Despite the many advances in cancer treatments at major cancer centers, the answer to this question can be ‘no’.  You should consider traveling far away to get chemotherapy or radiation therapy when there is a clinical trial you would like to participate in.  Consider the marginal benefit and how innovative the treatment is at a center far away.  In the case of having surgery, traveling far to get an experienced surgeon makes sense if there is not one close to home.  But if the chemo or radiation you would be get at a hospital far away is the same chemo or radiation you would get close to home (i.e. same medication, same dose, same length… or at least very similar), then consider enjoying the comfort of home.

Family support is an important part of your cancer care, and when a recommended chemo or radiation regimen is one that you can have close to home, many oncologists will suggest having it done at a cancer center close to your family and support network.   Chemo and radiation can require frequent trips to the hospital (sometimes as many as 3-5 appointments per week).  In addition these treatments can sometimes be tiring.  Family and friend support can be helpful and sometimes critical.  This includes everything from rides to the hospital to verbal encouragement.  When getting a second opinion at a major cancer center far away from home, ask the oncologist if the recommended chemo or radiation regimen is the same or similar to what you can get closer to home.  Most importantly, consider the importance of your support network.

Expert Analysis Highlights:

• There is some evidence, although somewhat controversial, that acupuncture can be effective in reducing frequency of hot flashes
• A small, 12-week study concluded “Acupuncture appears to be equivalent to drug therapy…”
• A large, 4-week study did not demonstrate a statistically significant reduction of hot flashes
• However, the 4-week study concluded: “We cannot exclude the possibility that a longer and more intense acupuncture intervention could produce a larger reduction of these symptoms.”

Hot flashes can be a debilitating condition for cancer patients who are being treated with chemotherapy or hormone therapy. This includes women with breast cancer and men with prostate cancer. I have written about this condition previously, including a listing of various medications that can be taken to reduce the frequency and intensity of hot flashes. (for more information, read Study May Help Cool Hot Flashes for Cancer Patients).

There is some evidence, although somewhat controversial, that acupuncture can be effective in women…and in men…who suffer from hot flashes. In a scientific study conducted at Henry Ford Hospital and published in the Journal of Clinical Oncology (February 1, 2010; vol. 28:pages 634-40; abstract listed below), 50 breast cancer patients volunteered for a  randomized controlled trial that tested whether acupuncture reduces vasomotor symptoms and produces fewer adverse effects than venlafaxine (Effexor), a commonly used drug for hot flashes. The investigators concluded that: “Acupuncture appears to be equivalent to drug therapy in these patients. It is a safe, effective and durable treatment for vasomotor symptoms secondary to long-term antiestrogen hormone use in patients with breast cancer.”

However, the evidence for acupuncture is not compelling. For example a slightly larger study from Memorial Sloan Kettering Cancer Center in 2007 did not convincingly demonstrate that acupuncture worked (J Clin Oncol. 2007 Dec 10; volume25:page 5584). They concluded: “Hot flash frequency in breast cancer patients was reduced following acupuncture. However, when compared with sham acupuncture, the reduction by the acupuncture regimen as provided in the current study did not reach statistical significance. We cannot exclude the possibility that a longer and more intense acupuncture intervention could produce a larger reduction of these symptoms.” This is an important point, since the positive Detroit trial administered acupuncture for 12 weeks while the New York trial was only 4 weeks in duration. FYI, sham acupuncture is a commonly used control group using techniques that are not intended to stimulate known acupuncture points.

While the evidence about the value of acupuncture treatments for refractory hot flashes are still preliminary, there seems to be enough potential value for this to be considered as an adjunct to conventional treatments for hot flashes, as described in previous blogs (for more information, read Study May Help Cool Hot Flashes for Cancer Patients). More research on this subject is needed.

Please read the abstracts below for more information. An interesting small study about acupuncture for hot flashes was recently reported in men with prostate cancer who were receiving hormone therapy (abstract listed below).

Acupuncture for Hot Flashes in Patients With Prostate Cancer.

Beer TM, Benavides M, Emmons SL, Hayes M, Liu G, Garzotto M, Donovan D, Katovic N, Reeder C, Eilers K.

Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, Oregon.

Urology. 2010 May 20. [Epub ahead of print]

Abstract

OBJECTIVES: To determine the effect of acupuncture on hot flash frequency and intensity, quality of life, and sleep quality in patients undergoing hormonal therapy for prostate cancer. Hot flashes are a common adverse effect of hormonal therapy for prostate cancer. METHODS: Men who had a hot flash score >4 who were receiving androgen deprivation therapy for prostate cancer underwent acupuncture with electrostimulation biweekly for 4 weeks, then weekly for 6 weeks, using a predefined treatment plan. The primary endpoint was a 50% reduction in the hot flash score after 4 weeks of therapy, calculated from the patients’ daily hot flash diaries. The hot flash-related quality of life and sleep quality and biomarkers potentially related to hot flashes, including serotonin, calcitonin gene-related peptide, and urinary 5-hydroxyindoleacetic acid, were examined. RESULTS: A total of 25 men were enrolled from September 2003 to April 2007. Of these, 22 were eligible and evaluable. After 4 weeks, 9 (41%, 95% confidence interval 21%-64%) of 22 patients had had a >50% reduction in the hot flash score. Of the 22 patients, 12 (55%, 95% confidence interval 32%-76%) met this response definition at any point during the therapy course. No patient had a significant increase in hot flash score during therapy. A reduced hot flash score was associated with improvement in the hot flash-related quality of life and sleep quality. CONCLUSIONS: Multiple placebo-controlled trials have demonstrated a 25% response rate to placebo treatment for hot flashes. Of the 22 patients, 41% had responded by week 4 and 55% overall in the present pilot study, providing evidence of a potentially meaningful benefit. Additional studies of acupuncture for hot flashes in this population are warranted. Copyright © 2010 Elsevier Inc. All rights reserved.

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Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with hormone receptor-positive breast cancer: a randomized controlled trial.

Walker EM, Rodriguez AI, Kohn B, Ball RM, Pegg J, Pocock JR, Nunez R, Peterson E, Jakary S, Levine RA.

Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI 48202, USA. ewalker1@hfhs.org

J Clin Oncol. 2010 Feb 1;28(4):634-40. Epub 2009 Dec 28.

Abstract

PURPOSE: Vasomotor symptoms are common adverse effects of antiestrogen hormone treatment in conventional breast cancer care. Hormone replacement therapy is contraindicated in patients with breast cancer. Venlafaxine (Effexor), the therapy of choice for these symptoms, has numerous adverse effects. Recent studies suggest acupuncture may be effective in reducing vasomotor symptoms in menopausal women. This randomized controlled trial tested whether acupuncture reduces vasomotor symptoms and produces fewer adverse effects than venlafaxine (Effexor). PATIENTS AND METHODS: Fifty patients were randomly assigned to receive 12 weeks of acupuncture (n = 25) or venlafaxine (n = 25) treatment. Health outcomes were measured for up to 1 year post-treatment. RESULTS: Both groups exhibited significant decreases in hot flashes, depressive symptoms, and other quality-of-life symptoms, including significant improvements in mental health from pre- to post-treatment. These changes were similar in both groups, indicating that acupuncture was as effective as venlafaxine. By 2 weeks post-treatment, the venlafaxine group experienced significant increases in hot flashes, whereas hot flashes in the acupuncture group remained at low levels. The venlafaxine group experienced 18 incidences of adverse effects (eg, nausea, dry mouth, dizziness, anxiety), whereas the acupuncture group experienced no negative adverse effects. Acupuncture had the additional benefit of increased sex drive in some women, and most reported an improvement in their energy, clarity of thought, and sense of well-being. CONCLUSION: Acupuncture appears to be equivalent to drug therapy in these patients. It is a safe, effective and durable treatment for vasomotor symptoms secondary to long-term antiestrogen hormone use in patients with breast cancer.

PMID: 20038728 [PubMed - indexed for MEDLINE]

Expert Analysis Highlights:

• Genetic test (oncotype DX) aids decision as to whether or not to undergo chemotherapy after surgery
• Profile of the breast cancer genes can be used to predict whether or not there is a survival benefit of adding chemotherapy to hormone therapy
• Test is covered by most private insurance and by Medicare
• A good starting place to learn more  is the section on predicting recurrence and genetic testing on our companion website

Genetic testing may help decisions to avoid breast cancer chemotherapy. For some women with early stage breast cancer, a genetic test (oncotype DX) may be helpful to you and your oncologist when deciding whether or not to undergo chemotherapy after surgery. This test is made on the breast cancer itself for which a multi-gene assay is performed to determine the “genetic signature” of your tumor. The profile of the breast cancer genes can then be used to predict with accuracy whether or not there is a survival benefit of adding chemotherapy to hormone therapy for those women who have hormone-responsive (ER+) breast cancer, especially those who are post-menopausal. This assay has been recommended both by the Guidelines of the American Society of Clinical Oncology and the National Comprehensive Cancer Center. When indicated, the test is covered by most private insurance and by Medicare.

Those women for whom the genetic testing may yield valuable information are two groups:

1. Women who have no evidence of spread to their lymph nodes and whose breast cancer expresses hormone receptors (estrogen-receptor-positive) and
2. Women after menopause whose cancer has spread to their regional lymph nodes and whose breast cancer is hormone-receptor-positive.

In both of these circumstances hormone therapy with either Tamoxifen or one of the aromatase inhibitors (Arimidex, Latrozole, etc.) would be indicated as standard therapy for at least five years. The side effects in most women are very tolerable, if not minimal. On the other hand, chemotherapy has more side effects and should be considered only when the potential survival benefit outweighs the risk or toxicity of receiving drug therapy in addition to hormone therapy.

Ask your doctor about this genetic test if you have the stages of breast cancer described above. Though advances in cancer chemotherapy have been dramatic, especially in breast cancer, it is equally valuable to know which women have such a good outcome after surgery and hormone therapy that they do not otherwise get from additional chemotherapy.

In the March 8,2010 issue of the journal Cancer, researchers at the University of North Carolina surveyed 77 women with breast cancer who underwent genetic testing. One-third reported that they did not understand the doctor’s explanation of the genomic test and one-quarter felt distress as a result of the discussion. On the other hand, most women agreed that genetic testing helped them understand whether their treatment would be successful. I learned from this article that:

1. Doctors need to do a better job of educating patients and explaining the test results, and
2. Patients need to get enough basic information and knowledge of the jargon (terminology) of these tests so they can understand the results and the meaning behind them.

A good starting place to learn more  is the section on predicting recurrence and genetic testing on our companion website, patientresource.net.

Also for more information, go to www.oncotype.com or review the Guidelines from ASCO at www.Cancer.net or NCCN at www.nccn.org.

Expert Analysis Highlights:

• For repeated injections and blood drawing during cancer treatment, you will likely need to have an implantable device for gaining access to your central veins
• Veins in the arms are usually used on a short-term basis, but they may be difficult, or even painful, to stick into repeatedly
• A range of products give access to the larger veins without causing pain from repeated injections or damage to these veins
• CR Bard Company has a nice website for patients who are being considered for an implantable device

The video segment here shows how a pediatric patient can have his chemotherapy administered without much discomfort, and without risking damage to his veins due to repeated injections. Whether you are an adult or a child with cancer requiring repeated injection or infusion of drugs, you will likely need to have an implantable device for gaining access to your central veins.

Why? Because administering drugs or other agents by intravenous infusion over a long period, or drawing repeated blood samples, can be a painful and difficult ordeal for patients and the healthcare team, especially when the patient is a child. Veins in the arms are usually used on a short-term basis, but they may be difficult, or even painful, to stick into repeatedly. The veins can dry up (thrombosis) or even get inflamed or infected (thrombophlebitis). Even more difficult and painful is resorting to getting blood, or giving infusions, from veins in the neck or the legs. This is a last resort when the veins in the arms have “given out”. We also know that it’s not just the needle and sometimes the drugs themselves can cause damage to the vein.  So-called “sclerotic agents”, such as adriamycin, can cause damage to the veins and infiltrate into the surrounding tissues, causing great tissue damage.

One of the significant technical advances for the cancer patients is the range of products that give doctors and nurses access to the larger veins without causing pain from repeated injections or damage to these veins.  Your doctor will go over with you about the different kinds of venous access to a major vein going to the heart. In each circumstance, it involves some minor surgery to put these catheters in place. These options are an implantable (subcutaneous) port, an , or a peripherally inserted central catheter (PICC).

The CR Bard Company has a nice website for patients who are being considered for an implantable port. They also have some great booklets for children (in English and Spanish) that describe these catheters which can help the kids understand the process with clearer expectations of how they are used during treatment. As described in the booklet to parents: “By maintaining a matter-of-fact and positive attitude, you can help your child adjust favorably to his … [central line, implantable port, PICC line].” If you or a loved one is facing this procedure, talk to your doctor about the options that would be most appropriate in your circumstance.

I highly recommend these books for children to help describe and explain catheters:

For a children’s book about the implantable venous port, go to: http://www.bardaccess.com/pdfs/other/MC-0406-00_A_Port_For_Me_web.pdf

For a children’s book about the central venous catheter, go to: http://www.bardaccess.com/pdfs/other/MC-0404-00_My_Central_Line_Book_web.pdf

For a children’s book about the peripherally inserted central catheter, go to: http://www.bardaccess.com/pdfs/other/MC-0405-00_My_PICC_Line_web.pdf

Expert Analysis Highlights:

• Growing body of scientific research demonstrating the benefits of acupuncture in treating side effects that result from cancer treatment
• Study as depicted in the video shows acupuncture successful in reducing hot flashes by 50%
• Recently published study demonstrated significant pain relief in breast cancer patients who had joint pains or stiffness as a result of hormone therapy
• Health insurance providers are beginning to reimburse for this therapy on the basis of such positive, evidence-based clinical trials

OK, I’ll admit it…I have been a skeptic about the value of acupuncture for alleviating cancer treatment side effects like joint pain, hot flashes, fatigue, and so on.  Scientists can’t explain it on physiological grounds…the pain-relieving properties, for example, may be mediated by release of neurotransmitters… and yet it appears to be beneficial in some patients. The video above and a recently published study are among the growing body of scientific research demonstrating the benefits of acupuncture in treating side effects that result from cancer treatment, such as hormone therapy for breast cancer.

The video above is about a clinical trial that demonstrated a 50% reduction in hot flashes for breast cancer patients suffering from this treatment side effect. For women with breast cancer, 80% suffer from hot flashes after receiving an anti-estrogen drug like Tamoxifen. Read more about “Breast Cancer Treatment with Femara (letrozole) and Tamoxifen.” Usually women are treated with estrogen to relieve hot flashes, but breast cancer patients can’t because estrogen increases the risk of cancer. Instead, they are given other medications such as Effexor, which is an anti-depressent that relieves hot flashes, but these drugs have side-effects of their own. Acupuncture gives the patient a non-pharmecutical option. The video points out that acupuncture is used for a variety of other side effects, such as stress and anxiety. I recently came across a study about significant pain relief using acupuncture for breast cancer patients taking a new class of hormone pills for which the side effect is joint pain and stiffness.

A new study published in the Journal of Clinical Oncology (March 1, 2010) from Columbia College of Physicians and Surgeons demonstrated a significant pain relief in postmenopausal breast cancer patients taking a new class of hormone pills called aromatase inhibitors (such as Arimidex, Femara, Aromasin) and who had joint pains or stiffness as a side effect of their medicine. Among 20 study patients, there was a significant improvement of joint pain and stiffness with acupuncture compared to a blinded, control group of 18 patients who randomly did not have acupuncture.  While this is a relatively small study, the investigators used rigorous scientific methods and showed a 50 to 70% reduction in pain using standardized pain measures. In recent years, more rigorously controlled scientific studies have demonstrated that acupuncture is effective in the treatment of pain from knee arthritis and other musculoskeletal pains, and it is generally a safe and well-tolerated procedure in experienced hands.

This type of study is exactly the type of evidence that should be used more to clarify the indications for acupuncture and demonstrate its value as a complementary treatment in patients with cancer who are suffering from side effects of treatment.  As the authors pointed out, acupuncture is often not used because of concern regarding the out of pocket expenditures associated with its use and the uncertainty regarding insurance coverage. Nevertheless, many third party payers are beginning to reimburse for this therapy on the basis of positive, evidence-based clinical trials.

If joint pains and stiffness are a significant side-effect of taking long-term hormone treatment with aromatase inhibitors as a component of your breast cancer treatments, or if you’re suffering from other side effects like hot flashes, talk to your doctor about whether acupuncture might be of benefit. Also, be sure to check with your insurance company about whether this pain-management approach could be reimbursed.

I have included a blog on this subject because inflammatory breast cancer is such a sneaky, silent killer that can affect young women. The video is very educational and should be of interest to women of all age groups. I have summarized a description of this breast cancer from the National Cancer Institute website (http://www.cancer.gov/cancertopics/factsheet/Sites-Types/IBC):

Inflammatory breast cancer is a rare but very aggressive type of breast cancer in which the cancer cells block the lymph vessels in the skin of the breast. This type of breast cancer is called “inflammatory” because the breast often looks swollen and red, or “inflamed

Symptoms of IBC may include redness, swelling, and warmth in the breast, often without a distinct lump in the breast. The redness and warmth are caused by cancer cells blocking the lymph vessels in the skin. The skin of the breast may also appear pink, reddish purple, or bruised. The skin may also have ridges or appear pitted, like the skin of an orange (called peau d’orange), which is caused by a buildup of fluid and edema (swelling) in the breast. Other symptoms include heaviness, burning, aching, increase in breast size, tenderness, or a nipple that is inverted (facing inward) (3). These symptoms usually develop quickly—over a period of weeks or months. Swollen lymph nodes may also be present under the arm, above the collarbone, or in both places.

Biopsy, mammogram, and breast ultrasound are used to confirm the diagnosis. IBC is classified as either stage IIIB or stage IV breast cancer (2). Stage IIIB breast cancers are locally advanced; stage IV breast cancer is cancer that has spread to other organs. IBC tends to grow rapidly, and the physical appearance of the breast of patients with IBC is different from that of patients with other stage III breast cancers. IBC is an especially aggressive, locally advanced breast cancer.

Chemotherapy (anticancer drugs) is generally the first treatment for patients with IBC, and is called neoadjuvant therapy. Chemotherapy is systemic treatment, which means that it affects cells throughout the body. The purpose of chemotherapy is to control or kill cancer cells, including those that may have spread to other parts of the body. 
After chemotherapy, patients with IBC may undergo surgery and radiation therapy to the chest wall. Both radiation and surgery are local treatments that affect only cells in the tumor and the immediately surrounding area.

There is now a Inflammatory Breast Cancer Foundation based in California, and MD Anderson in Houston, Texas now has the first Center dedicated to research and treatment of IBC.