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]

There are many options for breast reconstructive surgery. One of the more popular is the TRAM flap, especially for a woman with excess belly fat or an abdomen that has been stretched out by pregnancy. You end up with a “tummy tuck”; as a fringe benefit of surgery. I like this video because it shows some nice anatomical drawings that explain the operation.

At many Breast Centers, including our own at Johns Hopkins, the TRAM flap has been replaced by the DIEP flap of abdominal tissue. This has the advantage of not taking any of the rectus abdominal muscle and thus decreases the risk of abdominal weakness or hernias.

Here’s more information from patientresource.net:

Breast reconstructive surgery is done by an experienced plastic surgeon. This surgery is usually done at the time of total mastectomy or later (within months after mastectomy).

Immediate reconstruction can be done for early-stage (stage I or some stage II) breast cnacers, but it is usually best to wait for reconstruction if the breast cancer is more advanced (stage III or some stage II). Increasingly, a “skin-sparing mastectomy” and temporary breast implants are used as the initial process of breast reconstructive surgery, with the final stages of reconstruction performed after all the cancer treatments are completed. If you are to have a mastectomy and think you will want reconstructive surgery, it is best to discuss your choice with your cancer surgeon and a plastic surgeon before the mastectomy so they can properly plan your treatment, even if the reconstructive surgery will not be done until later.

Reconstructive surgery cannot be done for all types of breast cancer. Women who do not want or cannot have reconstructive surgery can be fitted with a breast prosthesis. This prosthesis is a breast form (made of artificial materials) that you put in your bra to make your breast look natural and balanced.

Hot flashes can be a very debilitating condition for women who undergo estrogen depletion, either naturally (with menopause), with surgical ablation (of the ovaries), with certain types of chemotherapy, or with pelvic radiation, any of which can induce sterilization.  For many women, hot flashes are a tolerable condition, even though it has great “nuisance value”. For others, the symptoms are much more severe and can be quite debilitating.  Of course, estrogen or progesterone replacement are “natural therapies”, but there are known risks of taking estrogen for a prolonged period of time.  And some women are still symptomatic with estrogen replacement therapy, except in high doses.

A new study has identified yet another drug for hot flashes.  This trial was conducted by Dr. Charles Loprinzi and colleagues from the Mayo Clinic in Rochester, MN (see video) who found that a commonly used neurology drug can significantly reduce the frequency and intensity of hot flashes. A substantial number of these women had a history of breast cancer and many of them were taking various anti-estrogen hormone therapies for their breast cancer.  In this trial, a total of 207 women were enrolled into the trial because they had “bothersome hot flashes,” as defined by occurrence at least 28 times per week and sufficient severity to make the patient desire therapeutic intervention.

Two doses of Lyrica (Pfizer, NY, NY) were administered (75 mg twice a day, or 150 mg twice a day) compared to a placebo (sugar pill). The investigators found that Lyrica decreased hot flashes and was reasonably well tolerated. The lower dose was recommended (75 mg twice daily) and its effects were roughly comparable to those previously reported with other drugs. The higher dose of Lyrica (150 mg twice daily) had significantly more toxicity than the placebo and was primarily associated with symptoms of dizziness, mental confusion and memory disturbances.

Compared to base-line, the frequency of hot flashes was reduced by 58.5% with the lower dose of Lyrica, and 61% with the higher dose.  Interestingly, there was a 36% reduction in the frequency of hot flashes for women were on the placebo! (This emphasizes the need for such control trials when the end points of the trial are symptom relief.)

This is a very nice clinical trial with a convincing result that adds another tolerable and safe drug to the list of those that physicians can use for treating severe hot flashes. There have been a number of other drugs that provide a 50% or greater reduction in hot flash frequency or severity. A partial list of those prescription drugs approved for use in treating hot flashes include:

1. Gabapentin (Gabarone, Pfizer, NY, NY)
2. Venlafaxine (Effexor, Wyeth Laboratories, Pfizer, NY, NY)
3. Desvenlafaxine (Pristiq, Wyeth Laboratories, Pfizer, NY, NY)
4. Fluxotine (Prozac, Lilly, Indianapolis, Indiana)
5. Citalopram (Celexa, Forest Laboratories, NY, NY)
6. Sertraline (Zoloft, Pfizer, New York, New York)
7. Paroxetine (Paxil, GlaxoSmithKline, Philadelphia, PA)
8. Estrogen (Premarin, Wyeth Laboratories, Pfizer, NY, NY)

Here’s more information about hot flashes from our companion website, patientresource.net:

A hot flash is a sudden, intense hot feeling on your face and sometimes upper body. A rapid heartbeat, nausea, dizziness, headache, weakness, and/or sweating may also occur at the same time. A “flush” follows the hot flash; during a flush, you become red and perspire. Hot flashes are perhaps the menopausal symptom that women find the most uncomfortable and inconvenient.

Among the general population of women, hot flashes may last for a year or two after menstrual periods have stopped or may persist for several years. The intensity of hot flashes caused by tamoxifen usually improves after the first 3-6 months of treatment. Hot flashes vary in duration and frequency; most episodes last a few minutes, and they often occur at night, with night sweats often waking up women in the middle of the night.

Hot flashes may have specific triggers. These triggers vary among women, but the most common ones include alcohol, caffeine, spicy food, stress, hot weather, hot showers, and saunas. Identifying and avoiding triggers can help decrease the frequency of hot flashes.

Some suggestions for coping with hot flashes include the following.

* Wear cotton and avoid wool and synthetic materials.
* Dress in layers, so you can remove clothes in layers if needed.
* Keep ice water nearby to drink when a hot flash begins.
* Wear cotton pajamas or a nightgown and use cotton sheets on the bed.
* Take a cool shower before going to bed.
* Open the refrigerator door and put your head in when a hot flash begins.

Some studies have shown that vitamin E or vitamin B6 supplements can help reduce hot flashes. If hot flashes are severe, your doctor may suggest a low dose of an antidepressant. The drug that has been shown to be most effective is venlafaxine (Effexor); paroxetine (Paxil) is another alternative and may be better tolerated by some women. Mild sedatives may also be of benefit but there are risks associated with their use.

Many menopausal women have turned to herbal remedies, such as ginseng, black cohosh, evening primrose oil, licorice root, and others to alleviate hot flashes. However, the safety of these remedies in women with breast cancer has not been determined. Do not take any herbal supplements without talking to your doctor first.

Here is a quick and helpful video demonstrating important exercises for managing lymphedema. This can be a very frustrating side effect of cancer surgery. Here’s more information about managing lymphedema from our companion website, patientresource.net:

Lymphedema is an excess of fluid in body tissues that causes abnormal swelling of an arm or leg. Swelling can also occur in other parts of the body, depending on the type of cancer and the treatment. The amount of swelling can range from mild increases to extreme swelling that interferes with motion or function of the affected area. The frequency of lymphedema has decreased over the past few years because of improvements in surgical and radiation therapy techniques.

Prevention of infection is an important part of managing lymphedema because infection causes your body to respond by making more lymph, and if the lymph nodes and/or vessels are damaged, the excess fluid has nowhere to go.

Management of lymphedema focuses on ways to minimize swelling and control discomfort. Avoid constriction of the area by wearing loose clothes or jewelry on the affected side, carrying a handbag or back pack on the unaffected side, keeping legs uncrossed while seated, and avoiding socks or stockings with tight bands. It is also important to keep blood from pooling in the affected limb. When possible, elevate the affected limb to a point higher than the heart; do not swing the limb quickly in circles or let the limb hang down, and do not apply heat to the limb.

Your doctor may recommend elastic compression stockings, especially for lymphedema of the legs. Occasionally, a mild diuretic may be ordered to lower the tissue fluids in your body.

Your doctor may also suggest that you be treated by a physical therapist or health care professional who has specialized training in the treatment of lymphedema. This specialist will help you with gentle exercises to help pump lymph fluid out of the affected limb. For some people, a special massage technique called manual lymph drainage may help lymph fluid flow out of the arm or leg. Other techniques to increase the flow of lymph fluid include wrapping the arm or leg in bandages; wearing a compression garment (a specially made tight sleeve or stocking); and using pneumatic compression, a compression sleeve with an attached pump that intermittently inflates the sleeve, putting pressure on the limb. If you have lymphedema of an arm, avoid having injections (blood draws or vaccines) and blood pressure measurements in that arm.

You should talk to your doctor about the possibility of lymphedema when discussing the risks and benefits of surgery or radiation therapy. Early treatment of lymphedema can help control swelling and discomfort, so it is important to call your doctor’s office if signs of lymphedema persist for 1 to 2 weeks.

These signs include:

* Swelling in the breast, chest, shoulder, arm, hand, leg, or foot
* An extremity or affected area feels full or heavy
* Changes in how the skin in an area looks (red) or feels (tight and hard)
* New aching or discomfort in an area
* Less movement or flexibility in nearby joints (shoulder, hand, wrist, hip, or knee)
* Difficulty fitting your arm into a jacket or shirt
* Difference in how your bra fits
* Tightness of jewelry on your hand or wrist

Contact your doctor or nurse immediately if:

* The affected limb or body area feels hot, looks red, or swells suddenly
* You have a fever (oral temperature of 100.5°F or higher) that is not related to a cold or flu

Cancer fatigue is a debilitating condition that is different from usual “tiredness”.  Fatigue felt by people with cancer is different from fatigue felt occasionally by healthy individuals. Compared with “normal” fatigue, fatigue related to cancer treatment usually is more severe, lasts longer, and is unrelieved by sleep. For some people with cancer, fatigue is a more distressing symptom than pain and other symptoms because it can interfere with normal activities.

Now a report from the Mayo Clinic indicates a somewhat positive finding in a controlled study comparing three doses of ginseng compared to a placebo. Dr Deborah Barton reported their results of a pilot study involving 290 cancer patients ( just published in Supportive Care Cancer, 2010 Feb 18:179-187). They concluded that “there appears to be some activity and tolerable toxicity at 1000-2000 mg/day doses of American ginseng with regards to cancer-related fatigue.”

Remember that there are several preparations of ginseng roots: American ginseng (Panax quinquefolius) and Asian ginseng (Panex ginseng). This ingredient can be found in nutritional stores. Ginseng is also used in some popular “energy drinks”.

For more information about cancer-related fatigue and web-based resources, go to our companion website.

This is an Oncology Podcast segment for women about preparing for hair loss and how to cover the head with wigs and scarves.

Here’s more information from our companion website, patientresource.net:

Hair loss from chemotherapy usually begins within 10-14 days after the start of treatment and gets worse within 1 to 2 months. In some instances, depending on the chemotherapy drugs, hair loss may begin with a sensation of the scalp itching, and within a few hours hair begins to fall out. Hair loss typically continues throughout treatment. Hair usually begins to grow back 4-6 weeks after the end of treatment. In general, hair grows back at a rate of about one-quarter inch per month.

It takes longer for hair to be lost during radiation therapy. Hair loss in the area being treated usually begins 2-3 weeks after the first treatment. All hair in that area falls out within about 1 week and may begin to regrow 3-6 months after treatment has ended. However, the hair loss may be permanent.

There are no effective ways to prevent the loss of hair during cancer treatment. Being gentle with your hair may help make your hair loss more gradual and improve the regrowth of your hair.

The best way to manage hair loss (medical term is alopecia) is to think about what will make you feel most comfortable with your appearance. Most people with cancer have found that it is easier to make that decision before treatment starts. Many women choose to wear a wig, but some women find wigs to be irritating or itchy. If you decide to get a wig, consider several factors.

Tips on Wigs
* Buy the wig before treatment begins or at the beginning of treatment — you can better match your hair color and texture
* Try on several different wigs to find one that you really like
* Consider buying two wigs, one for everyday use and one for special occasions
* If you can’t afford a custom wig, buy a standard (less expensive) wig and have it professionally styled
* Ask if the wig can be adjusted — your wig size can shrink as you lose hair
* Get a prescription from your doctor for the wig because it is often covered by health insurance (Prescription must state “skull prosthesis for hair loss caused by cancer treatment”)
* Contact your local branch of the American Cancer Society to learn about free wigs that have been donated by patients after they have completed treatment

Wearing a scarf, hat, or other type of head covering is also a choice. Your scalp may be tender from treatment (especially radiation therapy to the head), and a head covering can protect your scalp against cold and sunlight. If you do not wear a head covering, make sure to use sunscreen on your scalp when you will be outside.

Some people choose to cut their hair short so that hair loss will not be as traumatic when it falls out. Others shave their head completely before treatment begins. How you handle hair loss is a personal decision and the right choice is the one that makes you feel most comfortable.

Being Gentle To Your Hair
* Use a soft-bristle brush and/or a wide-toothed comb
* Wash hair with a gentle, pH-balanced shampoo (avoid shampoos with strong detergents, chemicals, or frangrances)
* Do not use hair dryers, hot rollers, or curling irons
* Do not bleach or color your hair or get a permanent
* Avoid hair sytles that pull on the hair, such as braids or ponytails
* Sleep on a satin pillow case or put a hair net on to decrease friction

There are a number of resources that provide wigs and related products. The following is list of retailers provided by the American Cancer Society:

ChemoSavvy
PO Box 175
Green Mountain Falls, CO 80819
Toll-free number: 1-888-599-3560
Web site: www.chemosavvy.com
This company supplies wigs, hats, scarves, turbans, and accessories for women and children to consumers.

Doma Designs
426 East Bissell Avenue
Oil City, PA 16301
Toll-free number: 1-888-603-1206
Web site: www.domadesigns.com
This company supplies hats, bandanas, and accessories for women, men, and children to consumers.

Headcovers Unlimited
2020-C Anders Lane
Kemah, TX 77565
Toll-free number: 1-800-264-HATS (4287)
Web site: www.headcovers.com
This company supplies wigs, turbans, hats, and accessories for women, men, and children to consumers.

Look of Love International
1795-B Route 27 South
Edison, NJ 08817
Toll-free number: 1-800-526-7627
Web site: www.lookoflove.com
This company supplies wigs and accessories to consumers.

“tlc” Tender Loving Care®
PO Box 395
Louisiana, MO 63353-0395
Toll-free number: 1-800-850-9445
Web Site: www.tlcdirect.org
This company supplies wigs, hats, turbans, breast prostheses, bras, and other products to consumers. “tlc” is a part of ACS Products, Inc., an affiliate of the American Cancer Society.

Yako Corp DBA Hai’s Wigs
6474 Lake Worth Road
Lake Worth, FL 33463
Toll-free number: 1-888-471-2659
Web Site: www.ladywig.com
This is an online retailer that also has a physical store selling wigs and hair accessories. This company specializes in treatment-related hair loss.

Tender Loving Care®
PO Box 395
Louisiana, MO 63353-0395
Toll-free number: 1-800-850-9445
Web Site: www.tlcdirect.org
This company supplies breast prostheses, bras, wigs, hats, turbans, and other products to consumers. “tlc” is a part of ACS Products, Inc., an affiliate of the American Cancer Society

Making decisions about breast cancer treatment involves a range of choices from double mastectomy to lumpectomy. Each woman must be informed and educated about her treatment and prevention options so she can make a decision with her doctor that balances the right treatment with her quality of life. In this video, Sheryl Crow talks with her surgeon about why she chose a conservative approach.

Our companion website has more information to offer, and here’s an example:

Breast cancer is the most common type of cancer among women in the United States, accounting for more than a quarter of all cancers in women. Approximately 2.5 million women in this country are breast cancer survivors, and an estimated 192,370 new cases of breast cancer will be diagnosed in women in 2009. Breast cancer can also develop in men, but this is rare; the disease will be diagnosed in approximately 1,900 men in 2009.

The rate of new cases (known as incidence) of breast cancer varies according to race/ethnicity. The incidence is highest among white women and lowest among American Indian/Alaska Native women. However, the death (mortality) rate is highest among black women. This high rate is related to the greater number of black women (compared with white women) who have more advanced cancer at the time of diagnosis. Better use of breast cancer screening by women in minority populations would provide a greater chance for increased survival.