Dr. Mai Brooks MD

10/20/2021

https://www.youtube.com/watch?v=vuV5PvYad8U

Celebrating 25 years of breast cancer awareness, Los Robles Health System is pleased to bring you “The Power of Pink” with programming focused on prevention,...

05/17/2015

Ovarian Cancer - An Update
In the United States in 2014, there was an estimated 21,980 new cases of ovarian cancer. Also in 2014, approximately 14,270 people died from this malignancy. Hereditary cases account for only 5% of ovarian cancer. However, any patient with ovarian cancer should be tested for the BRCA gene. Women who carry a BRCA gene mutation are usually advised to have bilateral salpingo-oophorectomies (removal of both tubes and ovaries) to prevent the occurrence of ovarian cancer.
Epithelial ovarian cancer accounts for 90% of ovarian malignancies. Surgery is the initial treatment for all stages of ovarian cancer. This includes a hysterectomy and bilateral oophorectomies (removal of both ovaries). Any tumor seen in the abdomen should be resected, as well as lymph nodes. Sometimes, other abdominal organs may need to be taken out, if they are invaded by ovarian cancer. This "debulking" surgery has been shown to improve survival. Most patients receive chemotherapy after surgery. Chemotherapy may be administered intravenously or intraperitoneally (directly into the abdomen). Radiation is rarely used for this malignancy. Recurrent cancer may be treated with more debulking surgery and more chemotherapy.
Less common ovarian malignancies include germ cell neoplasms, s*x cord stromal tumors, and ovarian LMP (low malignant potential) tumors. Less radical surgery is recommended, and if fertility is desired, one o***y may be saved. If advanced disease is discovered at surgery, patients would benefit with adjuvant chemotherapy. Other uncommon ovarian malignancies such as carcinosarcoma and fallopian tube cancer are aggressive and are managed similarly to epithelial ovarian cancer.
Active research is carried out to discover better treatments for this deadly disease. Avastin (bevacizumab), an inhibitor of blood vessel growth, has been approved by the FDA. Other agents are available to patients who enroll in a clinical trial. One promising drug is olaparib, which inhibits PARP (poly-ADP ribose polymerase), is being tested in chemotherapy-refractory ovarian cancer.

02/22/2015

https://www.youtube.com/watch?v=pEG14QYxwA0

Dr. Mai Brooks is a board-certified surgical oncologist/general surgeon practicing in Thousand Oaks. As an active member of the CscVvsb Professional Advisory...

10/04/2014

Cancer in the USA - what to expect in 2014

One out of four deaths in the US is due to cancer. In 2014, approximately 585,720 Americans will die of cancer. The following tables summarize the distribution of the top ten types of invasive cancer among men and women. Please note that this number does not include the early in situ carcinomas from any organ (except the bladder). Excluded from this table are 62,570 breast carcinomas in situ, 63,770 melanomas in situ, and millions of unreported cases of squamous cell and basal cell skin cancers. Only the top 10 death causes are listed below. (http://onlinelibrary.wiley.com/doi/10.3322/caac.21208/full).

Cancer in women:
New cases Ranking by % Deaths Death by %
breast 232,670 1 (29%) 40,000 2 (15%)
lung 108,210 2 (13%) 72,330 1 (26%)
colore**al 65,000 3 (8%) 24,040 3 (9%)
uterus 52,630 4 (6%) 8,590 7 (3%)
thyroid 47,790 5 (6%)
Lymphoma* 32,530 6 (4%) 8,520 8 (3%)
melanoma 32,210 7 (4%)
kidney 24,780 8 (3%)
pancreas 22,890 9 (3%) 19,420 4 (7%)
leukemia 22,800 10 (3%) 10,050 6 (4%)
o***y 14,270 5 (5%)
liver 7,130 9 (3%)
brain 6,230 10 (2%)
All organs 810,320 275,710
* non-Hodgkin

Cancer in men:
New cases Ranking by % Deaths Death by %
prostate 233,000 1 (27%) 29,480 2 (10%)
lung 116,000 2 (14%) 86,930 1 (28%)
colore**al 71,830 3 (8%) 26,270 3 (8%)
bladder 56,390 4 (5%) 11,170 8 (4%)
melanoma 43,890 5 (5%)
kidney 39,140 6 (5%) 8,900 10 (3%)
Lymphoma* 38,270 7 (4%) 10,470 9 (3%)
oropharynx 30,220 8 (4%)
leukemia 30,100 9 (4%) 14,040 6 (5%)
liver 24,600 10 (3%) 15,870 5 (5%)
pancreas 20,170 4 (7%)
esophagus 12,450 7 (4%)
All organs 855,220 310,010
* non-Hodgkin



As shown above, the #1 cancer killer in both men and women is lung cancer. As lung cancer is predominantly caused by ci******es, smoking cessation can significantly decrease this type of mortality. Breast cancer is the most common (and #2 killer) in women, as is prostate cancer in men. Colore**al cancer ranks #3 in both new case incidence and death rate for both genders. Since there are good screening tools for breast, prostate and colore**al cancers, these death rates can also be reduced if more of these cases are detected earlier at curable stages.

09/01/2014

New treatments for advanced and metastatic melanoma
In the United States in 2014, there will be an estimated 76,100 new cases of invasive cancer and 63,770 of in situ melanoma. Also in 2014, approximately 9,710 people will die from this malignancy. Most patients with metastatic melanoma die within one year. Until recently, the only two approved treatments are dacarbazine (a chemotherapy agent) and interleukin-2. Neither drug has clearly demonstrated improved survival.
Now, there are four new drugs that can be used for unresectable (cannot be completely removed by surgery) and metastatic melanoma. The first drug is Yervoy (ipilimumab), which was approved by the FDA in 2011. Yervoy is an antibody that blocks T-lymphocyte associated antigen 4 (CTLA-4). This blockage increases T-cell proliferation, which results in a more active immune system to attack the melanoma cells. In clinical trials, Yervoy reduced the risk of death by 34%, and median overall survival was 10 months.
The second agent is vemurafenib, which was approved by the FDA in 2011. Vemurafenib targets a mutation in the gene BRAF (Serine/threonine-protein kinase B-Raf) V600E. About 50% of melanoma cases have this mutation, and these patients would qualify. This drug reduced the risk of death by 56%, compared to treatment with dacarbazine.
Last year 2013, the FDA approved two more drugs. Dabrafenib was also indicated for unresectable or metastatic melanoma cases that have the BRAF V600E mutation. Compared to dacarbazine chemotherapy, Dabrafenib delayed tumor growth by 2.4 months. The fourth drug is trametinib, which can be used for melanoma cases that have the BRAF V600K mutation, as well as the V600E mutation. Compared to dacarbazine, trametinib delayed tumor growth by 3.3 months.
In general, these new drugs add a few more months of life to these terminal melanoma patients. Further research is needed to produce better treatments for this deadly disease.

07/04/2014

Exciting news in novel personalized medicine for breast cancer
Three new targeted drugs approved by the FDA

Active research in breast cancer is producing novel targeted drugs at a rapid pace.
Perjeta (pertuzumab)
In September 2013, the FDA approved Perjeta for use in combination with Herceptin (trastuzumab) and docetaxel for the neoadjuvant (prior to surgery) treatment of patients with HER2-positive, locally advanced, inflammatory or early-stage breast cancer (either greater than 2 cm in diameter or node positive). Pertuzumab is an antibody that targets the extracellular dimerization domain of HER2, and thereby blocks ligand-dependent heterodimerization of HER2 with other HER family members. Clinical trials have shown that neoadjuvant therapy with this combination resulted in a 39% complete response rate, meaning that cancer can not be found at the time of surgery. This rate is superior to any other existing neoadjuvant treatments.
Kadcyla (ado-trastuzumab emtansine)
The FDA approved Kadcyla in February 2013. Kadcyla is a HER2-targeted antibody-drug conjugate. Upon binding to the HER2 receptor, ado-trastuzumab emtansine results in intracellular release of DM1-containing cytotoxic catabolites. Binding of DM1 to tubulin disrupts microtubule networks in the cell, which results in tumor cell death. Kadcyla is indicated for patients with HER2-positive, metastatic breast cancer who previously received Herceptin and a taxane, separately or in combination. A large clinical trial has shown that this new drug gave patients a median overall survival of 31 months, in comparison to 25 months with other drugs.
Afinitor (everolimus)
In July 2012, the FDA approved Afinitor for the treatment of postmenopausal women with advanced hormone receptor-positive, HER2-negative breast cancer in combination with exemestane, after failure of treatment with other hormone blocker pills. The tumors in these cases essentially developed resistance to existing hormone blocker pills. Afinitor is an inhibitor of mTOR, which is important for cancer cell proliferation. A large clinical trial yielded a median progression-free survival of 8 months for patients receiving this new drug, versus 3 months for those on placebo. The final analysis of overall survival is expected to occur in June 2014.

06/04/2014

Colon Cancer - An Update
In the United States in 2014, there will be an estimated 96,830 new cases of colon cancer and 40,000 re**al cancer. Also in 2014, approximately 50,310 people will die from these two malignancies.
Once colon cancer is diagnosed on a complete colonoscopy, a CT of the chest abdomen and pelvis should be done. If there is no distant spread of disease, colectomy (resection of the colon) is recommended. The extent of colon removal depends on the location of the cancer. Usually, it is not necessary to remove the entire colon. Surgery may be performed with an open midline incision, or with the laparoscope via multiple small incisions. Both approaches have similar long-term outcome in regards to recurrence and survival. After surgery, adjuvant chemotherapy is given in cases where cancer has spread to surrounding lymph nodes, or if cancer has penetrated through the wall of the colon. FOLFOX is the most commonly used regimen, and includes folinic acid (leucovorin), 5-fluorouracil, and oxaliplatin.
About 25% of colon cancer cases present with concurrent spread to the liver. If possible, the liver metastasis should be resected as well as the cancer in the colon. If surgery is not feasible, the liver metastasis may be treated with: 1) chemotherapy delivered into the hepatic artery; 2) occlusion of the artery feeding the cancer; 3) radiation; or 4) radio-frequency ablation. Sometimes, a patient may have a single metastatic nodule in the lung that can be removed with surgery. In advanced or metastatic cases, chemotherapy is usually administered first. This treatment may sometimes be successful in shrinking the tumor enough to make surgical resection possible.
After treatment for early colon cancer (stage 1), follow-up includes colonoscopy at 1 year, 3 year, and then every five years. Locally advanced (stages 2-3) patients should also have blood tests (with tumor marker CEA) and contrast-enhanced CT of the chest abdomen and pelvis during the first five years.

05/18/2014

Active research in breast cancer is producing novel targeted drugs at a rapid pace.

Perjeta (pertuzumab)
In September 2013, the FDA approved Perjeta for use in combination with Herceptin (trastuzumab) and docetaxel for the neoadjuvant (prior to surgery) treatment of patients with HER2-positive, locally advanced, inflammatory or early-stage breast cancer (either greater than 2 cm in diameter or node positive). Pertuzumab is an antibody that targets the extracellular dimerization domain of HER2, and thereby blocks ligand-dependent heterodimerization of HER2 with other HER family members. Clinical trials have shown that neoadjuvant therapy with this combination resulted in a 39% complete response rate, meaning that cancer can not be found at the time of surgery. This rate is superior to any other existing neoadjuvant treatments.

Kadcyla (ado-trastuzumab emtansine)
The FDA approved Kadcyla in February 2013. Kadcyla is a HER2-targeted antibody-drug conjugate. Upon binding to the HER2 receptor, ado-trastuzumab emtansine results in intracellular release of DM1-containing cytotoxic catabolites. Binding of DM1 to tubulin disrupts microtubule networks in the cell, which results in tumor cell death. Kadcyla is indicated for patients with HER2-positive, metastatic breast cancer who previously received Herceptin and a taxane, separately or in combination. A large clinical trial has shown that this new drug gave patients a median overall survival of 31 months, in comparison to 25 months with other drugs.

Afinitor (everolimus)
In July 2012, the FDA approved Afinitor for the treatment of postmenopausal women with advanced hormone receptor-positive, HER2-negative breast cancer in combination with exemestane, after failure of treatment with other hormone blocker pills. The tumors in these cases essentially developed resistance to existing hormone blocker pills. Afinitor is an inhibitor of mTOR, which is important for cancer cell proliferation. A large clinical trial yielded a median progression-free survival of 8 months for patients receiving this new drug, versus 3 months for those on placebo. The final analysis of overall survival is expected to occur in June 2014.

04/27/2014

Gastric Cancer - An Update
In the United States in 2014, there will be an estimated 22,220 new cases of gastric cancer. Also in 2014, approximately 10,990 people will die from this malignancy. In other countries, gastric cancer is much more prevalent. In Japan, it is the most common type of malignancy in men. The incidence of gastric cancer is much higher in China than in any other country. There is no screening program in the US for this disease. Therefore, gastric cancer is usually diagnosed when the patient develops symptoms. Risk factors include H. pylori infection, smoking, and heavy alcohol use.
Surgery is the primary and most effective treatment for early gastric cancer. Yet, only about 50% of patients were able to have complete resection of their tumor with negative margins (an adequate rim of normal tissue around the cancer). Gastric cancer is considered unresectable if: 1) there is distant metastasis (for example, to liver or lungs); 2) spread into the abdomen; 3) encasement of major blood vessels in the abdomen; or 4) involvement of many lymph nodes. Sometimes, even when the disease is incurable, surgery is still done for relief of obstruction or bleeding.
For selected patients with gastric cancer, neoadjuvant chemotherapy is given before surgery. This is done to shrink the tumor, so to maximize the chance that surgery would be successful. This treatment includes epirubicin, cisplatin and 5-fluorouracil (ECF). In other cases, chemotherapy and radiation may be offered after surgery if the cancer is deep/large, or if lymph nodes are involved. In cases where the cancer is deemed unresectable or has metastasized to distant organs, chemotherapy is recommended as palliative therapy.
There is active research to discover new and more effective therapies for this deadly disease. Patients are highly encouraged to participate in clinical trials in the fight for better treatments for gastric cancer.

04/07/2014

How to calculate your risk for breast cancer

National Cancer Institute Model: http://www.cancer.gov/bcrisktool
The NCI risk assessment tool is essentially a simplified Gail Model that also factors in race. Race is a factor in determining breast cancer risk but is excluded when determining eligibility for clinical trials. This tool is probably the most popular risk assessment tool available to the public as an on-line, interactive risk calculator. The on-line quiz is a shorter, nine-point questionnaire that includes multiple factors, giving a woman her future five-year risk of breast cancer and her lifetime risk of breast cancer.
The NCI tool does not account for a lot of risk factors that can be modified. For this reason, it is difficult to use this test as a motivation tool to show people how lifestyle can alter their risk of breast cancer. It also cannot be used in breast cancer survivors, in patients with DCIS, LCIS, or people who carry one of the BRCA genes. It does not account for other factors such as hormonal replacement therapy, lifestyle factors, breast feeding, menopause, or mammographic density.

Harvard Center for Cancer Prevention Risk Assessment Tool:
http://www.diseaseriskindex.harvard.edu
This is another breast cancer risk assessment tool that includes more lifestyle factors than the NCI or Gail Model tools. It has not been studied as extensively as the Gail Model or the simplified NCI model, but it is promising in that it includes many lifestyle factors that people can do to modify their risk of developing cancer. This is a great interactive questionnaire that calculates five-year and lifetime risk of breast cancer developed by the Harvard Center for Cancer Prevention and made public online in 2000. The risk calculator includes lifestyle factors such as weight, dietary vegetables, alcohol intake, as well as Jewish ethnicity. It does not include other ethnicities, however, and is not accurate for BRCA mutation carriers or breast cancer survivors. Despite these issues, this is a great free online risk calculator since it is very interactive and gives you a personalized description of your risk in the form of a colored bar graph, which they can electronically manipulate to experience "virtual" risk reduction. The bar graph is a seven-level scale that compares users to a typical man or woman your age. Users learn where to focus their prevention efforts and how to make lifestyle changes by "clicking on" personalized strategies. With each click, the bar graph shrinks, and the user watches his/her predicted risk drop. This is a great concept to motivate people to participate and comply with lifestyle modification measures.

An interactive tool designed by scientists at the National Cancer Institute and the NSABP to estimate a woman's risk of developing invasive breast cancer.

03/28/2014

Surgery for prostate cancer - an update
Prostate cancer is the most common form of cancer in men and the second leading cause of cancer deaths in American males. In 2013, approximately 238,590 patients were estimated to be diagnosed with this malignancy. An estimated 29,270 died of this disease in 2013 alone.
In recent years, there emerges a trend to not treat prostate cancer, called "watchful waiting". This is because in some cases, this malignancy does not affect life expectancy. Screening for prostate cancer also became optional for men of "normal" risk.
A new study, however, indicates that radical prostatectomy reduces mortality among men with localized prostate cancer (cancer that has not spread). This was published on 3/6/14 in the New England Journal of Medicine (Radical Prostatectomy or Watchful Waiting in Early Prostate Cancer, by Anna Bill-Axelson MD PhD, and others). The Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) randomly assigned 695 men with early prostate cancer between 1989 and 1999 to watchful waiting or radical prostatectomy. The follow-up lasted through the end of 2012, for about 23 years. The overall death rate was 58% (200 of 347) in the surgery group, and 71% (247 of 348) in the watchful waiting group. Prostate cancer-specific mortality was 18% (63 of 347) in the surgery group, and 28% (99 of 348) in the watchful waiting group.

The authors concluded that the benefit of surgery with respect to death from prostate cancer was largest in men younger than 65 years of age and in those with intermediate-risk prostate cancer. There was no significant difference in mortality in either high-risk or low-risk cases. In patients 65 or older, surgery reduced future cancer spread (metastasis), although it did not change mortality rate.

Thus, surgery for early prostate cancer may be more beneficial than previously thought. This decision should take into consideration the significant side effects that accompany radical prostatectomy, such as incontinence and impotence.

03/19/2014

Treatment for early in situ breast cancer - an update
Breast cancer is the most common form of cancer in women and the second leading cause of cancer deaths in American females. In 2013, approximately 238,590 patients were estimated to be diagnosed with the invasive form of this malignancy. An estimated 40,030 died of this disease in 2013 alone. About 64,640 additional patients had the early form called DCIS (ductal carcinoma in situ).

Recently, there have been articles in the popular press suggesting that breast ductal carcinoma in situ is "over-treated" with surgery, radiation, and hormone blocker pills (usually prescribed for five years). It is still standard of care to remove DCIS with surgery. Some people question whether radiation therapy is really necessary after lumpectomy.

A new study indicates that radiation reduces the risk of recurrence by a factor of two. This was published on 11/10/13 in the Journal of Clinical Oncology (Breast-conserving treatment with or without radiotherapy in ductal carcinoma In Situ: 15-year recurrence rates and outcome after a recurrence, from the EORTC 10853 randomized phase III trial, by M Donker, and others). Between 1986 and 1996, 1,010 women with complete surgical excision of DCIS (size less than 5 cm) were randomly assigned to no further treatment (503) or radiation therapy (507). In this European Organisation for Research and Treatment of Cancer study, the median follow-up time was 15.8 years.
The authors report that radiotherapy reduced the risk of any cancer recurrence by 48%. The recurrence rate was 30% in patients treated with surgery only, compared to 17% in those who received both surgery and radiation. Of these recurrences, 48% were again the early type, ductal carcinoma in situ. However, 52% of cases recurred as invasive breast cancer. These women had five times higher risk of death than those who did not recur.

Therefore, radiation therapy is still beneficial in cases of ductal carcinoma in situ. Exceptions to the standard of care may be acceptable in older patients with small DCIS, who prefer to avoid radiotherapy.