Dr. Noelle Cutter drives the spirit of Dr. Nancy Cappello's mission for early cancer detection for women with dense breasts alongside Dr. Robert Bard's dense breast screening pilot program (8/27-29) - and the global pursuit to expand current screening standards.
A mammogram shows how dense your breasts are. When you get the results of your mammogram, you may also be told if your breasts have low or high density. Women with dense breasts have a higher risk of getting breast cancer.
PARTS OF THE BREAST
A woman’s breast has three kinds of tissue: FIBROUS TISSUE holds the breast tissue in place. GLANDULAR TISSUE is the part of the breast that makes milk, called the lobes, and the tubes that carry milk to the nipple, called ducts. Together, fibrous and glandular tissue are called fibroglandular tissue. FATTY TISSUE fills the space between the fibrous tissue, lobes, and ducts. It gives the breasts their size and shape.
BREAST CANCER RISK: Women with dense breasts have a higher chance of getting breast cancer. The more dense your breasts are, the higher your risk. Scientists don’t know for sure why this is true. Breast cancer patients who have dense breasts are not more likely to die from breast cancer than patients with non-dense (fatty) breasts.
TRIBUTE TO A GLOBAL CRUSADER
(Play Video-L) The NY Cancer Resource Alliance gives loving tribute to Dr. Nancy Cappello, co-founder of "Are You Dense" and chief crusader of the mission to bring change to the protocols and standards of Early Detection. Her organization embarked in a global advocacy project to win legislation for dense breast scanning and to bring awareness to the need for better technologies and imaging interpretation. Today, her loving husband Joe continues her unending fight to save more lives through awareness, advocacy and her crusade for change. (Also see below to read her full story in our ORG SPOTLIGHT section)
7/8/2021- A wave of recognized medical sites, journals and reports are now indicating that dense breast tissue increases the risk of developing breast cancer and often masks a tumor from being seen on the mammogram since dense tissue is white and cancerous tissue is also white. Mammograms are the standard screening test for breast cancer, however, in the 21st Century, ultrasound non invasive imaging is the preferred exam for dense “lumpy” mammary disease.
The 1st World Conference of Breast Ultrasound in Philadelphia (1979) recognized ultrasound superiority in dense breast diagnostics but the density level was never quantified until recently. Mammography assessment of breast density is graded into four categories. Mammographers readily admit that these levels are subjective at best and technical factors such as mammary tissue compression and x-ray voltage/amperage dramatically influence the darkness or whiteness of the image.
URGENCY IN THE EVOLUTION OF TECHNOLOGY & IMAGING STRATEGIES FOR DENSE BREASTS
Written by: Dr. Robert L. Bard
Decades since the advent of breast scanning technology, innovations in non-invasive diagnostic imaging provide new options in the field of early detection. These technologies directly align with breast density screening (and are part of the Bard Breast Density Diagnostic Program) include:
• Doppler blood flow
• Contrast enhanced ultrasound vascularity
• 3D Vessel Density Histogram
• 4D Volumetric Density Histogram
• Strain and shear wave tissue Elastography
• 3 T MRI
• Optical Computed Tomography (OCT) for nipple lesions
• Reflectance Confocal Microscopy (RCM) for dermal invasion
• Hybrid Mammo Imaging Fusion
•Thermo-sensor
•Trans Illumination
•Near Infrared Specroscopy
Hybrid imaging refers to combining diagnostic modalities to assess disease and monitor therapy. A useful combination of options is the tumor vessel flow density to assess aggression and treatment progress. Similarly, tissue elastography is useful for border detection of malignant masses.
4D VOLUMETRIC DENSITY HISTOGRAM
This new variation of the 4D ultrasound imaging involves real time scanning of the entire breast and focusing of the greatest density tissue with 3D volumetric capture of the tissue. The computer searches the gray level of the images under study and provides a percentage (%) number of the whiteness of the volume under study.
This investigative process began in 2017 under a study of scar tissue and presented at the 2018 ASLMS meeting using elastography and volumetric sonogram density analysis. Breast cancers, like scar tissue, are dark while fibrocystic abnormal tissues is more white.
The clinical utility of 4D image acquisition is:
1. Automated electronics sampling of the tissue volume in real time
2. 200-300 images of a data set are generated in 5-15 seconds
3. The process is User-INDEPENDENT unlike standard 2D ultrasound which is highly user dependent
4. The data set for serial studies uses fixed parameters so that treatment efficacy may be rapidly compared
INNOVATIONS REFLECTING A NEW IMAGING STRATEGY: MEET THE ABUS
The medical imaging and cancer communities are now taking strides toward the dedicated scanning of Dense Breasts. As mammograms have been known to have difficulty seeing tumors through dense breast tissue, the demand to upgrade imaging standards is at its highest. Dense breasted patients carry the risk of a mis-read which may miss advanced cases of breast cancer.
According to GE Healthcare, "Approximately 40% of women have dense breasts, one of the strongest common risk factors for developing breast cancer. Having dense breasts increases a woman's chance of developing breast cancer by four to six times, and seventy-one percent of breast cancers are found in dense breasts.
Clinical evidence is growing about the effectiveness of ultrasound for finding small, node-negative, invasive cancers missed by mammography. In 2018, GE Healthcare launched the Invenia automated breast ultrasound (ABUS) 2.0 system in the U.S. This FDA Approveed ultrasound supplemental breast screening technology specifically designed for detecting cancer in dense breast tissue. When used in addition to mammography, Invenia ABUS can improve breast cancer detection by 55 percent over mammography alone. Invenia ABUS 2.0 supplemental imaging is designed for the screening environment, specifically for dense breast imaging. Invenia ABUS 2.0 diminishes operator variability and creates 3D ultrasound volumes to enable comprehensive analysis and comparison to multimodality exams. [1]
“We believe ABUS can help clinicians find significantly more cancers than mammography alone, especially in women with dense breasts,” said Luke Delaney, general manager of Automated Breast Ultrasound at GE Healthcare. “As breast ultrasound technology continues to advance, we are investing to continually improve image quality, workflow and patient comfort - all of which contribute to early detection and improved outcomes.” [1]
Dense Breasts: Answers to Commonly Asked Questions
Q: How common are Dense Breasts?
A: Nearly half of all women age 40 and older who get mammograms are found to have dense breasts. Breast density is often inherited, but other factors can influence it. Factors associated with lower breast density include increasing age, having children, and using tamoxifen. Factors associated with higher breast density include using postmenopausal hormone replacement therapy and having a low body mass index.
Q: Are dense breasts a risk factor for breast cancer?
A: Yes, women with dense breasts have a higher risk of breast cancer than women with fatty breasts, and the risk increases with increasing breast density. This increased risk is separate from the effect (false negatives) of dense breasts on the ability to read a mammogram.
Dr. Nancy Cappello's Story: "I have dense breast tissue – and women like me (2/3 of pre-menopausal and 1/4 of post menopausal) have less than a 48% chance of having breast cancer detected by a mammogram. In November 2003 I had my yearly mammogram and my "Happy Gram" report that I received stated that my mammogram was "NORMAL" and that there were "no significant findings." Six weeks later at my annual exam in January, my doctor felt a ridge in my right breast and sent me for another mammogram and an ultrasound. The mammogram revealed "nothing" yet the ultrasound detected a large 2.5 cm suspicious lesion, which was later confirmed to be stage 3c breast cancer, as the cancer had metastasized to 13 lymph nodes.... Since then, I learned that there are many women like me with recent normal mammogram reports with a hidden intruder stealing their life. I am on a quest to expose this best-kept secret of dense breast tissue to ensure that women with dense breast tissue receive screening and diagnostic measures to find cancer at its earliest stage - isn't that the purpose of Screening Programs?"
Nancy's story is a widely common one, and demands to be recognized to change the current standards. We established an advocacy group to help create a new standard protocol for diagnosis because the current standard is clearly an injustice to ALL women. This includes public education and awareness for the many women who get side swiped because of a lack of understanding and clinical information.
Our advocacy work led us to reach out to our legislators, explore the current insurance coverages and eventually got our first win with a disclosure law in 2009, making Connecticut the first state in the nation to pass legislation making it a law for Docs to disclose to the patient if they have dense breast tissue. This says that if a woman has dense breasts, she'd must be told by her physician that she's got dense breast there's alternative screening. This includes options like an ultrasound or an MRI. Also, two years ago, ‘Are You Dense Advocacy, Inc.’ was instrumental in passing the first national dense breast disclosure law. We are now working with Sen. Feinstein to enact this legislation.
FORGING A NATIONAL MOVEMENT It used to be that when you Googled ‘dense breast’, there was next to NO information available. But over time, as we started making ‘noise’ about this issue, more and more interest began coming our way. As news broke of our ‘touchdown’ with our state, it wasn’t long before other states started asking how we did it. Before long, Nancy started helping women across the country and the next state was Texas. She helped the girl down in Texas to get legislation passed – and next came our public educational website for the many others who definitely need this.
Nancy quit her job with the state of Connecticut and started doing “Are You Dense” full-time and she helped pass 38 different laws in 38 states. It's a tremendous amount of work to pass laws on a state by state basis, but she was really the catalyst. Nancy was the person behind and the voice and the face behind dense breast tissue. As outreach work goes, we created a major effort around what we've done now. Manufacturers are supporting our interest as far as the expansion of full breast automated ultrasound and others came into existence (and are doing quite well) because of our efforts.
In New Jersey, we have the Breast Density Law that literally says women with very dense breasts should be getting more than just screening mammography and the insurance companies have to cover. And that can either be an ultrasound or an MRI, but women over 40 do not usually like the idea of getting an MRI and gadolinium IV each year. Instead, adding ultrasound allows you to scan the whole breast and see through the very dense breast tissue. Ultrasounds will also work to the full depth of the breath straight down to the chest wall, so that if there are any masses, it will see right through the fibers and thick tissue- not limited like mammogram.
Even extremely dense breast patients should get a mammogram because it also shows things like calcifications-- something that the average ultrasound tech may find harder to capture. Women with extremely dense breast definitely can benefit from added surveillance because as your breasts get more dense, mammography can miss things. Due to a higher volume of dense tissue, a little tumor can hide underneath fibercystic tissue making it very hard to see in mammography, even with tomosynthesis or the 3d mammo.
By: Dr. Stephen Chagares | https://www.drchagares.com
TREATMENT OPTIONS
Risk stratification is important since the cost/benefit of any therapy must be weighed against the likelihood of health consequences. Hormone treatments have been controversial for 50 years and remains so to date. Since Dr. Selig Strax (my late partner) developed the “lumpectomy” for conservative therapy of breast cancer at Mt Sinai Medical Center in the 1960’s, advances in limiting tissue damage have yielded progress in chemotherapy, radiation therapy and immunotherapy. Similarly focal treatment options that began with prostate cancer in 2000 with HIFU (High Intensity Focused Ultrasound) are now found in thyroid and breast treatment centers and Laser Ablation and Cryo Ablation are now available alternatives.
Elastography is used worldwide since 2010 for cancer detection because cancer is hard (inelastic) and benign tissue is soft (elastic). This quantitative technology for cancer detection has not been adapted for breast density analysis to date.
1) Breast density and risk- European Radiology 31:4839-4847, 2021
2) 4D histogram analysis of malignancy- Mt Sinai Surgical Symposium 2020- 3D/4D breast density histogram
3) Proceedings: Male Breast Cancer Coalition 2019
4) Ultrasound imaging of subdermal pathology /Springer Heidelberg 2018
5) 3D Doppler imaging of malignant melanoma- Intl Dermatologic Surgery Symposium 2016
6) 3D Doppler imaging in dense breasts Proceedings: 2012 Societe Francaises de Radiologie
CONTRIBUTORS
DR. ROBERT L. BARD has paved the way for the diagnostic study of various cancers both clinically and academically. He runs an active NYC practice (Bard Diagnostic Imaging) using the latest in digital Imaging technology which has been also used to help guide biopsies and, even replicate much of the same reports of a clinical invasive biopsy. Imaging solutions such as high-powered Sonograms, Spectral Doppler, sonofluoroscopy, 3D/4D Image Reconstruction and the Spectral Doppler are safe, noninvasive, and does not use ionizing radiation. His commitment to lead the community of cancer imaging and diagnostic experts has led to the establishment of the "Get Checked Now!" campaign.
JOSEPH J. CAPPELLO married Nancy Marcucci, in 1974 and the story began. Joe is the co-founder and executive director of Are You Dense, and Are You Dense Advocacy- in January of 2019 after Nancy’s passing from treatment related bone marrow cancer (MDS). His passion is to continue Nancy’s legacy by pursuing the goal that they set in 2004; that not one woman would die from a late stage breast cancer due to dense breast tissue. In 2009, Joe and Nancy championed the first in the nation breast density inform law in the State of Connecticut (and now, 36 States have breast density legislation).
Disclaimer & Copyright Notice: The materials provided on this website/web-based article are copyrighted and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and Bard Diagnostic Research & Educational Programs). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers. Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately. This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.
For surgical procedures of breast cancer, NYCRANEWS explores wire-free Radar Localization - a pre-surgical procedure to locate and mark the exact breast abnormality through the use of a small, 12×1.6 mm implanted radar reflector device, roughly the size of a grain of rice.This micro-electronic implant communicates with the scanning handpiece, allowing the surgeon to identify the exact tissue (and how much of it) to extract during a lumpectomy [1]. The early process of localization came in the form of a guide wire insert but later advancements offered other solutions including a wireless radioactive seed and (then) a non-radioactive version called SCOUT®- formerly called SAVI-SCOUT (until July, 2019) [2]. It wasdeveloped by Cianna Medical and then acquired in 2018 byMerit Medical, an American medical technology company.
Publishers of FightRecurrence.com and PinkSmart News dedicated a review of this surgical solution in support of improvements in the preservation of the breast during surgery. In this feature article, we present Dr. TroyShell-Masouras of Paradise Coast Breast Specialists in NaplesFla. - and David Gilstrap, Director & Global Product Management of Merit Medical. Together, we explored technical perspectives and design strategies behind radar localization and the SCOUT® technology. They shared the procedural advantages provided by the wire-free upgrade as well as its overall improvements to the patient's well-being in the pre and post-surgical phases.
WIRE-FREE UPGRADE IN LOCALIZED IMPLANTS
This segment is from Mr. David Gilstrap's 5/2021 interview.
The concept ofSCOUT® wire-free radar localizationwas developed by CiannaMedical in 2010 and was an alternative to the predominant guide wire concept. The launch of the SCOUT® introduced "going wire free" for the patient, providing a huge impact on patient satisfaction. Prior to this, the original process included placing a wire in the patient the day ofsurgery, and the patient maintains this wire sticking out of their breast until surgery time, which could be up to several hours.
The genesis of the non-radioactive reflector came about in 2010 as the company started re-evaluating the breast surgery localization space, because at the time there were only two other options available;the guide wire solution (standard for 50+ years) and theradioactive seed alternative.Despite its advantages, the radioactive seedsolution showed its own set of limitations and regulatory issues, limiting its public acceptance."It needed a lot of training and tracking and was restricted to a limited time where you can actually place it."
By December 2014, Cianna Medicalreceived FDA Clearance for the first generation of SCOUT®allowing full commercialization in the U.S, and CE Mark for Europe would follow. The implant is technically called the reflector. It doesn't transmit a signal, but actually reflects a signal that's being sent to it. It has its own electronic circuitry, an antenna and it is sealed with a bio-compatible coating called APTEK. There's no power source or moving parts in the reflector- it's inert. With FDA long-term implant status, when it's placed into a patient,there are no limitations on removal and it can remain in the patient forever. It doesn't have to be removed again. There's no risk to the patient or the area of interest.
Once placed into the region for surgery, the surgeon uses the SCOUT®surgical guide which transmits pulsating infrared light and a pulsating radar signal (at 50 million pulses/sec). This infrared light activates the reflector which bounces the radar signalback to the system, giving an audible cadence when detected as well as distance measurements from the end of that guide, accurate to one millimeter. To simplify, the technology is very similar to the micro power impulse radar used in your backup sensors in automobiles. So it is very accurate in detecting things over very short distances.
Merit attributes their success in tech feature upgrades to collected end user data from the surgical community. Prototypes are underway for a reduced reflector size, advanced image guidance, customized targeting cadence and improved ease of use in installationSince SCOUT® is approved for soft tissues it is rapidly expanding into other surgical sites such as pulmonary nodules and soft tissue sarcomas.
Dr. Barry Rosen, breast surgeon at Good Sheppard Hospital (Chicago, IL) describes the many advantages of wire-free localization technology in oncoplastic surgery. For the patient, this innovation adds a new level of ease and adaptability over the traditional (pain and stress of) the wired version.
FROM THE SURGICAL FIELD
Breast surgeon Dr. Troy Shell-Masouras expands on the benefits of the wire-free (non-radioactive) radarin comparison to the former solutions like the localization wire and radioactive seed. This segment is excerpted from Dr. Shell-Masouras' direct interview in 5/2021.
Initially, the first breakthrough into a wireless approachwas the radioactive seed - technology that was well-known in prostate cancer. These pellets can be placed into the breast in a similar fashion where the SCOUT reflector would be placed. Once installed, you would use a probe that detects the signal of the seeds. The issue here is that because it is radioactive, there are very strict monitoring and nuclear medicine guidelines on this process as far as its retrieval. To describe this a different way, imagine inserting this radioactive seed in a patient before their surgery-- then if that patient gets into a car accident or disappeared in some way, your entire radioactive seed program could be shut down because you have to be able to retrieve that seed.
There are limitations on how long that seed is active and detectable. Because of these issues, products like SCOUTwere developed where there are no limitations on the activity of the device. Time is of no concern if your patient grows ill and their procedure is postponed a month or so down the road. There's no urgency to retrieve the product at any time. These real-life situations are really why products like this are developed.
Comparatively speaking, there appears to be no difference in accuracy between the wired solution, the radioactive seed and the SCOUT. The radioactive seed is significantly smaller than the SCOUTbut this size difference is a non-issue to surgeons. Statements about SCOUT’s (minor) limitations however mention a slight adjustment in work parameters around the distance between the skin and the device particularly with large breasts or very dense breasts. The SCOUT technology is something that continues to evolve... they are trying to develop where you have a different signal if you have more than one lesion from multiple markers within the breast. Merit is also leading to a lot of competition because everybody wants a piece of that wire free action- but the SCOUT developers set the bar pretty high and a lot of institutions have embraced it... I think it's going to be tough for them to break in since SCOUT has already made their mark.
It is noted that programs using radioactive seeds continue to exist, but the market appears to reflect a transition to non-radioactive devices for reasons described.
Dr. TroyShell-Masouras conducts life saving Breast Cancer Surgery at Paradise Coast Breast Specialists in NaplesFla.Dr. Shell-Masouras specializes in the diagnosis and treatment of breast cancer and benign breast disease, and provides high risk breast cancer assessments, breast ultrasounds, ultrasound-guided breast procedures to include biopsies and aspiration, partial mastectomy and lumpectomy, total mastectomy to include Hidden Scar™ Breast Conserving Surgery and Hidden Scar™ Nipple Sparing Mastectomy, sentinel lymph node biopsy, axillary lymph node dissection, and radar localization for lumpectomies.
VIEWPOINTS
STEPHEN A. CHAGARES, MD FACS- Cancer Surgeon/ General,Laparoscopic, Robotic Surgery - “Yes, the Scout technology is a great progression of technology. It allows accurate localization with site of incision at the Surgeon’s discretion allowing for significantly increased cosmetic appearance of a lumpectomy. Also, it’s placed days earlier so no radiology delays on OR days waiting for patients to return after being sent down for guidewire placement."
* Opinions expressed in this VIEWPOINTS section are supportive comments about the contents of this article and are solely those from the contributors credited.
The Male Breast Cancer Coalition presented the work of Dr. Jose Pablo Leone, medical oncologist and researcher at the Dana-Farber Cancer Institute about his research plans covering tamoxifen and aromatase inhibitors for the treatment of male breast cancer. While women have the benefits of switching to AI should they contract side effects from Tamoxifen, men are in a harder situation when making this decision because not enough data about the efficacy of aromatase inhibitors (AI) are available for men.
"Currently, only retrospective studies are available out there, which are prone to selection bias. We need to do more research to get scientific validity to dictate treatment for patients. Due to the physiological differences in the endocrine system between men and women, there may be differences in the efficacy of aromatase inhibitors, leaving men with only Tamoxifen as their primary option. Tamoxifen for men is the standard recommended drug for men with metastatic breast cancer. If there is progression of disease after Tamoxifen, then other endocrine therapies can be used in the metastatic setting. This is why we need prospective studies evaluating AI in men." (See complete article)
BREAST CANCERSCAN NEWS: From the International Oncology Community (Comunità Oncologica Internazionale)
4/30/2021 Dr. Robert Bard has been elected as the Sr. Medical Advisor of the Integrative Cancer Resource Alliance- an international community of diagnostic imaging specialists. His educational presentation has been translated in over 5 different languages for the world stage, supporting partners in The Netherlands, Italy, France and Germany. This 2021 report recognizes the advancements in non-invasive, real-time diagnostic imaging of cancer tumors for tracking, monitoring, screening and dual diagnosing as well as preop and image guiding intervention during procedures. Dr. Bard identifies the global movement and demand for virtualization- a medical innovation for remote multi-disciplinary collaboration (ie, TeleRad, Tele-Health and Virtual Conferences) to support the expansion of data sharing as a modern paradigm of problem-solving in cancer care.
In an earlier feature, Dr. Bard celebrates the global solidarity of cancer imaging scientists including the work of some of his most respected research colleagues including Professors Luigi Solbiati, Carlo Martinoli, Rodolfo Campani. These are just some of the many highly regarded members of the pioneering community who helped pave the movement for a much improved detection of cancer tumors and other subdermal disorders.
(Image-L) Once you have a vascular map of the cancer, we have the initial vessel density of 4.5%. Successful treatment over weeks or months will bring it down. In this case, it's down to one quarter of the initial treatment so this is treatment success. This is quantitative mapping of treatment follow-up because if it's working, it's better to change treatment, to avoid the side effects of chemo or other immunotherapies. The first circle on top shows the red tumor vessels. The 4D Instagram computer reconstruction gives you a quantitative measure of how many tumor vessels are present. Once you have a number, you can follow the number up or down to verify treatment success or failure to adequately adjust treatment that's needed up or down. (For complete review of CLINICAL IMAGING OF BREAST CANCER Explained, visit: breastcancernyc.com)
GET CHECKED NOW! : EARLY DETECTION SAVES LIVES
According to the World Health Organization, early detection of cancer greatly increases the chances for successful treatment. In the ongoing battle against cancer, it is common knowledge that most cancers in their early stages are far more likely to be treated with positive results. Moreover, a thorough checkup of one's physiological analyses, heredity review and personal data gathering are all strong info-gatherings for early warning signs that someone may be a candidate for cancer. PROACTIVE tasking starts from AWARENESS, EDUCATION & REGULAR SCREENINGS. The right attitude of self-preservation and an appreciation for longevity is lesson #1. Pursuing a balanced lifestyle covering all the bases of nutrition, exercise, sleep, detoxing and de-stressing is also part of an overall plan for better quality of life. Also visit: www.FightRecurrence.com
Disclaimer & Copyright Notice: The materials provided on this website are copyrighted and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and Bard Diagnostic Research & Educational Programs). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers. Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately. This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.
The FDA (US Food & Drug Administration) first identified a possible association between certain breast implants and the development of Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) in 2011 [1]. On July 24, 2019, ALCL advocacy groups and the global community of implant users finally achieved the long awaited recognition about this emergent disorder when the FDA announced Allergan's voluntary recall of their textured implants. Such a recall raises a level of urgency about the public health risks behind BIA-ALCL with the hopes that other manufacturers would soon follow this lead. "Whenever a company accepts responsibility to pull a risky product from the market, they usually aim to correct product flaws to eliminate public health risks. Recalls also set a great precedence for new research that can add to our scientific understanding about preventing the disorder and other paradigms like it", states implantscan.org.
Note that ALCL is not breast cancer - it is a type of non-Hodgkin’s lymphoma (cancer of the immune system) that in most cases is found in the scar tissue and fluid near the implant, but in some cases, it can spread throughout the body [1]. A significant number of cases are recorded to appear within 8-10 years after implantation but new reports are showing symptoms earlier. A recent report from the American Society for Aesthetic Plastic Surgery states that the first symptom of BIA-ALCL is usually a swelling of the breast between 2 to 28 years after the insertion of breast implants, with an average of about 8 years after implantation. A theory that the increased surface area of textured implants allows a higher number of bacteria around the implant, which forms a biofilm in some patients, and can result in chronic inflammation, ultimately leading to a proliferation of lymphocytes. [2]
PinkSmart News conducted an interview by late 2018 with Dr. Patricia Clark of Ironwood Women's Centers and the Ironwood Cancer and Research Centers in Scottsdale, AZ. She provided great insight on various breast-related cancer topics, and she also helped clarify many areas of the BIA-ALCL associated Lymphoma crisis. Dr Clark is a respected nationally recognized onco-plastic (reconstructive) surgeon. These surgeries plastic surgery techniques like breast lifts or breast reductions with cancer surgeries to conserve the breast and reconstruct the defects without implants. Hence, if she performs a lumpectomy for breast cancer, rather than leave a lumpectomy defect or a deformity in the breast, she can modify techniques used during cosmetic breast lifts and reductions to fill the hole, repair the defect and prevent deformity. She might even operate on the other side so that the two match. She teams with leading board certified plastic surgeons to ensure patients have access to the full range of both mastectomy and partial mastectomy reconstructive options.
Dr. Clark and others speculate the true number is of BIA-ALCL cases is likely under-reported to the FDA registry. Incidence estimates range from 1:3817 patients to 1:30,000. The treatment of BIA-ALCL that has not spread beyond the capsule of the implant is simply to remove the capsule and replace the implant. Because it forms in a different manner than other primary non-Hodgkin lymphomas that arise in lymph nodes, chemotherapy and radiation therapy are rarely necessary unless diagnosis is delayed and the disease has spread beyond the capsule. There are likely patients with implant problems who have had the implant and capsule removed, and for which a thorough pathologic examination may not have been done, but for whom the patient’s surgery was curative. Because of increased awareness, this is less likely to happen now than in early years. A quick raise of hands to see who had treated a case by the hundreds of reconstructive plastic surgeons attending the 2018 BC3 meeting sponsored by Georgetown University resulted in more than 20 surgeons who had personally seen or worked with ALCL cases. At that time, records showed less than 500 cases being reported internationally with 16 deaths from over 30,000,000 implant placements.
A capsule is tissue laid down around the implant that is part of the body's normal process of walling off any foreign body. In addition, the formation or buildup of seroma fluid doesn't mean a patient is going to get cancer. That clear fluid that appears during injury or infection, or in the case if implants, is the body’s reaction to a foreign matter and to large, raw, cut areas of tissue. Hence, every single breast implant, whether it's smooth or textured, forms this capsule. When capsule become too thick, contract, develop persistent seromas, or start to deform the implants, plastic surgeons remove and replace the implants and perform a capsulectomy- the surgical removal of scar tissue and capsule. In doing so, this complete removal procedure inadvertently treats the disease successfully since the lymphoma is usually confined to just the capsule.
THE TEXTURED IMPLANT DILLEMMA
Manufacturers developed textured implants as an upgrade to the smoother counterpart. Smooth implants would result in the shrinking of collagen and the fibers, leading to shrinkage and eventually causing the implants to become hard as a rock and painful. Textured implants were designed to prevent this while accommodating many shaped implants from rotating or shifting over time. Some shapes are thicker on the bottom, thinner on the top, and more teardrop-shaped like a breast. With textured implants, one Because of the texture, a leading theory of cause of BIA- ALCL is the high amount of surface area with more little nooks and crannies can trap more bacteria, which causes more immune cells to move in (lymphocytes) which are subjected to prolonged inflammation and can become cancerous. Other theories include allergic reactions associated with textured implants, and genetic factors.
BIA-ALCL may occur in all implants, smooth as well as textured, but most are associated with Allergan Biocell textured implants. These have now been recalled from the market. Since the risk of development of BIA-ALCL is so low, the FDA does not recommend removal of these implants if there is no swelling or pain. If a patient develops a seroma or fluid around the implant, this should be sampled and sent for pathology evaluation.
A current update of an estimated 1 in 30,000 textured implant risk has been reported and 573 unique and pathologically confirmed BIA-ALCL cases worldwide related to breast implants [3]- according to Dr. Clemens at the July 2019 review with the American Society of Plastic Surgeons. But prior to this year’s recall, the use of textured implants remained prevalent and the risk figures showed an inconclusively low number and did not warrant any public safety action or manufacturer’s recall.
“BIA-ALCL is not the same disease as the lymphomas that you see spontaneously arise in lymph nodes in the general public. It's not a disease that you treat with chemotherapy or radiation. This is somewhat limited to the implant capsule in most cases. Proportionately speaking, it is very rare … it can invade the local tissues you can have wide-spread disseminated disease or, but that's stunningly rare.”
Dr. Clark’s most recent experience with an ALCL case emphasizes the multidisciplinary care patients receive. This included radiology, pathology, medical and radiation oncology and plastic surgery. Capsules must be completely removed and are often densely adherent to the chest wall and even the periosteum (lining) of the bone of the rib. This increases complexity and difficulty in removing every single piece of it. She recently collaborated with Scottsdale plastic surgeon Dr. Joe Berardi due to his previous experience with BIA-ALCL and meticulous approach to capsulectomies.
In summary, it is believed that the two strongest factors that provoke breast implant related lymphomas included formation of a BIOFILM; an infectious coating of bacteria embedding themselves in the surface of the implant. This biofilm recruits the immune cells, which develop the cancer. Also, research have found immune-mediated or allergy-like eosinophils, indicating there could be an allergic component to development of ALCL.
Biofilms are not penetrated by antibiotics and are poorly penetrated by immune cells which can result in chronic, sub-clinical infection that the body and antibiotics can’t clear. The capsule is a physical barrier between the implant and the normal breast tissue within which it has been inserted.
THE RECALL: LANDMARKING A GAME-CHANGER
Each time a product is recalled, it reflects upon the manufacturer’s aim to rectify a known issue that could cause eventual harm to the consumer. The community of implant users and medical professionals have viewed enough cases (and fatalities) of BIA-ALCL historically that the July 24 recall marks a significant touchdown toward the industry’s recognition and global restitution of the possible disaster that this product has yet to face. “It validates the seriousness of the situation, because the layperson can understand that a company doesn't do that… (unless) there's a serious problem”, says Jennifer Cook of BIAALCL.com.
“I’m grateful for the chance that future women will develop this lymphoma has been greatly reduced. Its not only Allergan implants that create the risk, but it does appear from current data that their implants create the highest risk, and so with those implants being removed from the market, its going to greatly reduce the number of new cases of this disease being created. There's obviously a lot more work to be done but it is the first step, and an additional part of that equation for me was just awareness because all the women out there with this lymphoma, or the implants that can create it, still in their bodies right now, may have no idea about this lymphoma because no one is obligated to warn them. So any immediate attention potentially can reach them and so the withdrawal created more media attention and then hopefully, more awareness.”
August 8, 2019 –
A new article has been published out of MD ANDERSON in a Modern Pathology Journal addressing the proper way to evaluate and sample an implant capsule
that has been removed from a patient suspected of Breast Implant Associated ALCL. The article indicates that the disease can
often be missed if proper and thorough evaluation of the capsule is not
done. Not only can the disease be
missed but often positive margins of lymphoma on the implant capsule can be
missed and this can create a risk of incomplete resection of the disease w/c
increases the risk of recurrence and worsens the patient's prognosis. Therefore, a person who is suspected of having
BIA-ALCL should have their surgeon and pathologist become aware of these
latest new recommendations on proper pathology protocols so they can benefit
from the state of the art information on how to diagnose and treat this
disease. (See complete report: https://www.nature.com/articles/s41379-019-0337-2)
CONTRIBUTORS / TECHNICAL ADVISORS Patricia Clark, MD, FACS is a board-certified general surgeon with a passion for treating breast cancer and for using oncoplastic surgery to improve outcomes. Additional plastic surgery training led her to become nationally recognized as a teacher of oncoplastic surgery at national and international conferences. These techniques reduce the need for mastectomy in patients with complex breast disease and they minimize deformity. She is an active member of the American Society of Breast Surgeons, the Society of Surgical Oncology, the American College of Surgeons, the National Consortium of Breast Centers and the American Society of Breast Disease. She currently practices at the Ironwood Women's Centers in Avondale AZ. (www.ironwoodwomenscenters.com)
Jennifer Cook was diagnosed with Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) in August of 2017- which started her on a road to major research to collect all information about the disorder as well as seek out an international social media group of fellow survivors and a supportive community (www.BIAALCL.com). Today, Jennifer stands as one of the top advocates of the group, conducting outreach efforts to seek out other victims of this health issue. She is also an active voice in many leadership circles dedicated in the fight to bring public recognition and corporate accountability to this crisis. (See Jennifer's interview on Survivor Stories)
EDITORIAL TEAM Robert Bard, MD, PC, DABR, FASLMS has paved the way for the diagnostic study of various cancers both clinically and academically. His main practice in midtown, NYC (Bard Diagnostic Imaging) uses the latest in digital Imaging technology which has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. Imaging solutions such as high-powered Sonograms, Spectral Doppler, sonofluoroscopy, 3D/4D Image Reconstruction and the Spectral Doppler are safe, noninvasive, and does not use ionizing radiation. His commitment to lead the community of cancer imaging and diagnostic experts has led to the establishment of the "Get Checked Now!" campaign.
Disclaimer & Copyright Notice: The materials provided on this website/web-based article are copyrighted and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and Bard Diagnostic Research & Educational Programs). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers. Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately. This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.
Our DNA and our genetic material is breaking and being damaged every single day. That's just the wear and tear of life. Our bodies have genes and mechanisms to repair broken DNA, and our immune systems have mechanisms to identify and destroy cancerous cells. With breast cancer, 5% to 10% of people have a genetic predisposition that raises their risk of development of breast cancer. If we have a cell that can't be repaired, our immune system can recognize it and our natural killer cells can destroy it. So that's how things ought to work. Eventually, you accumulate MUTATIONS over a lifetime as more genes and genetic information are damaged and break down. Somebody like Angelina Jolie had a gene that predisposed her to get breast cancer. She had a gene called BRCA which is a DNA repair mechanism gene. She had one copy of that gene that did not work causing an 87% chance she was going to get breast cancer. She decided with a risk this high for the particular genetic mutation she had, she was going to get mastectomies and remove her ovaries, which were also at risk. Genes are like a paragraph of instructions that tell a cell what it is supposed to do, such as what proteins it should make. If all the letters in the instructions are in the correct order, or the gene is “spelled’ correctly, the gene can be read by the cell and everything works. Pathologic mutations in genes have to occur in very specific locations for a cell to no longer be able to understand the instructions it carries. We have all read paragraphs where letters or words are left out, but we can understand the meaning of the paragraph. Changing the letters at a key location though, can change the entire meaning of the paragraph of instructions. For instance, If I have a sentence in that paragraph with the word CAR, and I change that "R" to a "T" it now reads CAT. That might change the entire meaning of the message to the cell, and it will no longer be able to carry out it’s functions. That would be a pathological mutation and raise the risk of inheriting cancer or of a cell becoming cancerous. Had I changed the C to a K, and made the word 'KAR', the cell may have still been able to read and understood the word carrying that mutation and can happily continue making the proteins it was supposed to manufacture. This is why some mutations may cause no harm to the cell as long as the cell can still read and understand it’s instructions while other mutations can stop a gene in its tracks, being rendered pathologic. This is the simplest way to describe mutations. A lot of mutations aren't going to matter. You have to mutate them in very specific spots before a cell cant read it. To get a cancer, it's not enough to have one mutation. You have to have one or more specific mutations to enable cells to divide uncontrollably. Then you've got to have a mutation that allows it to get out of the organ that it's in (such as a milk duct) and escape into the nearby adjacent tissues, forming a tumor. That's a whole other gene that has to be bad. You have to have a gene in there that allows those cells to bring in their own blood supply so they can keep the tumor fed and alive.. So that's yet another genetic mutation. Like with breast cancer, people don’t die of the breast cancer in their breast. They die if it traveled into their entered their bloodstream and lodged in their lungs, it lodged in their liver, it lodged in their bones it lodged in their brain... if it had the mutations it needed to escape the breast and lodge in an organ system that you need. In order to do that it that takes a whole other set of genetic mutations. We can test the tumors for these mutations. Putting a garden variety breast cancer cell in the lung (per se), may be sort of like putting a Palm tree in Alberta, Canada. You can put a Palm tree up there, unless it has a set of very specific genetic mutations, it's not going to survive the winter up there. “IT’S NOT THAT EASY TO GET CANCER”: So that's why all of us aren't running around with cancers. 1 in 8 women will develop breast cancer over their lifetimes. We have genetic mutations that we accumulate, a lot of them meaningless. Then the other thing is you've got to have the exact right mutations all lined up in a row for something to become cancerous. For the same reason not all firefighters in 9/11 die of cancer, it also depends on genetic predisposition and a person’s ability to protect from and heal environmental insults. We see families where it seems everybody's getting cancer but we can't find a nice single smoking gun or a silver bullet that “caused” it. If cancer were a single process or silver bullet, we’d have it cured already. We're going to have cancer forever because you can't stop the body from mutating or accumulating genetic damage. If you could, we would all be immortal. So that's the briefest of the basics. Understanding cancer from the angle of genetic mutation and predisposition helps you see why some people get it, some people don't. Some people may not have the robust repair mechanisms or the lifestyle to fight it off. Many are sedentary-- they don't exercise, they drink alcohol, or have other lifestyle risks that are another part of it. There are also a lot of environmental factors that can turn genes on and turn genes off. That’s a whole other layer. You can be predisposed because you carry a unique malfunctioning gene ... which carries a variable increase in somebody's risk. They may have a 40% risk they're going to get cancer- or you can see it as that there's 60% risk they never will. We have proto-oncogenes that must be turned on to cause a tumor to form, and tumor suppressor genes that must be turned off to allow a cancer to form. We may or may not be exposed to the environment inside or outside the body that's going to turn it on - or off.
Awareness
for a Cure welcomes our newest cancer expert, Dr. Patricia Clark- Breast and Oncoplastic Surgeon. Dr. Clark is a
renowned speaker at the BC3 (National Breast Cancer Conferences) and is
currently the medical director and surgical oncologist at the Ironwood Breast Cancer
and Research Centers in Scottsdale, AZ. You can learn more about Dr. Clark at: www.drclarkmd.com
Eliminating Cancer is not enough:
A woman’s
function and body image matter. For most women, there is no survival advantage
to mastectomy. By using oncoplastic techniques such as breast reduction or
mastopexy at the time of lumpectomy, selected women with larger tumors or more
complex disease can now have complete removal of their cancer and still have a
good cosmetic result. While Dr
Clark personally performs oncoplastic procedures, high quality plastic surgery
consultation is available for all women requiring reconstruction from
mastectomy, and to optimize outcomes in selected women undergoing oncoplastic
procedures.Surgery can be performed on
the other breast to provide symmetry. We don’t want the breast to be a reminder
of cancer in years to come. www.drclarkmd.com
Disclaimer & Copyright Notice: The materials provided on this website/web-based article are copyrighted and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and Bard Diagnostic Research & Educational Programs). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers. Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately. This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.
Here some reflections, and a plea for further, more systematized
and coordinated action and consensus:
First, the just published LYSA Registry data from the French
Cancer Agency [reported at ASCO 2018] has shed some further light on two prognostically distinct
classes of BIA-ALCLs (based on effusion, breast tumor mass, and lymph node
involvement), with in situ BIA-ALCLs exhibiting an indolent clinical
course that enables complete remission typically after implant removal, in
contrast to infiltrative BIA-ALCLs exhibiting a more aggressive clinical
course, with in fact a prognosis virtually identical to systemic anaplastic
large cell lymphoma (ALCL), despite real differences. Further clarification was
provided in AU-NZ studies [especially Loch-Wilkinson,
Plast Reconstr Surg. 2017 Oct], higher-surface-area (HAS)
textured implants significantly increased the risk of BIA-ALCL (over 14 times
higher with Biocell textured implants and almost 11 times higher with
polyurethane (Silimed) textured implants compared with Siltex textured
implants, so there clearly is a risk hierarchy at play here.
Second, being mindful of overtreatment (always a concern),
nonetheless given that BIA-ALCL related death, although rare, is predominantly
due to uncontrolled local disease progression, there is a role in patients with
more advanced local disease – particularly in the minority of patients whose
disease extends beyond the capsule – for chemotherapeutic intervention, and at
this time the best evidenced first-line therapy apart from the strongly toxic
CHOP family of regimens is the monoclonal antibody brentuximab vedotin
(Adcetris) based on its role in refractory in ALCL, despite the limited but
still positive data of its off-label use in BIA-ALCL; and I have seen some
cases of patients progressing on CHOP therapy but achieving pathological
complete response (pCR) with brentuximab vedotin in the second line. Given its
comparatively favorable side effect profile and higher tolerability over
traditional chemotherapies, it retains some considerable appeal.
Third, for myself, given that:
(1) the NF-kB) pathway is commonly deregulated in lymphomas, and
that
(2) curcumin can inhibit growth of these cell lines and increase
their chemosensitivity to cisplatin, and given also that
(3) it (curcumin) increases apoptosis and differentiation of
vitamin D-treated tumor cells, with direct binding of curcumin to the vitamin D
receptor (VDR), and that
(4) curcumin modulates the well-known overexpression of EZH2 in
anaplastic lymphomas and can down-regulate the JAK/STAT pathway that is
also incriminated in BIA-ALCL, then I have (strictly ad hoc-ly and off-label) counseled the
deployment, with provisional but promising success, of a regimen of
high-penetrance curcuminoids (either phytosomal or nanoparticulate) and
optimal-dosed Vitamin D3 (achieving 25(OH)D assay levels of at least 66
ng/ml and above), in the small number of BIA-ALCL cases I have consulted on,
but clearly this requires validation in clinical trial. And Mark Clemens'
recent findings suggesting that some BIA-ALCL are associated with a chronic
allergic immune response to currently undetermined antigen(s) - with IL-13
activity (associated with allergic inflammation) as well as eosinophils and
mast cells surrounding the BIA-ALCL tumors plus the presence of IgE – is
tantalizing in this connection of anti-inflammatory interventions.
Going Forward, Work Still To Do:
1.I am also looking to press
for the expansion of the European Commission Medical Device Expert Group
(VMDEC) Task Force with respect to collection and analysis of EU-based BIA-ALCL
cases, but VMDEC registry data must be coordinated with other non-EU entities –
like the PROFILE Registry maintained by the The Plastic Surgery Foundation here
in the States, the Australian Breast Device Registry, among many others –
if we are to establish a larger and more comprehensive cross-boundary collaborative
BIA-ALCL surveillance initiatives to advance our knowledge and better serve the
many women affected (and often overlooked and sometimes misdiagnosed as Hodgkin
lymphoma or other entities).
2.It is disconcerting that we
still, even in 2018, lack consistent standardization and reporting regarding
pathological examination of mammary implants (most institutions often continue
to recommend gross examination alone).
3.Furthermore, we are not
doing enough to educate patients and their health professionals on the
importance of routine surveillance after implantation.
4.And we must finally – long
overdue -bring explicit consent issues to the fore to assure fairness to
patients. It would appear that most breast-focused plastic surgeons in the U.S.
and the UK fail to consistently include risk of BIA-ALCL and that uniform
informed-consent documents lack widespread adoption and use, so a model
BIA-ALCL informed consent is required and effective efforts made to assure that
the patient is not simply “allowed” to read and decipher the information as it
is found in the informed consent agreement as is all too commonly the case, but
that health professionals first openly and candidly discuss not only the risk
of BIA-ALCL but also the common presenting symptoms (a mass, breast
swelling/pain, or delayed-presentation seroma / effusion) of BIA-ALCL the
patient should be on guard for which would trigger a mandated evaluation. I
call this the need for “informed discussion” in addition to mere “informed
consent”, and that need was best put by the UK High Court (Judgement in
Montgomery ‘v’ Lanarkshire Health Board) that stated that “risk shouldn't be
a numbers game, it should be part of dialogue”.
Director, Medical Research, No Surrender Breast Cancer Foundation
(NSBCF)
Oncology Reviewer, Current Oncology
Member, Society for Integrative Oncology (SIO)
European Association for Cancer Research (EACR)
Disclaimer & Copyright Notice: The materials provided on this website/web-based article are copyrighted and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and Bard Diagnostic Research & Educational Programs). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers. Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately. This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.
