Answers to Your Cancer Questions

The AARP Bulletin recently invited readers to send in questions about cancer to specialists at the University of Texas M.D. Anderson Cancer Center in Houston. Here are some of their answers*:

BREAST CANCER

Q. I recently had a lumpectomy for breast cancer and was told that I would need radiation. Now my doctor is saying that I won’t need it. But the article in the Bulletin (“Good News About Cancer,” May 2008) said it is necessary after a lumpectomy. I am getting very confused.

A. The majority of patients with an invasive breast cancer benefit from radiation after a lumpectomy. The one group of patients for whom it is reasonable to consider treatment with surgery and tamoxifen, or some other hormonal treatment without radiation, is women 70 or older who have a lymph node-negative, estrogen receptor-positive cancer. Clinical trials indicate that such patients have a favorable prognosis and that the chance of having a recurrence in the breast despite omitting the radiation is less than 10 percent over the ensuing seven years. For women ages 70 to 80 who are very healthy (without serious medical problems), the lifetime risk of having a breast recurrence is higher because they will live longer. So it is reasonable to consider a course of radiation in addition to the other treatments. —Thomas Buchholz, M.D., professor, Division of Radiation Oncology

PROSTATE CANCER

Q. We have heard that the robotic procedure sometimes used in prostate surgery may not completely remove all of the cancer that is present in the prostate and lymph nodes. Will you please comment on this?

A. The goal of robotic-assisted laparoscopic surgery is exactly the same as the open surgical procedure: to completely remove the prostate and, when appropriate, the regional lymph nodes. In some cases where cancer may travel beyond the prostate into the fatty tissue around it, the cancer may not be removed. Currently we are unable to precisely tell when this happens with all patients, but in some we can predict it based on clinical data. In these latter cases we will take a wider margin. —Curtis Pettaway, M.D., professor, Urology

Q. I’m 71 and my prostate and testicles were removed 11 years ago. My PSA (prostate-specific antigen) level was 8.5 at my last test, up from 1.16. Does an increasing PSA necessarily mean I have prostate cancer? If so, what is the best treatment to try and stop its progression?

A. A rising PSA level after prostate and testicular removal is most certainly due to cancer cells present in the body. Doctors will at some point perform radiology or other imaging studies to try and find where the disease is. Based on their findings they may recommend certain additional treatments like radiation or chemotherapy. —Curtis Pettaway, M.D., professor, Urology

Q. “Many men die with prostate cancer but only a few die from the disease.” What does this mean?

A. Prostate cancer is one of only a few cancers that can be present in the body but cause no symptoms and go undetected for some time. Because it is in general slow-growing, it may neither require immediate treatment nor affect life expectancy. In those cases in which we need to treat the disease early, we need to intervene appropriately with respect to the stage of disease, the man’s age and his general health, always striving to preserve the highest quality of life. —Jeri Kim, M.D., associate professor, Department of Genitourinary Medical Oncology

Q. I had my prostate removed in 1992, and cancer escaped into the lymph system. What PSA level indicates some danger? Twice my PSA went from 0 to 8 in a year, and I had hormone therapy with Lupron [which treats the symptoms of prostate cancer]. Is a PSA level of 8 reasonable, or can it go higher before treatment begins again?

A. The rate at which PSA rises may be more important than any absolute level. Given that your PSA level rose from 0 to 8 in only a year, it would be reasonable to begin hormonal therapy. —Jeri Kim, M.D., associate professor, Department of Genitourinary Medical Oncology

Q. Theraseed claims their form of brachytherapy results in a significantly lower incidence of post-procedure complications than surgery, and some doctors using the procedure claim the results are far better. Are other forms of brachytherapy as effective?

A. The two commonly used radioactive seeds for early-stage prostate cancer are iodine-125 and palladium-103 (trade name Theraseed). Iodine-125 has a half-life of 60 days, and palladium-103 has a half-life of 17 days. This means that one-half the radiation is given off in that period of time. Therefore, more radiation is given in a shorter period of time with the Theraseed. Some studies have shown that the urinary side effects with Theraseed may be more intense initially after implant, but then dissipate more rapidly than with the iodine seed. In the long run, residual effects are of the same magnitude with either one. Studies have also shown that the effectiveness in eradicating the cancer is similar for both types of seeds. —Deborah Kuban, M.D., professor, Division of Radiation Oncology

LUNG CANCER

Q. A recent CT (computed tomography) scan taken to check my aorta revealed “multiple nodules” on my lungs. When a new scan was taken two months later, the nodules appeared stable. Is my worry about lung cancer over?

A. There are many reasons why nodules can appear in the lungs, including anything from past infections to cancer. If these nodules are small (less than 1 centimeter), then having a biopsy will be difficult. Although it is somewhat reassuring that the nodules are stable after two months, I would continue to follow these closely every couple months for at least the next year. One would expect cancer to grow. —Edward S. Kim, M.D., assistant professor, Department of Thoracic/Head and Neck Medical Oncology

Q. I want to know where I can get screened for lung cancer. Both my parents died of lung cancer, my father at 52 and my mother at 82. When she was in the hospital, her oncologist suggested I get an EBT (electron beam tomography) scan, but when I tried to contact someone, I was more or less blown off. My family doctor sent me for a chest X-ray, which showed nothing. With cancer high in my family, I am concerned and would like to do what I can now before it is too late.

A. Currently there is no definitive data for generalized screening for lung cancer. The biggest risk factor remains a history of smoking. Ongoing studies are trying to test the role of a CT scan for lung cancer screening. Chest X-rays will pick up only larger abnormalities. Even if you did have a CT scan or a full-body scan, these tests are not specific enough to say you are “cancer-free,” as they are not good enough to pick up cancer cells. Currently, I do not recommend screening, but hopefully we will have a better test in the future.—Edward S. Kim, M.D., assistant professor, Department of Thoracic/Head and Neck Medical Oncology

Q. My father has small-cell carcinoma of his right lung. We have just applied for a pill called Tarceva. How effective is this pill? Do we have other options? He has had radiation. His doctor says chemo is too strong.

A. Tarceva has not proved effective for small-cell lung cancer, although it is approved for non-small-cell lung cancer. Options for small-cell lung cancer are limited, and tolerance of chemotherapy depends on the patient’s overall condition. A second opinion is always a good way to get reassurance about a treatment decision. I would recommend for an opinion a large, university-based hospital that participates in research studies. —Edward S. Kim, M.D., assistant professor, Department of Thoracic/Head and Neck Medical Oncology

OVARIAN CANCER

Q. I am 51, and at age 48 I was diagnosed with early-stage ovarian cancer and am now in remission. I’m looking for new treatments that help lower the rate of recurrence, a significant factor with ovarian cancer. I’ve recently looked into the ovarian cancer vaccine, for which I am currently not a candidate. Do you have any information on when the vaccine will be available? Do you know of any other options that may be available now or soon that might lower the risk of recurrence?

A. Currently there are no known treatments that will reduce your risk of recurrence. The vaccines for ovarian cancer are all in the very early stages of clinical trials and none is near FDA approval. At each visit with your doctor, ask if there is any new treatment or trial appropriate for you. —Judith Wolf, M.D., professor, Department of Gynecologic Oncology

Q. Are there any new treatments in use or being developed to treat ovarian cancer? The majority of the information online or otherwise relates mainly to breast cancer. Any information on ovarian cancer would be greatly appreciated.

A. The current standard of treatment for ovarian cancer in the United States is surgery followed by chemotherapy with carboplatin and paclitaxel. Although 75 percent of patients will go into a remission from their cancer with this treatment, the majority of them will recur and eventually die from ovarian cancer. This is likely because 75 to 80 percent of the time when ovarian cancer is found, it is already advanced to stage 3 or 4 and has spread throughout the abdomen. If we could find a way to detect it earlier, this could make a big difference in the outcome, because patients who are diagnosed with stage 1 ovarian cancer have a 95 percent chance of cure. There is currently no screening test; however, researchers working in this area think such a test will be available within the next five years. In the meantime, recent clinical trials have found that certain patients with ovarian cancer have an improved outcome if part of their chemotherapy regimen is given directly into the peritoneal cavity (into the abdomen). Also, current clinical trials in ovarian cancer are evaluating whether it is beneficial to add the drug Bevacizumab (Avastin) to carboplatin and paclitaxel to treat ovarian cancer. —Judith Wolf, M.D., professor, Department of Gynecologic Oncology

TONSIL CANCER

Q. Is there any treatment after removal of a malignant tonsil, other than a series of radiation treatments? Are there side effects from this treatment that may be permanently damaging to the patient?

A. In general, removal of a tonsil is not considered adequate treatment because microscopic cells are often left behind, leading to the regrowth of the tumor. In addition, there can be microscopic cells in the lymph nodes of the neck that are not addressed. Nevertheless, in very small tumors (usually under 2 centimeters) that have not spread, an oncologic tonsillectomy (which removes much more tissue than a “regular” tonsillectomy) and removal of lymph nodes in the neck can result in cure of the tumor without radiation.

However, in the vast majority of patients with tonsil cancer, radiation, often combined with chemotherapy, is the preferred treatment. In large tumors both the tonsil region and both sides of the neck are treated with radiation. This can lead to permanent xerostomia (dry mouth) and sometimes can lead to difficulty swallowing. However, newer radiation technologies such as Intensity Modulated Radiotherapy (IMRT) can decrease the severity of dry mouth after treatment. Finally, in certain cases, usually in patients with smaller tumors, only one side of the neck and tonsil region may be treated with radiation. In these patients, the incidence of dry mouth is very low, as the salivary glands on the other side are not irradiated. —Gregory Chronowski, M.D., assistant professor, Division of Radiation Oncology

* The answers to these questions are for informational purposes only. AARP does not provide medical advice nor does AARP recommend or endorse any specific tests, physician, products, procedures, opinions, or other medical information that may be mentioned in the AARP Bulletin or on AARP Bulletin Today. Seek professional advice for medical problems.