Breast Cancer Treatments

Breast Cancer Treatments
In the last article, we briefly alluded to the staging of breast cancer. Staging (I to IV) is important because early stage breast cancer can be successfully treated, even curable, while late stage cancer is difficult to treat. Thus, the importance of annual mammography cannot be overemphasized. Every woman over the age of 40 must get an annual mammogram (no excuses!) because the incidence of breast cancer rises dramatically at middle age.

If breast cancer is detected early by mammography -- that is, before the tumor has spread out to other areas of the breast or other regions of the body, such as lymph nodes, bones, liver, brain, etc., the tumor can be easily excised or removed completely by surgery.

Cancer is early when it is still "in situ" (in its place). It is late when it has become "invasive or infiltrating", i.e., the tumor has broken through the ducts and lobules of the breast to spread via the blood stream and lymphatics to other areas.

In situ cancer is easily treated with surgical excision (called "lumpectomy") without removing the entire breast. Even bigger cancers can now be removed in a limited way, or treated "conservatively" as opposed to "radically", as long as radiation is performed after surgery. Nevertheless, modified radical mastectomy is still considered the gold standard of treatment, until, perhaps, the advent of comprehensive genetic oncology (genetic treatment of cancer).

Dr. William S. Halsted, the father of American Surgery, developed the surgical treatment for breast cancer in New York and was the first to perform a radical mastectomy in 1882. For almost the next century, Halsted's operation became the standard treatment for breast cancer. In 1978, Dr. Bernard Fisher, from the University of Pittsburg, published a study which showed that lumpectomy (or limited breast resection) coupled with radiation therapy was as effective as total radical mastectomy. This led to a change in how breast cancer is currently treated. In the 1990s, sentinel node biopsy was developed to refine the removal of axillary nodes which determines whether cancer is localized or already spread out to the lymph glands.

Depending on the biological behavior of the cancer, its size, hormone dependence, etc., there is now an array of treatment modalities available.

When a tumor is detected by mammogram (remember, most breast cancers present as painless lesions), a choice can be made between a needle biopsy with ultrasound or stereotactic guidance (with the patient awake) or an open biopsy in the operating room under anesthesia (with the patient asleep).

The tissue that is sampled is then sent to pathology for a series of tests. Pathologists will examine the tissue under the microscope to determine if the lesion is cancer (malignant) or if it is not (benign fatty tissue, fibroadenoma, cyst, etc.). If the biopsy is positive for cancer, the patient can discuss with her surgeon the necessity of removing only a portion of the breast or removing the entire breast (with or without plastic surgery reconstruction).

If a limited resection is the choice, the patient will have to undergo radiation as well to guarantee that microscopic cancer cells, outside of the area of resection, are eradicated. If the entire breast is removed and the axillary nodes are found to be clean or free of cancer cells, no further treatment aside from hormonal treatment, such as the antiestrogen Tamoxifen, may be necessary. However, if the axillary lymph nodes are positive, adjuvant chemotherapy might be beneficial, regardless of the side effects.

Chemotherapy, which is started only after the surgical wound has healed, usually requires placement of a MediPort or access chamber into the subclavian vein so that powerful drugs such as clyclophosphamide, methotrexate, fluorouracil adriamycin, etc. can be safely administered for 3-6 months. External beam radiation for 5-7 weeks might also be necessary. Internal radiation or brachytherapy is an option. The latter involves low-dose or high dose implantation of radioactive substances.

Other treatments are put in place depending on whether the cancer is estrogen postive, progesterone positive or if there is overexpression or amplification of HER2/neu gene ( 15-20% of breast cancers) which is associated with a worse prognosis and higher recurrence rate. The monoclonal antibody trastuzumab (Herceptin) may be effective in these aggressive types of breast cancer.

The take home message is that breast cancer comes in many forms and can be treated in a variety of ways. The most important message to women in their 40s is: get your yearly mammogram.

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Breast Cancer 101

Greetings from the Philippines!

Just before Lucie and I left El Centro for an emergency trip to Cebu City, I was invited to lecture on breast cancer to a cancer support grassroots organization.

Breast cancer incidence in the United States is an alarming 90 per 100,000 women. The take home message of my Saturday morning talk was: get a baseline mammogram. At age 40 and above, an annual mammogram can save your life. Regular mammography is the single most effective method of breast cancer surveillance.

While the incidence is highest in the United States and Western Europe where lifetime risk is 12% but lower in Asia and third world countries, carcinoma of the breast is the most common cancer among women worldwide.

Lowest incidence is in 20-24 year old women. However, breast cancer increases with age. 95% of new cases are diagnosed in 40 year old women and older. Median age is 61 years.

The statistics which I presented to the group of cancer survivors and supporters hit close to home this time. A day before our return flight to Southern California, my aunt called to say she had noticed a breast lump. I was very concerned, knowing that breast cancer most commonly manifests as a painless mass.

We brought her to the local hospital where a quick mammogram showed a suspicious 3 centimeter spiculated lesion. A core needle biopsy, done under local anesthesia with ultrasound guidance, confirmed invasive cancer on the frozen section microscopic slides.

We postponed our return flight. With another local surgeon, Dr. Spanky Tablante, who had relocated to the Philippines after practicing twenty years in Virginia, we performed a standard mastectomy with axillary node dissection. My 81-yr-old aunt is recuperating well as I write this and should be back home by the time you read this article.

The operating suite at Perpetual Succour Hospital in Cebu City may not have the latest gadgets we have at our disposal in the United States. For instance, we operated without a harmonic (bloodless) scalpel. But, during the entire two and a half hours of surgery, the Chief of Cardiology, Dr. Victor Gonzalez, was seated next to the Chief Anesthesiologist, Dr. Enricoso, constantly monitoring my aunt's vital signs. We certainly don't have that kind of personalized luxury in California!

Again, it is important to emphasize the need for yearly clinical examination and mammography. Early breast cancer cannot be felt. It is usually not painful. But a good mammogram should detect a suspicious lesion 85-90% of the time. In cases of dense or fibrocystic breasts, physicians may order an MRI (Magnetic Resonance Imaging) which increases detection rate by an additional 5-10%. Soon, digital mammography will be readily available, which will make detection of very tiny and early stage cancers even more accurate.

Several factors are known to put women at risk of developing breast cancer. Increasing age, as mentioned, is one. As one gets older, the risk increases. At age 20 - 24, only 1.4 per 100,000 women are diagnosed with breast cancer. At age 75-79, the incidence rises to 465 per 100,000.

A first degree relative with breast cancer, delayed childbearing, fewer children, late age at first full term pregnancy (>30 years), early menarche (<12>55 years), high dose radiation to the chest, obesity, use of contraceptive pills and hormone replacement therapy are all known risk factors.

Patients with a history of endometrial, ovarian, and colon cancer are also at risk. Mothers that do not breast feed are at higher risk than the average population. Women who are found to have atypical ductal or lobular hyperplasia (by mammography and biopsy) are at risk for developing breast cancer.

Bottom line is that all women should be vigilant. Monthly self breast examination is a worthwhile practice. A woman should be familiar with changes in her breast and should learn to detect thickening, swelling, redness, nipple inversion, discharge and skin erosion. Once noticed, she should not delay in bringing this to the attention of her physician.

In addition to self examination and regular mammography, avoiding rapid weight gain and obesity is important. Regular physical activity and exercise is known to cut down the rate of breast cancer, in addition to improving general health.

Minimize alcohol intake. Two alcoholic drinks a day increases cancer risk by 21%. Hormonal therapy should be taken with caution. Discuss thoroughly with your physician the risks involved before taking hormones as contraceptive pills or menopausal supplements.

In the next article, I will discuss the current standard treatment of breast cancer.

Medicine and Spirituality

Reprinted from the Asian Journal
February 8, 2008

Some readers may wonder if the MD after my name was for real. After all, except for two articles about traditional Philippine remedies, I have not written anything related to medicine since starting this column in October.

Well, it is. I earned it back in 1974. For the last 33 years, I have been working as a physician and surgeon -- 13 years in academia and two decades in clinical practice. It is not unusual for physicians to write about religion and spirituality.

That may be because of the very thin line that separates medicine and spirituality. When doctors run out of stuff from their medicine bag to save a patient's life, it is time to call in the priest to administer the last sacraments and "take it from there." Likewise, there is nothing like being hospitalized or going under the knife to encourage serious reflection on things beyond the temporal world.

Dr. Alexis Carrell (1873-1944) was the first physician in the United States to win the Nobel Prize in medicine and physiology. Born and raised in France, he immigrated to the US in 1906 and worked at the Rockefeller Institute for Medical Research in New York City. Among other things, he did pioneering work in vascular surgery and blood transfusion. He invented the technique of connecting severed blood vessels after the assassination of the French president. Dr. Carrel was convinced that, if doctors knew how to repair and anastomose blood vessels, they could have saved the president from exsanguinating to death.

Dr. Carrell captured the attention of the scientific world when he described the technique of connecting the artery from the arm of a father to the leg of an infant to save the dying child from intestinal bleeding. He also became well known for his preliminary work on transplant surgery.

What is little known is that Dr. Carrell was as devoted to religion as he was to science. He faithfully made a pilgrimage to Lourdes every summer. He was so enthralled by the miraculous happenings in Lourdes that he wrote about them, stating that it was worthwhile investigating the religious phenomena and subjecting the healings to scientific scrutiny. This stance drew sharp criticism from both the scientific and clerical establishments.

A year after he was awarded the Nobel Prize in 1913, Dr. Carrell married Anne-Marie Laure de Meyrie. They had met as pilgrims in Lourdes.

Another physician who wrote on religious subjects was the famous Dr. Albert Schweitzer (1875-1965). Before entering medical school, he wrote The Quest for the Historical Jesus, the treatise that established his reputation as a theologian. His other religious writings include Civilization and Ethics, and Christianity and the Religions of the World.

In 1904, Dr. Schweitzer came across an article in a magazine appealing for health workers in Africa, so he decided to become a missionary physician. With the help of his wife Helene, who studied nursing so she could assist her husband, Dr. Schweitzer established a mission hospital in Lambarene, in the west central African country of Gabon.

Utilizing funds raised from lectures, concerts (he was an accomplished pianist and organ player), and royalties from his writings, he expanded the mission hospital to seventy units, providing care to 500 hospitalized patients.

Who has not heard about Dr. Tom Dooley (1927-1961), the remarkable young man who studied at University of Notre Dame before joining the US Navy Medical Corps in 1944? After earning his MD degree from St. Louis University in 1953, Dr. Dooley worked as a Navy physician and got involved in evacuating over half a million Vietnamese refugees. Later, he founded MEDICO and focused on building small hospitals in Southeast Asia where medical services were practically nonexistent. Named among the most outstanding young men of America, Dr. Dooley wrote three books: Deliver Us From Evil (1956), The Edge of Tomorrow (1958), and The Night They Burned the Mountain (1960).

Dr. Adrienne Von Speyr (1902-1967) was the first female physician in Switzerland. Her father was an ophthalmologist and her brother was a general practitioner. Dr Speyr was a remarkable person who, despite her uncontrolled diabetes, crippling arthritis, and coronary artery disease, maintained a very busy practice, attending to 60-80 patients a day. In addition to her ailments, she received the stigmata. Yet, somehow, she found the energy to found a lay religious institute. She also wrote or, when she got very sick, dictated (to theologian Fr. Hans Urs von Balthasar, her spiritual director) 60 books essentially dealing with Christian spirituality.

We all know about St. Luke the Evangelist, who wrote one of the four Gospels of the New Testament and the Acts of the Apostles. Well, St. Luke was also a physician, who probably studied medicine at the famous school in Tarsus, and may have worked for some time as a ship doctor. St. Paul in Colossians 4:14 refers to him as "Luke, our dear physician."

Medicine and spirituality run along parallel pathways. Indeed, there is a tradition of physicians writing about spirituality and religion over the centuries.

Indigenous Philippine Remedies

Reprinted from the Asian Journal
(Second installment) | December 7, 2007

Tawa-tawa: cure for dengue fever


by Edgar A.Gamboa,MD,FACS

The native treatments that I witnessed (or received) growing up in Cebu, whether administered by albularyo or manghihilot, fascinate me because they must have somehow worked, otherwise why would people return for treatment? Viewed now from the perspective of modern science, many of the indigenous or antique therapeutics look more like placebos. But they were readily available, arguably effective, and definitely affordable or, for the most part, free.

The term albularyo derived from the Spanish herbolario (herbalist). Albularyos are general practice healers who take care of common illnesses such as fever, cough, cold, diarrhea, etc. using medicinal herbs, which rural area folks commonly stock in their medicine cabinets. Albularyos also take care of people believed to be afflicted by supernatural illness or witchcraft. Thus their medical repertoire, in addition to herbs, includes chants, prayers, icons and religious articles.

The manghihilot is a more specialized medicine man or woman, focusing on musculoskeletal problems, much like chiropractors. They use massage techniques utilizing oil and salves to cure panuhot (strained muscle or air trapped in body cavities) or lisa (sprained joint). Some of the modern manghihilots have incorporated reflexology and acupuncture mapping into their practice.

In addition to the albularyo and the manghihilot, other native healers include midwives (mananabang in Bisaya, magpapaanak in Tagalog), the mangluluop, manghihila, mangtatawas, mediko, faith healers, etc. Medikos or medicos supplement native therapeutics with Western pharmacology. Filipino faith healers have, in some cases, achieved international fame (or notoriety) and, in some ways, are the pioneers of medical tourism.

There are about two dozen scientifically recognized medical herbs and plants in the Philippines. Boiled ginger to soothe sore throat is fairly well known. In fact, the concoction is now commercially available in powdered form or ginger tea (salabat).

A mixture of sampalok or sambag (tamarind), luy-a (ginger), and calamansi or lemoncito (citrus) works well for cough. Avocado, guava, and star apple (kaimito) leaves are the local version of Lomotil or Loperamide (Imodium). My mother used to heat rice grains until they turned brown, then added water to make an anti-diarrhea drink.

My sister Daisy, when pregnant with her first child, was advised by my aunt, who bore eleven healthy children, to boil thirteen kinds of roots and drink the bitter brew to ensure an uncomplicated delivery. She faithfully followed the time-tested advice but got so sick with the brew’s aftertaste that she no longer cared if she had a difficult labor. Those were the days before epidural anesthesia became common practice.

Talking about nasty medicines, cod liver oil in the form of Scott’s Emulsion was a popular source of multivitamins A and D, calcium, phosphorus and omega 3. I cringed every time my turn came to swallow two full tablespoons of the awful syrup. I'm amused to learn that Scott’s Emulsion is still available in some drugstores in the United States, and remains popular in Mexico, Central and South America, Asia, Africa, etc. My sympathy goes to those kids whose daily dose of vitamins emanate from that nasty brown bottle.

Raw eggs (with the attendant risk of Salmonella infection) blended in milk or Tru-Orange was not as nasty as Scott’s was but why did people think the frothy potion was helpful for hangovers? Was there credible research that showed that the eggnog mix protected alcoholics from developing liver cirrhosis and portal hypertension?

Lately, the popularity of Tawa-Tawa usage for Dengue fever is supported by government health agencies. Research has reportedly confirmed the common plant's antiviral and antibacterial properties. Tawa-Tawa is believed to help sustain platelets and counter hemorrhagic dengue. Two dozen plants boiled in seven glasses of water, from a report I've read, is the current recommended dosage

Gumamela or Hibiscus, also boiled in water, may be applied as poultice to inflamed wounds or abscesses. Some claim the flower has varied uses for cough, fever, hypertension, urinary tract infection, etc. But have you heard of inhaling adobo to get rid of your cold? Not sure about that one. Inhaling Vicks Vaporub dropped in steaming hot water may work, however. You can maximize the effects of such treatment by capturing vaporized oil with a large tent-like cape or blanket draped over your head.

Boiled guava leaves, particularly leaf sprouts, make excellent salve for new mothers, as effective as TUCKS Witchazel pads. Its topical application extends to those who suffer from inflamed hemorrhoids. Before Hibiclens and Bacitracin became commercially available, warm water blended with guava leaf extracts were used to cleanse nuka (Staphylococcal skin infection) so prevalent in children.

Kamunggay leaves commonly used for vegetable soup are also traditionally utilized to stop local bleeding. The leaves may not be as effective as Surgicel or Avitene but are cheap and readily available.

Soapsuds enema is practically out of style except for cleansing the bowels preparatory to endoscopy. I recall it being used for a variety of undiagnosed illnesses, manifesting as fever, cough, or abdominal pain. Being at the receiving end of an enema was one of the worst part of getting sick.

As beneficiaries or practitioners of modern Western medicine, we may tend to dismiss many of these primitive therapies as ineffective or unscientific. Yet, we may recall that back in the 5th century BC, Hippocrates, the father of medicine, wrote about a bitter powder extracted from the bark of the willow tree that relieved pain and reduced fever. Knowledge about the analgesic willow tree survived through the centuries.

In 1853, the French chemist Charles Frederic Gerhardt synthesized acetylsalicylic acid and in 1859, von Gilm purified it. In 1897, Felix Hoffmann, a chemist at Friedrich Bayer and Co., refined the process so that he could administer aspirin tablets to his father who suffered from severe arthritis. The rest, as they say, is history.

Manghihilot of Consolacion

November 30, 2007

Manghihilot of Consolacion
(First of two installments)


Reprinted from the Asian Journal (Article #10)


By Edgar A. Gamboa, M.D., FACS





Santo Nino de Cebu



It started with an email of nostalgic pictures culled from the 1950s --- WW II toy soldiers from Kellogg's Corn Flakes boxes, 45 RPM records, Studebakers, 15 cent McDonald hamburgers and 5 cent Coca-Colas, Brownie cameras and aluminum Christmas trees, etc., with the daunting remark: "If you can remember these, you have lived!" To which those who regularly avail of senior discounts at Denny's and movie theatres resoundingly responded in the affirmative.

Not without a hint of cynicism, my brother Robert commented that none of the above qualifies one "to have lived" more than having your frail chest and back greased with hot coconut oil and plastered with gabi leaves to get rid of "panuhot", the all-encompassing diagnosis for childhood ailments. Which commentary in turn initiated a flurry of emails regarding native Philippine remedies.

Medicine in the 1950s was not exactly that primitive. Growing up in Cebu City, the "Queen City of the South", there were excellent family doctors and pediatricians to go to when we got sick. I remember my father bringing me very early in the morning to the residence of Dr. Ramon Arcenas on several occasions.

Dr. Arcenas was a general surgeon who trained at Cook County Hospital in Chicago. He also practiced general medicine and cared for patients who traveled from all over the Visayas. He was my father's paisano (they both grew up in Bantayan Island) and he readily got out of bed in his pajamas to treat me before his schedule of rounds and operations. He was a great man. In no small measure, I became a surgeon because of the kindness and goodness I saw in him.

However, on certain days, when Dr. Arcenas was out of town or busy in the operating room (or when my father was not looking) my mother, whose faith in both Eastern and Western medicine were equally unshakable, hauled us to the clinic of a popular native healer, 12 kilometers north of the city, in a town aptly called Consolacion. Back then, it was a nice little town along the breezy Northern coast. At present, the municipality of Consolacion, with a population of over 60,000, has integrated into greater Metro Cebu.

The manghihilot of Consolacion was a gentle middle-aged Cebuano. He held clinic in the basement of his nipa hut, which was larger than the average bahay kubo. We usually arrived at midmorning. Typically, one of us would wake up with a fever or a hacking cough. My mother would then telephone the school to inform the teacher we would be absent, and then she would arrange for the driver to transport us to Consolacion.

By 9 or 10 AM, the waiting room would be packed; several patients would be standing outside. There was no receptionist. As soon as you arrived, you picked a number fashioned out of tansan (Coca-Cola or Pepsi tops hammered flat and engraved -- by tiniltil method -- with numerals) and awaited your turn. Speaking of tansans, you could, if you planned on going Christmas caroling, nail stacks of tansans together to a piece of wood and enjoy your own handmade percussion instrument.

When your number was called, you were led into the examining room. Dr. Consolacion -- my anesthesiologist brother Alan remembers patients calling him Nong Aurelio -- would take a brief history ("how long has the child been sick?", "did he fall down the stairs?", "has he been vomiting?"), then he would gently place his hands on your chest and back, close his eyes, and say a brief prayer.

Nodding his head, Nong Aurelio would sit back and tell your parent(s): "Your child has panuhot or lisa (sprain)... he must have fallen down a flight of steps". He then poured warm (or hot) globs of thick, greasy coconut oil on his hands and rubbed your chest and back to exorcise your illness, while reciting more prayers.

Soon, the dreaded moment came. Nong Aurelio would summon his "physician assistant" who promptly lifted and carried you on his back, rocking you back and forth to stretch your spine and hips. After the judo-like routine, the muscular medical assistant would grab you by the ears, lift you clean off the ground, and sway you back and forth until your neck cracked. Luckily, none of us ever got paralyzed!

Then it was back to the manghihilot's examining chair for more goops of oil. Taking a handful of gabi leaves stacked by his side, Nong Aurelio would run them over a lantern flame, toasting them ever so slightly, before plastering them against your chest and back. I guess the idea was to keep the oil from evaporating too quickly and to use whatever medical properties the leaves had.

We would thank Dr. Consolacion and leave money in a donation box. He never charged for anything. That would have risked losing the healing powers God gave him. There were no insurance papers to fill, no billing claim to be sent, no co-pay. There were no middle managers, no HMO authorization process, and no bureaucracy whatsoever. Native medicine was purely a sacred traditional relationship between the healer and the sick.

The best part for me was going home tired and sleepy (from the long 12 kilometer car ride), and going to bed with the latest DC Comics copy of Superman or Batman (one of the perks of getting sick) and sipping a glass of Welch's grape juice or 7-up. We had the choice of keeping the gabi leaves stuck to our bodies the rest of the day or my mother would peel them off and exchanged them for tinastas nga panapton (pieces of cloth left over from her sewing chores) caked with pink yucky Numotozine.

Dr. Consolacion's ICD list of diagnoses was limited to "panuhot" (strained muscle or air trapped in body cavities) or lisa (strained joint). Likewise, therapeutic measures were confined to coconut oil, gabi leaves, and prayer. But, somehow, sick children got better....and survived to adulthood (all my eight siblings are alive and well, thank God). Luckily, no one got paralyzed from the vigorous physical therapy. Bottom line is: we were cured.

I did hear many years later that none of Nong Aurelio's kids took over his "hilot" practice. They all became either physicians or nurses.

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"Dear children! God sent me among you out of love that I may lead you towards the way of salvation. Many of you opened your hearts and accepted my messages, but many have become lost on this way and have never come to know the God of love with the fullness of heart. Therefore, I call you to be love and light where there is darkness and sin.

I am with you and bless you all. Thank you for having responded to my call." -- Message of October 25, 2007

The Medjugorje Web http://www.medjugorje.org