Cancer Surgery Innovation

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I usually don’t write about new technology until its actually available in the marketplace. However, photoacoustic microscopy is likely to be available in the near future and has a potential benefit that’s important enough to be worth knowing.

One of the classic problems with cancer is that the surgeon can’t see which cells are cancerous.  That means, when they do surgery to remove cancer, they may not get all of the cancerous cells on the first try.

The surgical response has been to talk extra tissue around the margins of the tumor to try to ensure getting all of the cells.  As I like to tell people, if that involves taking a little extra skin tissue, that’s probably OK. A little extra brain tissue, maybe not so much.

The inability to visualize which cells are cancerous helps to make treatment of certain cancers particularly difficult. Obvious examples are brain, prostate and pancreatic cancer. Biopsies depend on sampling tissue, and it’s possible for samples to miss cancer cells. However, complete removal of an organ can be problematic as well.

There are various research projects to try to develop tools to eliminate this problem.

  • Immunotherapy involves using a virus to identify and mark cancer cells, enabling the body’s immune system to eliminate the cells without surgery. The problem is that it can have side effects, including attacking cells you want to keep (heart tissue, liver, etc.). Duke University has been one of the leaders in this field for brain tumors. MD Anderson Cancer Center has been a leader in other cancer forms (pancreatic, prostate).
  • Coloring cancer cells to make them more readily visible. There was a recent clinical trial at UPenn on this method.
  • Photoacoustic microscopy.

This last procedure has been under development at the Optical Imaging Lab (formerly based at Washington University, St. Louis; as of the first of this year, at Caltech) for breast cancer surgery.

  • Cancer tissue has a larger nuclei than normal breast tissue
  • Cancer tissue is packed more tightly than normal breast tissue
  • Using sound to cause tissue to vibrate, the surgeon can see which cells have with characteristics while surgery is in progress. This improves the odds that he will remove all malignant tissue while minimizing removal of good tissue, and reduces the need for follow-on surgeries.

That’s particularly important for “breast-conservation” or lumpectomy procedures. It may have value with other cancer forms.

Because photoacoustic microscopy is an imaging procedure, approval by the FDA is expected to be faster than for pharmaceuticals or surgical procedures that actually contact the body. Thus, this is a method that could be available for use relatively soon.


Sources:

  1. Lihong V. Wang et al. Fast Label-free Multi-layered Histology-like Imaging of Human Breast Cancer by Photoacoustic Microscopy. Science Advances, May 2017 DOI: 10.1126/sciadv.1602168
  2. California Institute of Technology. “Cutting down on cancer surgeries: New microscopy technique could reduce repeat surgeries for breast cancer patients.” ScienceDaily. ScienceDaily, 17 May 2017. <www.sciencedaily.com/releases/2017/05/170517154728.htm>.

Paradox: Breast Cancer Survival and Healthcare Costs

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Metastatic breast cancer — where the cancer has spread to distant part of the body — is ben_franklinthe most severe form of the disease.

A new study from NIH documents improvement in life expectancy among women with this form of the disease.

The researchers estimated that between 1992-1994 and 2005-2012, five-year relative survival among women initially diagnosed with MBC at ages 15-49 years doubled from 18 percent to 36 percent. Median relative survival time between 1992-1994 and 2005-2012 increased from 22.3 months to 38.7 months for women diagnosed between ages 15-49, and from 19.1 months to 29.7 months for women diagnosed between ages 50-64. The researchers also reported that a small but meaningful number of women live many years after an initial diagnosis of MBC. More than 11 percent of women diagnosed between 2000-2004 under the age of 64 survived 10 years or more. (1)

Obviously, the survival rates, while better, aren’t good. The best results occur when the cancer is caught at a much earlier stage where it is more easily treatable.

While improving the life expectancy of people with advanced cancer is a good thing, it means higher costs in treating the cancer. Simply, the patient is under treatment for a longer period of time.

The current health insurance system in the US basically penalizes everyone for patients surviving for a longer time with advanced disease. Costs go up, driving health insurance rate increases.

The ACA attempted to address the paradox by driving consumers to have more frequent exams and earlier detection of disease.

The AHCA, by reducing enrollment in health insurance, actually makes the situation worse. 


Sources: National Institutes of Health, “Study estimates number of U.S. women living with metastatic breast cancer,” press release, 18 May, 2017. https://www.nih.gov/news-events/news-releases/study-estimates-number-us-women-living-metastatic-breast-cancer

 

What you need to know about breast implants

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There are some nasty surprises associated with implants. If you’re thinking about them, ben_franklinyou need to have a serious conversation with your doctor. If he or she seems unaware of these issues, find another doctor.

A New York Times article today discusses a rare form of cancer that seems to be caused by implants. The problems are particularly linked to implants that have a textured shell or covering. Presumably, the texturing was introduced to help the implant stay in place. The theory now is that the roughness triggers inflammation that can facilitate cancer. The disease originates in scar tissue that builds around the implant.

The cancer is breast implant-associated anaplastic large-cell lymphoma. It’s a cancer of the immune system that is easily treated if detected early, but can (and has been) fatal if not.

The first case of this disease was reported ion 1997. The FDA reports that it has known about this since 2011, but refers to disease as rare. However, the FDA’s reporting system is strictly voluntary, and there is some evidence that a majority of doctors are unfamiliar with this cancer version. One study reports that only 30% of doctors who do implants discuss this risk with their patients.

Right now, the burden of protection from this disease appears to fall on the patient.

The FDA released an advisory statement to doctors on March 21st, 2017, six years after the topic first came up. The American Society of Plastic Surgeons republished the information from the FDA to its members after the FDA statement was released. That’s how new this is.

That’s one reason why it’s likely that there have been misdiagnosed cases, and that the incidence of this disease is under reported.

Another reason for misdiagnosis is that detection of this disease isn’t simple. The Anderson Cancer Center provides this guidance:

Because other diseases and cancers of the breast can cause similar symptoms, implant-associated ALCL is often a difficult diagnosis. Symptoms can vary from person to person.

More common symptoms include:

  • A spontaneous fluid collection in the breast, developing many months or years after receiving a breast implant
  • Redness and swelling of the breast around an implant that is not from an infection

Less common symptoms:

  • Contraction of the scar tissue capsule surrounding the breast implant

If you have one or more of these symptoms, it does not mean you have implant-associated ALCL. However, it is important to discuss any symptoms with your doctor since they may indicate other health problems.

So how many cases are there, really?

There are enough cases that one major cancer center brags about their expertise in this form of cancer:

MD Anderson’s Breast Center cares for more patients with breast implant-associated anaplastic large cell lymphoma (ALCL) than almost any other center in the United States.

There are two other facts buried in the Times article that women — and the people who love them — need to know:

  • Implants often require follow-on surgery. The additional surgery may be more expensive than the original, and may not be covered by insurance even if it is medically necessary. There are law suits pending.
  • The first line of treatment for implant-associated ALCL is REMOVAL OF THE IMPLANT. Based on case studies, that’s something else that some doctors don’t know.

It’s critical to find a competent doctor. Don’t feel bashful about changing doctors if you’re not sure the first one you see has the experience and knowledge you need. Ask questions. It’s your life at stake.

Happy Mother’s Day!


Sources:

  1. Denise Grady, “A Shocking Diagnosis: Breast Implants ‘Gave Me Cancer’,” The New York Times, 14 May 2017.
  2. US Food and Drug Administration, “Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239995.htm
  3. MD Anderson Cancer Center, “Implant Associated Anaplastic Large Cell Lymphoma.” https://www.mdanderson.org/cancer-types/implant-associated-anaplastic-large-cell-lymphoma.html
  4. Mark Clemons, MD, “Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL),” American Society of Plastic Surgeons. https://www.plasticsurgery.org/for-medical-professionals/quality-and-registries/bia-alcl-by-the-numbers
  5. Garry Brody et. al., “Anaplastic Large Cell Lymphoma (ALCL) Occurring in Women with Breast Implants: Analysis of 173 Cases,” Plastic & Reconstructive Surgery 135(3) · December 2014, DOI: 10.1097/PRS.0000000000001033