 Good day and welcome to Issues and Answers. I'm your host for today, Jacques Kingston Compton. Today we're going to discuss a topic very important, breast cancer, and here with me today is our invited guest, Dr. Glenn Jones, who's the radio oncologist at the Cancer Center of the Eastern Caribbean. Welcome Dr. Jones. Thank you for having me. First of all, before we get started on the breast cancer topic, could you tell us, talk to us briefly about the Cancer Center. Yeah, the Cancer Center was established as a joint partnership between a sort of private business interest and the governments of the Organization of Eastern Caribbean States. So in 2009, there was a memorandum of understanding amongst all those partners as 10 different groups to say that we would become a preferred cancer center or as a regional cancer center for the OECS countries. And then it took several years to decide where the first building would be put, and so on. So it opened in 2015. So we've now been open now more than three years. Okay, that's good. Okay, so let's get right to it. I'd start off by explaining what exactly is breast cancer and what causes it. Yeah, so normally every cell in the body, and there's many of them obviously, every cell in the body is tightly controlled so that nothing is unusual and everything works properly and cells are replaced. What happens in cancer is that one or more cells become abnormal so that there's too many of those cells, they don't function normally, and they don't die off as quickly. So there's a tendency for them to grow and to be able to spread. So I'm breast cancer because the breast is composed of fat and ducts and lobules. So the ducts and the lobules are related to the milk production and things like that. So if those cells become a cancer, then you'll get too many ductal cells or too many lobular cells. So 95% of all of the breast cancers are ductal carcinoma or a lobular carcinoma. What's sort of the difference between the … They're just the nature of the origin of the cell. All the cells, when you're born, have basically the same DNA. There are slight changes over time, but basically every cell has the same DNA, but different parts of the DNA are expressed differently. So that some cells look different. So liver cells don't behave the same as duct cells of the breast, for example. So when you get a cancer, you get a cancer that comes from that cell line and it partly recapitulates its history. Is there anything in particular that would put a woman at risk of breast cancer? Yeah. So one of the primary factors is age. So as a woman ages, especially over the age of 40 to 50, then the risk of breast cancer goes up considerably. Another one is if there's a family history. So if there's a strong family history of breast, prostate, colon cancer, ovary or colorectal cancers and endometrial cancer, all of these ones define a kind of a subgroup where there might be genetic factors at play. So age is a significant factor to consider and then a positive family history. After that, it's either whether the woman is exposed to hormones or not had hormones. So that could be birth control pills, hormone replacement therapy, and then obesity, which may or may not play a role in hormones. The fat tissue of the body is now recognized more as an endocrine organ, similar to other endocrine organs, meaning it's related to hormones in the body. So a woman who is particularly obese may be at higher risk. And you also mentioned that birth control puts women at a higher risk of... There's some evidence that different amounts of exposures to hormones in things from foods to tablets may play a role in manipulating the risk. Many of these things, though, aren't very strong factors. You also mentioned that women over 40 are the ones at risk. Do you have any cases where younger women might be at risk as well? Yeah, pediatric tumors are considered to be under the age of, say, 19. So when you get to be about 13, 14, or 15 in the pediatric range, instead of having the childhood cancers like leukemias and that, it starts to flip over to the adult side. So you do occasionally see a woman who is, say, 18 or 17 and actually has breast cancer. But this is quite uncommon, like less than 1% would be probably less than about the age of 25. Okay. And how would a woman know what to look for and when should she visit a doctor and how often should someone visit a doctor? Yeah. So if you're... There's two ways to look at it. One is what are you looking for if you actually think you have cancer or there is a cancer there? And then the other one is screening, looking to try and detect the cancer earlier. So the most common presentation of breast cancer, if you're not getting mammograms routinely for screening, the most common thing would be for a woman to feel a lump. And the lump will be painless. So it's very unusual to have pain with the lump. So the main message for any woman that's listening is that if they feel a painless lump in the breast, this is important to pay attention to. Now if you're only 20 years of age and you find this, the chance of it being a cancer might be 1 in 4,000, 1 in 9,000. But if you're 50 or 60 and find a painless lump, the chance might be 1 in 3 or 1 in 5. So it's not necessarily cancer, but it needs to be looked at. But you would still advise a younger woman in about in her 20s to see a doctor after she feels that... Yes. If a painless lump is felt, that's the main thing. Although there's long lists of things that can happen, such as rashes of the skin, nipple discharge. Many of these things happen in only a few women in every 100 who has a cancer. So the most important thing is to look for painless lumps. Now in terms of frequency to see a doctor, the screening tests that we have for breast cancer are not actually that good. They are important and politically they've been staked out as an important thing for governments to invest in. So for instance, screening mammography in provinces and states in the United States has had significant inroads in terms of many women getting mammograms, ultrasounds if they're younger, maybe an MRI test if there's something unique about their breast that would justify doing that kind of screening test. Those tests generally have to be ordered by a doctor, so consequently you have to see a doctor in order to be part of that screening unless the government has a public system and mammography becomes say routinely available for all women in which case the woman can just show up and they will do the screening. So in terms of seeing doctors, although you could start physician screening and an assessment of risk at age 20 and with seeing the doctor once a year for a breast exam and then being taught how to do breast self-exam, these are not very good methods to pick up lumps, the painless lumps that I'm talking about. So one could spend a lot of time if you were not at high risk, especially at a young age trying to look for breast cancer but have almost no chance of finding it. So it's important to actually assess your risk and then decide what's the best frequency to see a doctor, what's the best frequency to do breast self-exam and then also whether you should be getting things like mammograms once a year, once every three years or even five years if you're low risk. Okay, and how exactly is breast cancer diagnosed? Like what is involved in the diagnosis and the examination exactly? Yeah, so if there's a imaging study such as a mammogram that shows something that's abnormal then there'll be a needle put into that location to pull back and see if there's any abnormal looking cells and then if there are then that would lead to then probably removing of that apparent lump, it's not a real lump, it's just showing up on an x-ray picture but if the surgeon, nobody can feel the lump but they'll put a wire in, they'll track the wire to the location and then take out that tissue. If there's an actual lump then still a needle biopsy will be done to establish whether it's ductal or lobular or it's something else entirely. Okay, and what different stages of breast cancer are there? Well, stage one and two are more limited to just the breast. Once you get to higher stages you have involvement of the lymph nodes under the arm or possibly in the neck or just behind the bone here in the chest. That's far less common. So once the lymph nodes are involved it's a higher stage. Once the disease goes beyond that local regional area then it's considered to be stage four. Meaning that and that's the high stage that we have meaning that the disease is in some soft tissue in the body such as it's in the lungs or the liver or it's in some of the other tissues like bone. Okay, I don't mean to cut you off right now but we're due for our first break. Stay tuned to issues and answers on this station, we'll be right back in a moment. Welcome back to issues and answers. I'm your host for today, Jacques Kingston Compton. I'm here with radiation oncologist Dr. Glenn Jones. So back to our topic before we were talking about the different procedures for detection. Could you speak a little bit more about them aside from mammograms? Yeah, so for screening there's breast self-exam and clinical exam meaning that a neurosurgeon or a doctor exam is the breast looking for signs of either a painless lump or something else like nipple discharge. The other imaging studies are ultrasound which can be used for a younger patient. So this uses sound waves that bounce off the structure in the breast to see if the structure looks normal or abnormal. Mammograms look at the density of the sort of atoms and their electrons in the breast. It's more physics based as compared with sound. And so it looks to see if there's so-called shadows in the breast like white areas that shouldn't be as white. So typically the breast would be generally dark with the fine structure of the lobules and the ducts. But if a cancer develops you may start to see calcium deposits in the ducts first. So you get flecks of calcium which are very white on the mammogram. And then you may start to see a more stellate structure as the disease invades the surrounding tissue and replaces the fat so it becomes more gray as compared with a darker gray. It becomes lighter gray. So you see these changes and that's sufficient to tell a surgeon that there's something happening. We need to get a biopsy. So also coming from the Caribbean you hear a lot of the older generations say we didn't have this cancer thing back in my day. Do you find that it is more prevalent now or do we have enough data for that? What do you say to people who say that it wasn't as prevalent in their time as it is now? Well the general trend over the last probably ten decades or so has been an increase in cancer rates around the world. It's hard to say exactly why. It could be due to so-called western lifestyles, types of food processing, stress in life, hormone exposures, new chemicals that are produced. I mean there's a lot of environmental things that could be at play. So it's possible that the true incidence has actually gone up. But we've also been living longer and it could just be that you accumulate through your age more and more things that happen to you so that you're more likely to have a cancer. So if we're successful at stopping your heart attack when you're 55, making your diabetes not lead to your early death, then what you're going to see perhaps is more cancer. So it's an interplay of a number of factors. It probably is increasing. The lack of data in this area means that the best that we can say in terms of how many cases it should be is the world average. So the world average would be about 114 or 117 per 100,000 people per year. So in St. Lucia that means a couple of hundred new cases every year. But it's probably the case that it's almost twice that. But we don't yet have solid data to really prove that you're different than the world average. So everybody will just default to the world average and say, well you must be just the average, right? So until you've got data to say you're different than the average, then when you know that, then you can plan accordingly. Because then you know how many cases are going to be, what kind of services are going to need, how much is it going to cost. And so government, society and individuals can then take a more informed approach to trying to tackle cancer and getting effective cancer control. Okay, and what sort of methods are used to treat or to cure breast cancer or any cancer rather? Yeah, so the primary approaches for most cancers is surgery and radiation is a significant component and these treatments go back obviously to the 1800s. Newer treatments are chemotherapy, hormone treatments and things like breast cancer and prostate in particular, and then targeted therapies, which means a drug that has been developed. It may be natural occurring in the world or it might be something that's synthetic. But a drug that is very specific to some chemical that's in the body. I don't mean an artificial chemical, I mean a biochemical, one that your body is producing. So it may be that only the cancer cells are producing this molecule. But the substance that can be given, the drug, the targeted treatment, just like the hormones can go to a specific receptor or location and only work in that location. So this is a little bit different than chemotherapy because chemotherapy causes more general side effects. Whereas targeted therapies tend to cause fewer side effects and so that's a significant improvement. So we are seeing that. And this coming along now is immunotherapy. So there's a number of studies looking at that. So in terms of the conventional suite of what we have for breast cancer, we have surgery, radiotherapy, chemotherapy if necessary, hormone treatments if necessary, and targeted therapy for a small number of all of the women. Where can St. Lucian's get radiation and chemotherapy treatment on the island? Or do you have to go to any of the other cancer centers around the OECS? Yeah, so generally right now chemotherapy can be provided here. So we work the TCCC organization, the cancer center that I'm with, works in partnership with the other doctors that are already in the island. So in this case there's several individuals here who will give chemotherapy. And chemotherapy is fairly standard. So there's no particular reason to go to Texas or whatever to get your chemotherapy. You get your chemotherapy in St. Lucia. What you cannot get in St. Lucia right now is radiotherapy. So you can still get your surgery and your chemotherapy and get your hormones and probably mostly targeted therapies. This is not a problem, it's a sourcing issue. Do you have the doctors? Do you have access to those drugs? Is it on the formulary and do pharmacies provide it, for example? But for radiotherapy there is no radiotherapy center in St. Lucia at the present time. So the patients have to leave to get that. So that means coming to Antica for the Cancer Center Eastern Caribbean. There are also several other providers in the region. And sometimes people will go for different reasons to those locations. Maybe they have family there, for example. So Jamaica, Trinidad, Guiana, there's some of the other radiation centers. So as we grow then we will expand and put in more centers that are part of TCCC within the OECS. And what is the process of getting shortlisted for those treatments? Well, they have to be indicated treatments. So you need a consultation by the relevant specialists. Ideally, once a diagnosis of cancer is made or is very likely, then a team of specialists will actually discuss the person's case. So this means that if I was found to have prostate cancer, there would be a multidisciplinary professional group, which would include urologists, chemotherapy therapists, radiation oncologists, and nursing maybe, and maybe other people, sexologists kind of involved in that. Those would meet and discuss my case. And then they would make recommendations to me about what would be the appropriate treatments. Now, obviously if you don't have the financial resources or the insurance to cover it, or you don't want the treatments that are recommended, but you want perhaps some version of that, then that's up for negotiation at that point. Okay. Work due for our second and final break. So stay tuned to issues and answers on this station. We'll be right back after this message. Good morning, sir. Good morning. Good morning. Nice to have you. Yeah, thanks. How was your weekend? Same thing. I went to the beach, but to tell you the truth, I should have just stayed home and slept. I just feel like I need help with my future goal, but I just don't know where to start. I love my job, but I'm not as productive as I used to be. Maybe I should speak to a councillor. What should I do? But it's so expensive. It's not my business, you know, but look, it's not even listening to you. You work with the government of Zellusia and the ministry of the public services offering free counselling to government workers under the Employee Assistance Program. All in. Really? The ministry is offering free counselling services for government workers? Yes, it's easier as calling the unit. The EAP telephone number 468-2269. Call him. If you have to pour out your heart, talk with a caring professional who is trained to listen to your deepest feelings. Call the EAP unit at 468-2269. EAP Works let it work for you. Hey, Joe, you were saying something? Welcome back to Issues and Answers. I'm your host, Jacques Kingston Compton, here with Radiation Oncologist, Dr. Glenn Jones. We're talking about breast cancer. So can men be diagnosed with breast cancer? Yes, so cancer in the Caribbean area is more a women's issue than a man's issue because about 65% or two out of every three cancer diagnoses actually occur in women, breast being obviously the most common. Men can get breast cancer as well, but they get it at 100th the rate, meaning that if there's 100 breast cases here, say in a year, there would only be one man during the year that would actually get breast cancer. Now, that individual is more likely to get breast cancer if there's a family history of prostate and breast cancer. Is the treatment for breast cancer in men the same as for women? Yeah, it's almost identical. So the five treatments that I mentioned earlier and adding immunotherapy, all of those are basically the same. The main difference obviously is that there's breast conservation as not an issue in men because the breasts that men have are only three centimeters or smaller in size, about an inch. So if you've got an inch tumor in an inch breast, then you're going to end up having a mastectomy. Okay, now you mentioned a term that I do hear quite frequently, especially with, I believe, Angelino Jolie had a mastectomy before she was even diagnosed with breast cancer. What is a mastectomy exactly, and is it something that you would advise to pay for patients? Yeah, mastectomy attempts to remove all the breast tissue. So it's obviously going to remove the fat that I mentioned, which is about a third of the breast. And then there's the ducts and the lobules and the nipple area. There's such thing as nipple sparing mastectomy and so on. So there's versions of this. But basically the idea is to remove all the area of risk for breast cancer. Typically, 99% of the breast tissue would actually be removed at the time of mastectomy. So it doesn't guarantee that you won't get breast cancer, but it will reduce the risk down by two orders of magnitude, basically 99% down to 1%. So it is an effective prevention. The problem is, of course, the cost, the fact that there's side effects, you could get a serious infection, potentially even die from a mastectomy, although that would be a very rare event. But it's not without risk. So it's not a routine strategy. So what you have to do is look at your own personal risk. So some women have a 65% lifetime risk of getting breast cancer. If you know that, then at some point between the ages of 40 and 60, depending upon family structure, like if you have kids to look after, these kind of things, you might, like Angelina Jolie, decide that the best strategy is to have a bilateral mastectomy, meaning removing both breasts completely and then go through reconstruction. Because the reconstruction is made from fat and muscle and skin from other parts of your body that don't carry any breast cancer risk. Other than, I suppose, the cost of it, is there any negative sort of side to doing that? Well, there's a psychological impact of a person in terms of their self-concept and body image. It might affect their relationship with another individual. So there's a number of things like that that have to be taken into account. The point is that if you had like a negative family history with many sisters and you had a mother and grandmothers and so on and you had no real family history of breast cancer, you were age 50, you were from an ethnic group like people who live in Slovenia who have a lower risk, your lifetime risk for the rest of your life for the next 30 years might be 2-3%. So there's no reason to perhaps even screen for breast cancer if your risk is that low. If the average woman is 8%, that's where screening and that should be considered. But if you're at the 50-60% range, then it's appropriate to at least think of doing something to prevent it. But that being said, there's still a 40-50% chance you'll never get breast cancer even if you live to be 100. So do you really want to undergo mastectomy just to kind of reduce your risk? The other thing is that if you're in an effective screening program for early detection, then the chance of curing you is quite high, like maybe 90% or so. So that's another factor to consider. Like just because you have breast cancer means you're going to die from breast cancer. We might be able to salvage the situation. So your true benefit is only that 10% of the deaths that you could avoid by having the bilateral mastectomy. And then that's discounted by the fact that there's only a 60% chance you're going to get breast cancer. So you're really looking at about a 6% benefit. So you've got to do 100 bilateral mastectomies to help possibly six women. So it starts to not make sense. Okay, now I hear a lot of people speak about the effectiveness of natural remedies. What is your take on that? Yeah, so naturally the body is designed to be effective to put all the cells in order and to function properly. So the reason why a cancer emerges, sometimes it is a sporadic event and there's nothing an individual could do about it. But sometimes it's related to the fact that there's lifestyle factors, stress levels, bad sleeping behavior, those kinds of things that just play out to produce more chaos within the body, change the immune system, these kind of things. So natural remedies are trying to correct this problem. So it's true that probably all patients with cancer need both physical treatments for the physical problem, but they also need a comprehensive plan to manage their lifestyle and other risks of cancer. So there's two or three kind of categories that you can put these things into. One is having good sleep, what's called sleep hygiene, sleeping properly, allowing your body to naturally heal overnight, protecting the brain, supporting your immune system. Then you've got exercise and then you move into nutritional issues. So for example, proper diet, good quality food. But then you have herbs and supplements. So this is what people start to think of as natural. But the first part of what I mentioned is actually what everybody should start to do as part of their management. It would help control the cancer in some studies that's indicated, but it would also improve the quality of your life, the function of your body, the ability of you to withstand second treatments if you need treatments later. You're going to be aging, but if you can keep your function at a high level because you're exercising and eating right, then you may be able to better tolerate second-line treatments and live even longer in these studies. So there's those things, but then there's the natural substances like herbs and so on. Then you've got other types of supplements. And these may play a role. The problem is that they've not been studied very well. And even nutrition has been poorly studied. So there's a recent review article which indicated that maybe 70% of the nutritional studies were fundamentally flawed and that we need to move beyond this and do better studies. What's the sort of survival rate for women who have been diagnosed with breast cancer? Yeah, so if they're diagnosed, say by a mammogram, and it shows that it's not yet invaded, then the cure rate is about 98%, or at least 10 years. It's going to be up in that range. Once you get more extensive disease, the cure rate starts to drop. So for early stage, like stage 1, about 10 years, 5 to 10 years, it might be 93, 95%. Our current numbers for Antigua and St. Lucia and that, the patients that we've seen is actually low. We've only got up to four years of follow-up, but we've actually got a 93% survival rate which is tracking almost exactly where it should be, given the types of stages of the patients that we've got. So once you get up to stage 4, then obviously the survival is poor, but it can be extended significantly with treatments. Well, I want to thank you very much for being with us today. I am Jacques Kingston Compton. This is Issues and Answers, and I've been talking with Dr. Glenn Jones, a radiation oncologist from the Cancer Center of Eastern Caribbean. Thank you very much for watching. Stay tuned to the station.