In the wake of Angelina Jolie’s disclosure that she had a preventive double mastectomy after discovering she has the BRCA1 gene mutation, many women are asking if they should get genetic testing for BRCA.  As a genetic counselor and educator, I’m glad that Jolie is bringing attention to this issue.  However only a small percentage of women have a BRCA1 or 2 mutation, so genetic testing is not right for everyone.  Of all breast cancers, only about 5% are due to a BRCA1 or 2 mutation, while about 15% of ovarian cancers are related to mutations in one of these genes. Family history is the key to knowing if a woman would benefit from seeing a cancer genetic counselor.

Family history features which suggest you should consider cancer genetic counseling – both your mother’s and father’s relatives count:

• multiple cases of breast and/or ovarian cancer
• breast cancer diagnosed under 50
• cancer in both breasts
• both breast and ovarian cancer in the same person
• male breast cancer
• Ashkenazi (Eastern European) Jewish ancestry

As part of the genetic counseling process, the counselor will review the details of your family to assess the chance you may have a BRCA 1 or 2 mutation, as well as discuss the benefits, limitations, and implications of genetic testing. Genetic testing provides the most information for a family if someone with cancer is the first person tested.  If a BRCA mutation is found, for example, in a mother with early breast cancer, we know that each of her children and siblings have a 50% risk to have also inherited the mutation.  Those in the family who test negative for the identified BRCA mutation are then considered to have the same risk for breast and ovarian cancer as women in the general population – and, their children are not at risk.

For women who are found to have a BRCA1 or 2 mutation, the risks for breast and ovarian cancer are greatly increased over that of the general population.  While the average woman’s lifetime risk to develop breast cancer is about 12%, the risk for a woman with a BRCA1 or 2 mutation ranges from 50-87%.  Similarly, the general population lifetime risk for ovarian cancer is less than 2%, while it ranges from 40-60% for women with a BRCA gene mutation.  These increased risks are why knowing that one has a mutation is so important – because increased screening and prevention strategies can dramatically reduce the chances of cancer, and save lives.

An important part of the cancer genetic counseling process involves helping women understand their medical management choices if they are found to carry a BRCA1 or BRCA2 mutation. Having all the information is a crucial step in the process of making a decision to get a double mastectomy or consider other options.  Your decision should take into consideration both medical and emotional concerns and be individual to your personal situation.  Many times, a woman who lost her mother or sister to breast cancer will feel differently than a woman who has a close relative who is a cancer survivor. There are alternatives to double mastectomy to consider, such as surveillance, risk avoidance and chemoprevention. Involving a medical team that includes breast surgeons, oncologists, radiologists, and gynecologists along with genetic service providers can help women determine the best approach for them.

Surveillance for breast cancer for women with a BRCA1 or 2 mutation is different than that offered to women at average risk.  It involves both breast MRI and screening mammography, starting typically by age 25.  Breast MRI has been shown to be much better at detecting breast cancer in young women, and in BRCA mutation carriers.  Screening for ovarian cancer is unfortunately not very effective.  The CA-125 blood tests and trans-vaginal ultrasounds are offered, but often fail to detect ovarian cancer in its early, curable stages.  This is why preventive removal of the ovaries and fallopian tubes is strongly recommended for women who have a BRCA1 or 2 mutation.  Preventive removal of the ovaries and fallopian tubes is highly effective at substantially reducing the risk not only for ovarian cancer, but also breast cancer.

Chemoprevention is also sometimes used to reduce the risk for developing cancers.   Tamoxifen may reduce the risk of breast cancer in women who carry a BRCA2 mutation, though its effect with BRCA1 is less certain.  Oral contraceptives use can reduce the risk for ovarian cancer by up to 50%.

There are benefits, risks and limitations to all options, but with the help of a genetic counselor working in partnership with surgeons, oncologists and others involved in cancer care and prevention, you will have the information to make the best possible decision for you and your family.

About Dr. Bellcross

Cecelia Bellcross, PhD, MS, CGC Dr. Bellcross is an assistant professor with the Emory University School of Medicine Department of Human Genetics, and the Director of the Emory Genetic Counseling Training Program.  She is an ABGC board-certified (1993) genetic counselor with over 20 years of experience. She received her master’s degree in medical genetics through the University of Wisconsin-Madison Genetic Counseling Training Program in 1990, and her PhD in Population Health Sciences from U.W.-Madison in 2007. She practiced 18 years as a clinical genetic counselor specializing in cancer genetics and supervised students from the University of Wisconsin-Madison for over 10 years. Dr. Bellcross has a background in education, and recently completed a two-year ASHG fellowship in Public Health Genomics at the Centers for Disease Control and Prevention. Her areas of research interest and expertise include screening for hereditary cancers and public health genomics. She joined the faculty of Emory University in 2010 to develop and direct the new Genetic Counseling Training Program.

Related Resources:

Some helpful tips to examine your moles:

• Examine your skin after a shower, in good light, in front of a mirror without your clothes on.
• Make sure to do a thorough, full body inspection. Start with your toes or your face and work your way over every surface of your body. Be sure to also check your scalp, underarms and genitals, parts that could be covered with hair.
• Look for moles or skin markings that you haven’t noticed before, or areas that have changed in appearance since your last exam. Pay special attention to lesions that bleed or don’t heal.
• Photos taken over a period of time can be helpful in determining whether a skin marking has changed.
• Follow the ABC method for examining suspicious markings:
  • A = Asymmetry – do both sides of the mole match? If one side does not match the other, it could indicate melanoma.
  • B= Border – If the border has jagged or irregular edges, see your physician right away.
  • C = Color – Black, red, white and multi-colored moles should be seen by a professional right away. Tan and brown moles are usually ok, but make sure to watch for changes to these moles as well.
• Diameter – Usually moles should be smaller than the end of a pen.
• Elevation – moles should be flush with the skin around the mole. If you notice a mole is raised, visit your physician right away.
• Do what you can to prevent skin cancer. Some ideas:
• Wear sunscreen in the sun, in all seasons!
• Wear a hat and sunglasses
• Avoid tanning salons
• Try to stay out of the sun between 10am and 3pm

Take action today to protect yourself and your family members!

Chat with Dr. Delman about Skin Cancer:

Join Winship Cancer Institute of Emory University physician Keith Delman, MD at noon on Wednesday, May 29, 2013 for an online web chat on melanoma and other skin cancers. He will talk about skin cancer prevention and answer questions such as:

-What are signs of melanoma and skin cancer?
-How is melanoma or skin cancer treated?
-What is the latest research on treating these cancers?

Join us for an informative session that could save your life. Register by visiting emoryhealthcare.org/mdchats.

About Margi  McKellar, MS, PA  Emory Winship Cancer Institute’s Melanoma Coordinator

Margi plays a unique role for the team as our Melanoma Coordinator. In this position, she serves as the point of contact for referring physicians and the patients and guides  them from the point of  their initial referral through long-term follow up. She helps our patients use their time efficiently, analyzing patient flow, appointment availability, clinical trial eligibility and ensures that patients see the correct complement of specialist to receive optimal care – medical oncology, surgical oncology, radiation oncology, lymphedema specialists. Margi actively interfaces with our clinical trial nurses to ensure patients have the opportunity to be considered for clinical trials while facilitating prompt screening for these programs. In addition to coordinating the care of patients, she also sees patients in our long-term follow up clinics.

Related Resources:

• Top 5 Skin Protection & Skin Cancer Prevention Tips
• Skin Cancer Prevention: Which Sunscreen is Best?
• Dermatologist #1 Skin Cancer Prevention Tip: Wear Sunscreen!
• Indoor Tanning Beds: The Bad, The Ugly, & The Uglier

A new era in cancer treatment in Georgia recently began as Emory Healthcare and Winship Cancer Institute broke ground on the first facility in Georgia to offer the most advanced radiation therapy possible – proton beam therapy.

Proton therapy is the next generation of radiation oncology. It uses protons to precisely treat cancerous tumors and minimize radiation to the healthy tissue surrounding the tumor. For certain cancers, and for pediatric cancer patients, it may provide more effective treatment with fewer side effects. This innovative therapy is offered at fewer than a dozen centers in the United States but is available in other countries and more than 110,000 people worldwide have received this FDA-approved therapy.  The Emory facility is being built in partnership with Advanced Particle Therapy, LLC of San Diego, CA.

Proton therapy may be most beneficial for patients with cancerous our benign tumors in certain anatomic areas, including  the brain, prostate, liver, esophagus, head and neck and the base-of-skull.  It’s also  beneficial for treating children because of the risk to growth and developmental from conventional radiation.  Studies in children have shown that proton therapy minimizes damage to healthy tissues and produces fewer side effects.

The Emory Proton Therapy Center will enable Winship researchers  to continue studying the benefits of proton therapy, with the goal of producing better outcomes for our patients.  At Winship we constantly seek out the most effective treatment available, and for many of our patients, proton therapy is that treatment.

As Georgia’s only National Cancer Institute designated cancer center, Winship is committed to cancer research projects which improve our patients’ lives.

About Dr. Curran

Walter J. Curran, Jr. was appointed Executive Director of the Winship Cancer Institute of Emory University in September 2009. He joined Emory in January 2008, as the Lawrence W. Davis Professor and Chair of Radiation Oncology and Chief Medical Officer of the Winship Cancer Institute.

To prepare yourself and your family for the summer and protect yourself from any form of skin cancer, join Winship Cancer Institute of Emory University physician, Keith Delman, MD, Wednesday, May 29th for an online web chat at 12 noon.

Dr. Delman will be able to answer questions such as:

• How to prevent melanoma and skin cancer
• What causes skin cancer and melanoma
• Signs of melanoma and skin cancer
• Treatment options for melanoma and skin cancer
• The latest research on the horizon

Spread the word and sign up today by visiting emoryhealthcare.org/mdchats!

About Keith Delman, MD

Dr. Delman is a Surgical Oncologist at Winship Cancer Institute of Emory University.  His research interests include experimental treatment of melanoma and clinical trials and protocol-based treatment of melanoma and sarcoma.

Dr. Delman earned his Medical Degree from Stony Brook School of Medicine, State University of New York. He then went on to complete his Internship and Junior Residency in the Categorical General Surgery Program at the Albert Einstein College of Medicine of Yeshiva University. He followed this with a Research Fellowship at the Hepatobiliary Oncology Laboratory at the Memorial Sloan-Kettering Cancer Center. He completed his Senior Residency at the Categorical General Surgery Program at the Albert Einstein College of Medicine. He conducted his Surgical Oncology Fellowship at the University of Texas MD Anderson Cancer Center.

Related Events:

Winship Cancer Institute of Emory University will be performing visual skin cancer screenings on Friday, May 10 at the Atlanta Buckhead YMCA from 8:30 a.m. – 10:00 a.m. Screenings will be provided by Winship Survivorship team members, Joan Giblin, FNP and Margi McKellar, PA.

The American Cancer Society will provide additional resources for prevention.

Carl E. Sanders Family YMCA
1160 Moores Mill Rd
Atlanta, GA 30327
(404) 350-9292

Related Resources:

• Skin Cancer Chat Sign Up

When news of the boost in survivor numbers made headlines, CNN Newsroom anchor Brooke Baldwin brought Emory surgical oncologist Charles Staley, MD on set to interview him as both a cancer doctor, and a cancer survivor. Watch the full interview below:

As more people are living longer after a cancer diagnosis it is very important to educate survivors on the after effects, long term effects, nutrition, and fitness following cancer care. Winship Cancer Institute at Emory University has a Survivorship program to help patients get back to life after surviving cancer. Get more information about the survivorship program.

Over the course of the next few months we will highlight many different areas of survivorship on the Winship blog so make sure to follow us to get more detailed information on living after cancer.

About Dr. Charles Staley

Dr. Staley is the Chief of Surgical Oncology for Emory University Hospital and Chief Medical Officer for Winship Cancer Institute of Emory University. Dr. Staley specializes in treating cancers of the esophagus, pancreas, stomach, liver, small bowel and rectum. He has investigated gene therapy for metastatic colon cancer and radiofrequency ablation with intra-arterial chemotherapy for patients with colorectal liver metastases. Currently, he and his colleagues are exploring methods of using nanotechnology to treat and diagnose pancreatic and breast cancer. He joined Emory University School of Medicine faculty in 1995 after a surgical fellowship at MD Anderson Cancer Center in Houston. Dr. Staley earned his medical degree at Dartmouth University School of Medicine and conducted his residency at the University of Pittsburgh’s University Health Center. Dr. Staley is an active member of the American Society of Clinical Oncology, The Georgia Surgical Society, and the Society of Surgical Oncology.

Related Resources:

• Survivorship Program at Emory
• Winship Cancer Institute
• Cancer Survivorship Resources
• Cancer Survivors Network

Few experiences in life match the feeling patients and family members have when they complete acute treatment for cancer and begin their road to survivorship. Some patients move on quickly and experience no further challenges associated with cancer, but others experience “after effects,” or long-term or late effects. Cancer survivors, and their families, should be aware of these potential after effects so they can prepare themselves to deal with them as they get back to a more normal life.

After affects can range from mild to severe and vary from survivor to survivor.

• Long–term effects of cancer develop during cancer treatment and may not go away.  Some long-term effects can improve such as anemia, fatigue or anxiety.  Some potentially permanent long-term effects are limb loss, weakness or nerve damage.
• Late effects are delayed effects of cancer treatment and they can surface months to years after treatment.  Some late effects of cancer treatment are heart disease, lung disease, lymphedema, osteoporosis, depression and secondary cancers.

After effects are categorized into physical, emotional and practical after effects.

Physical after effects include:

Neuroendocrine tumors develop in the cells of the neuroendocrine system, a network of glands throughout the body that produce hormones. Neuroendocrine tumors are rare, typically affecting 1 – 2 people per 100,000 people.

The different types of neuroendocrine tumors depend on the particular cells that are affected.  They usually develop in the digestive system and the lungs.  Approximately 38% of tumors are in the appendix, 23% in the ileum (also known as carcinoids), 13% in the rectum and 11.5% in the bronchi.

Symptoms of Neuroendocrine tumors

Neuroendocrine tumors may be slow growing (low grade or well differentiated) or rapidly growing (high grade or poorly differentiated).  They may be functional (release hormones) or nonfunctional.  When functional neuroendocrine tumors release a variety of hormones including a hormone called serotonin, a condition called carcinoid syndrome may occur. Symptoms most commonly associated with neuroendocrine tumors include flushing, diarrhea, weight loss, abdominal pain and cramping.   Patients with carcinoid syndrome may also experience cardiac changes, which are caused from fibrotic damage to the heart.  Usually a patient with carcinoid syndrome does not experience these symptoms until the tumor has spread within the body.

Other terms used for neuroendocrine tumors include
• Gastroenteropancreatic neuroendocrine tumors – tumors in the gut or pancreas
• Pancreatic neuroendocrine tumors – also known as islet cell cancer, or PNET
• Gastrointestinal neuroendocrine tumors – tumors that develop in the bowel, stomach or esophagus
• Pheochromocytoma of the adrenal gland
• Carcinoid tumors of the lung or intestinal tract
• Carcinoid Syndrome
• Gastrinoma, Insulinoma, Glucagonoma, VIPoma (vasoactive intestinal peptide tumor)

Treatment of neuroendocrine tumors

Treating neuroendocrine tumors can be a challenge due to the various types, locations in the body, the symptoms they produce and the diverse number of treatment modalities. Treatment is individualized to  each patient but can include surgery, liver directed therapy, medications, and/or radiation.

When treating a rare, challenging cancer such as neuroendocrine cancer, it is important to have a team of healthcare professionals at your side who are experts in the  disease and can collaborate to create a treatment plan individualized to each patient.

At Winship Cancer Institute of Emory University, we take this multidisciplinary approach with teams of  expert medical oncologists, surgical oncologists, interventional oncologists, gastroenterologists, pulmonologists, endocrinologists, nurses, and dieticians ( just to name a few) to create a care plan unique to each patient.

About Bonnie Josaphs, RN, BSN, OCN

Ms. Josaphs received her Bachelor of Science in Nursing from the University of Delaware, Newark, Delaware in 2002. She has been practicing within Gastrointestinal (GI) Oncology since 2004.  She specializes in gastrointestinal cancers which include cancers of the esophagus, liver, colon, rectum, pancreas, gallbladder and stomach.

Related Links

Dr. Fadlo R. Khuri, surrounded by colleagues at Winship Cancer Institute, including institute executive director Dr. Walter J. Curran Jr., who stands to Khuri’s immediate right.

Winship Cancer Institute of Emory University deputy director, Fadlo R. Khuri, MD, one of the world’s leading experts in lung and other aerodigestive cancers, will be awarded the Richard and Hinda Rosenthal Memorial Award from the American Association for Cancer Research. The Rosenthal Award is given each year to an investigator under the age of 50 whose contributions to cancer research have led to new understandings of cancer and show promise for even greater advances in the future.

The award recognizes Dr. Khuri’s outstanding contributions and accomplishments as an investigator in lung and aerodigestive medical oncology, especially in the area of prevention and treatment of lung and head and neck cancers. He will receive the award April 10 at the AACR’s annual meeting in Washington, D.C.

Walter J. Curran, Jr., MD, executive director of Winship Cancer Institute, nominated Khuri for this award and said that the honor is not a surprise to those who know his work.

“Fadlo’s leadership in lung and head and neck cancer research is legendary, and he has helped advance our understanding of the nation’s number one cancer killer by introducing novel therapeutic agents that have changed how people live with this disease,” said Curran.

Khuri was instrumental in obtaining the National Cancer Institute (NCI) designation to Winship Cancer Institute in 2009. He holds the Roberto C. Goizueta Chair in translational research at Emory University School of Medicine and is also the Editor-in-chief of Cancer.

Dr. Khuri’s achievement illustrates one of many ways Winship Cancer Institute is helping patients win the fight against cancer. Congratulations, Dr. Khuri!

Related Resources:

• Full Press Release on Dr. Khuri’s receipt of the  Richard and Hinda Rosenthal Memorial Award from the American Association for Cancer Research
• Winship Cancer Institute Website

March is national colorectal cancer awareness month.  Take control of your destiny, and schedule your regular screening today!  It could save your life.

For more information on all the topics we discussed in the chat, please review the chat transcript.

Contact us for more information about our colorectal cancer treatment programs: 404-778-1900 or request an appointment online.

About Bassel El-Rayes

Dr. El- Rayes is an Associate Professor of Medicine at Emory University School of Medicine, the Director of the GI Oncology Translational Research Program and the Associate Cancer Center Director for Clinical Research at Winship Cancer Institute of Emory University.

Dr. El-Rayes completed medical school at the American University of Beirut (AUB). He subsequently joined the internal medicine residency program at Wayne State University. After completing the residency, he joined the hematology oncology fellowship program at the Karmanos Cancer Institute, Wayne State University. He then joined the faculty as an Assistant Professor in the area of GI oncology. During this time, he was involved in translational research focused on pancreatic cancer. Dr. El-Rayes joined Emory University in September 2009 as the director of the GI Oncology program. He is designated as a Distinguished Cancer Scholar by the Georgia Cancer Coalition.

Related links

• Blog – An Intro to Colorectal Cancer Part I: Risk Factors, Symptoms & Diagnosis
• Blog – An Intro to Colorectal Cancer Park II: Prevention, Diagnosis & Treatment
• Website – Winship Cancer Institute of Emory University colon cancer web

A significant proportion of women with breast cancer have one or more risk factors for heart disease at the time of breast cancer diagnosis that further increase the risk of cardiotoxicity, including smoking, obesity, lack of activity and high cholesterol. Additionally, if a woman had radiation therapy on the area of body that includes the heart, there may be an increased risk of cardiomyopathy, coronary artery disease and heart attack. The combination of radiation and chemotherapy can further increase a woman’s risk of heart damage. Thus, after second malignancies, heart disease is the leading cause of long-term morbidity and mortality among breast cancer survivors.

If you are a survivor of breast cancer, take control of your heart and breast health by following some simple guidelines:

• Maintain a healthy weight
• Avoid smoking
• Limit alcohol intake
• Manage stress!  - Stress can shut down your immune system, making it harder for you to fight off disease. It also can prevent the body from healing, which can put you at greater risk for heart disease.
• Exercise! Get at least 30 minutes of physical activity 3 times a week.
• Monitor and manage diabetes.
• Eat healthy! Your diet should be low in fat and include generous amounts of fruits and vegetables.
• Actively monitor your blood pressure and cholesterol levels. Work with your physician to reduce your blood pressure and cholesterol if they are high.
• Get rest. Most people need 7 to 8 hours of sleep at night to heal and keep the immune system healthy.

Importantly, if you have received chemotherapy or radiation for breast cancer, it may be useful to follow up with a preventive cardiologist on a regular basis. If you experience significant problems such as shortness of breath or chest pain, report it immediately to your health care providers.

About Dr. Parashar

Susmita Parashar, MD, MPH, MS is a Board certified cardiologist at the Emory Heart and Vascular Center and Assistant Professor of Medicine (Cardiology) at Emory University School of Medicine. Prior to joining the Division of Cardiology, Dr. Parashar was Assistant Professor of Medicine in the Division of General Medicine at Emory for 8 years. She applies her experience as a Board certified internist in providing a holistic care to patients.

She has received several grants and awards from the National Institutes of Health (NIH) and the American Heart Association to conduct research on women and heart disease. She has served as Emory principal investigator for large NIH – funded clinical research for heart attack patients. She was also invited to participate as a co-investigator for the NIH- fnded Cardiovascular Health Study for older adults.

Related Resources:

• Women & Heart Disease
• Videos: Understanding Women & Heart Disease
• Breast Cancer Information from the Winship Cancer Institute