormones responsible for milk production, the other is oxytocin. A mammogram is also in order and here at VBC we would carry out infrared and ultrasound. If the prolactin level is up, a CTof the head is ordered. We can also do analysis of the discharge by placing the discharge on a slide and sending it to the pathologist. This is a cytology specimen. For unilateral discharge we try to carry out a ductogram in addition to the above. We can gently dilate up the offending individual duct (and inject contrast material) using magnification glasses and a tiny syringe and many times identify the source of the discharge. Alternatively we can use the HALO device. This device circulates warm water around the nipple for three minutes, then the last two minutes it provides a gentle section and can suck out a spectrum of abnormal cells from atypia to cancer cells without actually doing an invasive biopsy.

There are various colors associated with nipple discharge, clear to various shades of green/gray and bloody. While bloody discharge is very alarming by sight, the most common reason for bloody discharge is an intraductal papilloma. This is a benign tumor (not cancer) that looks like a little raspberry and grows inside the ducts. They can get large. Green/gray shades of discharge are most likely associated with fibrocystic condition. Of the very few times I’ve diagnosed breast cancer on nipple discharge, it’s been clear. If we can identify the cause it makes it easier at surgery to get the target out. Sometime these things are not visible on mammography or ultrasound and only on ductogram. But that tells us pretty much where it is so we can make a reasonable attempt at removal without needle localization.

NEO-ADJUVANT CHEMOTHERAPY - This refers to chemotherapy given before any surgery. It is also called primary chemotherapy. It was first introduced around 1982 by the Tumor Institute of Milan in Italy and later by the NSABP in the U.S. via clinical trial B-18 which we participated in.

While giving chemotherapy pre or post op made no difference in survival, it made a big difference in down staging patients from mastectomy to lumpectomy. Over the years other trials have confirmed that if a patient receives neo-adjuvant (also known as primary chemotherapy), 80% of the time there will be a 50% reduction in tumor size and about 30% of the time there will be a complete response meaning it just disappears. This was the spring board to our first published series of patients with rather large invasive breast cancer that were treated with neo-adjuvant chemotherapy and radiation and never had surgery. That abstract was published in 1997 in ASCO American Society of Clinical Oncology (the largest oncology organization in the country). Incidentally, all those patients are alive eighteen years after.

N.S.A.B.P. – (National Surgical Adjuvant Breast Project) – This is the largest breast cancer research group in the world with some 500 plus centers. I was the Principal Investigator at Eisenhower Memorial Hospital with NSABP for about twenty years and I brought them to the valley to start clinical trials here in 1989. Together with other doctors we pioneered breast cancer clinical trials here in the desert and participated in many trials over the years.

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Our association with them enabled us to go beyond cutting edge treatment like treating invasive breast cancer without surgery (back in 1997), just chemotherapy and radiation. Every one of those patients is alive and well. In fact, we just treated one of those patients who had a local recurrence after some seventeen years with cryoablation. We learned a lot from participating in those trials.

NUCLEOBASE – There are four in DNA, Adenine, Guanine, Thymine and Cytosine. There is one more nucleobase (Urasil) but we find it in RNA (in decoding processes such as in messenger RNA). Nucleobases result from purine metabolism. A purine is a heterocyclic aromatic organic compound. It consists of a nitrogen based pyrimidine ring fused to an imidazole ring. Necleobases bond with pentose sugars and a phosphate group to form the DNA molecule. The DNA molecule is typically 3 billion base pairs long. Again, it depends on how those four nucleobases line up A-T, G-C and combinations of them that make up the 46 chromosomes and mostly determines everything about you.

ONCOTYPE DX – This is a genetic test by Genomic Health and is done on a piece of tumor. Once analyzed it provides the surgeon and oncologist with a recurrence score for distance metastasis. Essentially it was meant for women who have an ER+ node negative tumor who traditionally would have been spared chemotherapy. However, cancer can spread elsewhere than the sentinel node, i.e., through other lymphatics in the breast or via the blood stream. Initially it was meant for invasive breast cancer, however, now it has been cleared for DCIS as well. The cost is over $3,000 and some insurance companies won’t cover it.

You can almost throw out all we have learned traditionally about any predictive nature of tumors based on pathology like mitosis, grade, architecture, size, invasion, even number of nodes. It’s all upside down now that these new genetic tests have come out. I think they’re the real deal. How long will it take the system to recognize the scope of the genome and its impact? Too long, I fear.

There is a new medical journal just published called GENOME. To paraphrase the editor, the wonder the Genome holds in potential for diagnosis and treatment of cancer was overshadowed by the lack of intellectual and logistic preparedness of the medical community outside major centers. The trouble is that doctors are more concerned with staying in practice now (or just leaving) and those that stay will find it hard to abandon old ways of how we decided to give chemotherapy and make other diagnostic and treatment calls. The system has nothing at its disposal to rapidly integrate these kinds of wondrous advancements. So in practical terms if I am faced with a breast cancer, if the ONCOTYPE DX recurrence score is low and the tumor is relatively small, then I believe cryoablation is the best option. While the goal of the Lavender Procedure is to kill the cancer in the twenty minutes and have the patient resume normal activity (be it a trip to Lavender Bistro or not), scott free as it were, the procedure doesn’t preclude sentinel node biopsy or the like.

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OPEN BIOPSY – This is usually carried out in the operating room under either local or general anesthesia. There are two types, either an incisional or excisional biopsy. An incisional biopsy only takes a piece of the target. The surgeon might do this with large tumors that would then require neoadjuvant chemotherapy to shrink the tumor. An excisional biopsy removes the entire mass. If you think of a biopsy as a piece of pie, an incisional biopsy is like taking a piece of the pie but most of the pie is still there. An excisional biopsy is taking the entire pie as in a lumpectomy with normal tissue around the tumor. To reintegrate, any kind of needle biopsy wither FNA or core usually gives us the information so an open biopsy isn’t necessary. The caveat is this. In order to do any needle biopsy one has to have a legitimate target that you can guide the needle into either free hand or guided by say ultrasound.

OSTEOPENIA - This condition of the bone is defined as bone loss but not enough to call it osteoporosis. We diagnose it with a DXA test (See DXA). On the DXA results are diagnosed with a T-score of -1 to -2.5. Anything more negative than -2.5 is termed osteoporosis (see below). Bone loss isn’t something that takes place overnight (like appendicitis.) It takes decades of silent neglect. I say silent because usually the first sign of weak bone is a fracture. This downward slide is accelerated in women just after menopause where without support, a woman usually loses upwards of 30% of her bone mass three years after the start of menopause, then it really slows down but the bone loss continues until fracture develops if nothing is done to prevent that process. See treatment below.

OSTEOPOROSIS – This is thinning of the bone. It starts at the micro-architectural level. We’ve all see the little old ladies bent over with Dowager’s Hump. We have been dealing with osteoporosis (even though we didn’t know it) for thousands of years but only relatively recently have had some help with medication as well as an understanding of the physiology involved in maintaining bone density. The big concern about osteoporosis is hip fracture. Women in their 80s who fall and break a hip have a big problem. About 50% of them end up in a wheel chair and 20% die in the first year following the fracture. They go from being completely independent to someone having to change their diapers in a heartbeat. You know that commercial about, ‘I’ve fallen and I can’t get up?’ That’s what happens. It happened to my mother and mother-in-law. So what’s the best way to avoid osteoporosis? Like everything else it seems it goes back to diet and weight bearing exercise early on. In addition, I believe most doctors are now tuned into the benefits of Vitamin D, calcium and prevention with weight bearing exercise.

Throughout a woman’s life there is a constant turnover of bone. In fact you get a new skeleton about every six years, just like you get a new blood supply every 120 days or so. If proper nutrition and exercise are being followed (early on), there is an orchestrated harmony the takes place at a microscopic level in the bone called ‘turn over’. That is, there are cells that make new bone called an ‘osteoblast’ and cells that recognize fatigued bone and remove (resorb) it called an ‘osteoclast’.

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There are signaling pathways (just like everything else at a molecular level) that governs where these cells go. At any one time about 10% of the bone is being worked on. It is the microarchitecture of the bone that is most concerning and keeping it healthy. Up until the mid-nineties we had no real answer for osteoporosis and limited understanding of prevention and treatment. There are about 700,000 spine (vertebral) fractures a year, about 250,000 hip fractures and about 250,000 wrist fractures as a result of a fall or fragility fractures where the patient just gets up and the bone breaks. Osteoporosis treatment has evolved over the years from nothing to having about six different medications, exercise, Vitamin D and calcium. Weight bearing exercise is the mainstay. This is very important especially if you are Asian and or weigh 120 or less.

For those who can, it’s probably a good idea to go to a gym and temporarily hire a trainer to show you weight lifting techniques so you don’t injure yourself. Diet also goes a long way toward a healthy body. You are what you eat. You want a very holsum environment for your cells to grow and work in. Please look at the Bretz diet. Supplements taken daily include Vitamin D3. I recommend 5000IU (International Units) daily. This comes in one pill, capsule or drops daily. Also, along the way you should have your Vitamin D level checked. About 85% of people are shown to be Vitamin D deficient. We are starting to maintain a working list of benefits of taking daily Vitamin D. Generally the literature points to higher levels of Vitamin D are is helping to prevent many forms of cancer, but it does many other things that help the body work right. Calcium should be taken daily after your calcium level is checked. Generally it’s around 1000mg daily in divided doses. Calcium comes in multiple forms. A big problem with calcium is constipation. Some people don’t have any problem so pills are ok, but some people would do better with liquid calcium or chocolate chews. The body only absorbs about 600mg at a time so taking your entire calcium allotment at once is wasting it. Also calcium carbonate is the hardest on the GI tract while calcium citrate is gentler. There are various concoctions on the market and generally they are good also. It’s like everything else. The supplements don’t do you any good in the bottle. You have to be disciplined enough to take them religiously. Like any supplement, calcium, etc., should be taken with a meal. The more digestive juices out there, the more is absorbed.

Medications came around the late nineties and range from a daily pill to weekly to monthly to every six months and once a yearly infusion. The names of the drugs I use are Fosamax, Actonel, Evista, Prolia, Reclast and Forteo. We will explore them briefly.

The pros and cons of all those are beyond the scope of this work but can be discussed with you at your visit. I will say though that with the class of drugs called Bisphosphonates (like Fosamax and Actonel) early on we had some major problems with GI distress including bleeding. Now we know much better how to prevent these things from happening. Drugs like Evista provide a double benefit for the woman taking it. First is the prevention and treatment of osteoporosis and then it is approved by the FDA for active breast cancer prevention. It lowers your risk by 50% just like Tamoxifen but generally doesn’t have the uterine cancer issue like Tamoxifen.

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Bisphosphonates work by stopping the osteoclast from resorbing bone as does Reclast which is really zoledronic acid. Prolia (denosumb) the twice yearly injection works through an entirely different mechanism via the RANK and RANKL (LIGAND) network. Osteoblasts not only produce bone but they regulate the metabolism of osteoclasts through the human receptor activator nuclear factor –KB (RANK). Osteoblasts stimulate osteoclast activity by secreting RANK (which is blocked by Prolia) and block osteoclastic activity by secreting osteoprotegerin (OPG). Forteo (teriparatide) works like no other osteoporosis medication as it is the only one that builds new bone.

When one talks about building bone with medication sometimes semantics get in the way. Most of these medication mentioned reinforce the bone that is there. But once bone is lost there is only one medication that actually builds new microarchitecture and that’s Forteo. Forteo is actually the first 34 amino acids off the hormone PTH (parathyroid hormone). Forteo is recombinant human PTH. It’s a once daily injection (20mcg) which the patient gives themselves via a special pen. There is some evidence in the literature that if the patient is first diagnosed with severe osteoporosis that giving Forteo first creates better/stronger bone. Again the best treatment for osteoporosis is prevention through a good diet, calcium, Vitamin D supplementation and weight bearing exercise. Some girls walk with weights in a backpack. Now for patients who have been on a bone builder for a few years I give a ‘drug holiday’ for a year or more.

PATHOLOGIST – This is the doctor that is trained to look at tissue both macroscopically (or gross exam by sight/feel) and under a microscope to decide where the tissue came from and if it is benign or malignant. At this point they are also the ones who send tissue out for various tests like genetics tests or hormone receptor tests.

PERMANENT SECTION - This usually occurs at the end of the day after all the scheduled surgical cases are complete. The pathologist now has the time to take a complete look and microscopic evaluation of the tissue. This is where rarely changes in the report come, not because the pathologist made a mistake the first time (like at frozen section) but because they are looking at a different area of the tissue so the diagnosis may change on permanent.

PET/CT – Positron Emission Tomography is a nuclear medicine scan to give a color 3D image of the inside of any organ. It looks at the physiology rather than just the anatomy like mammography. It is great at highlighting small metastatic deposits. Again, while it’s a really cool modality, not only does the patient get the x-rays of the CT but also the radioactive contrast material (fludeooxyglucose or FDG) injected into the vein. The FDG alone carries radiation exposure of about 14 mSv. Unlike a yearly mammography I use PET/CT only when necessary.

RADIATION THERAPY – This topic will be dealt with in detail by Dr. Mantik in the radiation options section. Suffice it to say, there are major changes in options from the old Cobalt usage in the 1950s. Generally, let me say as a surgeon we want to optimize its use while we minimize its side effects.

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Genetics will now help us select out patients who actually don’t need radiation therapy from those who do.

SENTINEL LYMPH NODE – The Sentinel Node is the very first lymph node that a developing breast tumor will spread (metastasis) to. Basically, the rationale is that once a tumor cell enters the lymphatic vessel system, it floats down the vessel the easiest way each time and arrives at the entrance to the axilla in the sentinel node each time. If the surgeon removes the sentinel node and it is negative on frozen section, no further surgery on the axilla need be done. This is done in order to preserve and spare the axilla from unnecessary damage and long term side effects such as lymphedema or shoulder pain. There are a couple of ways to identify the sentinel node. One is to use a radioactive tracer injected by a radiologist down in Nuclear Medicine at the hospital. In a few minutes the tracer shows up in the sentinel node and the surgeon uses a small Geiger counter to detect the radioactivity. The other way is to use lymphazurin (methylene blue) dye. A small quantity is injected around the nipple where the lymphatic drainage starts and in about twenty minutes it travels to the sentinel node and is usually easily seen all blue as opposed to the yellow fat pad.

One caveat with sentinel node biopsy, at frozen section the pathologist can’t take as much time as they can to examine the nodes after surgery. A frozen section is done while the patient is on the operating room table and thus we want to move along. There are instances where the sentinel node is reported to be negative on frozen and then on permanent section they have discovered cancer cells, usually via keratin staining. This process, which takes a couple of days, can actually select out one or two cancer cells in the nodes. This is called micrometastasis or occult metastasis. There is a debate in the surgical literature as to whether the surgeon should go back and do another axillary surgery to remove additional nodes. See my approach under surgical options in the handbook. A recently published paper from Europe, October 2014 indicates that they are starting to support that with a positive sentinel node axillary radiation of recommended instead of surgery. Their reasoning was less side effects but I think we’ll have to wait some time as radiation effects can play out over time. You see the rational for surgery in breast cancer is getting less and less thus more support for the Lavender Procedure.

SIEVERT – It’s the new way to measure radiation. The older term was REMs (Roengten Equivalent for Man). 100 REM = 1 Sievert = 1000 millisieverts. Fortunately, we measure human exposure to radiation in thousandths of a REM or millisievert. You get radiation naturally not just from medical x-rays. For instance, if you live on the East coast you get about 50 milli-rems a year. If you live in Denver (mile high) you get about 150 milli-rems. A set of full mouth radiation at the dentist is about 40 milli-rems. How much does it take to make you sick? About 25 REMS or 2,500 millirems, that would likely cause nausea, vomiting, etc. How much radiation will kill you? The LD 50 (lethal dose) is about 350 REM or about 3.5 Sieverts and half the people would be expected to die within 60 days. The most common cause of radiation is Radon accounting for about 50% of the radiation we absorb. Medical imaging accounts for about 18%.

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Japan’s Fukushima accident was pumping out about 400 mSV an hour. About 100 mSv a year has been estimated the lowest dose at which you can expect some cancer to develop as a result of the radiation. A cumulative dose of 1000mSv will probably cause cancer years down the line in about 5 out of a 100. Many experts feel there is no safe dose depending on an individual’s own risk

TISSUE EXPANDER - For those women undergoing mastectomy and wanting immediate reconstruction, a tissue expander is placed under the skin. Sometimes the flaps created during a mastectomy compromise the blood supply to the flaps and if a large implant was placed right away it might injure the skin to the point of necrosis (dead tissue).

We don’t want that so the expander is placed which has a valve that saline can be injected into the expander (like an implant) periodically to achieve the size the patient is happy with. It lets the flaps adjust the blood flow and the expander is removed when the implant is placed.

TARGET – Like the word lesion it just refers to anything we are after like a cyst, solid mass on mammography, ultrasound etc., or by physical examination. It’s not necessarily bad. There are a lot of benign ‘targets’ in the breast.

TUMOR MARKERS - These markers are an ever expanding list (as discoveries are ongoing) of proteins that are in different ways associated with a particular developing cancer. They basically tell us how aggressive or nonaggressive a tumor is. This helps us determine if chemotherapy is necessary or not. At times we have to send a piece of the tumor out to a specialty lab. We can do these studies on the tumor, however, insurance usually doesn’t pay for it because it’s considered experimental.

There should really be a command committee that looks at new discoveries on tumor markers (or any new findings that are paradigm changing) to say this test/study should be covered by insurance, but that won’t happen. Our old friend’s estrogen (ER) and progesterone (PR) and HER2 are part of the tumor markers. Others are P53, Cathespin D, Epidermal Growth Factor (EGF), Ki-67 (proliferation rate, how fast the tumor is dividing) and the list goes on.

ULTRASOUND – Humans have been tinkering with objects that make vibrating sounds (acoustics) for a long time. Pythagoras (an ancient Greek philosopher and mathematician) in the 6th century BC was probably one of the first to study acoustics. Animals use their own ultrasound like bats and porpoises. The sound waves generated could be heard by humans if our ears were set to those wave lengths. Ultrasound that we know came into its own during World War II, but instead of looking for submarines, we are now looking for a breast mass that forces the sound waves back to the transducer. The transducer (the object that the person doing the ultrasound holds) picks up the sounds through an interface between the skin and the transducer using ultrasound gel.

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The result of this is displayed on the screen. Ultrasound doesn’t have radiation but there is still some concern about subjecting a body part to prolonged wave length forces. Therefore, we all use ALARA (as low as reasonably achievable). That is, we can increase the intensity of the wave lengths by raising the power settings much like increasing the flame on your stove. So we make an effort to subject the patient’s breast to as short as time as possible during the ultrasound exam. We also dial in as low a setting that will allow achievement of good resolution of any target. Most women who know about ultrasound are introduced to it during pregnancy. It’s a very useful tool.

A common notion is that ultrasound is somehow better then mammography since it doesn’t hurt and there is no radiation and it can resolve (image sharply) targets at about 1mm. Yes, this is true and if all breast cancers showed up the same way, we could do away with mammography. But that isn’t the case. Some breast cancers just don’t show up on ultrasound and ultrasound usually doesn’t pick up tiny evolving malignant calcifications like mammography.

Actually, the calcifications themselves aren’t malignant but are deposited as a byproduct of an evolving malignancy. A good analogy is soot produced by car exhaust left in the snow. Even though the car might not be there anymore, we know that because the soot is there, a car was once there. So calcifications produced by a developing breast cancer let us know by their particular design (pleomorphic) that this area might contain a cancer and should be biopsied. So an ultrasound exam may not show 1-2mm pleomorphic calcifications but a mammogram will.

A mammogram might also show architectural distortion or asymmetry that might not be picked up on ultrasound. That’s part of the importance of doing yearly mammography, finding minute changes. On the other hand, if a woman develops a breast cancer that doesn’t deposit calcium, then the first time it is likely to be diagnosed is if the woman finds it herself or on ultrasound. Also, if the woman has very dense breast tissue and we have no telltale calcifications, ultrasound may identify an otherwise undetectable cancer. Yes MRI or PET/CT would find the cancer but in most instances insurance won’t pay for those exams since mammography was reported just with dense tissue.

A problem with ultrasound is the pictures we end up seeing are at the discretion of the person doing the ultrasound. This is unlike a chest x-ray for example that the entire chest is visible to whoever looks at it. The technician or doctor performing the ultrasound needs to take enough time to image the entire breast and often the axilla and make sure the images they keep are the ideal one to make an accurate diagnosis. The key to all these technologies is that none of them are 100%. That is why at Visionary Breast Center we use multiple modalities as necessary. The rational is that all these technologies have their pros and cons but using them together is the key to helping find an ultra-small breast cancer.

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Conversely, if we do a genetics test as a baseline (to pinpoint risk) and implement infrared, ultrasound/elastography and Halo, if needed and all these tests are negative (in addition to a physical), then it is highly unlikely that the patient has a cancer that is hiding. Ultrasound is just another step we can do to assure the patient is cancer free.

What does an ultrasound tell us? It will tell us a number of things. First, it will locate precisely a target and second, it will usually tell us if that target is solid or fluid filled (generally a cyst). Except in rare circumstances, cancers are solid (taller then they are wide) and as they develop have irregular margins. The rare circumstance would be, where is cancer is associated with fluid as in a cyst that harbors an evolving cancer or a small DICS. That scenario is around 1% of the time for the cyst/cancer scenario. DCIS is much more common and we currently need the help of mammography to ferret out a small DCIS that has yet to form a mass. When sound waves come back to the transducer, it measures the amplitude or the wave (how tall it is) and this is changed by the software into dots. This is spoken of as echogenicity. Brighter dots are spoken of as being hyperechoic. Examples are gallstones and bone. Hypoechoic targets produce less amplitude and examples are a fibroadenoma.

Anechoic targets produce no dots and the target shows all black. An example is a cyst. Besides the target itself, we look behind it. For example, if we have a cyst, it will show up black since the sound waves go right through it but sounds waves will be reflected from the tissue immediately behind the cyst and cause posterior highlight (like the tail of a comet). Solid masses on the other hand reflect the sound waves so instead of a bright comet tail as in a cyst, we see dark tail (called posterior shadowing). We also look for telltale signs of malignancy. One sign besides irregular margins is that cancers usually appear taller than they are wide on ultrasound. If we see a solid mass that we can’t determine its benign nature (using other modalities like mammography), we may try and order an MRI and or proceed to core biopsy.

We can also determine abnormal ductal ectasia (dilation of the mild ducts). This may be caused by both benign and malignant lesions. Depending on the amount of ectasia, we may want to proceed to another test like MRI or biopsy. We can also see small metal clips that the radiologist has placed during a core biopsy. Just like mammography, if you have a good ultra sonographer with a good machine, we get good information. At Visionary Breast Center all ultrasounds are done with the state-of-the-art Hitachi Avius machine with Elastography.

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