Nipple discharge

Nipple discharge is common after childbearing.  Usually a mother may still have milky discharge a few months after cessation of breast feeding, but sometime longer.  Milky discharge may also be caused by hypothyroidsm or prolactin-producing pituitary tumors, and certain medications (antipsychotics and tricyclic antidepressants).

You should call your doctor or health care providers if you have spontaneous, clear, colored, sticky or bloody unilateral nipple discharge. Leis reported that in 503 patients operated on for one of these types of discharge, 67 (13.3%) had cancer, and 36 (7.2%) had a precancerous lesion. Among the 67 patients with cancer, eight (11.9%) had no palpable mass, 11 (16.4%) had negative cytology ("pap smear of the breast discharge"), and seven (10.4%) had a negative mammogram.

You could also get breast discharge when you stimulate your breast.  It is usually less worrisome if the discharge stops when you stop the breast stimulation.  However, do talk to your health care providers with any of your concern or finding.

Reference:
- Leis HP Jr, et al. Nipple discharge: surgical significance. South Med J. 1988;81(1):20.
- Sabel MS.  Breast mass and other common problems.  Uptodate November 2012. 

I found a breast mass - what do I do now?

Most breast masses are benign such as fibroadenoma.   But most patients and physicians are concerned for possible of breast cancer. There are certain characteristics that are concerning mass for cancer such as single hard, immovable lesion with irregular borders. 

If you found any breast mass, I recommend that you see a physician who will obtain your history and do breast examination. The next steps may include ultrasound, mammography and/or biopsy, depending upon the findings from the history and physical examination, patient age and other clinical factors.  If your age is less than 30 years old, your breast probably more dense.  Thus, your physician may start with ultrasound first.  If you are 30 years or older, your breast usually less dense.  Then your doctor may order mamogram first.

Do remember that no test or exam is 100 percent accurate.  Thus, if you have persistent mass or concern, despite negative test, you should get 2nd or more opinion from other doctors or providers.

Reference:
- The palpable breast lump: information and recommendations to assist decision-making when a breast lump is detected. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Canadian Association of Radiation Oncologists. CMAJ. 1998;158 Suppl 3:S3
- Sabel MS.  Breast mass and other common problems.  Uptodate November 2012.

HE4 blood test and ovarian cancer prognosis

A study published in December 2012 evaluated the relationship of preoperative HE4 with ovarian cancer survival.  HE4 (Human Epididymis protein) is a blood test that appears to be elevated in patients with ovarian cancer - almost similar to CA125 blood test.

The study found that preoperative (before surgery) levels of HE4 were strongly associated with all ovarian cancer standard prognostic factors. HE4 levels increased significantly with age (p=0.02), cancer stage (p<0.0001), grade (p=0.005), preoperative CA-125 levels (p<0.0001), and residual tumor (p<0.0001). HE4 levels above the median value (394pmol/L) were significantly associated with mortality (HR=2.17; 95% CI: 1.42-3.32) and progression (HR=1.81; 95% CI: 1.21-2.72). After adjustment for the FIGO stage, which was the only factor significantly associated with prognosis in multivariate analyses, the association of HE4 with death remained statistically significant (HR=1.67; 95% CI: 1.08-2.59). However, the association with progression was no longer significant (HR=1.32; 95% CI: 0.87-1.99).

In English, the way I understood it, the high level of HE4 before surgery correlates with aggressiveness of ovarian cancer and the risk of death from this cancer.  Thus, preoperative HE4 level may be used to discuss prognosis of the cancer.  Do be careful since this study is based only on 136 patients.   Usually, we want to see more studies before using this approach clinically.

Reference:

Trudel D, et al. Human epididymis protein 4 (HE4) and ovarian cancer prognosis. Gynecol Oncol. 2012 Dec;127(3):511-5.

 

Painful bones and muscles after Neulasta/Neupogen injection

Patients undergoing chemotherapy usually experience bone marrow suppression.   Our bone marrow is actively dividing, just like cancer cells, thus are prone to be affected by chemotherapy.  As a results, low white blood cells (neutropenia), low red blood cells (anemia) and low platelets (thrombocytopenia) are common in patients on chemo.   When your white blood cells are too low, you may get severe infection.  Your doctor may prescribe you Neulasta (Pegfilgrastim) or Neupogen (Filgrastrim)  injection in between of your chemo sessions.

Neulasta/ Neupogen induces your bone marrow to work harder to produce white blood cells.  Commonly, patients would complain of muscle and bone aches after Neulasta/ Neupogen injection.  One patient complained in her blog "My stomach felt like I did a hundred sit ups, without the flat abs to show for it"  :-).
Bone pain has been reported in approximately 22% of patients.

One of rare complications of Neulasta/ Neupogen is it may cause your spleen to enlarged and can rupture.  A ruptured spleen can cause death. The spleen is located in the upper left section of your stomach area. Call your doctor right away if you have pain in the left upper stomach area or left shoulder tip area. This pain could mean your spleen is enlarged or ruptured.  There are other serious risks that you could review from the website below.  

For the common aches, taking acetominophen (Tylenol) before and after the injection usually help.  Sometimes, your doctor may have to give a stronger pain medication such as hydrocodone or oxycodone.  Reducing the dose of neulasta also may reduce the pain while still giving you the benefit of white blood cell production.  Some patients reported that claritin also help reducing the bone pain.  But I could not find a study confirming it.

Reference:
- http://www.neulasta.com/starting-chemo-with-neulasta/white-blood-cell-counts.html?src=ppc&WT.srch=1&SRC=2

- Kubista E,et al; Pegfilgrastim Study Group.Bone pain associated with once-per-cycle pegfilgrastim is similar to daily filgrastim in patients with breast cancer. Clin Breast Cancer. 2003 Feb;3(6):391-8

Herbal medication and surgery

Herbal medications taking before surgery may cause bleeding complications and adversely interacting with anesthetic agents.    I copied a few more commonly usage here and not intended to be completely inclusive from Uptodate: 

• Garlic may increase bleeding risk and should be discontinued at least seven days prior to surgery.
• Ginkgo may increase bleeding risk and should be discontinued at least 36 hours prior to surgery.
• Ginseng lowers blood sugar and may increase bleeding risk and should be discontinued at least seven days prior to surgery.
• Kava may increase the sedative effect of anesthetics and should be discontinued at least 24 hours prior to surgery. An association between kava use and fatal liver toxicity has been reported.
  
• St. John's wort may diminish the effects of several drugs by induction of cytochrome p450 enzymes and should be discontinued at least five days prior to surgery.
• Valerian may increase the sedative effect of anesthetics and is associated with benzodiazepine-like withdrawal. There are no data on preoperative discontinuation. Ideally it is tapered weeks before surgery; if not, withdrawal is treated with benzodiazepines.
• Echinacea is associated with allergic reactions and immune stimulation. There are no data on preoperative discontinuation.
• Ephedra (ma huang) may increase the risk of heart attack and stroke and should be discontinued at least 24 hours prior to surgery.

In general, if you take any herbal medications, please let your doctor and nurses know.

Reference:
Uptodate. Perioperative medication management.  2012. 

Cervical cancer in young girls

Some of you have asked me about the new pap smear guideline where the starting age is now 21 years old.  There are concerns of cervical cancer may be missed in young girls.  A study published in November 2012 evaluated this question by reviewing combined data from US cancer registries and SEER program covering 92% of US population.  The study found that for women younger than age 40 years, only 1% of cancer is found in women younger than 20 years old.  Since we have about 12,000 new cervical cancers each year in the US, the new pap smear guideline will miss about 120 cervical cancer in young girls.

Various organizations (NCCN, American Cancer Society, USPFTF, ACOG, etc) recommend starting pap smear at age 21 (for "average risk" women) knowing that there will be these a few girls missing their cancer diagnosis.  Their reasoning is earlier age pap smear may cause more harm and cost with follow up procedures than the benefit of diagnosing these girls of cervical cancer.   I have to admit that I have a mixed feeling about this...   Intellectually, I understand the concept but emotionally I have difficulty since I have cared for young girls with cervical cancer.

Reference:
- Benard VB, et al.  Cervical carcinoma rates among young females in the United States.  Obstet Gynecol.  2012; 120:117-23.
- US preventive services task forces. 2012
- Saslow D, et al. CA Cancer J Clin. 2012;127:516-42

Shark cartilage and cancer

Shark cartilage has been promoted to cure cancer since around 1950.  It started with surgeon John Prudden claimed that shark cartilage reduced tumor almost by half the size.  Laboratory studies suggested that it may have anti angiogenesis (reducing cancer blood vessels).  Unfortunately, clinical studies showed no prove of its effectiveness in cancer patients.   Most recently, a purified shark cartilage extract (Neovastat) failed to help survival of patients with non-small cell lung cancer.  The Federal Trade Commission has prevented several companies from promoting this cartilage for cancer treatments.

My opinion is to leave the shark cartilage alone.  Sharks should be allowed to live too....

Reference:
-Loprinzi CI, et al.  Evaluation of shark cartilage in patients with advanced cancer.  Cancer. 2005; 104:176-82
- Lu C, et al. Chemoradiotherapy with or without AE-941 in stage III non small cell lung cancer: a randomized trial.  J Natl cancer Inst.  2010; 102:859065
- Federal Trade Commission.  "operation cure all" nets shark cartilage promoters. http://ftc.gov/opa/2000/06/lanelabs.shtm