Dr. Love Responded to a Question I had about Scanning!!
Ladies -- This was my question to Dr. Susan Love. I posted it in her blog and she responded -- see second paragraph. Just wanted to share with you all.
Dr. Love, I found your blog fascinating and do have a question that I hope you can answer….to scan or not to scan. I have an oncologist who doesn’t believe in yearly PET/CT and another who feels remiss if they aren’t done. Just wondering what your take is on this in light what you’ve said in this blog. Thanks, Rachel
Rachel, there was a randomized controlled study looking at whether it was better to scan regularly or wait until someone has symptoms. The answer was that there was no difference in outcomes. In other words it does not matter if you treat mets early when only seen on scans or wait until there are symptoms. Survival and responses are the same. This could change if we had better drugs. That being said oncologists like to scan and treat. They have trouble getting out of the mindset that early must be better. Some own the scan equipment and all make more money when they treat. I don’t want to imply that they are all in it for the money, because I don’t think that is true! I just think if you could go either way and one way is more lucrative…….
Comments
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Thanks for posting Rachel...nice to get her opinion -
I'm personally glad to hear that. For me, blissful ignorance is my preference. I'm glad to know that at least at this point, early mets detection isn't important in terms of length of survival. Thanks for posting -
My onc is 73, so he's been practicing a long time, and he says for the most part his stage IV patients who survive more than 10 years are the ones whose mets he catches early. (That's not always the case. For example he does have one patient who presented with extensive bone mets and also mets to an organ and he got her to NED and she has been NED since 2002.)
Plus it is known that smaller weaker tumors are easier to eradicate than larger more well established tumors, which I believe develop complex blood supplies.
Also it seems intuitively to me that the longer you have untreated tumors growing, the more chance there is for cells from those tumors to spread.
And one more thing - genetics is changing everything. Things like the Caris report, which gives a gene profile of a person's cancer, can potentially let a doctor zero in on the most effective treatments for that person's tumor biology right away, so there's none of this trial and error. (Admittedly the science is new and largely theoretical but they are making great strides in that direction.)
So while the study may show that in general when mets are found doesn't matter, I think for the right doctor, and the right patient, it can matter very much.
ps: If I'm not mistaken Susan Love is on board with the new recommendation of starting routine mammograms at age 50. -
It really is a sad statement about current treatment that outcomes could be the same. I don't believe it myself. It's got to be better to catch and treat a bone met before it breaks a bone. -
Rachel - I very much respect whatever Dr Love writes too ( her book was like a BC bible to me. ) but will add that I had a yearly mammo for 6 yrs post mastectomy on my other breast and just now discovered to have mets this year on original side only after I complained of arm pain and numbness. Quite progressed and in my lung too.I am now 66 so I think Drs under pressure by Medicare to save money. Millions of us baby boomers needing expensive diagnosis and treatment.
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I agree with dr Love, as I am an example of someone whose mets weren't caught early, yet I am doing well. When I was diagnosed with mets, I had 2 liver tumors, one of which was 11 cm, the biggest I have ever seen anyone on here have. Yet, here I am over 3 years out ( Ned for over 2 1/2 years) and doing really well because I responded well to treatment. I have seen women diagnosed with very small liver mets who are now gone because their cancer didn't respond to treatment.
Laurie -
frankly, if we're talking bone mets which can be very painful, better to catch and treat earlier to lessen pain. I'd also rather catch and treat early.
Not a Dr. Love fan. She spends a great deal of time advocating not scanning. -
She's a medical doctor and I'm not, but that just does not make intuitive sense! Is she saying that catching one lone bone met, which occasionally can be curable, is the same as catching the cancer after it spreads to vital organs? MEH -
What she did not say is that the randomized study she is refering to is more than 20 years old when neither imaging nor medication were as good as today. So it might actually be the case that by now we have the medication that makes early detection worthwhile. It just hasn't been tested again because insurances do not really have an incentive to test an outcome that might cost them a fortune. So take this with a pinch of salt. -
personally i think these MO s get some kind of bonus or incentive if they order less scans. i think its a conspiracy and that she is on the take too. not a Love fan either
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We were just discussing this on another thread, so I will repost what I posted there from a recent paper:
"There is no proven value of routine ‘screening’ tests for metastatic disease in asymptomatic early breast cancer patients. However, the available data are from a time when neither biological therapy nor effective (in terms of local control) and less invasive (in terms of quality of life and side-effects) locoregional therapeutic techniques, such as radiosurgery for central nervous system (CNS) metastases or radiofrequency ablation for liver metastases, were available. In addition, new detection techniques are now available, such as MRI, PET-scan, PET–CT and others, that may allow the detection of very early metastatic disease. Therefore, new studies are needed to evaluate the role of early diagnosis of metastatic disease in the current context." http://annonc.oxfordjournals.org/content/23/suppl_7/vii11.full -
I am a fan of Dr. Love and her foundation. Much more than Susan G. Komen and Nancy Brinker. At least all proceeds are going towards research. Dr. Love is also facing her own cancer diagnosis (not breast) so, I would trust her more than these highly paid CEO's of many of the so called "Pink Charities". I wish more women would sign up for the foundation's research projects, maybe we would have an answer to the scanning question if they did. -
kar123. I am a big fan of Dr. Love's research and have signed up for her Army of Women study. I wish she would spend more time focusing on the cure message instead of criticizing scanning. I was stage IV out the gate and this was only found when my oncologist put me through a bone and ct scan before chemo. Also, new guidelines for routine scanning starts age 50. But HER2+ breast cancer seems to love per menopausal women.
In the system's desire to not overtreat, so don't scan, premenopausal women are going to die. -
I guess from my perspective, I don't put a lot of trust in scans. My ILC wasn't found on any scan, not even MRI. It wasn't until after a biopsy and they knew what they were looking for, could they see it on a CT/PET scan. I agree that more research should be focused on a cure. I didn't feel that she was criticizing scans though, they have their place in all this mess, but maybe not in followup with no symptoms. Personally, I couldn't take being scanned just to check every year. The anxiety would drive me insane. -
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30 years of mammograms didn't catch either of my breast cancers so I am not a fan of routine mammograms. In fact, I've only had one since my 2011 diagnosis; have been putting off making the appointment. I check myself every month; that is how I found the two I had.
I had an MRI after my biopsy because of a suspicious lymph node in the opposite armpit, but nobody has suggested further MRIs. -
This reminds me of something my MO told me when we first met, but some on this board in the past disagreed with. My MO told me that there was no such thing as "early detection" when it came to mets. It didn't extend your chances at longevity in any way, as apparently early detection of bc in earlier, possibly more localized stages, does. Left a question in my mind..Thanks for asking Dr Love and reposting!!! -
The data she is refering too is old as someone else has said. Also im always weary when someone suggests financial gain from scanning or not scanning.. in Canada we have socialized medicine and our guidelines in ontario are the same..wait for symptoms. What about quality of life ? My sister had bone mets and they were extremely painful -
That is SO cool, and I am glad to hear her reply as my onc is a "no symptoms, no scan" doc too!
Thanks for sharing.
Sharon -
the treatment and standard of care for stage iv is changing slowly. Me? I do not want bone mets to get so bad that I live in excruciating pain and the bones begin to crumble. The idea that there is no difference between early and later detection and outcomes for stage iv is based on outdated data. My hope is to live as long as I can with quality of life. And to do that, we need to know if the disease is progressing so that we can knock it back. I have life left in me, and want that life to have quality. -
well said.
i presented with hip pain to my new MO in aug. no scans. it did go away when I stopped exercising. but on oct bone scan early mets was there. i had to travel 1200 miles to new MO to get scans and tumor markers. this is freaken ridiculous.
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Momine -Thanks for including the link to the EJMO. Boy to read that BC is still increasing in numbers diagnosed across the world boggles tbe mind. I do not agree w/ Dr Susan Love on re testing schedules but I know she has consulted Univ of Mich chief MO in her book where I worked as a nurse or many years, so I know they ar some of the best. It amazes me that post BC studies stop at 5 years and only note if patient alive or not. For us mets folks that does no tell the full story.
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Thanks for sharing....my onc only does scans if the patient is symptomatic.....I am happy to not have to deal with scans!! -
fredntan-I agree with you- it is ridiculous you had to travel so - the initial MO should have treated you / given a scan when you presented with a symptom (pain in your hip).
Related note to original post - ASCO recently released 'top 5" list of tests to avoid. PET scans or CT scans to monitor for recurrence in ASYMPTOMATIC patients is number 3.
http://www.curetoday.com/index.cfm/fuseaction/news.showNewsArticle/id/13/news_id/3838 -
interesting article but "these expensive tools" and ". High-value care not only benefits patients, but also reduces societal health care costs which should be a concern for everyone. " makes me wonder if cost is the driving force. My MO does not believe in scans unless symptoms present and when I'm feeling insecure, this bothers me. But then I didn't like all the radiation I was getting either. -
I was just told this by my onc office as well, having finished with my initial dx treatment plan (and now treating to lower chance of recurrence). There is something to be said about the stress of ongoing testing, and if something is found--the stress of the dx, treatment, etc. To me, I am comfortable with the tradeoff of being less stressed with possibility that mets may progress faster had it been found prior to symptoms presenting. But then, I'm 46, and stage 1. -
slv58, cost is definitely a factor in the recommendations. The more I have tried to search the subject, the more I think new research is sorely needed to look at factors that can improve both survival and QOL after a stage VI DX, as well as research into the factors that contribute to disease-free/progression-free survival at any stage. -
I believe that with cancer patients the concern for unnecessary radiation is real. There is so much toxicity associated with treatment, that unnecessary toxicity is a goal to avoid (for all patients, let alone cancer patients). I'm thinking about CT scans specifically…
Once, a couple of years back, I mentioned to my MO another doctor's recommendation re another possible medical concern (not to do with breast cancer) that I get a CT scan.
My MO freaked that another prominent doctor would recommend a CT scan in the face of NO symptom. Just as a baseline, just to be sure, was the thinking, re this other concern. MO explained that radiation is real and you don't just do these tests for no reason. I see MO's point. I actually turned out to have this other symptom a few weeks ago; a CT scan was ordered and I'm in the clear, thankfully. But that CT scan was for a reason, I presented with a symptom. I think now, back to when I was about to get a CT scan a couple of years ago with no symptom, and I'm very thankful (re unnecessary radiation) that I didn't. Just think about all the radiation we get that is necessary, or in the even of actual, potential, symptoms! So while I do agree cost has something to do with this, I don't think that's the whole story. The radiation factor is real, and must be considered, weighed, as part of the 'cost' in the cost benefit analysis.
At the same time, it does seem intuitive that the sooner you treat something, the better your chances of response or success. -
I am getting a name of pulmonary specialist due to some chest pain (heart issue ruled out for now) I just knows he will want a CT scan and I recently turned out another CT scan (on the advice of my internist who was worried about radiation. That one was suggested due to my vertigo, but that has since been diagnosed as "positional" vertigo by the ENT doctor and I manage it with exercises. So sometimes I think the docs jump the gun and immediately go for a CT scan instead of following a process of elimination. In the vertigo case, I did NOT need one.
I guess I'm hoping the pulmonary guy will rely on the x-ray which was taken in the ER where I went due to chest pain behind my left breast (which had the lumpectomy 2 years ago) and will be able to diagnose without further tests. PS I have also posted on another thread asking how lung mets present) -
lol. I'm dead anyway. I'll take the radiation in order to catch progression earlier and treat earlier. It's all about quality of life.
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