NEWSLETTER – MARCH 2018 

Welcome to our first Surgery with Soul newsletter for 2018! We hope that this little monthly note from us to you will benefit patients and health care practitioners alike. We have a few interesting topics lined up — aimed to give you enough to think about and spark your curiosity without boring you to tears. We will often put things in point format or use information blocks to make the read as easy as possible. You can look forward to some experts weighing in, yummy free recipes from Michelle and short book reviews on interesting reads you may want to consider. I hope we provide not only valuable information but also a spark of inspiration! Please feel free to share this with patients, family or friends.

       Letters to look forward to:

April: Don’t be taken for a fool — trends in screening for breast disease

May: May the force be with you — the murky but marvelous world of mind-body medicine

June: Less is more — trends in breast conserving surgery

July: Chemotherapy catharsis

August: The mastalgia monster — understanding and treating breast pain

September: Spring clean your life with tools from integrative and functional medicine

October: Happy hormones — what to make of HRT and exploring alternatives

November: Healing in the absence of cure — dealing with metastatic breast cancer

December: Genetics and epigenetics — is your DNA your destiny?

Let’s get cracking with this month’s letter!

A BIRD’S EYE VIEW ON AN INTEGRATED APPROACH TO BREAST CANCER

As a practitioner, it is likely one of the hardest conversations to have. As a patient, it is life changing news to hear: knock-you-off-your-feet, wind-out-of-your-sails, this-cannot-be kind of stuff.

“You have breast cancer.”

Now what?

Getting this utterly devastating news almost always pushes patients into a whirlpool of emotions and thoughts. For practitioners, it is more often than not a moment of helplessness and a tipping point where many will resort to focusing on practicalities in order to avoid the flood, or aery absence, of raw emotions flying at them.

When fear grips you by the tail end, it is useful to have something to anchor you. When you are tossed out in the wilderness and need to find your way back home, the one thing you really need is a road map.

So this is what we aim to provide this month — a bird’s eye view on the breast cancer wilderness and the outlines of what you may want to use as a treatment map.

Anchoring advise for patients:          

1. This sucks. And it is ok for you to feel utterly overwhelmed and devastated. Feel it. And then lift your chin. Take a deep breath — often.
2. Put on your hiking boots because this is a journey with some windy but beautiful roads. You won’t believe me now but you will meet other survivors. And most of them will tell you the same thing: that you will never be the same — for the better. Because, yes, your body is going to be put through the paces but your soul, if you so choose, is in for a heck of ride.
3. Develop selective hearing — everybody will have an opinion on what you should or shouldn’t do… who you need to see, what you need to eat, when you should sleep or meditate or poop. There will also be a lot of “ xyz happened to me / my auntie/my neighbor/Angelina Jolie.” They mean well. But this is your body. Your cancer. Your journey. And it really is — on a molecular, biological and scientifically proven level.
4. Empower yourself with information but pick your sources well. Ask questions. This is why it is so important to trust your treatment team. Let them guide you if you are looking for reading material. The internet can be your worst enemy.
5. One step at a time. Don’t loose yourself in ifs and maybe’s and a future none of us can predict anyway.
6. Don’t isolate yourself. Pick at least one person that you can trust completely with your experience — and that can accompany you to scary appointments. If you can’t, speak up and let your treatment team help.

 Anchoring advice for practitioners:

1. Be present. Sounds simple but in general allopathic practitioners are quite uncomfortable with this and are in some ways taught to emotionally check-out when hard conversations are on the table.
2. Be honest but kind.
3. No guess work. In cancer treatment and management, you have to get very comfortable with not knowing, with grey areas and with reaching out for advice and help. Never make decisions alone — you have to work with the treatment team. If you don’t get the feedback you need from specialists, insist on it.
4. Not all patients will resonate with the same specialist. Make sure you refer to a team that you trust but that will also be able to connect with your patient.
5. Take care of yourself — as caregiver it is of the utmost importance that your own wellbeing is a priority. That is the only way we can fully show up for our patients.

The territories of the map

Remember first and fore most that each patient will have a unique treatment journey. Here are a very brief summary of the terminology and modalities that you want to familiarize yourself with:

1. What type of cancer?

   In breast cancer we have moved away from focusing on the morphology of the cancer although it still has a role to play. The most common type is by far ductal carcinoma and its subtypes (it may have mucinous or papillary differentiation) followed by lobular carcinoma. What is far more important is the molecular footprint or receptor status. These include oestrogen receptor (ER) and progesterone receptor (PR) status as well as Her2Neu expression. The Ki67 score is also important. The proportion in which all these elements are expressed in the tumour will play a big role in determining:

   1. The sequence of treatment (surgery first versus neo-adjuvent chemotherapy)
   2. How to deal with positive axillary lymphnodes
   3. If chemotherapy is necessary
   4. If endocrine therapy (oestrogen receptor blockers) is necessary and in pre-menopausal women if ovarian ablation is needed
   5. If biological / immune therapy is neccessary
   6. If radiotherapy is necessary

   Another useful tool, particularly to aid in the decision around chemotherapy, is Oncodx or Mammaprint — so called genomic testing that can assess a particular tumour’s response to chemotherapy.

2. Staging

   Personally, I prefer to steer clear of labelling patients with a “stage” — I have seen little psychological benefit in it. Academically, it is however useful. Staging is done pre- and post-operatively as we can gain a lot of information from the tumour specimen. Clinically the TNM classification (tumour size, nodes palpable, presence of metastatic disease) is still used. Metastatic screening (especially in those with palpable nodes) would typically involve basic blood work, a CT Chest and CT abdomen (although an abdominal ultrasound can also be used) and bone scan. PET-CT is a one-stop option although not recommended in Stage 1 and 2 patients.

3. Genetic testing

   Although I believe that this will play an even bigger role in the future, genetic testing should currently be used selectively and always only after proper genetic counselling by a trained professional. In general, patients with a strong family history or patients diagnosed before the age of 40 should be referred.

4. Surgical options — always divided in a breast procedure and an axillary procedure

   • Breast conserving surgery (taking out only the tumour with a clear margin) has become the gold standard and should be offered to all patients if at all possible. There is a mountain of evidence to support the safety of BCS and we will dedicate an entire newsletter to it in June!
   • Modified radical mastectomy — removing the whole breast — with or without reconstruction. Reconstruction can be done as a delayed procedure or immediately and can be done with implants or with a tissue flap (the most popular now being the DIEP flap — very much like a tummy-tuck and using that tissue to create a new breast)
   • Skin sparing mastectomy/nipple sparing mastectomy — in select patients skin and/or nipple can be spared and only the underlying breast tissue removed. This will then be followed by reconstruction.
   • Axillary node clearance (removal of all the lymphnodes under the arm) is rarely indicated and sentinel lymphnode biopsy has become the gold standard.
   • It is very important that patient’s receive proper post-operative physiotherapy to ensure arm and shoulder mobility.

5. Chemotherapy

   • We will dedicate a separate newsletter to this topic in July but the most common combination of chemotherapy would include the so-called red devil (Doxyrubicin or Adriamycin). Prior to getting this drug, patients will be sent for an echocardiogram since it is cardiotoxic.
   • Herceptin or trastuzumab is strictly speaking not a chemotherapy drug but rather a biological agent or monoclonal antibody that is used to treat patients that has Her2Neu (human epidermal growth factor receptor 2) expression in their tumours.

6. Radiotherapy

   • This is a non-negotiable when breast conserving surgery is performed.
   • We will make sure to dedicate a newsletter to this topic
   • Radiotherapy may be given as a short course delivered in slighter higher fractions over 3 weeks  (15 sessions) or as a longer course delivered in slightly lower fractions over 5 weeks (25 sessions). Both are supported by good evidence – very often the type of surgery the patient had or other patient related factors would sway us to use one rather than the other.

7. Endocrine therapy

   • All patients with oestrogen receptor positive tumours should receive endocrine therapy.
   • Tamoxifen (Novladex) is used for pre-menopausal women and an aromatase inhibitor (Arimidex) for post-menopausal women.
   • There is evidence to suggest that this treatment can be continued up to 10 years with a survival benefit
   • It is important for practitioners to look after their patient’s bone density, cardiac and uterine health when on this treatment

8. Alternative health care modalities

   • We will dedicate a whole newsletter to this in May, deep delving particularly into the emerging evidence for mind body medicine
   • In our practice we use a body talk and TRE — both energy medicine modalities — for those patients that are interested
   • Nutrition is extremely important and therefore all patients are encouraged to have at least one session with a nutritionist to guide their eating habits. Food really is medicine – so much can be gained by being more mindful of what we put in our tummies! To get you started, make sure you try our delicious recipe below!
   • Supplements — although the topic of debate there is fair evidence to suggest that vitamin C, zinc and selenium improve wound healing and immunity. Magnesium oxide can aid in digestion as well as improve sleep. These are basics but have at least some evidence to back their use unlike a multitude of products available in health shops.
   • Health care coaching/counselling — the psychological wellbeing and mindset of the patient and her/his family is of the utmost importance and should be as much of a treatment priority as the surgery or chemotherapy.

This really is just broad brush strokes to give some indication of the terrain ahead – but I hope that this will serve as good basic map to tackle the journey with. There are many wonderful resources available – and also very dangerous ones. Please choose your resources wisely. I find the Buddies for Life magazine very useful – evidence based science is explained and explored in very palatable, everyday language. (www.subcribe@buddiesforlife.co.za)

This months recipe from Michelle:

We hope you found this letter useful. We would love to hear from you so please leave a comment below!