Study sees benefit in prostate cancer surgery

Men with early prostate cancer who have their prostate glands surgically removed are less likely to die from the disease than those who take a more passive, wait-and-see approach, researchers said on Tuesday.

There is controversy over what approach is the best in dealing with prostate cancer, typically a slow-growing tumor that in some cases poses little threat to the man.

Some experts have questioned whether radical prostatectomy, which is surgical removal of the prostate gland and nearby tissues, is always merited soon after a man is diagnosed with prostate cancer.

The study involved about 700 men from Sweden, Finland and Iceland diagnosed early prostate cancer while in their 60s on average.

Half were assigned a radical prostatectomy and half were given a passive "watchful waiting" approach in which they were not immediately given surgery. Later treatment depended on changes in their condition.

After tracking them for an average of about 11 years, 13.5 percent of men in the surgery group died from prostate cancer, compared to 19.5 percent of men in the watchful waiting group.

Dr. Lars Holmberg of the Kings College Medical School in London, who helped lead the research, said that in this study in order to avert one man's death from prostate cancer, about 20 men must undergo radical prostatectomy.

With an estimated 254,000 men dying from prostate cancer annually, it is the sixth leading cause of cancer death in men worldwide, according to the American Cancer Society.

Surgery and other types of treatment such as radiation or hormone therapy pose their own risks and side effects, including urinary, erectile dysfunction and other problems.

CONSISTENT FINDINGS

The Scandinavian Prostate Cancer Group study was launched in 1989 with hopes of clarifying whether the best way to deal with prostate cancer is patience or aggressive treatment.

The researchers previously published findings after tracking the men for an average of eight years, also seeing a survival benefit for the men who got surgery.

"The gain in terms of prostate cancer mortality from radical prostatectomy still holds out 10 to 15 years after the operation," Holmberg, whose findings appear in the Journal of the National Cancer Institute, said in a telephone interview.

Because the study covered years when many men did not get regular prostate cancer screening using the prostate-specific antigen, or PSA, blood test, Holmberg said the results do not directly address the question of the value of PSA screening.

Studies looking into whether PSA screening saves lives are still ongoing. Some experts note that such screening often can detect tumors that may never threaten the life of the man, and lead to surgery and other treatment that is not necessary.

A U.S. panel of experts last week said PSA screening for prostate cancer is not likely to benefit men over age 75 and is not recommended for them. The panel said more evidence is needed to determine whether younger men benefit from early detection of this usually slow-developing form of cancer.

But researchers at Brigham and Women's Hospital in Boston this week said men who had been screened for a longer period of time using PSA tests were less likely to have more serious features of prostate cancer at the time of diagnosis.

Holmberg said the watchful waiting approach assessed in the study may be outdated, with "active surveillance" now favored by some as an alternative to aggressive surgical treatment. With active surveillance, doctors more closely monitor a patient's condition in deciding if treatment is merited.

With PSA screening finding tumors so early on, Holmberg said it is possible "up to 50 or even 100" men would need to have surgery in order to avert one prostate cancer death.

Radiation can zap cancer that has spread

Precisely targeted radiation therapy can eradicate tumors that have spread to other parts of the body, offering more months or years of life to patients who have no other options, U.S. researchers reported on Wednesday.They said new radiation techniques can attack metastases -- tumors that have spread -- one by one.

Experiments in 29 patients showed the radiation stopped all the tumors in six, or 21 percent, of the patients, for anywhere between 10 months and more than two years.

"This was proof of principle in patients who had failed the standard therapies and had few, if any, remaining options," said Dr. Ralph Weichselbaum of the University of Chicago Medical Center, who led the study.

But the results were inconsistent -- in another six patients, only the treated tumors grew, while in yet another six, untreated tumors remained and grew, the team at the University of Chicago Medical Center reported in the journal Clinical Cancer Research.

In eight of the patients, new tumors appeared but the treated tumors were stopped.

Higher doses of radiation have been shown to be safe for many places on the body and might work better, Weichselbaum said in a telephone interview.

He said more patients with a variety of cancers, including lung, head and neck, breast, colon and ovarian, are being treated now with higher doses and are surviving longer.

All have stage IV cancer, meaning it has spread to more than one place throughout the body. Almost all patients with stage IV cancer die, even with chemotherapy, except for patients with testicular cancer and some blood cancers.

FEW OPTIONS

"These patients had been through experimental treatments, so it is not like we got anybody who had standard of care left, Weichselbaum said.

Each volunteer got three doses of precisely targeted radiation to their tumors. New guided radiation techniques can limit the amount of damage to healthy tissue and new imaging techniques, such as CT and PET scans, can help doctors find tumors they previously might have missed.

All the patients had some fatigue but few had serious side effects. One developed severe vomiting and another had internal bleeding that required a blood transfusion.

"Although our radiation wasn't able to control the disease in everybody, if we had treated where they had recurred with further radiation, surgery or other types of ablation, they could have been rendered disease-free," Dr. Joseph Salama, who worked on the study, said in a telephone interview.

"Not all metastatic cancer is the same. In some people, more aggressive therapy can potentially be beneficial," Salama added.

Ten patients out of the original 29 remain alive, Salama said, and nine lived more than 20 months. They are treating more patients with higher doses of radiation now and of 51 patients treated so far, 15 are alive.

The researchers hope to find a genetic signature or some other way of identifying the patients who may hope to benefit from this radiation.

One key question is whether chemotherapy must first get rid of the tiny tumor seeds that spread and grow into metastases, Weichselbaum said.

"Most likely this will be used with the targeted therapies," he said.

New targeted drugs go straight for the mutation that causes the cancer, as opposed to traditional chemotherapy and radiation approaches that kill quick-growing cells, which include tumors but also healthy tissue.

Arm swelling after breast cancer surgery common

ncer, many women will experience arm swelling - a bothersome condition doctors refer to as lymphedema.
Lymphedema is a public health issue "deserving greater attention," doctors from Australia wrote in a recently published paper.

Among 287 women with breast cancer, 190 took part in all assessments during 18 months of follow-up after surgery and arm swelling developed in 62 (33 percent) of them during that time, Dr. Sandra C. Hayes and colleagues from Queensland University of Technology in Kelvin Grove found.

Roughly 60 percent of these women had fleeting symptoms, whereby the lymphedema dissipated with or without treatment. However, 40 percent of women experienced long-term arm swelling lasting more than 3 months, with or without intermittent periods of relief.

Women with lymphedema, Hayes told Reuters Health, "were twice as likely to have poorer upper-body function when compared with women who had not developed arm swelling. Poor upper body function is associated with reduced quality of life," she noted.

More extensive breast surgery increased the odds of lymphedema six-fold and having more than 20 cancerous lymph nodes removed increased odds four-fold.

Hayes noted that two identified risk factors for arm swelling post-surgery -- insufficient physical activity and not using the affected arm -- "are amenable to interventions and should be investigated for their preventive and therapeutic effects among women after treatment for breast cancer."

"It was found that use of the treated side likely decreases risk of developing lymphedema," Hayes said.

SOURCE: Journal of Clinical Oncology, July 20, 2008.

2 New Genes Tied to 3 Cancers

Two genes linked to breast, thyroid and kidney cancer have been identified by Cleveland Clinic researchers. The discovery of the genes SDHB and SDHD could help improve early detection of these cancers and boost patients' chances of survival.

In addition, the researchers said their finding could improve screening and treatment of patients with Cowden Syndrome (CS) and CS-like disease, which are difficult-to-recognize conditions that lead to a high risk of developing breast, thyroid and other cancers.

Normally, a gene called PTEN acts to suppress cancers. Mutations in PTEN determine susceptibility to CS, but some people with normal PTEN still develop CS, according to background information in a clinic news release.

The reseaqrchers identified SDHB and SDHD as markers of CS susceptibility in people with normal PTEN. In fact, mutations in these genes confer a higher risk of breast, thyroid and kidney cancers than PTEN mutations for individuals with dysfunctional PTEN, the researchers said.

"Clinicians should consider SDH testing for patients who have a strong personal history and/or family history of breast, thyroid and/or kidney cancers especially when their PTEN is normal. Patients with SDH mutations should be more rigorously screened for these cancers," lead researcher Dr. Chris Eng said in the news release.

Rigorous screening may reveal cancer at a earlier, more treatable stage.

The study is published in the Aug. 8 issue of The American Journal of Human Genetics.

Breaking the News About Breast Cancer

Shelley Volz, now 59, got the news about her breast cancer diagnosis 10 years ago, right before she was headed from San Francisco to New York for the wedding of her younger brother.After much thought, she decided to tell only her mother before the wedding and to hold off telling other family members. "My mother had a typical mother's reaction, tears and hugs, and we moved on," Volz said. "She really appreciated the fact that I didn't want to steal the limelight there."

Volz waited until after the wedding celebration to calmly tell others. Ten years later, after successful treatment, she is doing fine.

While she says she doesn't think she found it as difficult as many people to disclose the diagnosis, she did think about others' reactions.

In that sense, she is typical, according to a new study. "Even when women are facing a breast cancer diagnosis, they are still concerned about caring for everyone else, especially the emotions of others," said study author Grace J. Yoo, a medical sociologist at San Francisco State University's Biobehavioral Research Center.

She presented the findings Monday at the American Sociological Association annual meeting, in Boston. The research is especially timely, given the recent news that actress Christina Applegate, 36, is being treated for early breast cancer.

Yoo and her team interviewed 164 San Francisco-area breast cancer survivors, average age 57, of different ethnicities to evaluate the "emotion work" involved in telling others about the diagnosis.

In interviews with the researchers, the women talked about their feelings and actions after getting the diagnosis.

"Even telling someone, 'I have breast cancer,' it's well thought out," Yoo said. "They know the statement, to some, can overwhelm." Women react in different ways -- stifling their own emotions so they don't appear vulnerable, paying attention to the timing of their news, or sometimes letting it all out, she said.

>Women find it somewhat easier to tell friends than family members, she found. "Women are trying to protect older, aging parents and younger children and even their spouses, even during illness. Women are socialized to care about others."

Ideally, Yoo said, women should do less of that at this time. "It's a time they should be caring about themselves, what decisions they should be making about breast cancer. They shouldn't emotionally burn themselves out by caring for others' emotions."

One woman, for instance, told the interviewer that she didn't tell her mother about her breast cancer until after the surgery, because she knew her mother would worry. Many women said once they were told about the diagnosis, they were surprised about the outpouring of help, even from acquaintances. But some feared that if they told, people may not care enough to help.

The findings ring true with what another expert has seen in clinical practice. This has "documented what we have known instinctively," said Lori Worden, an oncology social worker in Grants Pass, Ore.

Her advice to women? "You don't need to tell people today." Feel free to process it yourself first. Practicing what you will say, by saying it out loud to yourself or writing it down, can help, she said.

Yoo's advice: "We tell women to seek out other breast cancer survivors, other women who understand, to increase their resources." And focus more on getting emotional support than giving it.

Prostate cancer prognosis worse in obese men

Prostate cancer diagnosis tends to be delayed and surgical treatment more difficult in obese men than in lean men, according to two studies published Friday.The primary reason for the later diagnosis, and consequently poorer prognosis, seems to be that the PSA test used to screen for prostate cancer is "biased" against obese men, according to researchers.

The problem, they explain, may stem from obese men's larger blood volume, which dilutes their PSA levels. High blood levels of PSA -- or prostate specific antigen - can signal the presence of a prostate tumor.

"We know that obese men tend to have lower PSA values than their normal-weight counterparts, possibly caused by larger blood volumes which dilute their readings," Dr. Stephen J. Freedland, who led the studies, said in a written statement.

"Now we know some of the real implications of this -- that these men are at a disadvantage in terms of prognosis compared to normal-weight men."

Freedland, of Duke University Medical Center in Durham, North Carolina, and his colleagues report their findings online in the journal BJU International.

In one study, the researchers looked at the outcomes of nearly 3,400 prostate cancer patients who had undergone surgical removal of the prostate between 1988 and 2007. Some had had their cancer detected by PSA, while the rest had had it discovered during a digital rectal exam.

Overall, Freedland's team found, obese men were more likely to have more-aggressive tumors and to suffer a cancer recurrence after surgery.

However, the link between weight and disease progression was limited to men treated since 2000, when PSA screening had become the norm.

By contrast, obesity had no effect on the risk of progression for cancers detected by digital rectal exam. The findings support the notion that PSA testing, in particular, confers a bias against obese men, according to Freedland.

In the second study, the researchers found that obese prostate cancer patients tend to have a higher rate of "positive surgical margins" after prostate removal -- which means the odds are higher that some tumor cells were left behind.

"The aggressiveness of obese men's tumors, coupled with the fact that they may be more difficult to remove, is like a double whammy for being obese," Dr. Jayakrishnan Jayachandran, another researcher on the studies, said in a statement.

The findings of both studies, according to Freedland, build up the case for developing alternative prostate cancer screening methods for obese men -- or for lowering the PSA threshold for these patients.

"The least we can do is find a way to level the playing field when it comes to diagnostic tools," Freedland said.

SOURCE: BJU International, online August 8, 2008.

Estrogen patch shows promise for prostate cancer

A patch that delivers estrogen through the skin may prove useful in treating advanced cases of prostate cancer, preliminary research suggests.In a study of 13 prostate cancer patients who were given the Fem7 estrogen patch, UK researchers found that the therapy substantially lowered the men's testosterone levels.

Because testosterone helps fuel the growth and spread of prostate tumors, men with more-advanced prostate cancer commonly receive drugs called LHRH analogues that block the body's production of the hormone.

However, these drugs can also have side effects, including osteoporosis and heart problems.

Estrogen patches have the potential to lower testosterone levels with a lesser risk of such side effects, according to the researchers on the new study, led by Dr. Ruth E. Langley of Imperial College London.

These early results, Langley noted, at least confirm that estrogen patches lower patients' testosterone to the desirable "castrate" levels.

"Therefore these patches show promise as a potential therapy for men with prostate cancer," Langley told Reuters Health.

The findings, published in the journal BJU International, are based on 13 men who are part of a larger trial designed to compare estrogen patches with LHRH therapy in treating prostate cancer. The researchers followed the effects of the Fem7 patch on the men's testosterone levels over 12 weeks.

The question of whether the patch should hold a place in the prostate cancer treatment arsenal requires further study, according to Langley.

"Transdermal estrogen therapy," the researcher said, "is a novel and potentially cost-effective approach to androgen (testosterone) deprivation therapy."

"Large long-term studies are required to assess its effect on prostate cancer and side effect profile compared to LHRH therapy."

SOURCE: BJU International, August 2008.

New Therapy Freezes Out Esophageal Cancers

A new method of freezing damaged cells in the esophagus to prevent them from turning cancerous is being used by gastroenterologists at the University of Texas Southwestern Medical Center at Dallas.A condition called Barrett's esophagus can result from ongoing heartburn, in which stomach acid constantly splashes into the esophagus. Untreated, this can become Barrett's with dysplasia, in which cells start to transform.

"Due to damage from chronic stomach acid, they are people who have a higher risk of developing esophagus cancer. The goal of this therapy is to literally freeze the damage in its tracks and stop it before it turns to cancer," Dr. Jayaprakash Sreenarasimhaiah, an assistant professor of internal medicine in the division of digestive and liver diseases, said in a UT Southwestern news release.

In this U.S. Food and Drug Administration-approved treatment, a special catheter is used to spray liquid nitrogen on the damaged tissue to freeze the lining of the esophagus. The treated tissue falls away, allowing normal cells to grow and replace the damaged cells in about six to eight weeks.

Patients are sedated for the cryoablation therapy, which takes about 30 to 40 minutes.

Typical treatment for Barrett's esophagus with dysplasia has included mucosal resection, in which the damaged lining is scraped away. This procedure can take hours and cause side effects such as bleeding or narrowing of the esophagus. In some cases, patients have surgery to remove the damaged sections of the esophagus. However, some patients are too sick or elderly for surgery while others want another option.

"This is a disease we see in a lot of older patients with other illnesses, so the decision to send them to surgery requires careful consideration. Cryoablation therapy is particularly attractive for older patients who may have complications or other medical issues -- such as accompanying heart or lung diseases -- that make traditional surgeries for Barrett's with dysplasia too risky," Sreenarasimhaiah said.

Obese Men Face Twin Threat From Prostate Cancer

The standard screening test for prostate cancer may not be accurate for obese men, leaving them more vulnerable to the disease, and surgery is less likely to be effective for them, a new pair of studies found.

"Obese men are more likely to be diagnosed with an aggressive form of the disease," said Dr. Stephen Freedland, an associate professor of urology and pathology at the Duke University Prostate Center, and an author of one of the studies.

The reason: The blood test that looks for elevated levels of the protein prostate-specific antigen (PSA), indicating a heightened cancer risk, doesn't seem as reliable for obese men, Freedland said.

"Our assumption is that these men have more blood volume, so PSA gets diluted, he said. "By the time obese men get to elevated levels, the cancer is more advanced."

The study, published online Friday in the journal BJU International included nearly 3,400 men who had PSA tests. The researchers found that the risk of an aggressive cancer was doubled in obese men diagnosed because of high PSA levels. No such association was found for obese men diagnosed by a digital rectal examination, in which the physician feels for an abnormally large prostate gland.

Prostate cancer is suspected when the PSA reading is 4 or higher. The current recommendation is for men aged 50 and older to be offered an annual PSA test, with explanations of its possible risks and benefits. A federal preventive medicine committee this week said that PSA screening should not be done for men aged 75 and older because the risks outweigh the benefits.

"I'm not sure that we should check obese men more often," Freedland said. "But we should have a higher [PSA] index of suspicion of what is not normal -- 3.4 rather than 4; for really obese men, 3.2."

The Duke study measured obesity using body-mass index, which is a ratio of weight to height. Obesity is defined as a BMI of 30 or more.

A second report from Duke in the same issue of the journal found that excess weight influenced the outcome of surgery for prostate cancer. Men with a BMI of 35 or higher were nearly 60 percent more likely to have a recurrence of the cancer than thinner men, the study of 1,434 men found.

One reason is "the difficulty of operating on obese men in general," said study author Dr. Jayakrishnan Jayachandran, a urology oncology fellow at the Duke Prostate Cancer Center. "The prostate is a narrow thing to operate on, and when there is a big wad of fat in your way, if the abdominal wall is thick, it becomes a technical issue."

The result is that not all the cancer may be removed, which means a recurrence after time, Jayachandran said. "The only thing we can think of is that when you operate on obese people, you have to be more careful," he said.

The studies results apply to men who might not regard themselves as obese, Freedland said. "We can't forget that when we use the term, we are not just talking about very large men," he said. "A man who is 5 foot 9 and weighs 203 pounds would be considered obese."

Jayachandran added, "We are not screening these obese men effectively and are not doing as good a job surgically as could be done."

One in five young men checked for prostate cancer

New research suggests that roughly one in five American men in their 40s has had a blood test to screen for prostate cancer within the last year. However, screening rates in black men are still considered suboptimal, the investigators say.

"Our findings for black men are discouraging," senior investigator Dr. Judd W. Moul from Duke University in Durham, North Carolina, commented in a written statement. "We've been encouraging black men to get screened at age 40 or 45 for more than a decade, yet only one-third of these high-risk men reported being tested."

Blood levels of a protein called prostate-specific antigen, or PSA, typically rise when a man has prostate cancer, so PSA testing is often used to screen for the disease.

It is generally recommended that men discuss PSA screening for prostate cancer with their doctors starting at age 50. However, the American Cancer Society recommends screening at age 45 for African American men, or earlier if there is a strong family history.

The new study posted online today in the journal Cancer involved an analysis of data collected in 2002 on 58,511 men aged 40 and older.

The findings suggest that young black men are 2.4 times more likely than their white counterparts to undergo PSA screening. Still, the investigators comment that the rate in black men -- 33.6 percent -- is disappointingly low considering that they are at higher risk for prostate cancer.

Overall, 22.5 percent of men aged 40 to 49 and 53.7 percent of older men reported having a PSA screen in the prior year. Predictors of PSA testing in young men included an annual household income of $35,000 or greater, having an ongoing relationship with a physician, and health insurance coverage.

SOURCE: Cancer, online August 11, 2008.

Researchers Hunt Normal Cells That Give Rise to Cancer

Learning more about normal cells that give rise to cancer may hold the key to understanding and treating cancer, according to Duke University Medical Center researchers who identified cells linked to a deadly brain cancer.

"Identifying the specific, normal cells that cancer come from can provide critical insight into how cancers develop. This may help us develop more rational and effective approaches to treatment," Robert Wechsler-Reya, an associate professor of pharmacology and cancer biology, said in a medical center news release.

In what's believed to be a first, the Duke team had identified two types of cells in the brain that can give rise to the malignant brain tumor medulloblastoma. It occurs most commonly in children and is treated with a combination of surgery, chemotherapy and radiation, which cause severe side effects.

In order to identify the normal cells associated with medulloblastoma, the Duke researchers and colleagues in Australia created mouse models of medulloblastoma by turning off the patched gene, an important regulator of cell growth in the cerebellum. Specifically, they switched off the patched gene in granule neuron precursors (GNPs), which make one particular type of neuron, or in stem cells, which can make all the different cell types in the cerebellum.

When the patched gene was turned off in GNPs, 100 percent of the mice developed medulloblastoma. When the gene was deleted from stem cells, most of them went on to form normal cell types within the cerebellum.

The findings provide the first definitive proof that medulloblastoma can be triggered in GNPs, the researchers said.

"Simply mutating a gene is not enough to cause cancer. The mutation has to happen in the right cell type at the right time. In the case of patched, GNPs provide the critical context for tumor formation," Wechsler-Reya said.

The study was published in the August issue of the journal Cancer Cell.

Cancer patients at increased risk of suicide

Cancer patients often think about ending their lives and their suicide rate is roughly twice that seen in the general population, according to the results of three studies appearing in the Journal of Clinical Oncology.In a survey of 2924 cancer outpatients treated at one regional cancer center, Dr. Jane Walker, from the Royal Edinburgh Hospital in the UK, and colleagues found that 7.8 percent of the patients thought they would be "better off dead" or had considered hurting themselves in some way within the last 2 weeks.

Emotional distress was the strongest predictor of suicidal thoughts, followed by substantial pain, and older age, the report indicates.

"Management of emotional distress and pain should be a central aspect of cancer care," the investigators emphasize.

In another study, Dr. Stephanie Misono, from the University of Washington in Seattle, and colleagues assessed the cancer-related suicide rates using the Surveillance, Epidemiology, and End Results program, a large national database containing information for nearly 3.6 million patients diagnosed with a malignancy between 1973 and 2002.

A total of 5838 suicides occurred, yielding a rate of 31.4 suicides per 100,000 people per year, which is nearly twice as high as the rate of 16.7 suicides per 100,000 people per year in the general population.

Male gender, white race, and older age at diagnosis were all linked with an increased risk of suicide. Patients with lung cancer had the highest suicide risk, followed by patients with malignancies of the stomach, mouth, throat and windpipe. The suicide risk was greatest within the first 5 years of diagnosis.

In a third study, Dr. Matthew Miller, from Harvard School of Public Health in Boston, and colleagues show that cancer is the only common medical condition that carries an elevated risk of suicide among older adults. His group noted that the rate was more than twice as high as that of the general population.

Their study included over 1400 patients with a variety of illnesses, such as diabetes, heart disease, and chronic lung disease. All of the subjects were at least 65 years old and New Jersey residents.

The risk of suicide was also increased among those with psychiatric diagnoses, primarily mood disorders, such as depression; these patients had 2.3 times the risk. Anxiety and personality disorders were linked with a 2.2 times increased risk of suicide.

Antidepressant use and treatment with opioid pain medications, such as morphine, were also tied to an increased risk.

The higher risk of suicide among cancer patients persisted even after concurrent psychiatric illness and the risk of dying with 1 year were considered.

In a related editorial, Dr. Timothy E. Quill, from the University of Rochester Medical Center in New York, comments that "lessening suffering of seriously ill patients though the diligent application of palliative measures and alleviating their aloneness and despair by maintaining an open, committed, receptive relationship may be the most important preventive measures with regard to suicide."

SOURCE: Journal of Clinical Oncology, August 11, 2008.

Breast cancer recurrence seen as low after 5 years

Women who survive breast cancer for five years after treatment have a relatively low risk of the disease recurring, according to a U.S. study published on Tuesday.

Even women with serious stage III breast cancer have only a 13 percent risk of the cancer returning if they survived the first five years cancer free, researchers said, commenting on a study that generally did not include some newer treatments such as Herceptin and the aromatase inhibitors.

The researchers tracked breast cancer recurrence in 2,838 U.S. women who had been cancer-free for five years after initial surgery and radiation to remove the tumor, followed by chemotherapy, hormone therapy, or both.

In those treated for stage I breast cancer -- the tumor was small and had not spread -- breast cancer came back after five years in just 7 percent.

The cancer returned in 11 percent of women treated for stage II disease -- the tumor may have been a bit larger or spread to the lymph nodes under the arm.

And 13 percent of women treated for stage III disease -- the tumor may have been larger, may have spread to additional lymph nodes or may have grown into the chest wall or skin of the breast -- saw a recurrence after five years.

"A very common question that women who are five-year breast cancer survivors ask us as oncologists is, 'What is my risk of recurrence of breast cancer now?' And that's a number that we've had a hard time coming up with," Dr. Abenaa Brewster of the University of Texas M.D. Anderson Cancer Center in Houston, who led the study, said in a telephone interview.

"I actually think that patients think that the risk is a lot higher than it is. So I hope that this paper somewhat reassures them that their risk of recurrence after they are five-year survivors is probably not as high as they think it is," Brewster added.

The women in the study, published in the Journal of the National Cancer Institute, were treated at M.D. Anderson between 1985 and 2001.

The study did not assess the effect on recurrence risk of some of the more recent additions to breast cancer treatment, including the class of drugs called aromatase inhibitors and the Genentech Inc cancer drug Herceptin.

The study found that women who had tumors known as estrogen receptor positive, in which the hormone estrogen is driving the tumor, had a higher risk of these late recurrences compared to women whose tumors were not this type.

Women who had low-grade, or less aggressive, tumors, actually had a higher risk of late recurrence than women who had higher grade tumors, Brewster said. "That was certainly a finding that we were surprised to see," she said.

Breast cancer is the top cause of cancer death among women worldwide, with an estimated 465,000 deaths annually, according to the American Cancer Society.

Postmenopausal Women With Breast Cancer Face Joint Issues

Postmenopausal women with breast cancer who are receiving endocrine treatment may be at increased risk of joint issues, including arthritis, a new study finds.British researchers publishing in the September issue of The Lancet Oncology, found that previous use of hormone replacement therapy (HRT), hormone-receptor positivity, previous chemotherapy, obesity and treatment with anastrozole -- an aromatase inhibitor -- all increased the chances of these women developing joint problems.

These increased risks appear to be tied to the significant drop in estrogen levels the patients experience during endocrine treatment. Estrogen deficiency previously has been associated with joint issues in other studies.

The researchers made their discoveries during a trial comparing the use of either an aromatase inhibitor (anastrozole) or tamoxifen in some 9,000 postmenopausal women with breast cancer. In the study, joint symptoms were reported in:

* 41 percent of women who had previously used HRT versus 29 percent of those who had not.
* Women who received previous chemotherapy also reported significantly more joint symptoms than those who had not (39 percent versus 31 percent).
* The more obese the women was, based on the body-mass index, the more likely she had joint issues.

"Awareness of risk factors for joint symptoms will help both clinicians and patients to anticipate and manage these symptoms and ensure optimum adherence to endocrine treatment," researcher Dr. Ivana Sestak of Cancer Research UK, said in a news release issued by her organization.

Risk of Breast Cancer Relapse Can Linger

The risk of relapse can linger for some breast cancer survivors even after completing five years of what doctors call systemic therapy, a new study found.But, as gloomy as that news sounds, there is a relative bright spot: the risk may not be as dire as many women fear.

"I would like to think these numbers are smaller than women think they are," the study's lead author, Dr. Abenaa Brewster, a medical oncologist at the University of Texas M.D. Anderson Cancer Center in Houston, said.

Most women, she added, "remain terrified they are going to relapse. I think the message for women is, the risk may not be as large as they think."

Brewster's team evaluated 2,838 breast cancer patients whose disease ranged from stage I to III. All had been treated with some form of adjuvant systemic therapy between 1985 and 2001 and had remained disease-free for five years, which is traditionally considered a landmark in cancer survival.

The women had a variety of treatments -- surgery, chemotherapy, radiotherapy or endocrine therapy. Endocrine therapy involves tamoxifen, aromatase inhibitors and a combination of the drugs and is usually given for five years.

About 10 years after the diagnosis, 89 percent of the women remained recurrence-free. And about 80 percent remained recurrence-free 15 years after the diagnosis.

In all, 216 patients developed a recurrence, Brewster said. She found that the risk or recurrence varied by stage and tumor type. Those women with stage I disease had a 7 percent chance of relapse; stage II, 11 percent; and stage III, 13 percent.

Besides the stage of cancer at diagnosis, hormone receptor status affected risk, the study found. "Women who had ER-positive cancer were more likely to have late recurrences than those with ER-negative," Brewster said. This finding held true for premenopausal and postmenopausal women. While 34 ER-negative women had a relapse, 149 ER-positive did.

"Estrogen receptor status is a tumor marker we look at," Brewster said. "We know that those who have ER-positive tumors [have] cancers that are responsive to the effects of estrogen."

While women in the study were taking a variety of hormone therapies, none took five years of aromatase inhibitors, which are now the standard of care for postmenopausal women but weren't when the study began in 1985, Brewster said.

The study findings were published online Aug. 12 in the Journal of the National Cancer Institute.

Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society, said the study findings leave some unanswered questions, such as the best course of action at the five-year mark. But it offers some interesting information, he added.

"The major message is that even though women may have gone through five years of hormonal therapy, they are still at risk of relapse," he said. Another important finding, he added, is that those women with ER-positive tumors seem to be at higher risk than those with ER-negative tumors.

"Basically the jury is out on the potential value of additional treatment strategies once the five years is completed," Lichtenfeld said. "Based on this study, we need to be open to question whether other treatment programs may be appropriate in some of these women after the five-year period is completed."

Surgery Helps With Prostate Cancer, Sometimes

The latest update from a European study that has followed men with prostate cancer for more than a decade leaves the debate about the advantages of aggressive treatment versus "watchful waiting" undecided.The advantage in survival seen for men who underwent surgery to remove the prostate disappeared after 10 years. While deaths attributed to cancer continued to be lower among those having surgery, the overall death rate for both groups was the same, according to the researchers with the Scandinavian Prostate Cancer Group.

The meaning of the study for men now being diagnosed with prostate cancer is uncertain, because the study began before the use of testing for prostate-specific antigen, today's primary method of diagnosis, the researchers added.

"In settings with a large proportion of PSA-detected tumors, the relative reduction in risk of death following radical prostatectomy [removal of the gland] might be somewhat larger or similar to that in our study, but the absolute reduction would be smaller," they wrote.

The findings were published online Aug. 12 in the Journal of the National Cancer Institute.

Dr. Yu-Ning Wong, an oncologist at the Fox Chase Cancer Center in Philadelphia, said it's "unclear how these results apply to the patients we are taking care of today. They show how many questions remain unanswered."

Wong led a study that found an apparent benefit in survival for men who had aggressive surgical treatment of early prostate cancer. But it wasn't a randomized, controlled trial -- the gold standard for medical research.

"Basically, I don't think we know the right answer about what to do," she said.

Prostate cancer is diagnosed in about one of every six American men. There's currently no way to distinguish between a cancer that will grow so slowly that it poses little danger to life from one that can grow aggressively enough to be fatal. A common medical saying is that "more men die with their prostate cancer than of it."

Uncertainty about prostate cancer treatment has led to a new federal recommendation that men over 75 should not have PSA tests because the risks of treatment outweigh the benefits.

A final answer about whether surgery and other aggressive treatment is preferable to merely watching the course of the disease will not come for years, Wong said. A controlled trial is under way in Europe, and one is planned for the United States, she said.

Meanwhile, the decision about treatment versus watchful waiting must be made for each individual, Wong said.

"I have discussions with a patient about his other medical conditions, his age, his willingness to receive treatment that may have long-term side effects, weighed against the risk that he may develop an aggressive cancer," she said.

Stephen Zeliadt, a research scientist at the Fred Hutchinson Cancer Research Center in Seattle, said the new study "does provide evidence that intervention in the form of surgery does have a curative effect for some men. The question is, which men?"

Another question is whether the study results apply to "a screening population" of men who have PSA tests, Zeliadt said. "With screening, you catch a lot of different types of cancer, and also at different ages. There is no information in the study on the age of detection."

So, Zeliadt added, this study doesn't help solve the prostate cancer riddle. "It probably makes it even more confusing," he said.

Dr. Peter T. Scardino, chairman of the department of surgery at Memorial Sloan-Kettering Cancer Center in New York City, said the study did offer an important finding: "The big benefit of treating potentially lethal prostate cancer comes early, in the first five to 10 years."

The study also "showed lots of benefits of surgery but did not find any benefit from surgery for men over the age of 65," he noted.

New Chemotherapy Combo Holds Promise for Lung Cancer

Preliminary research has produced promising findings regarding a possible alternative treatment for people with a common type of lung cancer.The new combination of chemotherapy drugs could eventually become another option for people with advanced non-small cell lung cancer, which is very difficult to treat, the Japanese researchers suggest.

Even if it works, however, the treatment isn't likely to add many months to the lives of patients. And the study only represents the second in three necessary stages of research.

"We really don't know if it's better than current therapy," said Dr. Norman Edelman, chief medical officer with the American Lung Association. Still, he added, "more study is warranted."

At issue are patients with advanced cases of non-small cell lung cancer, which makes up about 85 percent to 90 percent of lung cancer cases, according to the American Cancer Society.

Treatment with chemotherapy drugs is difficult, because the medications can cause side effects and may not add more than a few months to a patient's life, said lead investigator Dr. Isamu Okamoto, an associate professor in the Department of Medical Oncology at the Kinki University School of Medicine in Osaka.

But new treatments are needed, Okamoto said, even if they don't greatly extend life spans. "The main purpose of chemotherapy for metastatic advanced non-small cell lung cancer is to improve quality of life, since the patient populations are never cured," he said.

The new study looks at 56 patients with advanced lung cancer who were treated with chemotherapy drugs called S-1 and irinotecan.

Chemotherapy drugs are designed to kill cancer cells while causing as little harm as possible to healthy cells. Irinotecan is already in use in the United States; S-1 is approved in Korea and Japan, but not yet in the United States.

The findings are published in the Aug. 15 issue of Clinical Cancer Research.

About 28 percent of patients responded to the treatment. They lived for an average of 15 months and made it an average of 4.9 months without getting worse.

The researchers reported that the patients suffered less severe side effects than would be expected if they'd taken the usual platinum-based chemotherapy.

According to the researchers, studies of the existing platinum treatment suggest that patients who take it live for an average of seven to 14 months.

The next step would be to directly compare the new chemotherapy regimen to the existing platinum treatment by randomly assigning patients to one or the other.

Older Patients With Cancer at Heightened Suicide Risk

In the first study, researchers at the University of Washington analyzed U.S. data from 1973 to 2002 and found that the suicide rate among cancer patients was 31.4 per 100,000 person-years, compared to 16.7 per 100,000 person-years in the general population.

Higher suicide rates were associated being male, white and older at the time of cancer diagnosis. Patients with the highest suicide rates were those with lung, stomach, oral/pharyngeal and larynx cancers. Suicide risk was greatest within the first five years after diagnosis but remained elevated for up to 15 years after diagnosis.

The second study found that older Americans with cancer are more than twice as likely to commit suicide as those without cancer. The Harvard School of Public Health and Harvard Medical School study compared 128 New Jersey residents, age 65 and older, who committed suicide between 1994 and 2002 and 1,280 living people in the same age group.

The suicide risk was 2.3 times higher among cancer patients than among those who were cancer-free. This increased risk held true even after the researchers adjusted for age, sex, race, medical and psychiatric illnesses, and use of prescription medications.

The cancer patients in the study who committed suicide were more likely to have advanced metastatic disease, and two-thirds of them used a firearm to commit suicide. Most of the patients who committed suicide had seen a physician in the month before their death, and 25 percent had seen a doctor within a week before their suicide.

A third study by researchers at the University of Edinburgh in the United Kingdom found that cancer patients are at increased risk for suicidal thoughts. The survey of 2,924 cancer patients receiving outpatient care found that nearly 8 percent reported suicidal thoughts persisted for at least several days over the previous two weeks. A similar survey of the general population in Australia found that only 2.6 percent of respondents reported having similar thoughts.

The University of Edinburgh team found that suicidal thoughts among cancer patients were associated with having substantial emotional distress or pain, but not with cancer severity. Better management of patients' emotional distress and pain may improve quality of life and reduce suicide risk, the researchers concluded.

The research was published online Monday in the Journal of Clinical Oncology.

More attention needs to be given to suicidal thoughts and attempts by cancer patients, Dr. Timothy Quill, a professor of medicine, psychiatry and medical humanities at the University of Rochester Medial Center, said in an accompanying editorial.

"It is important to ask about suicidal thoughts regularly, especially when disease is worsening, symptoms are increasing, or the patient is entering a more serious phase of illness ... Creating an environment where these issues can be openly explored without being judged is critical," Quill wrote.

Low risk of breast cancer return if treated

The risk of patients treated for breast cancer seeing a recurrence of the disease within five years remains low, according to a new study by American scientists.The conclusion, published in the Journal of The National Cancer Institute (NCI), is based on a group of 2,838 women diagnosed with cancer that were treated with adjuvant systemic therapy -- chemotherapy or the drug tamoxifen or both -- between 1985 and 2001.

Eighty-nine percent of the women in the study group had no recurrence of cancer five years after treatment, or about 10 years after they were initially diagnosed with cancer, said Abenaa Brewster, of the Anderson Cancer Center at the University of Texas at Houston, the study's main author.

Eighty percent of the women had no recurrence 10 years after treatment, or 15 years after diagnosis, Brewster added.

Five years after treatment, the risk of a resurgence of breast cancer is seven percent for women who have the least advanced tumour -- stage one -- and of 11 and 13 percent respectively for cancers of stages two and three, the researchers said.

"Now we can tell some women, within a certain percentage, their future risk of recurrence and clinicians may be able to make more informed decisions regarding prescription of extended adjuvant endocrine therapy," Brewster wrote.

More than 180,000 new cases of breast cancer are expected to be diagnosed in the United States in 2008, and some 40,000 women die each year of breast cancer, according to American Cancer Society figures.