Is it all about the cost of CT Scans to wait for staging?

Hi,

My wife had a biopsy in December of 2007.  It was positive.  She had a single mesectamy in mid March of 2008.  We found out that her cancer had metasized in mid April.  It is now mid August and she may have a chance of a remission.  She had two rounds of oral chemo which was not effective and now she is on Taxol, Gemzar, and the bone strengthener.  She just finished her 4th round and the liver is physically normal.  We now have to have cancer markers and a new CT scan to check on progress.  She will then have hormone therapy and reconstructive surgery.

The keep her positive nobody has mentioned stage 4 to her and she doesn't need to hear it even though she knows it's not stage 2.

I understand the reason for staging.  I know even if the biopsy is an aggressive pathology result that the nodes might not be effective and we need to check the sentinal nodes etc...  I know she had the option of chemotherapy before surgery.  My question is why don't isn't a CT scan performed first?  Her liver and bones were full of leisons from one positive node.

Our youngest son died 10 years ago and the normal question is "what if?".  

Sorry for the spelling.  I'm not in the mood to do spell check.

[Dennis MD]

Hi.
How are you doing now?
Before starting any treatment, there is a need to do diagnostic work-ups (CT scan, x-ray, ultrasound) to look for possible metastatic site/s.  Oftentimes, the stage of the disease dictates the type of management given to the patient.  Further diagnostic work-ups are done after several cycles of chemotherapy to check for the response to treatment.  In general, if there is a progressive disease even with treatment, the treatment protocol is then changed.  
Good luck.

[Kemal]

Dennis,

My wife only had a scan of the lump in her breast.  The full body CT scans were not given until after the mesectamy.  

Thank you.

Kemal

[Dennis MD]

Hi.
What was your wife’s initial breast cancer stage?    
Diagnostic work-ups are needed before doing any treatment procedures.  In your wife’s case, perhaps her doctor was entertaining early breast cancer thus further diagnostic work-ups were not done before the mastectomy.  If your wife had symptoms pertaining to a possible metastatic site, then that should be documented.
You mentioned that your wife has a good chance of remission with her current treatment regimen.  That's great news!  
Regards

[Kemal]

Her CEA was 5700 in June.  It is now 888.  It is great news.  She might begin hormone therapy and continue Zometa beginning in October.  She will complete her sixth cycle of Taxol and Gemzar on Sept. 12th.  If the next two markers in the next two months continue to decrease we will be very happy.

She had a scan a year before her biopsy and they saw leisons in her spleen but as I understand it usually doesn't begin in the spleen.  Her oncologist said we can negociate the next CT scan since my wife hates taking the tasty liquid required to complete the scan.

My wife does not know the prognosis and does not want to know the staging.  She shouldn't have to but all of her sisters do.  I asked what the chemotherapy our oncologist would use if the cancer began to spread again.  She said she didn't know.  Why would she not know?  I totally respect the medical field as my father was a OBGYN.  Cancer is an art as everyone says since we just don't know everything we wish we did.

My wife has a psychologist who is battling incurable cancer also.  He told me never to give up even thought the oncologist said her prognosis was 2-5 years.  We just pray for advancements in treatment when she needs it in the future.

If all goes well she will finish her breast surgery , reconstructive, and be able to begin working out by January or February.

Any input on my comments would be helpful.

Thanks.

Kemal

[Dennis MD]

Hi Kemal,
It’s great to know that her tumor marker (CEA) has significantly decreased.  It means that she is responding to her treatment.  She should continue with her treatment and see if the tumor marker will continue to decrease and normalize.
There are other second-line agents available that can be given in case (hopefully not) her present regimen (Gemcitabine-Paclitaxel) fails.  Docetaxel is an option.  Capecitabine is also an option (though I’m not sure if this was the oral chemotherapy you mentioned.  Hormonal treatment (Tamoxifen) can also be given.
I do hope that your wife continues to respond to her treatment.  

[Kemal]

Dennis,



My wife has been on Zometa and will continue with this treatment once a week if our Oncologist thinks her tumor marker is low enough.  I assume Tamoxifen will be the hormone therapy she will begin.  The treatment would be month Zometa and Tamoxifen.  Once a month is better then once a week treatment and I know people go through longer treatments now and historically this treatment is soooooooooo much better.

I did read about an alternative to Tamoxifen which is an oral hormone therapy, Bonefos.  Our second opinion John Link, who use to work with our oncologist thought my wife should have started on hormone therapy.  The reason he stated was because he said hormone therapy will take up to 6 months to be effective.  

I asked our oncologist why there was a disagreement with treatment.  She said that she takes the American approach instead of the European approach.  The European approach according to her is to blast you to kill the cancer.  Since my wife is stage four she said we need to take the approach she suggested.  It seems to be working but I am worked that the estrogen will begin to feed the cancer when the chemotherapy stops before the hormone therapy take effect.  This is not a perfect science and I know we need to trust our doctor.

Would you suggest having a third opinion  such as City of Hope after a couple of months on hormone therapy?  I have a friend at work who has a rare bone cancer and he said we only have one chance to get as much information as possible to give her the best treatment.  I am of the opinion  that everyone thinks their oncologist is the best and I don't know when to stop and when to continue looking for more answers.  What do you think of the so called American verses European approaches?  What do you think about using Bonefos?  Do you know if the tumor markers my wife has can become normal which I think is under 30 or will we just live with a marker under 200?

The oral chemotherapy my wife was on before taxol was xeloda.  It was a month of failure.

I REALLY appreciate your responses and help to the community.

Kemal

[Kemal]

Dennis,


My wife has been on Zometa and will continue with this treatment once a week if our Oncologist thinks her tumor marker is low enough.  I assume Tamoxifen will be the hormone therapy she will begin.  The treatment would be month Zometa and Tamoxifen.  Once a month is better then once a week treatment and I know people go through longer treatments now and historically this treatment is soooooooooo much better.

I did read about an alternative to Tamoxifen which is an oral hormone therapy, Bonefos.  Our second opinion thought my wife should have started on hormone therapy from the beginning.  The reason he stated was because he said hormone therapy will take up to 6 months to be effective.  

I asked our oncologist why there was a disagreement with treatment.  She said that she takes the American approach instead of the European approach.  The European approach according to her is to blast you to kill the cancer.  Since my wife is stage four she said we need to take the approach she suggested.  It seems to be working but I am worked that the estrogen will begin to feed the cancer when the chemotherapy stops before the hormone therapy take effect.  This is not a perfect science and I know we need to trust our doctor.

Would you suggest having a third opinion  such as City of Hope after a couple of months on hormone therapy?  I have a friend at work who has a rare bone cancer and he said we only have one chance to get as much information as possible to give her the best treatment.  I am of the opinion  that everyone thinks their oncologist is the best and I don't know when to stop and when to continue looking for more answers.  What do you think of the so called American verses European approaches?  What do you think about using Bonefos?  Do you know if the tumor markers my wife has can become normal which I think is under 30 or will we just live with a marker under 200?

The oral chemotherapy my wife was on before taxol was xeloda.  It was a month of failure.

I REALLY appreciate your responses and help to the community.

Kemal

[Dennis MD]

Hi Kemal,
How are you doing?
Zometa and Bonefos will address the bone metastasis.  These drugs will provide pain relief from the bone pains your wife may be experiencing, through stopping further bone destruction and hasten bone remodeling.
Tamoxifen is a hormonal therapy used for hormone responsive (estrogen/progesterone receptor positive) breast cancer.  This can be used either in the adjuvant setting or in the metastatic setting.  Responses are usually observed in 3 to 4 months in majority of patients.  
Your wife’s current regimen is Gemcitabine + Paclitaxel, along with Zometa.  I think this is a reasonable option.  She’s responding well to this treatment as evidenced by the decrease in liver metastasis.  The basis for the response with regards to her bone metastasis would be harder to gauge.  Stabilization of the lesions in bone scan would be a good gauge to check her response.  Bonefos is an oral form of bisphosphonate and is a reasonable option when Zometa is discontinued.  This can be combined with Tamoxifen.
There is not much difference with regards to treatment based on American versus European protocols.  If your wife is symptomatic at the start of treatment, then systemic chemotherapy would be a better option since the effect would be faster relative to hormonal therapy.  As I’ve mentioned, responses with hormonal therapy usually takes 3 to 4 months.    
I’m not pretty sure whether the tumor marker will normalize at the end of her present chemotherapy.  Hopefully it does.    
Take care.

[Kemal]

Hi,

Based on what I understand we will not reach normal tumor markers but will be able to keep them at low levels.  I recently read that switching bisphosphonate to Bonefos might not be effective.  I will ask our ocologist.  I would assume if something is working why change and the only reason to change is the comfort of an oral drug.

I was told by an old friend today who had stage 1 breast cancer that she didn't take Tamoxifen because it is linked to cevical cancer.  She said she is taking Arimidex but this is a post menopausal medication.  What would you suggest?

I hope the 3-4 months it takes for the hormone therapy will effective in time since her last chemotherapy treatment might be September 12th.  Should I ask our oncologist to begin the hormone therapy ASAP instead of waiting?

Thanks for your help.

Kemal