Dr. Mai Brooks MD

Cancer in the USA - what to expect in 2014 One out of four deaths in the US is due to cancer. In 2014, approximately 585,720 Americans will die of cancer. The following tables summarize the distribution of the top ten types of invasive cancer among men and women. Please note that this number does not include the early in situ carcinomas from any organ (except the bladder). Excluded from this table are 62,570 breast carcinomas in situ, 63,770 melanomas in situ, and millio...ns of unreported cases of squamous cell and basal cell skin cancers. Only the top 10 death causes are listed below. (http://onlinelibrary.wiley.com/doi/10.3322/caac.21208/full). Cancer in women: New casesRanking by %Deaths Death by % breast 232,670 1 (29%) 40,0002 (15%) lung 108,210 2 (13%) 72,3301 (26%) colorectal 65,000 3 (8%) 24,0403 (9%) uterus 52,630 4 (6%) 8,5907 (3%) thyroid 47,790 5 (6%) Lymphoma* 32,530 6 (4%) 8,5208 (3%) melanoma 32,210 7 (4%) kidney 24,780 8 (3%) pancreas 22,890 9 (3%) 19,4204 (7%) leukemia 22,800 10 (3%) 10,0506 (4%) ovary 14,2705 (5%) liver 7,1309 (3%) brain 6,230 10 (2%) All organs810,320 275,710 * non-Hodgkin Cancer in men: New cases Ranking by %Deaths Death by % prostate 233,000 1 (27%) 29,4802 (10%) lung 116,000 2 (14%) 86,9301 (28%) colorectal 71,830 3 (8%) 26,2703 (8%) bladder 56,390 4 (5%) 11,1708 (4%) melanoma 43,890 5 (5%) kidney 39,140 6 (5%) 8,90010 (3%) Lymphoma* 38,270 7 (4%) 10,4709 (3%) oropharynx 30,220 8 (4%) leukemia 30,100 9 (4%) 14,0406 (5%) liver 24,600 10 (3%) 15,8705 (5%) pancreas 20,1704 (7%) esophagus 12,4507 (4%) All organs855,220 310,010 * non-Hodgkin As shown above, the #1 cancer killer in both men and women is lung cancer. As lung cancer is predominantly caused by cigarettes, smoking cessation can significantly decrease this type of mortality. Breast cancer is the most common (and #2 killer) in women, as is prostate cancer in men. Colorectal cancer ranks #3 in both new case incidence and death rate for both genders. Since there are good screening tools for breast, prostate and colorectal cancers, these death rates can also be reduced if more of these cases are detected earlier at curable stages.

New treatments for advanced and metastatic melanoma In the United States in 2014, there will be an estimated 76,100 new cases of invasive cancer and 63,770 of in situ melanoma. Also in 2014, approximately 9,710 people will die from this malignancy. Most patients with metastatic melanoma die within one year. Until recently, the only two approved treatments are dacarbazine (a chemotherapy agent) and interleukin-2. Neither drug has clearly demonstrated improved survival. N...ow, there are four new drugs that can be used for unresectable (cannot be completely removed by surgery) and metastatic melanoma. The first drug is Yervoy (ipilimumab), which was approved by the FDA in 2011. Yervoy is an antibody that blocks T-lymphocyte associated antigen 4 (CTLA-4). This blockage increases T-cell proliferation, which results in a more active immune system to attack the melanoma cells. In clinical trials, Yervoy reduced the risk of death by 34%, and median overall survival was 10 months. The second agent is vemurafenib, which was approved by the FDA in 2011. Vemurafenib targets a mutation in the gene BRAF (Serine/threonine-protein kinase B-Raf) V600E. About 50% of melanoma cases have this mutation, and these patients would qualify. This drug reduced the risk of death by 56%, compared to treatment with dacarbazine. Last year 2013, the FDA approved two more drugs. Dabrafenib was also indicated for unresectable or metastatic melanoma cases that have the BRAF V600E mutation. Compared to dacarbazine chemotherapy, Dabrafenib delayed tumor growth by 2.4 months. The fourth drug is trametinib, which can be used for melanoma cases that have the BRAF V600K mutation, as well as the V600E mutation. Compared to dacarbazine, trametinib delayed tumor growth by 3.3 months. In general, these new drugs add a few more months of life to these terminal melanoma patients. Further research is needed to produce better treatments for this deadly disease. See more

Exciting news in novel personalized medicine for breast cancer Three new targeted drugs approved by the FDA Active research in breast cancer is producing novel targeted drugs at a rapid pace. Perjeta (pertuzumab)... In September 2013, the FDA approved Perjeta for use in combination with Herceptin (trastuzumab) and docetaxel for the neoadjuvant (prior to surgery) treatment of patients with HER2-positive, locally advanced, inflammatory or early-stage breast cancer (either greater than 2 cm in diameter or node positive). Pertuzumab is an antibody that targets the extracellular dimerization domain of HER2, and thereby blocks ligand-dependent heterodimerization of HER2 with other HER family members. Clinical trials have shown that neoadjuvant therapy with this combination resulted in a 39% complete response rate, meaning that cancer can not be found at the time of surgery. This rate is superior to any other existing neoadjuvant treatments. Kadcyla (ado-trastuzumab emtansine) The FDA approved Kadcyla in February 2013. Kadcyla is a HER2-targeted antibody-drug conjugate. Upon binding to the HER2 receptor, ado-trastuzumab emtansine results in intracellular release of DM1-containing cytotoxic catabolites. Binding of DM1 to tubulin disrupts microtubule networks in the cell, which results in tumor cell death. Kadcyla is indicated for patients with HER2-positive, metastatic breast cancer who previously received Herceptin and a taxane, separately or in combination. A large clinical trial has shown that this new drug gave patients a median overall survival of 31 months, in comparison to 25 months with other drugs. Afinitor (everolimus) In July 2012, the FDA approved Afinitor for the treatment of postmenopausal women with advanced hormone receptor-positive, HER2-negative breast cancer in combination with exemestane, after failure of treatment with other hormone blocker pills. The tumors in these cases essentially developed resistance to existing hormone blocker pills. Afinitor is an inhibitor of mTOR, which is important for cancer cell proliferation. A large clinical trial yielded a median progression-free survival of 8 months for patients receiving this new drug, versus 3 months for those on placebo. The final analysis of overall survival is expected to occur in June 2014. See more

Colon Cancer - An Update In the United States in 2014, there will be an estimated 96,830 new cases of colon cancer and 40,000 rectal cancer. Also in 2014, approximately 50,310 people will die from these two malignancies. Once colon cancer is diagnosed on a complete colonoscopy, a CT of the chest abdomen and pelvis should be done. If there is no distant spread of disease, colectomy (resection of the colon) is recommended. The extent of colon removal depends on the locatio...n of the cancer. Usually, it is not necessary to remove the entire colon. Surgery may be performed with an open midline incision, or with the laparoscope via multiple small incisions. Both approaches have similar long-term outcome in regards to recurrence and survival. After surgery, adjuvant chemotherapy is given in cases where cancer has spread to surrounding lymph nodes, or if cancer has penetrated through the wall of the colon. FOLFOX is the most commonly used regimen, and includes folinic acid (leucovorin), 5-fluorouracil, and oxaliplatin. About 25% of colon cancer cases present with concurrent spread to the liver. If possible, the liver metastasis should be resected as well as the cancer in the colon. If surgery is not feasible, the liver metastasis may be treated with: 1) chemotherapy delivered into the hepatic artery; 2) occlusion of the artery feeding the cancer; 3) radiation; or 4) radio-frequency ablation. Sometimes, a patient may have a single metastatic nodule in the lung that can be removed with surgery. In advanced or metastatic cases, chemotherapy is usually administered first. This treatment may sometimes be successful in shrinking the tumor enough to make surgical resection possible. After treatment for early colon cancer (stage 1), follow-up includes colonoscopy at 1 year, 3 year, and then every five years. Locally advanced (stages 2-3) patients should also have blood tests (with tumor marker CEA) and contrast-enhanced CT of the chest abdomen and pelvis during the first five years. See more

Active research in breast cancer is producing novel targeted drugs at a rapid pace. Perjeta (pertuzumab) In September 2013, the FDA approved Perjeta for use in combination with Herceptin (trastuzumab) and docetaxel for the neoadjuvant (prior to surgery) treatment of patients with HER2-positive, locally advanced, inflammatory or early-stage breast cancer (either greater than 2 cm in diameter or node positive). Pertuzumab is an antibody that targets the extracellular dimerizat...ion domain of HER2, and thereby blocks ligand-dependent heterodimerization of HER2 with other HER family members. Clinical trials have shown that neoadjuvant therapy with this combination resulted in a 39% complete response rate, meaning that cancer can not be found at the time of surgery. This rate is superior to any other existing neoadjuvant treatments. Kadcyla (ado-trastuzumab emtansine) The FDA approved Kadcyla in February 2013. Kadcyla is a HER2-targeted antibody-drug conjugate. Upon binding to the HER2 receptor, ado-trastuzumab emtansine results in intracellular release of DM1-containing cytotoxic catabolites. Binding of DM1 to tubulin disrupts microtubule networks in the cell, which results in tumor cell death. Kadcyla is indicated for patients with HER2-positive, metastatic breast cancer who previously received Herceptin and a taxane, separately or in combination. A large clinical trial has shown that this new drug gave patients a median overall survival of 31 months, in comparison to 25 months with other drugs. Afinitor (everolimus) In July 2012, the FDA approved Afinitor for the treatment of postmenopausal women with advanced hormone receptor-positive, HER2-negative breast cancer in combination with exemestane, after failure of treatment with other hormone blocker pills. The tumors in these cases essentially developed resistance to existing hormone blocker pills. Afinitor is an inhibitor of mTOR, which is important for cancer cell proliferation. A large clinical trial yielded a median progression-free survival of 8 months for patients receiving this new drug, versus 3 months for those on placebo. The final analysis of overall survival is expected to occur in June 2014.

Gastric Cancer - An Update In the United States in 2014, there will be an estimated 22,220 new cases of gastric cancer. Also in 2014, approximately 10,990 people will die from this malignancy. In other countries, gastric cancer is much more prevalent. In Japan, it is the most common type of malignancy in men. The incidence of gastric cancer is much higher in China than in any other country. There is no screening program in the US for this disease. Therefore, gastric can...cer is usually diagnosed when the patient develops symptoms. Risk factors include H. pylori infection, smoking, and heavy alcohol use. Surgery is the primary and most effective treatment for early gastric cancer. Yet, only about 50% of patients were able to have complete resection of their tumor with negative margins (an adequate rim of normal tissue around the cancer). Gastric cancer is considered unresectable if: 1) there is distant metastasis (for example, to liver or lungs); 2) spread into the abdomen; 3) encasement of major blood vessels in the abdomen; or 4) involvement of many lymph nodes. Sometimes, even when the disease is incurable, surgery is still done for relief of obstruction or bleeding. For selected patients with gastric cancer, neoadjuvant chemotherapy is given before surgery. This is done to shrink the tumor, so to maximize the chance that surgery would be successful. This treatment includes epirubicin, cisplatin and 5-fluorouracil (ECF). In other cases, chemotherapy and radiation may be offered after surgery if the cancer is deep/large, or if lymph nodes are involved. In cases where the cancer is deemed unresectable or has metastasized to distant organs, chemotherapy is recommended as palliative therapy. There is active research to discover new and more effective therapies for this deadly disease. Patients are highly encouraged to participate in clinical trials in the fight for better treatments for gastric cancer. See more

How to calculate your risk for breast cancer National Cancer Institute Model: http://www.cancer.gov/bcrisktool The NCI risk assessment tool is essentially a simplified Gail Model that also factors in race. Race is a factor in determining breast cancer risk but is excluded when determining eligibility for clinical trials. This tool is probably the most popular risk assessment tool available to the public as an on-line, interactive risk calculator. The on-line quiz i...s a shorter, nine-point questionnaire that includes multiple factors, giving a woman her future five-year risk of breast cancer and her lifetime risk of breast cancer. The NCI tool does not account for a lot of risk factors that can be modified. For this reason, it is difficult to use this test as a motivation tool to show people how lifestyle can alter their risk of breast cancer. It also cannot be used in breast cancer survivors, in patients with DCIS, LCIS, or people who carry one of the BRCA genes. It does not account for other factors such as hormonal replacement therapy, lifestyle factors, breast feeding, menopause, or mammographic density. Harvard Center for Cancer Prevention Risk Assessment Tool: http://www.diseaseriskindex.harvard.edu This is another breast cancer risk assessment tool that includes more lifestyle factors than the NCI or Gail Model tools. It has not been studied as extensively as the Gail Model or the simplified NCI model, but it is promising in that it includes many lifestyle factors that people can do to modify their risk of developing cancer. This is a great interactive questionnaire that calculates five-year and lifetime risk of breast cancer developed by the Harvard Center for Cancer Prevention and made public online in 2000. The risk calculator includes lifestyle factors such as weight, dietary vegetables, alcohol intake, as well as Jewish ethnicity. It does not include other ethnicities, however, and is not accurate for BRCA mutation carriers or breast cancer survivors. Despite these issues, this is a great free online risk calculator since it is very interactive and gives you a personalized description of your risk in the form of a colored bar graph, which they can electronically manipulate to experience "virtual" risk reduction. The bar graph is a seven-level scale that compares users to a typical man or woman your age. Users learn where to focus their prevention efforts and how to make lifestyle changes by "clicking on" personalized strategies. With each click, the bar graph shrinks, and the user watches his/her predicted risk drop. This is a great concept to motivate people to participate and comply with lifestyle modification measures.

Surgery for prostate cancer - an update Prostate cancer is the most common form of cancer in men and the second leading cause of cancer deaths in American males. In 2013, approximately 238,590 patients were estimated to be diagnosed with this malignancy. An estimated 29,270 died of this disease in 2013 alone. In recent years, there emerges a trend to not treat prostate cancer, called "watchful waiting". This is because in some cases, this malignancy does not affect life ...expectancy. Screening for prostate cancer also became optional for men of "normal" risk. A new study, however, indicates that radical prostatectomy reduces mortality among men with localized prostate cancer (cancer that has not spread). This was published on 3/6/14 in the New England Journal of Medicine (Radical Prostatectomy or Watchful Waiting in Early Prostate Cancer, by Anna Bill-Axelson MD PhD, and others). The Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) randomly assigned 695 men with early prostate cancer between 1989 and 1999 to watchful waiting or radical prostatectomy. The follow-up lasted through the end of 2012, for about 23 years. The overall death rate was 58% (200 of 347) in the surgery group, and 71% (247 of 348) in the watchful waiting group. Prostate cancer-specific mortality was 18% (63 of 347) in the surgery group, and 28% (99 of 348) in the watchful waiting group. The authors concluded that the benefit of surgery with respect to death from prostate cancer was largest in men younger than 65 years of age and in those with intermediate-risk prostate cancer. There was no significant difference in mortality in either high-risk or low-risk cases. In patients 65 or older, surgery reduced future cancer spread (metastasis), although it did not change mortality rate. Thus, surgery for early prostate cancer may be more beneficial than previously thought. This decision should take into consideration the significant side effects that accompany radical prostatectomy, such as incontinence and impotence.

Treatment for early in situ breast cancer - an update Breast cancer is the most common form of cancer in women and the second leading cause of cancer deaths in American females. In 2013, approximately 238,590 patients were estimated to be diagnosed with the invasive form of this malignancy. An estimated 40,030 died of this disease in 2013 alone. About 64,640 additional patients had the early form called DCIS (ductal carcinoma in situ). Recently, there have been article...s in the popular press suggesting that breast ductal carcinoma in situ is "over-treated" with surgery, radiation, and hormone blocker pills (usually prescribed for five years). It is still standard of care to remove DCIS with surgery. Some people question whether radiation therapy is really necessary after lumpectomy. A new study indicates that radiation reduces the risk of recurrence by a factor of two. This was published on 11/10/13 in the Journal of Clinical Oncology (Breast-conserving treatment with or without radiotherapy in ductal carcinoma In Situ: 15-year recurrence rates and outcome after a recurrence, from the EORTC 10853 randomized phase III trial, by M Donker, and others). Between 1986 and 1996, 1,010 women with complete surgical excision of DCIS (size less than 5 cm) were randomly assigned to no further treatment (503) or radiation therapy (507). In this European Organisation for Research and Treatment of Cancer study, the median follow-up time was 15.8 years. The authors report that radiotherapy reduced the risk of any cancer recurrence by 48%. The recurrence rate was 30% in patients treated with surgery only, compared to 17% in those who received both surgery and radiation. Of these recurrences, 48% were again the early type, ductal carcinoma in situ. However, 52% of cases recurred as invasive breast cancer. These women had five times higher risk of death than those who did not recur. Therefore, radiation therapy is still beneficial in cases of ductal carcinoma in situ. Exceptions to the standard of care may be acceptable in older patients with small DCIS, who prefer to avoid radiotherapy.

Resveratrol - an "anti-aging" supplement Resveratrol is found in red wine, purple grape juice, red grape skin and grape seeds. Usually, supplement manufacturers use the root of the Japanese knotweed (Fallopia japonica) as a source of resveratrol. Laboratory experiments on resveratrol revealed anti-oxidant, anti-inflammatory, and anti-cancer activity. Mice fed resveratrol were shown to live 15% longer. In March 2013, David Sinclair, Harvard Medical School professor of gene...tics, showed that resveratrol stimulates production of SIRT1, which blocks diseases by speeding up the cell's energy production centers known as mitrochondria. There have been a few publications on human use of resveratrol. A study from Europe demonstrated that 30 days of resveratrol supplementation induces metabolic changes in eleven obese men, mimicking the effects of calorie restriction (http://www.sciencedirect.com//article/pii/S155041311100386X). The men had decreased blood pressure and triglycerides, as well as improved liver function and insulin sensitivity. A study from India with 3-month administration of resveratrol to 62 diabetic patients reported improved control of diabetes, lower blood pressure and cholesterol level (http://www.nrjournal.com/art/S0271-5317(12)00120-0/abstract). A study from Spain (Tomé-Carneiro, June 2013, http://www.sciencedirect.com//article/pii/S1043661813000601) reports that one-year supplementation with resveratrol results in beneficial immunomodulatory effects in diabetic and hypertensive patients with coronary artery disease. However, a recent 8-week study on 27 healthy, physically inactive men around 65 years old found that exercise training is highly effective in improving cardiovascular health parameters, but resveratrol lessens the positive effects of training on several endpoints including blood pressure, plasma lipid concentrations and maximal oxygen uptake ( http://jp.physoc.org///07/19/jphysiol.2013.258061.abstract). Currently, there are multiple human clinical trials in the United States to assess the potential benefits of resveratrol supplementation. The US National Institute of Health website (http://www.clinicaltrials.gov) lists 75 such trials. Hopefully in the next few years, more information will be available about long term use of resveratrol in people. Resveratrol has blood thinning capacity, and may also interact with prescription medications. Therefore, you should discuss with your doctor before taking this supplement. It has some estrogenic characteristic, and thus should not be taken by breast cancer patients. Due to its anti-growth activity, resveratrol should be avoided in children, pregnant or breastfeeding women, or women trying to conceive. See more

What to do about new controversy about mammogram The controversy about screening mammogram rages on. Last week, the Canadian National Breast Screening Study published its conclusion that "annual mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination." Some people may interpret this result as women don't need mammogram anymore. On the other hand, we have new laws recommending more tests beyond screening mammogram for...Continue reading

Asians have a lower incidence of breast cancer than Americans. However, Asians migrating to the United States have almost the same risk of breast cancer as American-born females. In addition, the age-adjusted death rates from breast cancer are 2-8 fold less in Asian countries than in the United States and Western Europe. This difference in breast cancer mortality has been correlated with differences in dietary patterns. In some Asian countries, women consume an average of... 20-50 times more soy products per capita than American women. Therefore, it has been believed that the lifetime consumption of soy is beneficial. However, a few years ago, some rodent experiments showed that soy increases breast tumor growth implanted in the animals. This made many women worry. But rats and mice metabolize soy differently than humans. It is well known in the drug development world that medications sometimes can have opposite effects in rodents than in people. Therefore, it is important to look at human data. Overall, the epidemiologic evidence supporting the idea that high soy consumption protects against breast cancer is favorable, although inconsistent. The majority of studies show that regular soyfood consumption reduces the risk of breast cancer. Yet, others report that high soy intake is associated with a lower breast cancer risk in premenopausal but not postmenopausal women. A few published reports suggest that soy consumption is not associated with any difference in breast cancer incidence. It should be noted that we have not found any human study reporting that soy increases breast cancer risk. In patients who had breast cancer in the past, the conclusion of multiple epidemiologic studies indicates that soy does not make prognosis worse. Some subgroups of women with soy consumption actually had better outcome. In Asian breast cancer survivors, postmenopausal women with high soy intake had lower risk of tumor recurrence or death compared to those with low soy. This finding has also been reported in Caucasian women. In our opinion, soy is safe. High soy consumption probably does help prevent breast cancer. In regards to patients who already had breast cancer, soy is not harmful, but may be beneficial.

Red yeast rice - a "natural" way to lower cholesterol. Red yeast rice has been used in China for over 1,000 years. Fermentation of rice with the yeast Monascus purpureus produces red yeast rice. It contains compounds that block cholesterol absorption in the gastrointestinal tract. Furthermore, red yeast rice reduces the body's cholesterol synthesis in the liver. Several studies have shown that red yeast rice is effective. Dr. David Heber (American Journal of Clinical Nut...rition, 1999, http://ajcn.nutrition.org/content/69/2/231.full) conducted a trial on 83 patients with an abnormal lipid profile. Subjects were given red yeast rice or placebo pills. After two months of this regimen, people taking red yeast rice had significantly decreased levels of total cholesterol, LDL (low-density lipoprotein, bad cholesterol) and total triacylglycerol. HDL (high-density lipoprotein, good cholesterol) did not change. Separately, Dr. David Becker (Mayo Clinic Proceedings, 2008, http://www.mayoclinicproceedings.org/ar/S0025-6196(11)60914) treated 62 patients who could not tolerate statin drugs due to the muscle pain side effect. One group took red yeast rice, and the other placebo pills. Measurements were taken at three months and six months. Patients on red yeast rice had lower total cholesterol and LDL. There was no effect on triglycerides or HDL levels. To determine if red yeast rice can reduce cardiovascular events, Dr. Zongliang Lu (American Journal of Cardiology, 2008, http://www.ajconline.org/art/S0002-9149(08)00353-6/abstract) performed a multi-year study in 5,000 Chinese patients after a heart attack. Total cholesterol and LDL levels declined. Patients given red yeast rice had fewer repeat heart attacks, deaths, and less need for angioplasty or cardiac surgery, A problem with over-the-counter red yeast rice products is that there is no consistent amount of "statin" like compound. Some brands may even contain toxins such as citrinin. This substance is made by yeast or fungi grown on the rice. Citrinin has been shown to damage kidneys in animals; its effect on humans is unknown. ConsumerLab (https://www.consumerlab.com) is a company that does independent testing on red yeast rice products commonly available. For a fee, you can obtain the company's results to help you decide which brand to buy. Abnormally high cholesterol and lipid level is a medical condition that should be treated by a physician. Red yeast rice tends to cause less muscle pain than well known "statin" drugs, but it likely is less effective than prescription drugs. Red yeast rice does have interactions with certain medications, grapefruit juice and St. John's wort. It should be avoided in patients with liver disease, pregnant or breastfeeding women. Therefore, you should discuss with your doctor before taking this supplement, instead of a prescription "statin" drug. See more