MAYO CLINIC HEALTH LETTER Reliable Information for a Healthier Life VOLUME 34

NUMBER 8

AUGUST 2016

Inside this issue HEALTH TIPS . . . . . . . . . . . . . . . . . . . . 3 Driving at night. NEWS AND OUR VIEWS . . . . . . . 4 Lyme disease-causing bacteria discovered by Mayo Clinic. Improved fitness may protect brain. SITUPS AND BEYOND . . . . . . . . 4 Improving stability and movement. RADIATION PROCTITIS. . . . . . 6 Bowel problems after radiation. ACOUSTIC NEUROMA . . . . . . . . . 7 A cause of gradual hearing loss. SECOND OPINION

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Thyroid function disorders Finding the right balance You used to love early morning walks, but lately you’ve had a hard time getting motivated. You feel kind of “blah” about a lot of things — which isn’t your usual self. You’ve felt other changes, too — dry skin, a bit of weight gain and constipation — but they hardly seem related. You wonder if it’s just a part of aging. In fact, these might all be signs and symptoms of an underactive thyroid gland. Thyroid disorders are more common with age and yet can appear more subtly in older people.

The thyroid gland has an enormous impact on your health. It helps set the rate at which your body functions, regulating all aspects of your metabolism, from how regular your digestive system is to how quickly your heart beats. In response to direction from the pituitary gland in your brain, the thyroid gland secretes the hormones thyroxine (T4) and in smaller amounts triiodothyronine (T3). The more thyroid hormone that’s circulating in your bloodstream, the greater the speed at which chemical activities occur in your body. A delicate balance As long as your thyroid gland produces the right amount of T4 and T3, your metabolism receives all the right signals. But sometimes the gland produces and releases too much or not enough hormone, upsetting the delicate

Shaped like a bow tie or butterfly, the thyroid gland is located at the base of the throat, just above the dip in the breastbone. The gland wraps around your windpipe (trachea).

balance of chemical reactions in your body. When your thyroid gland produces too little hormone, this is called underactive thyroid disease (hypothyroidism). When it produces too much, you have overactive thyroid disease (hyperthyroidism). Thyroid function abnormalities are caused by thyroid disorders such as autoimmune disease, inflammation, or abnormal growths or nodules, which are often noncancerous (benign) but sometimes cancerous (malignant). Older adults are more prone to underactive thyroid. The most common cause of hypothyroidism is a chronic autoimmune disorder called Hashimoto’s thyroiditis, where over-reactive immune cells destroy thyroid gland tissue. But previous thyroid surgery, and ironically, therapy for hyperthyroidism are other major causes of hypothyroidism. Low thyroid hormone levels also can be a side effect of certain medications. As your thyroid hormone production decreases, your metabolism slows. This can lead to signs and symptoms such as fatigue and sluggishness, slow heart rate, increased sensitivity to cold, unexplained weight gain, dry skin and hair, constipation, muscle aches and weakness, hoarseness, and elevated cholesterol. Often these kinds of generalized signs and symptoms are attributed to aging, and many adults with normal thyroid function have similar symptoms. This can make it easy to overlook the condition. Hyperthyroidism is most often caused by a different autoimmune disorder called Graves’ disease. In Graves’ disease, immune system antibodies attack your thyroid, and sometimes your eyes and skin. Overproduction of thyroid hormone also may come from nodules that grow within the gland and start producing hormones on their own. Inflammation of the thyroid, which can sometimes be painful, can cause too much stored thyroid hormone to be released into your bloodstream. As you might expect, hyperthyroidism speeds up your metabolism. In

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older adults, complications of metabolic acceleration typically show up in connection with body systems that are already more vulnerable, such as your heart and blood vessels or your brain and nervous system. This can cause signs and symptoms such as a rapid or irregular heartbeat, congestive heart failure, chest pain, and even a heart attack. Nervous system effects might include feeling confused, irritable, apathetic or depressed. Hyperthyroidism also can lead to irregular bowel movements, unintentional weight loss, hand tremor, increased perspiration, muscle wasting and bone loss. Tests for thyroid disease Not all doctors agree on screening adults for thyroid disorders. The American Thyroid Association and the American Association of Clinical Endocrinologists recommend that screening be considered for people older than 60. Practically speaking, doctors often test for thyroid problems to rule them out as part of a search for a diagnosis. There are several tests to measure thyroid function. The one your doctor is most likely to start with is a test that measures the level of thyroid-stimulating hormone (TSH) in your bloodstream. Your pituitary gland produces TSH to signal your thyroid to increase or decrease production of T4 and T3 as needed. An abnormal TSH level is an indication that your thyroid gland isn’t functioning as it should. The next step is to test for T4. Low levels of T4 indicate an underactive thyroid, whereas high levels indicate an overactive thyroid. For cases in which hyperthyroidism is suspected and T4 levels appear normal, your doctor may request a T3 test. If all three tests are requested at the same time, this is called a thyroid panel. Sometimes, other tests are requested to help with the diagnosis, such as a radioiodine uptake test for hyperthyroidism or imaging scans of the thyroid gland in patients with nodules. Symptoms can be very mild in some cases. Older adults in particular may

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experience only one or two symptoms rather than the wide range that tends to affect younger people. People with mild or barely existent symptoms may have subclinical hypothyroidism or hyperthyroidism. In this case, T4 and T3 levels appear normal even while TSH is abnormal. Treatment The goal of treatment is to restore normal thyroid function. The key is finding the right balance — not too much treatment, not too little. Treatment often depends on your age, personal preferences, level of thyroid hormone and severity of your symptoms: Q Hypothyroidism — Fixing an underactive thyroid typically involves taking a daily dose of a synthetic form of thyroid hormone called levothyroxine (Levoxyl, Synthroid, others). Signs and symptoms such as fatigue, weight MAYO CLINIC HEALTH LETTER Managing Editor Aleta Capelle

Medical Editor Robert Sheeler, M.D.

Associate Editors Rachel Bartony Joey Keillor

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EDITORIAL BOARD Shreyasee Amin, M.D., Rheumatology; Amindra Arora, M.B., B.Chir., Gastroenterology and Hepatology; Brent Bauer, M.D., Internal Medicine; Lisa Buss Preszler, Pharm.D., Pharmacy; Bart Clarke, M.D., Endocrinology and Metabolism; William Cliby, M.D., Gynecologic Surgery; Clayton Cowl, M.D., Pulmonary and Critical Care; Mark Davis, M.D., Dermatology; Kellen V. Lambeau, DNP, APRN, CNP, Family Medicine; Timothy Moynihan, M.D., Oncology; Daniel Roberts, M.D., Hospital Internal Medicine; Robert Sheeler, M.D., Family Medicine; Phillip Sheridan, D.D.S., Periodontics; Peter Southorn, M.D., Anesthesiology; Farris Timimi, M.D., Cardiology; Matthew Tollefson, M.D., Urology; Debra Zillmer, M.D., Orthopedics; Aleta Capelle, Health Information. Ex officio: Rachel Bartony, Joey Keillor. Mayo Clinic Health Letter (ISSN 0741-6245) is published monthly by Mayo Foundation for Medical Education and Research, a subsidiary of Mayo Foundation, 200 First St. SW, Rochester, MN 55905. Subscription price is $31.52 a year, which includes a cumulative index published in January. Periodicals postage paid at Rochester, Minn., and at additional mailing offices. POSTMASTER: Send address changes to Mayo Clinic Health Letter, Subscription Services, P.O. Box 9302, Big Sandy, TX 75755-9302.

gain and high cholesterol usually recede as thyroid hormone levels return to normal. Treatment is usually lifelong. For older adults — especially those with heart problems — treatment may start at a much lower dose than is required to replace what the thyroid gland isn’t making, and then gradually increase until normal levels are achieved. This approach allows your heart and nervous system time to adjust to the increase in thyroid hormone without undue stress. Q Hyperthyroidism — To bring an overactive thyroid under control, your doctor may initially prescribe antithyroid medications to prevent excess thyroid hormone production and gradually reduce symptoms. Beta blockers, commonly used to treat high blood pressure, can help reduce a rapid heart rate and help prevent or control

palpitations. In some people, hyperthyroidism will resolve after taking these drugs for 12 to 18 months, but in others it will recur after discontinuing antithyroid medications. In these cases, more definitive treatment, such as radioactive iodine, may be needed. Taken by mouth, radioactive iodine shrinks your thyroid gland, causing thyroid activity to slow considerably. This relieves symptoms of hyperthyroidism but will in turn lead to an underactive thyroid, so that you will need to take replacement thyroid hormone. Your thyroid can be surgically removed, but this treatment is generally reserved for people with very large goiters, and those who have not been helped by or have allergies to anti-thyroid drugs and refuse radioiodine. When surgery is chosen, it’s best performed by a skilled surgeon with expertise in the procedure. U

Working the loop Your thyroid gland produces two main hormones, thyroxine (T4) and triiodothyronine (T3), that exert a major influence on your body’s metabolism. The rate at which T4 and T3 are released is based on a continuous feedback loop between your thyroid gland, your pituitary gland and your hypothalamus — an area at the base of your brain that acts as a thermostat for your whole system. When the hypothalamus senses low levels of circulating T4 and T3, it signals your pituitary gland to make a hormone called thyroidstimulating hormone (TSH). TSH prompts the thyroid gland to produce T4 and T3 so that levels return to normal. If the thyroid gland is diseased and is releasing too much thyroid hormone on its own, TSH levels remain low. If the diseased thyroid gland can’t make enough thyroid

hormone, TSH levels remain high. This is why the TSH test is a very sensitive indicator of thyroid dysfunction.

When the hypothalamus senses low levels of circulating thyroxine (T4) and triiodothyronine (T3), it signals the pituitary gland to make the thyroid-stimulating hormone (TSH). TSH prompts the thyroid gland to produce T4 and T3.

August 2016

Health tips Driving at night As days grow shorter and nights grow longer, it pays to be attentive when getting behind the wheel, especially after dark. Age-related changes to your vision and eye diseases such as cataracts can make it more difficult to see clearly at night. You may have trouble reading road signs, adapting to glare from headlights, or correctly judging distances and speed of other vehicles. There are general measures you can take to help you drive safely at night, as well as specific precautions when you get behind the wheel. In general: Q Stay current with eye exams. Q Wear glasses that are antireflective and that don’t obstruct your peripheral vision. Q Check with your doctor about side effects of any medications you may be taking that might affect your driving abilities. Q Keep your windshield and headlights clean. Ask your mechanic to make sure headlights are aimed correctly. Q Don’t drive if you feel impaired or sleepy. Q Take a driving course. Even experienced drivers can benefit from a refresher now and then. Take precautions such as: Q Slow down so that you have time to react and stop if needed. Q Minimize distractions, such as fiddling with the radio or a phone, eating, or drinking. Q Stay alert to the road and other drivers. Q Pull over if you need to check directions, make a call, send a text, or just need a break or a nap, especially on longer trips. U

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News and our views Lyme disease-causing bacteria discovered by Mayo Lyme disease is the most common tick-borne illness in the U.S. It’s passed along by deer ticks (blacklegged ticks). Until recently, the bacterium Borrelia burgdorferi was the only species of bacteria believed to be responsible for Lyme disease in the U.S. That changed when researchers at Mayo Clinic — in collaboration with federal and state health agencies — found unusual results in six of 9,000 blood samples from Minnesota, North Dakota and Wisconsin. The samples were tested for Lyme disease between 2012 and 2014. The unusual results led to the discovery of a new bacterial species — the provisional name is Borrelia mayonii — and was recently reported in Lancet Infectious Diseases. The new bacterium causes unique symptoms that could potentially thwart diagnosis. Typical early Lyme disease signs and symptoms include a rash that may expand to form a large reddish circle or a bull’s-eye, and flu-like signs and symptoms such as fever, chills, fatigue and headache. A stiff neck, pain in muscles or joints, or neurological problems also may occur. Many symptoms of Lyme disease caused by B. mayonii and B. burgdorferi overlap. However, Lyme disease caused by B. mayonii also may include nausea and vomiting, and a fever of 102 degrees Fahrenheit. In addition, any rash may be more diffuse and widespread, rather than the single bull’seye rash. A much higher bacterial concentration of B. mayonii appears in a blood sample, compared with B. burgdorferi. The good news is that Lyme disease caused by B. mayonii can be detected with standard Lyme disease testing. In addition, antibiotic treatments commonly used for Lyme disease are effective for Lyme disease caused by the new bacterium. So far, the new bacterium hasn’t been detected outside the upper Midwest. It’s certainly possible — or even likely — that it will spread or appear elsewhere, but it’s impossible to predict when or if that may occur. U

Improved fitness may protect brain People with mild cognitive impairment (MCI) are at an increased risk of dementia caused by Alzheimer’s disease or other neurological disorders. However, not everyone with MCI develops dementia. As a result, the phase between normal cognition and dementia might be a good time for slowing or reversing the rate at which brain nerve cells are degenerating (neurodegeneration). Preliminary evidence suggests that exercise can affect the healthy brain’s ability to change and generate new nerve cells, a concept referred to as neuroplasticity. Recently, researchers wanted to see if exercise might also increase neuroplasticity in people already affected by MCI. Over a span of 12 weeks, a healthy group of older adults and a group with MCI both engaged in a customized fitness program. Researchers found increased fitness was associated with increased cortical thickness in both groups, meaning more nerve cells were created. In the MCI group, an even stronger association was found in two specific regions of the brain that are typically affected by MCI. The study suggests that increased fitness may help induce the creation of new nerve cells in the cortex, possibly counteracting the effects of neurodegenerative diseases, such as Alzheimer’s. U

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Situps and beyond Improving stability and movement It may have been a while since you were last in an elementary or high school phys ed class, but it’s unlikely that you’ve forgotten the near-universal exercise called the situp. Even though the situp has been around for a long time — along with other classic exercises such as the pushup or pullup — performed properly, it remains an excellent abdominal strengthening exercise. However, two common problems with the way situps are often performed include: Q Being performed as the only exercise specifically designed to strengthen the trunk (core) of the body. Q Lacking proper form, possibly making the exercise less effective or adding an increased risk of injury. Learning how to perform situps properly — and ways to complement situps with other exercises to strengthen other core muscles — can help safely and effectively set you on the path to increased balance and stability, better posture and ease of movement, and improved spinal support and resilience to low back pain. Getting to the core Your core muscles are located around your midsection and pelvis. They include not only your abdominal muscles — which are exercised with a situp — but also the muscles that support your spine, pelvis, hips, and lower back. Just about every movement your body makes involves your core muscles. Some movements — such as getting up from lying down or picking up a box — involve more obvious use of core muscles. However, any time you walk, go up or down a step, reach

for or carry something, your core muscles are continually adjusting to keep your spine balanced and stable. Strong core muscles make it easier to live an active, independent life, whether that means participating in a sport, doing yardwork, carrying in groceries or bending down to tie a shoe. Weak core muscles leave your spine less balanced and cause you to be less stable on your feet, making you more susceptible to falls and injury — including lower back injury or aggravation of a previous lower back injury. Keep your core fit with the exercises described and illustrated on this page. Perform these exercises on a carpeted floor or mat. During each exercise, breathe freely and deeply by counting aloud or blowing slowly through pursed lips. Don’t hold your breath, as this can cause dangerous spikes in blood pressure. Start by repeating each exercise five times, or as many times as you can while maintaining good form. As your core strength improves, you may be able to build up to 10 to 15 repetitions and breathe more freely and deeply. If you have back problems, osteoporosis or other health concerns, first talk with your doctor. The situp To properly perform a situp, lie on your back with your knees slightly bent. Plant your feet firmly on the floor about hip-width apart. Keep your knees comfortably apart. Fold your arms on your chest. Don’t clasp your hands behind your head, as this puts your neck at risk of injury and prevents you from effectively isolating the abdominal muscles. Tighten your abdominal muscles and raise your head and shoulders off the floor and hold. You’ll feel tension in the muscles in your abdomen. Hold for three to five seconds, then return to the starting position. Quadruped To perform the quadruped exercise, start on your hands and knees. Place

your hands directly below your shoulders, and align your head and neck with your back. Tighten your abdominal muscles. Raise your right arm off the floor and reach ahead. Hold for three deep breaths. Lower your right arm and repeat with your left arm. Raise your right leg off the floor. Tighten your core muscles for balance. Hold for three to five seconds. Lower your right leg and repeat with your left leg. Once each of these exercises is easy to do individually, for an added challenge, raise your left arm and your right leg at the same time, holding for three to five seconds. Repeat with your right arm and left leg.

Bridge To perform the bridge exercise, lie on your back with your knees bent. Keep your back in a neutral position — not arched and not pressed into the floor. Avoid tilting your hips. Tighten your abdominal muscles while keeping your back in a neutral position. Pushing through the heels, raise your hips off the floor until your hips are aligned with your knees and shoulders in a straight line. Hold for three to five seconds and return to the starting position and repeat. Keeping your arm position closer to your body increases the core challenge. Modified plank To perform the modified plank, lie on your stomach. Raise yourself up so that you’re resting on your forearms and your knees. Align your head and neck with your back, and place your shoulders directly above your elbows. Tighten your abdominal muscles to find your neutral position. Create resistance by pressing your elbows and your knees toward one another. Neither should move from their positions on the floor. Hold for three to five seconds. Return to the starting position and repeat the exercise. U August 2016

The situp

Quadruped

Bridge

Modified plank

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Radiation proctitis Bowel problems after radiation Radiation therapy can be a critical component of cancer treatment. Radiation damages the DNA inside quickly dividing cancer cells, interrupting their ability to grow and divide, and causing them to die. Radiation therapy can also affect normal body cells near the radiation site. Most cells recover over time and go back to working normally. However, that isn’t always the case. When it comes to radiation therapy to the pelvic area — such as for cancer of the prostate, bladder, cervix, uterus, testes, rectum or anus — post-radiation problems sometimes occur in the nearby large intestine (colon) and rectum. If you develop bowel problems at any point during or after pelvic radiation therapy — even years or decades later — let your doctor know about it, and about your radiation history. This can help alert your doctor to radiation proctitis as a possible cause, since there are a number of diseases and conditions that can cause similar symptoms. Short-term discomfort Radiation proctitis can occur in an acute form, meaning that it occurs during radiation treatment or within six weeks of radiation treatment. Signs and symptoms may include diarrhea, mucus discharge, cramps, frequent urges to have bowel movements and light bleeding. Acute radiation proctitis develops in about 20 percent of people undergoing pelvic external beam radiation. It usually develops during the course of radiation, and therapy may be paused to let the rectum recover. Hydration and use of anti-diarrheal medication are the mainstays of treatment, although an enema of an anti-inflammatory drug also may be considered.

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A delayed reaction Radiation can also occur in a longer term, chronic form. The chronic form is usually more delayed, with symptoms often first occurring about a year after radiation exposure. However, it can occur at any time after radiation exposure, including right away or years or even decades later. Chronic radiation proctitis shares many symptoms of the acute form. However, with chronic radiation proctitis, an area of normally supple and smooth colon tissues becomes stiffer and more fibrous. Tiny blood vessels on the surface of the lining of the colon become distorted, and vulnerable to bleeding. Because of this, bleeding can be much heavier. Narrowing (stricture) of a portion of the colon and rectum is also a potential problem that can lead to constipation or other difficulties passing stool. The risk of developing chronic radiation proctitis isn’t clear. However, the risk is higher with higher doses of external beam radiation. Pre-existing inflammatory bowel disease or HIV/AIDS appears to make people more vulnerable. The risk is lower in people who have radiation delivered only by implanted radioactive seeds (brachytherapy). Stopping bleeding Bleeding — and finding a way to stop it — is the primary concern with chronic radiation proctitis. Mild and infrequent bleeding, with occasional light bleeding that may be seen on toilet paper, often doesn’t require treatment. If bleeding is more frequent or heavier, a reasonable first treatment step is a one-month trial of a drug — sucralfate — commonly used to treat ulcers. With radiation proctitis, sucralfate is delivered by enema. One study found that sucralfate resulted in symptom relief in about 75 percent of those who tried it. Other drugs are sometimes considered in addition to sucralfate, but they appear to be of limited benefit. If bleeding isn’t controlled after a trial of medication through enemas, a

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procedure called argon plasma coagulation may be the next step. In this procedure, a scope instrument is inserted into the colon to the site of the bleeding. Through the scope, a probe is inserted that ejects a spritz of electrified argon gas, which turns into a plasma that seals off superficial bleeding vessels. Argon plasma coagulation is usually the preferred means of stopping rectal bleeding, but it’s not the only way. Laser or other forms of heatsealing, freezing therapy (cryotherapy), or topically applied sealing solution (formalin) are additional options. Other concerns Stricture of the colon caused by radiation proctitis can often be managed with steps to soften stools so that they pass through the narrowing more easily. If that isn’t enough, a scope procedure that attempts to stretch and dilate the stricture may be considered. While not common, surgery to address unstoppable bleeding, a stricture or other complications may be considered. Surgery is usually reserved as a last resort, as areas of radiationdamaged tissues can be difficult to work with surgically. Another expensive option for difficult-to-stop bleeding is hyperbaric oxygen therapy. In this, you breathe pure oxygen from within a pressurized room or tube in an attempt to increase the oxygen supply in the body to ramp up healing. U

Argon plasma coagulation is used to seal off superficial bleeding vessels.

Acoustic neuroma A cause of gradual hearing loss Damage from noise exposure and agerelated changes to the inner ear are the usual suspects when it comes to causes of hearing loss. But they’re not the only reasons you might lose your hearing. Hearing loss — especially if it occurs predominantly on one side — may be the result of an acoustic neuroma. An acoustic neuroma, also called a vestibular schwannoma, is a benign tumor that grows on the balance and hearing nerves. These nerves twine together to form the vestibulocochlear nerve, which runs from your inner ear to your brain. For many years, doctors thought surgical removal was the best treatment. But increasingly, doctors are concluding that in some cases, no treatment may be just as good or better in the long run. A natural history An acoustic neuroma arises from the cells (Schwann cells) that make up the insulation surrounding the vestibulocochlear nerve. What causes these cells to overgrow and form a tumor isn’t certain, but it may be related to sporadic genetic defects. Acoustic neuromas are uncommon and are usually diagnosed between ages 30 and 60. In rare cases, the overgrowth may be caused by an inherited disorder. Most acoustic neuromas grow very slowly, although the growth rate is different for each person and may vary from year to year. Some acoustic neuromas stop growing, and a few even regress. The tumor doesn’t invade the brain but may push against it as it enlarges. Signs and symptoms typically include loss of hearing in one ear, ringing in the ear (tinnitus) and unsteadiness while walking. Occasionally, facial numbness or tingling may occur. Rarely,

large tumors may press on your brainstem, threatening vital functions. A tumor can prevent the normal flow of fluid between your brain and spinal cord so that fluid builds up in your head — a potentially life-threatening scenario. Diagnosis can be a challenge because early signs and symptoms may be attributed to more familiar causes, such as aging or noise exposure. If an acoustic neuroma is suspected — such as when a hearing test reveals loss predominantly in one ear — the next step is to undergo imaging, typically magnetic resonance imaging (MRI), to look for evidence of a tumor on the vestibulocochlear nerve. An acoustic neuroma may also be detected when you’re undergoing imaging for another reason. Treatment options Treatment varies depending on the size and growth of the acoustic neuroma, symptoms, and your personal preferences. Options include: Q Monitoring — If you have a small acoustic neuroma that isn’t growing or is growing slowly and causes few or no signs or symptoms, you and your doctor may decide to monitor it. Recent studies indicate that more than half of small tumors don’t grow after diagnosis, and a small percentage even shrink. Monitoring involves regular imaging and hearing tests, usually every six to 12 months. The main risk of

monitoring is tumor growth and progressive hearing loss. Q Stereotactic radiosurgery — This approach may be used if the acoustic neuroma is growing or causing signs and symptoms. In this procedure, doctors deliver a highly precise, single dose of radiation to the tumor. The procedure’s success rate at stopping tumor growth is usually greater than 90 percent. Although the risk is small, stereotactic radiosurgery can damage nearby balance, hearing and facial nerves, worsening symptoms or creating new ones. Q Open surgery — Surgical removal is typically recommended when the tumor is large or growing rapidly. This involves removing the tumor through the inner ear or through a window in your skull. If it can be removed without injuring the nerves, your hearing may be preserved. Surgery risks include nerve damage and worsening of symptoms. In general, the larger the tumor, the greater the chances of your hearing, balance and facial nerves being affected. Other complications may include a persistent headache. An evolving approach Research is ongoing to compare the three treatment strategies. But based on existing long-term data, there appears to be surprisingly little difference in outcome no matter which treatment is chosen for smaller tumors. U

An acoustic neuroma grows on the balance and hearing nerves (vestibulocochlear nerve). August 2016

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Second opinion

Q

I recently had an implantable cardioverter-defibrillator installed to shock my heart back into a normal rhythm if a deadly arrhythmia starts. Should I avoid getting my heart rate up with exercise?

A

Recommendations to get at least 30 to 60 minutes of moderately intense exercise most days generally don’t change if you have an implantable cardioverter-defibrillator (ICD). Still, you’ll want to talk to your doctor about your specific situation before starting to exercise. Typically, there are activity restrictions for two to four weeks after the implant procedure, such as not raising your left arm above shoulder height to prevent dislodging the ICD lead wires. In the short and long term, you’ll want to avoid sports or activities that could cause impact to the body, which could then disrupt the ICD. Additionally, check with your doctor before engaging in strenuous exercise programs or participating in a strenuous event such as a race. When it comes to being active, research has shown that regular, moderately intense exercise such as brisk walking doesn’t increase the risk of receiving a shock from the ICD. In fact, there’s some suggestion that getting regular, moderately intense exercise may actually reduce the likelihood of receiving a shock. In addition, exercise and activity can help you get back into shape and improve your physical function, reduce anxiety that you may have regarding having an ICD, and in general improve your ability to enjoy life and remain fit, independent and healthy.

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In contrast, lack of exercise, diminished activity or avoidance of activity due to fear of receiving a shock may lead to a cycle of decreased fitness, more anxiety related to the ICD and decreased quality of life. Talk to your doctor if you’re concerned about exercising with a ICD. Your doctor may be able to help reassure you, or possibly even help set up supervised exercise sessions on a treadmill. That way, you can see for yourself that exercise is tolerable, and there is help nearby if you need it. U

Q

Is it better to quit smoking abruptly or to gradually taper off tobacco use?

A

While quitting either abruptly or gradually can work, quitting abruptly may work better, according to a recent study published in the Annals of Internal Medicine. The study involved about 700 smokers randomly assigned to either quit tobacco use abruptly with the aid of nicotine replacement patches, or to gradually reduce tobacco use using nicotine patches with a two-week structured cigarette reduction program. Behavioral counseling was provided leading up to the quit day for both groups. After four weeks, 49 percent of the abrupt quit group and 39 percent of the gradual reduction group remained tobacco-free. At six months, 22 percent of the abrupt quit group and 15.5 percent of the gradual reduction group remained tobacco-free. It’s not entirely clear why this gap exists. It may be that the taper for the gradual reduction group was too sudden

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or the tapering schedule may have made it more difficult to initiate the quit date. One thing is known — the best way to quit smoking is with the aid of one of several nicotine replacement products and behavioral counseling. Stopping smoking with no help — either gradually or suddenly — isn’t as likely to help you quit. In addition, each time a person tries to stop, the likelihood for success increases. If you’ve tried to stop smoking but failed, don’t give up. You’re more likely to succeed with repeated attempts and behavioral counseling and medications to help. Every state has a telephone quit line that you can access by calling 800-QUIT-NOW (800-784-8669). On the internet, www.becomeanex. org or http://smokefree.gov provide information and support. U

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Special Report Supplement to MAYO CLINIC HEALTH LETTER

AUGUST 2016

Breast cancer An individualized approach With approximately 3 million breast cancer survivors in the United States, awareness of breast cancer’s prevalence and impact continues to grow. And with 1 in 8 women expected to develop breast cancer over the course of her lifetime, it’s likely this disease has already touched your life in some way — whether it was a friend, co-worker, family member or even you who received a diagnosis. Breast cancer is the most common nonskin cancer in the United States and the second-leading cause of cancer death among women, second only to lung cancer. Few cancers carry the same psychological implications — affecting selfimage, confidence and fear of recurrence — as does breast

cancer. While it’s often thought of as a disease affecting women, male breast cancer does occur, though it’s much more rare. Fortunately, due to greater awareness and continued medical advances, early detection has become more common. This has led to the possibility of less invasive treatments, much better health outcomes and improved quality of life for many women. As researchers continue to learn about the disease, women are benefiting from an individualized, patient-centered approach to cancer management. If you receive a cancer diagnosis, working closely with the various specialists who are part of your health care team and equipping yourself with the latest information will help you navigate the questions and complexities ahead.

Breast cancer basics

Composed primarily of fatty tissue, the female breast has between 15 and 20 milk-forming lobes. Each lobe is made up of many smaller lobules that end in tiny milk-producing bulbs. A network of thin tubes called ducts connects these structures and carries milk to the nipple. The nearby axillary lymph nodes in the armpit are often the first site to which cancer may spread (metastasize) outside the breast.

Breast cancer is categorized by the appearance of the cancer cells and whether they’ve invaded surrounding tissue. Noninvasive (in situ) cancers remain within the ducts or lobules. Invasive cancers — which account for the majority of cases — have broken through the walls of their initial location and spread to surrounding breast tissue. The most common types of breast cancer are: Q Ductal carcinoma in situ (DCIS) — This is a noninvasive cancer that originates and remains within the ducts. Unchecked, a majority of these may progress into an invasive cancer. However, there’s nothing to suggest that having DCIS shortens life expectancy. Q Invasive ductal carcinoma (IDC) — Comprising the majority of invasive breast cancer cases, IDC starts in a duct and then invades nearby tissue. It can travel to lymph nodes or enter the bloodstream and spread to other parts of the body. Q Invasive lobular carcinoma (ILC) — This cancer starts in a lobule before spreading to nearby tissue. It may be more difficult to diagnose, as it can first show up as a thickening of the breast rather than a firm tumor. A handful of less common cancer types account for the last 10 percent of invasive cancer cases. These cancers include: Q Paget’s disease of the nipple — Associated with less than 5 percent of breast cancers, Paget’s disease causes nipple changes such as eczema, itching and thickening of the dark circle of skin (areola) surrounding the nipple. ¶

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Lobular carcinoma in situ In lobular carcinoma in situ (LCIS), abnormal cells remain within the lobules. LCIS is considered a precancerous lesion and signals up to a 20 percent increased risk of developing invasive cancer in either breast in the future.

Risk factors Being aware of breast cancer risk factors is the best way to determine and identify how you can reduce your risk. Keep in mind that risk statistics can be confusing. Before making sweeping changes based on the latest news headline, talk with your doctor about what a given statistic or risk factor means for you. Breast cancer risk factors include: Q Being female Q Increasing age Q Prior history of breast cancer or precancerous breast lesions Q History of radiation to the chest Q Family history of breast or ovarian cancer Q An inherited genetic mutation Q Dense breasts on a mammogram Q Obesity after menopause Q Longer estrogen exposure (early menstruation and late menopause) Q Use of combined menopausal hormone therapy Q Use of the medication diethylstilbestrol (DES) Q Alcohol consumption Q Smoking Q Never having children

Q Inflammatory breast cancer — This is an aggressive cancer involving the lymph vessels of the breast. With this type of cancer, the breast appears inflamed, red and swollen due to buildup of lymph fluid. The skin may take on a dimpled texture like that of an orange peel. Though rare — accounting for 1 to 5 percent of breast cancer cases — it’s considered advanced at diagnosis. Because of its symptoms, it can be mistaken for a breast infection (mastitis). Inflammatory breast cancer tends to occur more often in younger women and black women. It’s important to keep in mind that breast cancer is not a singular disease. There are many different subtypes that vary in terms of risk factors, aggressiveness, prognosis and which treatments may be effective. Key cancer features include: Q Grade — Tumors are graded on a scale of 1 to 3 to describe how aggressive the cancer cells appear under a microscope, with 1 being the least aggressive and 3 being the most aggressive. Q Stage — Though often confused with grade, staging looks at how large the cancer is and if it has spread to local, regional or more-widespread areas of the body. The most common staging method is the TNM system, where “T” refers to the primary tumor size and extent, “N” is for the degree of spread to nearby lymph nodes, and “M” is related to metastases — spread to other parts of the body. Considering these three factors in combination, cancers are assigned a stage between 0 and IV. Stage 0 is used to describe ductal carcinoma in situ, and the remaining stages describe invasive cancers. Stage I and II cancers also are referred to as early-stage localized, stage III is called locally advanced, and stage IV is advanced (metastatic) cancer that has spread to other parts of the body. Q Hormone receptor status — About 75 percent of breast cancers are fueled by hormones. Known as hormone receptor dependent, the cancer cells may be estrogen receptor (ER) positive, progesterone receptor (PR) positive or both. The presence of the receptor allows for the binding of estrogen or progesterone to the receptor and in turn can stimulate the growth of the cancer. Hormone receptor positive cancers tend to be slower growing and are more common in postmenopausal women. However, if these cancers recur, they may do so long after the initial diagnosis. Hormone receptor negative cancers (ER and PR negative), which aren’t fueled by hormones, tend to be more aggressive and are more common in premenopausal women. If they recur, they tend to do so within a few years of initial treatment. Q HER2 status — Some cancer cells overproduce HER2, a growth-promoting protein. Approximately 20 percent of breast cancer cases are characterized by excess HER2. HER2-positive cancers respond to treatments that target the HER2 protein, whereas HER2-negative cancers don’t respond to these treatments.

Reducing your risk Some breast cancer risk factors are within your control. Anyone can work to reduce the risk of breast cancer through changing lifestyle habits, including avoiding known cancer risks and maintaining a healthy weight. If you drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women. Numerous studies show that regular physical activity reduces breast cancer risk. The link between diet and breast cancer risk is less clear, though some studies indicate that high levels of fruit and vegetable consumption are associated with lower rates of hormone receptor negative breast cancers. If it’s been determined you’re at a high risk of developing breast cancer, you may want to consider additional preventive options. The use of anti-estrogen

Special Report medications to reduce breast cancer risk is called chemoprevention or preventive therapy. These medications work block the effects of estrogen by binding to the estrogen receptors in the breast. Other anti-estrogen medications work by reducing the production of estrogen in the body. These medications are only effective in preventing hormone receptor positive cancers. Options include: Q Tamoxifen — Tamoxifen is in a class of drugs known as selective estrogen receptor modulators (SERMs). Tamoxifen can be used before and after menopause and, when taken daily for five years, can reduce breast cancer risk by about 40 percent. It has also been shown to reduce breast density. It’s less clear whether tamoxifen improves long-term survival rates. Potential risks include cancer of the uterine lining (endometrial cancer) and blood clots. Q Raloxifene (Evista) — Another SERM, raloxifene is used in postmenopausal women to prevent breast cancer and to prevent and treat osteoporosis. One study indicated it was slightly less effective than tamoxifen at preventing breast cancer. However raloxifene has fewer serious risks. Side effects of both SERMs include menopausal symptoms such as hot flashes, night sweats and vaginal dryness. Q Aromatase inhibitors such as anastrozole (Arimidex), exemestane (Aromasin) and letrozole (Femara) — These drugs reduce the amount of estrogen in your body, depriving breast cancer cells of the fuel they need to grow. Though only approved to treat breast cancer, studies show they also reduce breast cancer risk by about 60 percent. Based on these results, some women are choosing to use aromatase inhibitors as a preventive measure. Aromatase inhibitors are only effective in postmenopausal women. They increase the risk of osteoporosis and can also cause hot flashes and vaginal dryness, joint and muscle pain, and headaches and fatigue. Preventive (prophylactic) surgeries are another option for women at high risk. A prophylactic mastectomy involves removal of one or both breasts and can reduce the risk of breast cancer by over 90 percent. Removal of the ovaries and fallopian tubes greatly limits estrogen production and can reduce breast and ovarian cancer risk. In premenopausal women, the procedure triggers early menopause. Some experts believe there’s a trend toward more-aggressive prophylactic surgeries — even among women without a genetic mutation. Often, the decision is based on family history and personal values, but also fear of cancer development. For women at average risk undergoing a mastectomy for early stage breast cancer, removing the healthy breast in addition to the affected breast has become more common in recent years. However, this hasn’t been shown to increase long-term survival, and it’s unclear whether it significantly improves quality of life. There are benefits, risks and limitations to medications and surgery. Talk with your doctor about your level of risk and what preventive measures may be best for you.

Screening for breast cancer Breast cancer tends to have few signs and symptoms, especially in its early stages. Catching cancer at this point — before it spreads — increases the likelihood of a good outcome, in part because you’re more likely to have the widest range of treatment options available to you. Though newer, investigational imaging tests are available, mammograms remain the primary and most effective tool for breast cancer screening. Studies have found that mammograms reduce the risk of dying of breast cancer by 15 to 30 percent. You may be confused by differing mammogram screening recommendations from various well-known, national organizations. Though not all organizations

Physical activity and breast cancer risk There’s a well-established link between physical activity and breast cancer prevention. Women who get regular physical activity — especially if that activity is of moderate to vigorous intensity — have a 10 to 30 percent lower risk of breast cancer than do inactive women. This is especially true among postmenopausal women, indicating that it’s never too late to start reaping the benefits of exercise. Two studies from Yale University found that exercise and weight loss reduced levels of a certain protein associated with a higher risk of breast cancer death. And, as little as two to three hours a week of moderate exercise such as brisk walking has been found to reduce breast cancer recurrence by 40 to 67 percent.

A look at the numbers In 2016, it’s estimated that nearly a quarter-million women will be diagnosed with invasive breast cancer and 60,000 with noninvasive cancer (carcinoma in situ). About 40,000 women will die of breast cancer. Though these statistics are sobering, the good news is that breast cancer is often curable if caught early. Overall, 89 percent of women survive five years or longer after receiving a diagnosis. That survival rate goes up to 98 percent when breast cancer is caught at its earliest stage.

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Understanding hereditary risk Although only 5 to 10 percent of breast cancers are attributed to inherited genetic mutations, the presence of these mutations can significantly influence the likelihood of developing the disease. Mutations in two specific genes — BRCA1 and BRCA2 — are the best studied and account for about half of all hereditary breast cancer. Women without a genetic mutation have a 10 to 12 percent chance of developing breast cancer over the course of their lifetimes. Women with the BRCA1 mutation have a 50 to 65 percent chance, with some estimates up to 85 percent. Women with the BRCA2 mutation have a 45 percent chance of developing breast cancer. Compared with the general population, women who have both mutations also have a substantially increased risk of ovarian cancer. Cancers related to the BRCA mutations are more likely to be triple negative, and women with BRCA mutations are more likely to develop a second cancer. These mutations are rare, but are more prevalent in certain ethnic groups, such as those of Ashkenazi Jewish descent. There are other hereditary genetic mutations that also are associated with increased breast cancer risk. Genetic testing — known as panel testing — is available to identify the BRCA and certain other mutations.

Testing for these genes has increased significantly among younger women, likely due to greater public awareness in recent years. Generally, testing is only recommended in cases where personal or a very strong family history suggests the presence of a mutation. Your doctor can help assess whether testing may be appropriate for you. If you’re considering testing, genetic counseling is recommended. A genetic counselor can help you understand the benefits, limitations, and potential medical and psychological implications of the testing. Computerized risk prediction tools, such as the Tyrer-Cuzick (IBIS) model, have been developed to help estimate breast cancer risk in women suspected to have an inherited genetic mutation and can also identify the likelihood of carrying a mutation. If you find out you have a genetic mutation, it doesn’t necessarily mean you will develop breast cancer, but it does substantially increase your risk. Test results need to be interpreted in light of your other risk factors to determine what decisions might be warranted, such as prophylactic mastectomy, preventive therapy and more-intensive surveillance — including magnetic resonance imaging (MRI) in addition to mammograms.

All breast cancer cases

Hereditary breast cancer No family history 80%

5% Some family history 15%

Unknown 55%

Hereditary BRCA1 30%

BRCA2 15%

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Screening considerations

During mammography, the breast is pressed against an X-ray platform.

agree on breast cancer screening guidelines, most emphasize working with your doctor to determine what’s right for your particular situation. Screening methods used to detect breast cancer include: Q Breast health awareness — Given the debate about the value of breast selfexaminations, the general concept of breast health awareness — knowing your breasts and being attuned to any changes — has largely replaced structured self exams as the standard for self-care. Know how your breasts look and feel and promptly discuss any changes or concerns with your doctor. Q Clinical breast examination — This is done by your health care provider and involves visually inspecting and feeling your breasts for abnormalities. There’s debate about the usefulness of this technique, either on its own or in conjunction with a mammogram for women at average risk, as it may lead to finding abnormalities that aren’t cancer (false-positives). However it can be useful for younger women with dense breasts and those at a high risk of cancer. Q Mammograms — The standard for screening, traditional mammograms use a low-dose X-ray to provide images of breast tissue. Newer 3-D digital mammography technology (tomosynthesis) provides improved visibility in dense breast tissue. It’s helpful in detecting invasive cancers, reducing false-positives and callbacks for additional imaging. Diagnostic mammograms use the same imaging processes but are more complex and are used to investigate areas of concern that may have shown up on your screening mammogram. They’re done with both a mammogram technician and radiologist present to interpret the results. Q Ultrasound — This technique uses sound waves to create images of the breast. It’s typically not used alone as a screening tool, but may be used along-

Since the intention is to detect breast cancer early, it’s easy to assume that more and earlier screening is better. But there are benefits, risks and limitations to screening. Because of this, various organizations recommend different ages at which women at average risk generally start regular screening and at what frequency. Mayo Clinic supports the option of annual screening beginning at age 40 for women at average risk — acknowledging that this needs to be a personalized decision that takes into account an individual’s values and an awareness of the benefits and risks of screening. For women with a genetic mutation, a family history of breast cancer or other risk factors, the initiation and increased frequency of screening tyically is done in consultation with a doctor.

Breast cancer in men It’s estimated that 2,350 American men learned they had breast cancer in 2015. Though male breast cancer is rare — accounting for less than 1 percent of all breast cancer cases — it can be a serious health issue, as it’s often diagnosed at a more advanced stage than it is in women. Risk factors for men include radiation exposure, high levels of estrogen — which can be caused by liver disease or a genetic disorder called Klinefelter’s syndrome — obesity and extra breast tissue, certain testicular conditions, and a family history of breast cancer, particularly related to the BRCA2 gene mutation. Men can develop breast cancer at any age, but it’s most frequently diagnosed between ages 60 and 70.

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Complementary and integrative therapies Although a lack of high-quality studies makes it hard to prove the impacts of complementary and integrative therapies, many people gain benefit from them. There’s little harm to some of these approaches when working with knowledgeable practitioners. While no alternative therapies have been found to cure breast cancer, complementary and integrative practices may help you relieve symptoms, cope with the side effects of treatment, and improve emotional well-being. Research indicates that mindfulness-based practices such as meditation, yoga, and stress management can help relieve depression and anxiety in individuals with cancer. They may also improve sleep, reduce fatigue and improve overall quality of life. Exercise has been found to reduce fatigue and anxiety while undergoing cancer treatment, and it may help relieve joint pain — a common side effect of aromatase inhibitors. Among cancer survivors, activities as varied as walking, cycling, strength training, yoga and tai chi have been found to play a role in improving quality of life. There are some indications these activities may improve body image, sexuality and sleep. Let your health care team know about any complementary therapies you’re considering — the team can help you identify how to integrate these practices into your cancer management plan. And consult with your doctor before taking any supplements, as they may interfere with your conventional treatments.

side mammography in women with dense breasts. Most often, ultrasound is used as a diagnostic tool to examine abnormalities found during a mammogram or physical exam. It tends to result in a higher incidence of false-positives. Q Magnetic resonance imaging (MRI) — MRI usex magnetic fields to create detailed images of the breast. MRI is used as a supplementary screening tool for women at very high risk or those with a hereditary genetic mutation. In these cases, an annual breast MRI alternating with a mammogram every six months or having both tests together annually is often recommended. Q Other tools — Other imaging methods are in use and being studied and include positron emission mammography (PEM), contrast enhanced mammograms and a nuclear medicine test known as molecular breast imaging (MBI). This test uses an injected radioactive tracer that attaches to breast cancer cells and makes them visible to a special camera. These and other tests may have advantages in some situations as well as trade-offs in terms of cost, availability, radiation exposure and the likelihood of a false-positive result. Your doctor can advise you on the screening and diagnostic tools that are best for you given your level of risk. If abnormalities are found during screening, you’ll likely be called back for additional imaging tests right away or advised to return for short-term follow-up. If there’s a suspicious mammogram or ultrasound result, you may have a biopsy, in which a needle is used to take a sample of tissue for further analysis. Although having a breast biopsy is considered an invasive procedure, having a biopsy confirm that no cancer is present can be reassuring. Talk with your health care team to understand testing recommendations, and ask whatever questions you need to in order to feel comfortable.

Breast cancer treatments If you’ve received a cancer diagnosis, you may be feeling overwhelmed. There’s a new vocabulary to learn, and you have some major decisions ahead. As you navigate your next steps, remember that there’s no one-size-fits-all approach to breast cancer. Treatment plans are highly individualized and will depend on many factors, including your medical history, the cancer’s features as well as your risk tolerance and preferences. Breast cancer treatments fall into two categories. Local or regional therapy targets the cancer cells and nearby tissue and includes surgery with or without radiation therapy. Systemic therapy treats cancer cells throughout your body. Which treatments are given and in what order will depend on the specifics of your situation. Treatment of local or regional disease typically involves an operation, with or without radiation therapy and with or without some type of systemic therapy — either hormonal blocking therapy or chemotherapy. If the cancer has spread beyond the local area, most therapy tends to be systemic — hormonal blocking therapy or chemotherapy — and may use treatments such as radiation or an operation only in very specific circumstances. The goal of an operation is to remove the cancerous cells. For many women with breast cancer, the most difficult decision is which type of surgery is best for the situation. A lumpectomy removes the tumor and a margin of surrounding healthy tissue. It’s also called breast-conserving surgery since it preserves as much of the breast as possible. It’s often followed by radiation therapy, as the use of radiation reduces the risk of recurrence by almost half. Most women with stage 0, I or II breast cancer are eligible for a lumpectomy, though it may not be the right choice in some situations — for example, if the tumor is large relative to the size of your breast, if you aren’t a good candidate for radiation treatment

Special Report or if there are multiple cancer lesions. For women who are good candidates for a lumpectomy with radiation, long-term survival outcomes are similar to having a mastectomy. A mastectomy removes the entire affected breast. A simple (total) mastectomy removes the breast only, whereas a modified radical mastectomy also removes the axillary lymph nodes. When a healthy breast is removed as well, it’s known as a contralateral prophylactic mastectomy. If you have a mastectomy, you’ll need to decide if you want to have breast reconstruction surgery, and whether to do it in conjunction with your mastectomy or at a later date. There are pros and cons to both options, as well as a variety of reconstruction methods to consider. Your choice of immediate versus delayed reconstruction may be constrained if you will need to have radiation treatment after your mastectomy. Reconstruction is a personal choice. If it’s clear that cancer has spread to the axillary lymph nodes, they’ll be removed during the breast surgery. Otherwise, a procedure called a sentinel node biopsy will be used to remove certain sentinel nodes and test them for cancer cells before removing additional nodes. Swelling of the area due to the retention of lymph fluid (lymphedema) may well be a complication if many axillary lymph nodes are removed. Swelling occurs less often after a sentinel lymph node biopsy. Studies show that exercise, targeted physical therapy and maintaining a healthy weight can help reduce the risk and severity of lymphedema. Radiation therapy uses high-energy X-rays to kill cancer cells and is used to treat breast cancer at nearly every stage. Traditional whole-breast radiation uses an external beam to direct radiation to the entire affected area. It’s generally given daily for five to seven weeks, though recent studies indicate shorter courses using slightly higher radiation doses — known as hypofractionation — are as effective. Newer accelerated partial breast irradiation (APBI) therapies use a focused beam to deliver a higher radiation dose to only part of the breast over a shorter time frame. APBI options include external beams, internal therapy that uses implants to deliver radiation directly to the tumor site (brachytherapy), and intraoperative radiation that administers a single radiation dose during surgery. Whole-breast radiation remains the standard radiation treatment, though APBI methods continue to show promise and may be appropriate for some women. Sometimes used as a first line cancer treatment, systemic therapies are frequently used as a secondary — or adjuvant — treatment after surgery in an effort to ensure cancer cells are killed and to prevent recurrence. Systemic therapy used to shrink a tumor before surgery is called neoadjuvant therapy. These treatments may have a range of troublesome side effects. However, they’re critical tools in treating breast cancer. The three main types are: Chemotherapy — This uses medications to kill cancer cells. It tends to be most effective in cancers that are triple negative or HER2 positive and less effective in hormone receptor positive cancers. Different combinations or sequences of drugs often are more effective than a single medication. Not everyone benefits from chemotherapy, and many women can avoid the toxic effects of these treatments. New tests such as Oncotype DX — which examines 21 genes — can help your doctor determine how much chemotherapy can help you, and whether hormone therapy alone is appropriate. These tests apply only to estrogen receptor positive and HER2-negative tumors. Hormone therapy — This is used to treat hormone receptor positive cancers. Unlike menopausal hormone therapy, which supplements your natural hormones, these treatments block the action of hormones or prevent their produc-

On the horizon Advances continue to be made in all aspects of breast cancer prevention, detection and management. Developments include: Q Researchers at Mayo Clinic and elsewhere are studying the potential for a blood test to predict who may be at high risk of breast cancer. This test examines genetic markers known as single nucleotide polymorphisms (SNPs). Mayo’s study aims to understand how women can use these test results to be better informed about their risks and about using preventive medications. Q An experimental breast cancer vaccine is being studied to see if it can prevent breast cancer recurrence in women with late-stage cancer. Q Fenretinide, a retinoid in the same family as vitamin A, is being studied for breast cancer prevention. In one study, it was as effective as tamoxifen in reducing risk. Q Sensitive lab tests can detect circulating tumor cells — cancer cells that have detached from the tumor and are present in the bloodstream. These tests may help predict cancer recurrence and, in the case of advanced cancer, determine if treatments are working. Q Research indicates that low levels of vitamin D may be associated with an increased risk of breast cancer and higher recurrence rates of metastatic cancer. Higher levels of vitamin D have been associated with improved survival rates in women with breast cancer. Q The Sister Study is collecting information from over 50,000 women whose sisters have breast cancer. Researchers hope the results will shed light on genetic, environmental and lifestyle causes of breast cancer.

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Advanced breast cancer When breast cancer has spread to other organs such as the brain, bones, lungs or liver, it’s called advanced (metastatic) cancer. Most often, metastatic cancer develops when cancer recurs, though a small percentage of women have advanced breast cancer when they’re first diagnosed. Though metastatic cancer typically can’t be cured, numerous factors affect the prognosis of advanced cancer, and more women are surviving longer thanks to improvements in treatment. When facing a diagnosis for which remission is unlikely, you’ll have to weigh the side effects of continued treatments with the potential benefit they’ll provide. It may be helpful to reframe your treatment goals into improving quality of life and relieving symptoms.

For more information Your health care team can be your best ally and source of information for cancer management. Other resources include: Q The Mayo Clinic Breast Cancer Book, available online at: https://store.MayoClinic.com Q American Cancer Society: www.cancer.org Q National Comprehensive Cancer Network: www.nccn.org Q National Cancer Institute: www.cancer.gov

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tion so that they stop fueling tumor growth. These treatments can reduce the risk of cancer recurrence by nearly half in selected patients. Options include: Q Selective estrogen receptor modulators (SERMs) — Tamoxifen is often prescribed for five to 10 years as an adjuvant therapy. It’s the primary option for premenopausal women with hormone receptor dependent breast cancer. Toremifene (Fareston) is another SERM that has been used to treat breast cancer. Q Aromatase inhibitors — These drugs decrease estrogen production in postmenopausal women. Aromatase inhibitors for breast cancer treatment include anastrozole (Arimidex), exemestane (Aromasin) and letrozole (Femara). They may be used alone or after five years of tamoxifen. They’re often given for five years. However, new data shows that continuing the aromatase inhibitors to 10 years provides additional protection against breast cancer recurrence, but with more bone loss and increased osteoporosis and bone fractures. Q Fulvestrant (Faslodex) — This may be another option for some postmenopausal women. It’s approved for locally advanced (metastatic) breast cancer or for recurrence after use of some other hormonal therapy. It works by destroying hormone receptors on cancer cells, preventing their ability to take in estrogen. Q Ovarian ablation — In premenopausal women, surgery or medications can be used to stop estrogen production by the ovaries. Targeted therapies — These attack specific features of cancer cells. A variety of HER2-targeted medications have been developed and include trastuzumab (Herceptin), pertuzumab (Perjeta), ado-trastuzumab emtansine (Kadcyla) and lapatinib (Tykerb). These drugs vary in their specific applications and may be combined with each other or used alongside chemotherapy or hormone therapy. Other targeted medications block non-HER2 abnormalities that fuel cancer cell growth. Everolimus (Afinitor) and palbociclib (Ibrance) are both used alongside hormone therapy drugs in postmenopausal women with hormone receptor positive, HER2negative cancers that have recurred or spread to other parts of the body. These medications can be well-tolerated but have a unique set of side effects. In the case of small cancers that haven’t spread beyond the breast, surgery alone or surgery followed by radiation may provide an excellent prognosis, and adjuvant therapy may not be needed. This approach of watchful waiting has its own benefits and risks but may be a reasonable choice for some women. After cancer treatment is over, you’ll transition to a period of follow-up and surveillance. If you don’t have symptoms, intensive testing isn’t generally recommended. Your doctor will guide you through your follow-up care as you go through the range of emotions — from relief to uncertainty — that the end of cancer treatment often brings.

Ongoing progress Progress toward understanding and fighting breast cancer is likely to continue due to ongoing support for breast cancer awareness and research. New discoveries will further personalize the approach to prevention and treatment. In the meantime, empowering yourself with information will prepare you to work with your doctor to understand and manage your risk. Whether you’re trying to prevent cancer from recurring or keep it from developing in the first place, focusing on lifestyle habits within your control — such as maintaining a healthy weight and getting plenty of physical activity — is a great starting point. U Printed in USA ISSN 0741-6245