Expert Analysis Highlights:

• There is continued evidence that prophylactic removal of the breast and ovaries decreases mortality rate
• This subject is not without controversy, but results of studies have been impressive
• For example, study demonstrates removal of the ovaries in select groups of mutation carriers can cut the risk of ovarian cancer by 70%
• Visit PatientResource.net for more information about breast and ovarian cancer

For breast cancer women who carry the BRAC-I or BRAC-II mutations, there is continued evidence that prophylactic removal of the breast and ovaries decreases mortality rate.  Prophylactic removal simply refers to surgically removing the breast or ovary that is not known to contain cancer for the purpose of reducing the patient’s risk. For your reference, below are relevant summary abstracts from professional medical journals. This subject is not without controversy. Removing healthy tissue, for example the breast that may otherwise never develop cancerous cells despite having cancer in the opposite breast, is a difficult choice that’s not for everyone. Talk to your doctor about your options.

A recent report from Dr Domchek and colleagues from the University of Pennsylvania in the Journal of American Medical Association showed that prophylactic mastectomy (breast removal) and removal of the ovaries significantly reduce mortality in this select group of women. They examined the survival outcome in a group of 2,482 BRAC-I or BRAC-II mutation carriers identified at 22 medical centers in North America and Europe who were participating in the prospective clinical trial. Approximately 10% of these women underwent prophylactic mastectomies and 40% underwent prophylactic removal of their ovaries.

The results were impressive. No breast cancers developed in mutation carriers who underwent prophylactic mastectomy whereas breast cancer did develop in 7% of those who declined prophylactic mastectomy. The results were even more impressive in preventing ovarian cancer which is much more lethal at the time of diagnosis. Among women who underwent prophylactic removal of their ovaries, only 1% subsequently developed ovarian cancer and only 11% subsequently developed breast cancer. In contrast, among women who declined prophylactic removal of their ovaries, about 6% subsequently developed ovarian cancer and 19% subsequently developed breast cancer. Thus, prophylactic removal of the ovaries in this select group of mutation carriers can cut the risk of ovarian cancer by 70% in those women who did not have prior breast cancer and decrease it even further, by 85%, in those who did have prior breast cancer.

These findings illustrate why breast cancer patients may want to know about their BRCA genetic status even if they have undergone bilateral mastectomy because prophylactic removal of their ovaries, even in this group of patients, may protect them from developing a new primary malignancy. Among women with no prior breast cancer, prophylactic removal of the ovaries reduced the breast cancer by 37% in carriers of the BRCA-I mutation and by 64% in carriers of BRCA-II mutation.

Another related medical study was reported in the November, 2010 issue of the ASCO Post on women who carried the BRCA mutation. This study by Dr Metcalfe and colleagues from the University of Toronto demonstrated that women younger than 50 years with BRCA-mutated breast cancers can have a 38% risk of developing breast cancer in the opposite breast within the next 15 years. In addition, there is a 68% risk in a woman diagnosed before age 50 who chooses to keep her ovaries and has two first degree relatives diagnosed with breast cancer before the age of 50. Thus, women with a younger age at onset of their breast cancer are at significant risk for developing an opposite breast cancer or ovarian cancer during follow-up over the next 10-15 years.

The results in women who are BRCA-mutant carriers who undergo prophylactic removal of their ovaries are similar to the results reported in the previous studies.  In this circumstance the object of the study was to examine the development of opposite breast cancer in mutant carriers who had a diagnosis of cancer in the opposite breast. In this study, women who underwent prophylactic removal of their ovaries and who were younger than 50 years of age at diagnosis have a 60% risk of developing opposite breast cancer within 15 years compared to 20% of those older than 50 years of age. Women younger than 50 who underwent prophylactic removal of their ovaries had a subsequent reduction in their risk for opposite breast cancer by more than one-third. The authors concluded that “women with early-onset breast cancer have the highest risk and get the most protection from prophylactic removal of their ovaries”.

Dr. Metcalfe emphasized how these risk factors can be used in counseling women. For example, while the 15-year risk for a woman diagnosed before age 50 is 37.6% it greatly increases if she decided against prophylactic removal of their ovaries and nearly doubles if she has two or more 1^st degree relatives diagnosed with breast cancer at an early age.

KEY REFERENCES BELOW:

JAMA. 2010 Sep 1;304(9):967-75.

Association of risk-reducing surgery in BRCA1 or BRCA2 mutation carriers with cancer risk and mortality.

Domchek SM, Friebel TM, Singer CF, Evans DG, Lynch HT, Isaacs C, Garber JE, Neuhausen SL, Matloff E, Eeles R, Pichert G, Van t’veer L, Tung N, Weitzel JN, Couch FJ, Rubinstein WS, Ganz PA, Daly MB, Olopade OI, Tomlinson G, Schildkraut J, Blum JL, Rebbeck TR.

Abramson Cancer Center and Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, USA.

Abstract

CONTEXT: Mastectomy and salpingo-oophorectomy are widely used by carriers of BRCA1 or BRCA2 mutations to reduce their risks of breast and ovarian cancer.

OBJECTIVE: To estimate risk and mortality reduction stratified by mutation and prior cancer status.

DESIGN, SETTING, AND PARTICIPANTS: Prospective, multicenter cohort study of 2482 women with BRCA1 or BRCA2 mutations ascertained between 1974 and 2008. The study was conducted at 22 clinical and research genetics centers in Europe and North America to assess the relationship of risk-reducing mastectomy or salpingo-oophorectomy with cancer outcomes. The women were followed up until the end of 2009.

MAIN OUTCOMES MEASURES: Breast and ovarian cancer risk, cancer-specific mortality, and overall mortality.

RESULTS: No breast cancers were diagnosed in the 247 women with risk-reducing mastectomy compared with 98 women of 1372 diagnosed with breast cancer who did not have risk-reducing mastectomy. Compared with women who did not undergo risk-reducing salpingo-oophorectomy, women who underwent salpingo-oophorectomy had a lower risk of ovarian cancer, including those with prior breast cancer (6% vs 1%, respectively; hazard ratio [HR], 0.14; 95% confidence interval [CI], 0.04-0.59) and those without prior breast cancer (6% vs 2%; HR, 0.28 [95% CI, 0.12-0.69]), and a lower risk of first diagnosis of breast cancer in BRCA1 mutation carriers (20% vs 14%; HR, 0.63 [95% CI, 0.41-0.96]) and BRCA2 mutation carriers (23% vs 7%; HR, 0.36 [95% CI, 0.16-0.82]). Compared with women who did not undergo risk-reducing salpingo-oophorectomy, undergoing salpingo-oophorectomy was associated with lower all-cause mortality (10% vs 3%; HR, 0.40 [95% CI, 0.26-0.61]), breast cancer-specific mortality (6% vs 2%; HR, 0.44 [95% CI, 0.26-0.76]), and ovarian cancer-specific mortality (3% vs 0.4%; HR, 0.21 [95% CI, 0.06-0.80]).

CONCLUSIONS: Among a cohort of women with BRCA1 and BRCA2 mutations, the use of risk-reducing mastectomy was associated with a lower risk of breast cancer; risk-reducing salpingo-oophorectomy was associated with a lower risk of ovarian cancer, first diagnosis of breast cancer, all-cause mortality, breast cancer-specific mortality, and ovarian cancer-specific mortality.

J Natl Cancer Inst. 2010 Nov 23. [Epub ahead of print]

Family History of Cancer and Cancer Risks in Women with BRCA1 or BRCA2 Mutations.

Metcalfe K, Lubinski J, Lynch HT, Ghadirian P, Foulkes WD, Kim-Sing C, Neuhausen S, Tung N, Rosen B, Gronwald J, Ainsworth P, Sweet K, Eisen A, Sun P, Narod SA; for the Hereditary Breast Cancer Clinical Study Group.

Affiliations of authors: Women’s College Research Institute, Toronto, ON, Canada (KM, PS, SAN); Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada (KM); Center for Hereditary Breast Cancers, Pomeranian Medical University, Szczecin, Poland (JL, JG); Department of Preventive Medicine and Public Health, Creighton University School of Medicine, Omaha, NE (HTL); Department of Cancer Genetics, Department of Medicine, and Department of Genetics, Epidemiology Research Unit, CHUM Hôtel-Dieu, University of Montreal, Montreal, QC, Canada (PG); Department of Genetics and Department of Medical Oncology, McGill University, Montreal, QC, Canada (WDF); BC Cancer Agency, Vancouver; BC, Canada (CK-S); Department of Population Sciences, City of Hope, Duarte, CA (SN); Beth Israel Deaconess Hospital, Boston, MA (NT); Department of Gynecology Oncology, University Health Network, University of Toronto, Toronto, ON, Canada (BR); London Regional Cancer Program, London, ON, Canada (PA); Department of Medical Genetics, Ohio State University, Columbus, OH (KS); Sunnybrook Regional Cancer Centre, Department of Medical Oncology, Toronto, ON, Canada (AE).

Abstract

Women who carry a deleterious mutation in BRCA1 or BRCA2 have high lifetime risks of breast and ovarian cancers. However, the influence of a family history of these cancers on these risks in women with BRCA mutations is unclear. We calculated cancer incidence rates for a multinational cohort comprising 3011 women with BRCA1 or BRCA2 mutations who were followed up for a mean of 3.9 years, during which time 243 incident breast or ovarian cancers were recorded. The 10-year cumulative risks of breast cancer were 18.1% (95% confidence interval [CI] = 13.3% to 22.8%) for women with a BRCA1 mutation and 15.2% (95% CI = 9.1% to 21.2%) for women with a BRCA2 mutation. Among women with a BRCA1 mutation, the risk of breast cancer increased by 1.2-fold for each first-degree relative with breast cancer before age 50 years (hazard ratio [HR] = 1.21; 95% confidence interval [CI] = 0.94 to 1.57) and the risk of ovarian cancer increased by 1.6 fold for each first- or second-degree relative with ovarian cancer (HR = 1.61; 95% CI = 1.21 to 2.14). Among women with a BRCA2 mutation, the risk of breast cancer increased by 1.7-fold for each first-degree relative younger than 50 years with breast cancer (HR = 1.67; 95% CI = 1.04 to 2.07).

Clin Genet. 2009 Mar;75(3):220-4.

Breast and ovarian cancer risk perception after prophylactic salpingo-oophorectomy due to an inherited mutation in the BRCA1 or BRCA2 gene.

Finch A, Metcalfe K, Lui J, Springate C, Demsky R, Armel S, Rosen B, Murphy J, Elit L, Sun P, Narod S.

Women’s College Research Institute, Toronto, ON, Canada.

Abstract

It is often recommended that women who carry a mutation in the BRCA1 or BRCA2 gene have their ovaries and fallopian tubes removed to reduce their risk of gynecologic cancer. The aim of this study was to evaluate women’s perception of their risk of breast and ovarian cancer before and after prophylactic salpingo-oophorectomy. We surveyed 127 women who carry a BRCA1 or BRCA2 mutation and who underwent prophylactic salpingo-oophorectomy at the University Health Network, Toronto. Subjects were asked to estimate their risks of breast and ovarian cancer before and after surgery. Their perceived risks of cancers were then compared with published risks, based on their mutation status. BRCA1 carriers estimated their risk of breast cancer risk to be, on average, 69% before surgery and 41% after surgery. They estimated their risk of ovarian cancer to be 55% before surgery and 11% after surgery. BRCA2 carriers estimated their risk of breast cancer to be 69% prior to surgery and 45% after surgery and their perceived risk of ovarian cancer to be 43% before surgery and 8% after surgery. Compared with published risk figures, the perceived risk of ovarian cancer before prophylactic salpingo-oophorectomy was overestimated by 47% of BRCA1 mutation carriers and by 61% of BRCA2 mutation carriers. Most women who have undergone genetic counseling and subsequently choose prophylactic salpingo-oophorectomy accurately perceive their risk of breast cancer. However, in this study, many women overestimated their risk of ovarian cancer, particularly women who carry a BRCA2 mutation.

Expert Analysis Highlights:

• Clinical trials serve two purposes: Offering patients the newest treatment options and advancing scientific knowledge for future patients
• Below are some useful questions you should ask when deciding whether or not to participate in a clinical trial
• To find out if there is a trial in the area you need treatment, check out clinicaltrials.gov where all trials are registered
• For more information about clinical trials, click on the following link to patientresource.net

The phrase “Clinical Trials” means one of two things to most people: An opportunity to get the latest and greatest new treatment, or a futile human experiment with no major benefit to them.  The truth is somewhere in between.  The bottom line is that it depends on the trial and its design.

To review, a clinical trial is a program offered by some hospitals which assigns you randomly to receive standard treatment or a new treatment for which the potential benefit is not yet proven.  Some trials have 3 “arms” or treatment paths.  The key to a good research study from a design standpoint is that patients are randomly assigned to a treatment path and then the outcomes are compared.  This is the most scientifically valid way of assessing how good the treatments work.

Here are some useful questions you should ask when deciding whether or not to participate in a clinical trial:

• What is the benefit seen in previous studies of the new treatment being studied in the trial?
• Does the new treatment being studied work by a different mechanism (i.e. a novel treatment) compared to the standard treatment?
• Where did the idea for the clinical trial come from?
• What are the quality of life and survival differences likely if I do not participate in the trial?

For some trials the new treatment may be very promising, while for other trials, the benefit may be marginal or even negligible based on prior studies.

For your protection, all clinical trials are governed by rules which hospitals are ethically and legally obliged to follow.  The rules are: 1) If the benefit of one of the treatment options is clearly apparent during the course of the study, the study must be ended early so that the results can be disseminated and patients do not have to continue a course of treatment which is known to be inferior, 2) You must be informed of every aspect of the design of the study, 3) You can opt out of the trial at any time, and 4) You are entitled to see the results of the study once completed.

Clinical trials serve two purposes: Offering patients the newest treatment options and advancing scientific knowledge for future patients.  Consider it not just a way of getting a new treatment, but also a way of helping inform future patients with a similar cancer.  In general, clinical trials provide hope for patients whose treatment options might otherwise be limited.  Many trials are managed on a multi-institution level, making the trials available on a local level for many patients.

To find out if there is a trial in the area you need treatment, check out clinical trials.gov where all trials are registered.  There you will be able to find out what the treatment arms are, whether the trial is open of closed to new patients, and where to go to see if you’re a candidate.

Previously, I have reported on studies that regular exercise may play an important role in prevention of depression among breast cancer survivors. (For more details, read “Lifestyle Makes a Difference in Combating Depression After Breast Cancer“). There is also a growing body of scientific evidence links the risk of developing a first breast cancer or recurrent breast cancer with such lifestyle factors as weight, physical activity, and alcohol use. As this video above from the Dana-Farber Cancer Institute in Boston shows, as little as 30 minutes per day of regular exercise, such as walking, can help you reduce your risk of breast cancer.

Overweight and obese postmenopausal women have been shown to be up to twice as likely to develop breast cancer as women of normal weight. Higher rates of breast cancer have also been associated with an inactive lifestyle and consumption of more than seven drinks of alcohol per week for women.

Furthermore, obese women who lead a sedentary life have an increased risk of breast cancer recurrence. One study showed that women who were overweight at the time of their initial diagnosis were 50% more likely to get a second breast cancer compared with women who were not overweight. Women who consumed more than seven drinks a week after their first breast cancer diagnosis were found to have a 70% increased risk of developing cancer in the opposite breast when compared with nondrinkers.

There are, however, some health benefits to moderate drinking — one drink or less per day for women and two drinks or less for men, especially of red wine — such as lowering the risk of heart disease. In addition, if you are receiving chemotherapy, your nutritional needs change and it’s not a good idea to go on a low-calorie diet because you need to add calories and protein to your diet to help you fight infections and boost your energy.

For more information about good nutrition and regular exercise from our companion website, go to this link patientresource.net

References:
1. Nagaiah G, Hazard HW, Abraham J: Role of obesity and exercise in breast cancer survivors. Oncology 2010;24:342-346.
2. McCarthy AM, Visvanathan K: Breast cancer prognosis: weighing the evidence on weight and physical activity. Oncology 2010;24:342-346.
3. Ligibel JA: Could modification of lifestyle factors prevent second primary breast cancers? Journal of Clinical Oncology 2009;27(32):5301-5302.
4. Li CI, Daling JR, Porter PL, et al: Relationship between potentially modifiable lifestyle factors and risk of second primary contralateral breast cancer among women diagnosed with estrogen receptor-positive invasive breast cancer. Journal of Clinical Oncology 2009;27:5312-5318.

Expert Analysis Highlights:

• Below are a few basic principles that will allow you to know your rights and get the records you need
• The most critical medical records in your cancer care are usually your CT scan (a.k.a. your ‘CAT scan’)
• To get a copy of your CT, MRI, or PET scan on CD-ROM, find out where your hospitals “Radiology Customer Service” counter is located
• Pathology slides can be obtained by calling the pathology department and asking them to have them ready for you to pick up

Getting your medical records can be a huge barrier to getting a second opinion. Trying to figure out our complex healthcare system on the fly can be a daunting task. Here are a few basic principles that will allow you to know your rights and get the records you need to get a second opinion quickly.

The most critical medical records in your cancer care are usually your CT scan (a.k.a. your ‘CAT scan’) and your pathology slides if a biopsy or surgery was performed.

The most important thing to remember is that your CT or MRI or PET scan is yours. You have a right to have a copy no matter what anyone tells you. The two ways a hospital typically provides you with a copy of your CT scan is 1) to provide a report or 2) to provide you with a CD-ROM copy of the actually pictures. In my experience, the report is not very helpful, and I never trust it in giving a second opinion. The actual CD-ROM is what a consulting doctor will insist on. In many instances, it’s the only thing needed to render an opinion about surgical respectability. In fact, as a routine practice, my office insists that a CD-ROM of a CT scan be mailed ahead of time to determine if an appointment is warranted. If it was never done, we simply get one done at our hospital prior to the appointment.

To get a copy of your CT, MRI, or PET scan on CD-ROM, find out where your hospitals “Radiology Customer Service” counter is located and what their hours of operation are. You can usually find this out by calling the hospital’s operator or your doctor’s office. There is sometimes a $10-15 fee for the CD-ROM although many hospitals offer the service for free. Also, when traveling to another hospital, its a good idea to bring a second copy with you to your consultation visit.

There are also times when an outside CT is not readable on the computers of another hospital. Until President Obama’s national health electronic record is standard practice, then we will have to continue to hope that hospital computers can open outside CD-ROM’s. Luckily, hospitals can open more than half of outside CT’s using their software.

Pathology slides can be obtained by calling the pathology department and asking them to have them ready for you to pick up. Alternatively, many hospitals have a system to send pathology slides directly from one hospital’s pathology dept to another. Of course this relies on them to not drop the ball so I recommend picking up the slides to ensure that the review is not delayed and things don’t fall through the cracks.

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:

• Lay media does a poor job of keeping a balanced perspective when reporting cancer information
• Study found that 95% reported exclusively on aggressive and expensive treatments such as chemotherapy, while only 13% mentioned that these treatments can fail
• Less than a third put their article in a balanced perspective by including a description of the adverse side effects and cost of cancer treatments; Only 8% mentioned the possibility that people die of their cancer
• Researcher from the study concludes, media “…play to this fear (of dying) by reassuring us that there are treatments that work, and that there are cures that are effective. That is, they tell us what we want to hear”
• That is why we are working to empower patients with accurate and straight-forward information on our site and our companion site www.patientresource.net

How well does the media do in reporting to you about the “hope” of cancer advances, while keeping a perspective that this is still a life-threatening disease that kills over a half million people each year?

Not very well, according to a study published in the Annals of Internal Medicine in March, 2010 by Drs  Fishman, Ten and Casarett from the University of Pennsylvania. They examined over 400 articles published in the lay press (i.e.: a public audience, not a medical journal) and found that a whopping 95% reported exclusively on aggressive and expensive  treatments –such as chemotherapy, bone marrow transplantation and radiation therapy—while only 13% mentioned that these treatments can fail. Moreover, less than a third put their article in a balanced perspective by including a description of the adverse side effects and cost of cancer treatments.

Please understand that I am not against the reporting of promising advances and the progress we are making, but I do think the media can do a better job. For example, I was recently interviewed on a new drug advance for melanoma, and was quoted (appropriately) that this was “ a single, not a home run”, meaning that is one of the first survival advances in the treatment of advanced melanoma, but probably won’t be used as a single agent to increase cure rates of melanoma. It was not reported that the drug can have serious side effects and that some patients died as a result of the treatment! On the one hand, if you are a patient for whom all other treatments have failed and you are facing the prospects of dying in the coming months, then getting a powerful drug with serious, sometimes life-threatening side effects may be your only choice. Or, if you have had potentially curative surgery but still have a risk of relapsing later on, you might have some pause about taking a drug that may interrupt or halt your present quality of life or even shorten your life. Doctors and cancer patients make these kinds of decisions every day based upon estimating the probability of success or failures among groups of patients. However, at the level of an individual patient, we don’t have a crystal ball! Some patients do better than expected and other do worse. We all have to make our best decision about the whether the benefits of a particular treatment outweigh the potential risks and complications and then accept the outcome as we go forward.

I’ll quote from a blog by Dr Casarett, one of the researchers on this study. “Of course, it’s not such a terrible thing if we can’t find what we need about cancer in newspapers and magazines. These are just one source of information that’s available to us. If we don’t find what we are looking for in one of these articles, we can look somewhere else. That’s why the real problem with these articles is not the information that’s missing from them, but rather the biased picture that they give of what it’s like to have cancer…..The most worrisome thing we found in these articles, though, was the way they carefully avoid mentioning death and dying. In fact, only 8% mentioned the possibility that people die of their cancer….So these articles play to this fear (of dying) by reassuring us that there are treatments that work, and that there are cures that are effective. That is, they tell us what we want to hear.” The full blog story can be found at www.huffingtonpost.com/david-casarett-md/cancer-news-offers-reader_b_499540.html.

Of course, this desire–indeed our passion– is to inform and educate cancer patients so they can learn about what they need to know, not just the things we want to hear. That is why we started Patient Resource Cancer Guides and its website www.patientresource.net and www.mycanceradvisor.com, so that cancer patients could learn about all aspects of the cancer journey, including the more difficult issues of pain management, treatment options and their complications, and the process of death and dying. We hope that empowering patients with accurate and straight-forward information will make a difference in their lives and the lives of their loved ones.

The abstract of the publication cited above is:

Fishman J, Ten Have T, Casarett D. Arch Intern Med. 2010 Mar 22;170(6):515-8.

Cancer and the media: how does the news report on treatment and outcomes?

BACKGROUND: Cancer receives a great deal of news media attention. Although approximately half of all US patients with cancer die of their illness or of related complications, it is unknown whether reports in the news media reflect this reality. METHODS: To determine how cancer news coverage reports about cancer care and outcomes, we conducted a content analysis of US cancer news reporting in 8 large-readership newspapers and 5 national magazines. Trained coders determined the proportion of articles reporting about cancer survival, cancer death and dying, aggressive cancer treatment, cancer treatment failure, adverse events of cancer treatment, and end-of-life palliative or hospice care. RESULTS: Of 436 articles about cancer, 140 (32.1%; 95% confidence interval [CI], 28%-37%) focused on survival and only 33 (7.6 %; 5%-10%) focused on death and dying (P < .001, chi(2) test). Only 57 articles (13.1%; 10%-17%) reported that aggressive cancer treatments can fail, and 131 (30.0%; 26%-35%) reported that aggressive treatments can result in adverse events. Although most articles (249 of 436 [57.1%]; 95% CI, 52%-62%) discussed aggressive treatments exclusively, almost none (2 of 436; [0.5%]; 0%-2%) discussed end-of-life palliative or hospice care exclusively (P < .001, chi(2) test), and only a few (11 of 436 [2.5%]; 1%-6%) discussed aggressive treatment and end-of-life care. CONCLUSIONS: News reports about cancer frequently discuss aggressive treatment and survival but rarely discuss treatment failure, adverse events, end-of-life care, or death. These portrayals of cancer care in the news media may give patients an inappropriately optimistic view of cancer treatment, outcomes, and prognosis.

Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, 19104, USA. fishman1@mail.med.upenn.edu

Expert Analysis Highlights:

• This video provides patients with the chance to see what actually happens during the course of radiation treatment
• On a daily bases there is no pain or discomfort with the treatment
• Treatment course can extend anywhere from 2-8 weeks
• Side effects are highly dependent on the region of the body being treated and the total dose

Radiation treatments are used in the majority of patients with cancer, and yet most patients have little idea of what to expect. This video is helpful in showing what happens during the course of a single radiation treatment. Some take home messages include that the technology has become relatively sophisticated, that the treatment has to be precisely delivered to one defined area of the body, and that on a daily bases there is no pain or discomfort with the treatment.

Prior to this patient’s treatments, a series of events had already taken place. You can see in the video that the patient’s head is immobilized by plastic mask that is fastened onto the table. The purpose of this and other forms of immobilization is to assure that the carefully planned treatment is able to be reproduced each day when the patient comes for their daily treatment. Treatment course can extend anywhere from 2-8 weeks and the ability of the treatment to hit its target is highly dependent on the ability to precisely reproduce the position of the patient each day. Also prior to the treatment, a CAT scan of the patient while he was immobilized in his mask was obtained. This information is transferred to treatment planning computers and the doctor outlines the targeted region and the normal tissues to avoid. Working with his team, the doctor then helps determine the optimal angle of beam entrance and exit and the shape and intensity of each field. In the video, four fields were used: one from the front, one from the back and one from each side. These four beams will have a mutual intersection point at the targeted region where the addition from each beam will result in a selectively high dose to this region. Within the treatment head of the machine are a collimation system that can shape the beam edges into almost any shape which further adds to the precision of the dose delivery.

Radiation treatments are a scary endeavor for any patient and the treatment can cause some side effects that are highly dependent on the region of the body being treated and the total dose. What I liked about the video is that it provides patients with the chance to see what actually happens within the treatment room. In doing so, I hope you were left with the impression that it’s not that bad and when it is warranted it can provide a great service to cancer patients.