You are misinformed. Actually, most patients receive treatment in the following order: Surgery, chemotherapy (if indicated), radiation therapy (if indicated), and hormonal therapy (if indicated). All patients have to sign informed consent before receiving any treatment at all, so they should be well aware of the risks. Also, patients receiving anthracyclines and/or Herceptin are generally monitored with a heart scan called a MUGA which shows heart function. If there is a drop in the ejection fraction (how well the heart pumps the blood through the left ventricle), then they are taken off the drugs.

Any cancer treatment has risk associated with it. I have worked in oncology for over 30 years, and I don't know of any physicians who are not "forthcoming" about the risks.

My regimen was chemo first (to shrink tumor), then surgery followed up by radiation. That was 9 years ago. So far, so good.

radiation therapy is known to damage the pericardium

umm..kind of, but irrelevant to this paper. Firstly, radiation induced injury usually appears a decade or so after the fact

But more importantly, reduced heart function secondary to pericardial disease causing pericardial constriction is pretty obvious on echo or cath or even CT, and can be distinguished from a myocardial process, which is what this article is discussing

Furthermore, the treatment for constrictive pericarditis is often anti-inflammatory meds or pericardectomy, which can often result in resolution of the problem

I think it depends what type of cancer, stage, grade etc. I have a good friend that was treated for Breast cancer a few years ago. She had lumpectomy, chemo, then radiation.

A deficiency of the mineral selenium is the primary reason for breast cancer (and most other cancers as well) and also just happens to be a primary heart protectant. Breast cancer indicates a greater deficiency of selenium than normal so since selenium deficiency is not addressed by oncologists (due to willful ignorance) then greater heart disease naturally follows. Selenium has been documented in medical journals as an effective treatment for breast cancer going back almost 100 years. 'SELENIUM: One Cancer Answer ... 100 years and counting' is a book that provides details. Currently I have personal knowledge of terminal cancers of breast, prostate and two with ovarian documented as cancer free by medical reports with targeted selenium therapy as well as non-terminal colon, prostate, and lymphoma.

I have taken these drugs with the exception of herceptin, I signed a form stating I understood the possible long term damage of the chemo, at the time when you are looking at stage 3 breast and lymph node cancer you are going to save your life now. My docs were very thorough and did an echo before and after treatment. The chest port goes directly to the heart so you've got to think the heart may be affected but I would do the same over again, I'll deal with whatever may or may not come later but I know I am spending quality time with my grandchildren now because of chemo. I am about 20 years younger than the women in the study but am still aware of the risks.

Deb P - I'm glad to hear oncologists are more forthcoming than doctors in certain other fields. However, I doubt that true informed consent is the rule. A boilerplate list of possible complications, followed rapidly with "But the important thing is that it could SAVE your LIFE!", does not suffice. Informed consent would require the provision of absolute numbers related to risk as well as benefit, and a mention of any published studies that would be likely to cause the patient to think twice if she knew about them. For example, oncologists would have to explicitly tell most patients who had DCIS or Stage 1 cancer, especially those who were over 75, that studies suggested that doing chemo and radiation could be more likely to cause them to die of heart failure than to save them from dying of breast cancer.

citation?

And the third but possibly greatest threat to women is outliving their savings. With an average life span that is five years longer than a male born in the same year, let's focus on spending more money on women's health.

Eric - Hello again! This study reports that for women over 75, as many as 40% ended up with heart failure within a finite follow-up period, and half of those might die of it. I saw just recently a study to the effect that women over 75 with early stage breast cancer were unlikely to die of it - less than 10% chance - no matter how conservatively they were treated. Simple math says that more will be harmed than helped by aggressively treating elderly women. The same is almost certainly true for younger women with most types of early cancer. I have seen other clinical trials reporting that adding chemo and radiation to surgery for early breast cancer reduces the long-term risk of cancer death from 6-8% to 3-4% - in other words, as few as 3 or 4% may benefit. I don't have time to spend hours on PubMed today, so am not going to do the work that you, as a practicing paid oncologist, should already have done by locating these papers in the literature and reading them. Just please be aware that if you bully a woman into drug treatment without telling her what research has to say about her odds of various outcomes with and without it, you may be liable in court for failure to obtain informed consent. Irreversible heart failure in a middle-aged woman with health insurance could have significant consequences for lifetime earnings.

This study

which study?

Id like to see it because before you extrapolate the results to all similiar women, we need to make sure its a fairly robust study with a large number of patients

s many as 40% ended up with heart failure

I also don't believe a 40% rate of heart failure. Thats awful high and many times the current observed rate--how are they defining heart failure?

I saw just recently a study to the effect that women over 75 with early stage breast cancer were unlikely to die of it - less than 10% chance - no matter how conservatively they were treated.

For that old maybe as they are likely to die of something else first. But you have to individualize the patient in front of you. Ive seen many 75 year olds that easily have 15+ more years to live. You really have to be careful extrapolating study results from sickly 75 year olds to that kind of patient

The same is almost certainly true for younger women with most types of early cancer

Thats a leap in logic right there. Sure, a 75 year old lady may die of something else before she dies from early stage lung cancer

But how can you say that about a young lady with no other comorbidities? Not only is that illogical, but Id like to see evidence supporting that

Very, very questionable logic there

in other words, as few as 3 or 4% may benefit

Or, out of the ones that were going to die, you have just saved 50% of them. I would love to know which ones those are before treatment is started, but we are nowhere near that yet. So tell people that and give them the choice

as a practicing paid oncologist

Im not an oncologist, remember?

so am not going to do the work t

typically if someone makes a claim, its their job to support it with evidence. Thats just the way things are done. Plus I don't know the studies you are referring to. Presumbly, you do. Shall I hunt for study after study that may or may not be the one you referenced?

No.

ust please be aware

a)common sense

b) i don't need to hear it from some random person on the internet who is still in school to know that

Dr. Eric - I must apologize for having confused you with another MD who frequents the MSNBC boards. I didn't expect to find a cardiologist commenting on a cancer story, and certainly not dismissing numerous cases of heart failure as unimportant. (Well, it does make sense from a certain perspective, I'm sorry to say.) But your last sentence reminded me of who you are - the guy who imagines that it must be devastating if you pretend to know that I am lying about having a PhD in a field that's unrelated to medicine. Oh yes, hello again. Cute!

From a practicing allopath of any stripe, your reading comprehension makes me shudder. "Which study?" Er, the one that this story was about. You "don't believe" the 40% rate of heart failure in elderly patients because it's "many times the observed rate"? Well, in this study that WAS the observed rate. In a real-world setting, within 5 years over 40% of the elderly who got chemo developed heart failure, versus 13.7% of those who did not. (The point estimate is therefore about 26% of patients over 75 given heart failure by the drugs, or a Number Needed to Harm of 4.) Heart failure was defined by the criteria used by the women's practicing physicians, since diagnoses were extracted from medical records - as the article told us. Do you wish to suggest that the study authors falsified data regarding those medical records? If you have reason to believe this, you need to contact the Journal of the National Cancer Institute ASAP. Or would you suggest that the many different doctors these women saw were, as a group, so likely to inflict incorrect cardiac diagnoses on women with a history of chemo that one in four elderly women were falsely labeled? I have seen enough malpractice from cardiologists to distrust the profession reflexively, yet I do not believe that such an explanation would be plausible.

Your comment about "saving 50% of" "the ones who were going to die" serves as an object lesson in why absolute, rather than relative, numbers must be demanded of all doctors by all patients. If all the doctor says is "50% reduced death risk", patients may hear "There's a 50% chance that chemo will save my life," when for large groups of patients (the elderly, most women with stage 1 cancer or DCIS) the real chance is roughly an order of magnitude less. Even if you assumed that the elderly patients in this study placed no value on avoiding disability or maximizing the quality of their remaining life, it's likely that more of them will end up actually dying of chemo than being saved by it, in which case chemo at best alters the distribution of causes of death rather than actually saving net lives. This also illustrates why total death rates rather than disease-specific death rates should be asked about when the treatment for a disease is highly toxic.

im not going to respond because you clearly cannot behave in an adult manner, and instead, as per usual, resort to your typical childish immature insults and obnoxius behavior

If you decide to act as an adult, I'll be happy to continue our discussions

to heck with it, I can't resist letting your mistakes go uncorrected...

and certainly not dismissing numerous cases of heart failure as unimportant

Now Jane, you shouldn't have to resort to lies to bolster your argument. Please quote where I said heart failure was unimportant. In fact, I have dedicated a good portion of my life, money, and effort into treating heart failure which is more than you have ever done. Commenting on a message board counts very little, unfortunately.

Cute!

Typical obnoxious behavior from you. The funny thing is you wear it like a badge of honor...

our reading comprehension makes me shudder. "Which study?" Er, the one that this story was about. You "don't believe" the 40% rate of heart failure in elderly patients because it's "many times the observed rate"? Well, in this study that WAS the observed rate. In a real-world setting, within 5 years over 40% of the elderly who got chemo developed heart failure, versus 13.7% of those who did not

Oh boy. This is going to teach you to be condescending. Your mistake here was substituting your own judgement, that of an alleged PhD candidate, for some journalist on a website.

Nothing is wrong with my reading comprehension. I read that 40% number and didn't believe it. But unlike you, I use my brain and decided to look at the primary source, the actual article. In it, it is clearly stated that the 40% is a RELATIVE risk not "over 40% of the elderly who got chemo developed heart failure" as you claim (an absolute risk).

You can't seriously believe a rate of 40%?? Do you have any common sense? That drug would be yanked from the market so quick it would make you dizzy

Dont you feel the least bit embarrased or foolish? You should...

http://www.nlm.nih.gov/medlineplus/news/fullstory_128800.html

erves as an object lesson in why absolute, rather than relative, numbers must be demanded

Actually, the lesson here is, as shown above, you don't know the difference between relative risk and absolute risk. But on a larger note, your other mistake is relying too much on mortality data collected during a trial. You must remember that this represents only the mortality seen during the trial, not the mortality of the disease

So when you calculate absolute risk based off of these numbers, it is only good for 5 years. You need to realize that mortality WILL increase after the study period.

If you show the study, I will show your errors.

one more thing...you know how many patients were included in the >75 year old females that had supposed 40% CHF rate? Two. Not two thousand, not two hundred. Two people. Literally, one got heart failure and one did not.

Seriously. You want to alter treatment for tens of thousands of women because one got heart failure in this study.

Really? And you call yourself a PhD candidate?

here's more reasons why you should read the fine print...

we could not use LVEF findings in our HF/CM definition

So they didn't use echo in their diagnosis of heart failure....really???? Are you kidding me??? Who can even trust their results without an echo? No one on earth diagnosis heart failure without some supporting evidence from echo (systolic dysfunction or diastolic dysfunction at least)

Again, 2 patients, without an echo. Even if the 40% is an absolute risk (which it may be for just those 2 patients), these results are not generalizable

Come on...

I don't know where Dr. Eric gets this "two patients" bit, but it's totally false. The study looked at medical records of 12,500 women broken down according to four age categories and four different types of chemotherapy regimens (versus "none"). By far the most toxic to the heart was the combination of anthracycline and trastuzumab, which was used by only 3.5% of the women (442 total), less than any other regimen except trastuzumab alone. Anthracycline was less used, either alone or in combination, in older patients, so the numbers in the upper age brackets of the combination group were the smallest of all (38 women in the 65-74-year-old bracket, 8 in the over-75 bracket). Those smallest groups are, indeed, the subgroups that had the highest risks of heart failure (adjusted 5-year cumulative incidence of 40.7% in the oldest, and 35.6% in the 65-74-year-old group) that were touted in the article. Therefore there are admittedly wide confidence intervals around these figures, though they were statistically significant.

However, no subgroup had only two women in it. Dr. Eric has misrepresented the literature before, perhaps assuming that patients can't check it for themselves. However, this study can be obtained from the journal's website for free; you should be able to Google it. Dr. Eric also claims that that 40% risk in that subgroup is a relative risk. This too is false. I have noted in the past that he - like many MDs, so in this case I intend no particular slam at him - seems to be confused about certain mathematical and logical issues relating to clinical trials. Cumulative incidence, not otherwise qualified, is by definition an absolute number; if 10 of 100 are affected by a condition, that's 10% "relative" only to the 100%.

It is true that other chemo regimens had much lower cardiac toxicity than the extreme numbers this story quoted for the combo regimen. After statistical adjustments to correct for age, radiation, etc., for the entire group the 5-year adjusted cumulative incidence of heart failure was 3.1% in those who had no chemo, 4.3% in those who had anthracycline alone, 4.5% in those who had other types of chemo, 12.1% in those very few who had trastuzumab alone, and 20.1% in those who had the combo. The overall adjusted relative risk was only 40% higher for anthracycline alone compared to no chemo, and 49% for other drugs, versus quadrupled for trastuzumab alone, and over 7 times higher for the combo. However, the authors note that heart failure caused by anthracycline is permanent, while that caused by trastuzumab may not always be.

It is also true that cumulative incidence of heart failure was much lower in younger women. However, since younger women are far less likely to develop heart failure naturally, the relative risk of the more toxic regimens was much higher and more significant in younger subgroups. For example, if we look at that most toxic combo regimen, the cumulative 5-year incidence in women under 55 was only 7.5%, but that was over 16 times the incidence in the placebo group. If a woman in that subgroup got heart failure, she could be over 90% certain that she'd paid cold hard cash for it. Among women using anthracycline alone, the relative risk was 2.5 times higher for the under-55s, but only a nonsignificant 60% higher in women 55-64, even though users of that age were well over twice as likely to develop heart failure.

Now,on to another issue. Dr. Eric pretends that the study is worthless because they did not hunt down each one of these women and do ultrasounds on them to get their Left Ventricular Ejection Fractions to prove they really had heart failure. (Almost half of all people diagnosed with heart failure have what is called "heart failure with preserved ejection fraction" [which has no good treatment, but a cardiologist will be happy to see you anyway], but never mind that.) Here's the real shocker: They didn't even prove that these women had ever had breast cancer! They didn't track down the tissue samples and redo the pathology specially for this study! Instead, they just sifted through medical records and recorded what drugs and diagnoses had been recorded. This is not error-free, but if you want to do a very large real-world study for a feasible price, there are few possible methods, and this is a standard accepted methodology.

The authors of this study very rationally discussed its limitations, including the fact that people who have gotten chemo might get more cardiac screening from their MDs. That would result in more people with mild heart failure being labeled as sick, meaning that the relative risks they reported would be somewhat inflated. However, do we believe, without evidence, that multiple doctors at eight separate sites were so aggressive that a large fraction of all breast cancer patients were needlessly made into cardiac patients? Do we believe that if that was the case, the effect would vary so much depending upon what kind of drug was used (i.e., why would excess screening and overdiagnosis be several times higher in people who had had trastuzumab than in people who had had anthracycline or "other" chemo)? No, the doctors who made those diagnoses probably did not know at the time that they would be the subject of a publication, and most of them probably made diagnoses that they thought relevant to their patients' welfare.

It is surely the case that not all chemo regimens create a huge heart failure risk even in the oldest and frailest; the numbers we were quoted were the most extreme numbers from a single particularly toxic regimen. Anthracycline doesn't seem to significantly increase risk of this particular complication in the elderly, for example. The article did not do a good job of clarifying that fact. But risk of heart failure from chemo is real, though its magnitude is highly dependent on the details. Potential patients/consumers need to demand those details. Most Americans seem willing to go through hell for even a small chance at a longer life, but I would surmise that many would be less willing to go through hell for a statistical change in their expected cause of death.

I don't know where Dr. Eric gets this "two patients"

Umm...the study jane. Look at the number at risk for the age>75 group from which the 40% number is derived. Its 2

http://www.oxfordjournals.org/our_journals/jnci/press_releases/bowlesdjs317.pdf

Your reading comprehension makes me "shudder"

Well, no. Look at Table 2, for Pete's sake. Of the 442 women who took the combo treatment - all of whom were at enormously increased risk of heart failure, whatever their age, 8 were over 75. This constitutes 1.8% of the total, the number in parentheses. Maybe you were confusing percentages with numbers of patients? If so, I shudder next to think how you think there could have been 1.8 patients in a group. Anyone can check this. There were 272 women under 55 who took that treatment, by the way. You made the "point" above that studies are of finite length and that people continue to die after they are over - both inevitable truths. One hopes that the heart failure risk in these younger women levels off over time; otherwise, for them as for the elderly, there's a good chance that more would be killed than saved by this regimen.

Jane, youre wrong

your mistake here is looking at the total number in the group. I agree there were 8 patients at enrollment. For whatever reason (the paper does not really specify) there was some loss at follow up. By 5 years, out of those 8, only 2 remained in the study. Again, it is from those 2 that the 40% number was derived. Its figure 2-D.

I just can't make it simpler for you

there's a good chance that more would be killed than saved by this regimen.

I have noticed you often make claims unsupported by the data. This is another one of those times. Theres simply no evidence for the above statement. Yes, chemo is toxic and causes heart failure. this is well known. But to then say that this outweighs the benefits belies a lack of understanding of medicine and the data.

Dr. Eric pretends that the study is worthless because they did not hunt down each one of these women and do ultrasounds

Hunt down? They are enrolled in a study and getting regular follow ups for christ's sake. Who are you trying to fool??

And a cardiac echo is a class IA indication for patients with suspected heart failure. Thats the highest recommendation possible. For a study with an endpoint of heart failure not to have an echo is inexcusable

alf of all people diagnosed with heart failure have what is called "heart failure with preserved ejection fraction" [which has no good treatment, but a cardiologist will be happy to see you anyway],

this is also known as diastolic dysfunction, which I alluded to earlier. And there is treatment for it including ACE-I (for cardiac remodeling) and diuretics for symptomatic relief. And good bp control helps a lot. Your above statement displays a lot of ignorance about cardiology

At any rate, chemo does not usually result in primarily diastolic dysfunction so your point is irrelevant

Instead, they just sifted through medical records and recorded what drugs and diagnoses had been recorded

Again, ignorance of medicine on your part. A diagnosis of breast cancer is fairly objective. A suspicious mass and microscopic exam by a pathologist

However, CHF is more subjective. I can't tell you how many patients I have sent to me for "chf" when they have essentially normal cardiac function. Some people, like yourself, don't realize that an echo really needs to be done in these patients. When I get one often the function is completely normal

There are many other diagnoses that present mimicking CHF--hypertensive urgency, myxedema, acute renal failure, sometimes even COPD--all I have personally witnessed labelled CHF with absolutely no primary cardiac pathology

Furthermore, even in patients with an abnormal echo, there are often other factors to explain this other than primary cardiac pathology. For example, the EF of any patient could look worse during tachycardia compared to normal heart rates. Ive seen echoes on patients with an EF of 40% and HR of 130--2 weeks later after the heart rate drops to normal the EF also normalizes

The same is true during infection, hypertension, hypothyroidism, etc.

So when someone gets a label of CHF, especially without an echo, I get very suspicious

But don't take my word for it--look at the study. The PPV for their CHF diagnosis algorithm varied anywhere from 44% to 90% depending on how they classified so called "indeterminates"

This fact ALONE tells you to take their label of CHF with a grain of salt

These women weren't "enrolled in this study"; only their medical records were used. You don't know how many of them got echos. It's simply false to claim that none got echos, simply because THESE authors didn't do it. While a few breast cancer diagnoses are simply wrong and more are overdiagnosis, I don't actually dispute that these women had breast cancer. The point is that many studies of real-world treatment outcomes are done using data from medical records, and the authors appropriately acknowledged the limitations of the approach. This is not a clinical trial with an "endpoint of heart failure." If you don't understand the difference between two distinctly different types of study, I don't see how you can possibly be keeping up with the literature in your field.

I see the confusion about Fig. 2. After 5 years, there were only two women in the "over 75, heart-wrecking combo" subgroup still "at risk", meaning that the other six in that group either had fewer than five years of follow-up, or had already developed heart failure (and so, were no longer at risk). The 40.7% value is an adjusted CUMULATIVE risk, not 40.7% in that year alone. (One out of two would be 50%, not 40.7%, although please remember that the risk figures are not raw but ADJUSTED for confounding factors such as radiation exposure.) The numbers at risk per year of follow-up drop off rapidly in larger subgroups as well, plainly because many of the women enrolled in the study had been diagnosed and treated recently enough that they did not have multiple years of follow-up. Risk estimates for heart failure at one year are therefore much more precise than those for heart failure at five years, because they are based on many more people.

Whether chemo is more likely to save you or kill you depends upon (a) your stage of breast cancer and its aggressiveness; (b) your age and any other potentially life-shortening conditions you may have; and (c) which chemo drug(s) you use and whether you combine them with radiation. I don't doubt that some regimens in some types of patient significantly reduce all-cause mortality - which is the only mortality-based outcome that does not involve a questionable value judgement - however, that does not mean that anything any doctor might wish to inflict on any patient will have a net benefit. Ask for details. And a good general policy is that if a doctor responds to questions with namecalling or emotional death threats, RUN - he is dangerous.

These women weren't "enrolled in this study"; only their medical records were used.

Um, thats really semantics. If I want to do a retrospective study, even a chart review, I have to get approval from an IRB. Furthermore, I have to get the patients' consent. Either way, Im not sure what your point is here

It's simply false to claim that none got echos

I quoted from the study. Allow me to repost it:

we could not use LVEF findings in our HF/CM definition

Did they get echoes at some point? Maybe they did, maybe they didn't. The point is, the authors didn't use echo data directly--they relied on a "diagnosis". By who, and by what means we can only speculate

How much did the EF drop to get labelled chf? Were there extenuating circumstances, such as the ones I listed above? How experienced were the readers?

All of those questions is why most trials that have CHF as an endpoint use echo, and list the findings. Its really improper not to.

many studies of real-world treatment outcomes are done using data from medical records, and the authors appropriately acknowledged the limitations of the approach.

Agreed, but these same retrospective studies still usually provide echo findings if CHF is a major concern. Either way, its enough of a fault to question the validity.

And let me remind you of the point you conveniently ignored. The PPV of their algorithm for diagnosis EF had a lower CI limit that was worse than a coin flip

f you don't understand the difference between two distinctly different types of study, I don't see how you can possibly be keeping up with the literature in your field.

Nice try. Endpoint, outcome...its just semantics. Please tell me what difference it makes.

I see the confusion about Fig. 2.

Yeah, actually we basically agree here. Im just less willing to make the assumptions you make. Agreed 8 started out. Agreed 2 are left at year 5. What happened to the other 6? CHF-for some, sure. How many of the 6? I have no idea, and neither do you. The authors don't say

But for the sake of argument, lets assume 40% of the original 8 all got heart failure. Lets even round up to 4 patients. Thats 4 patients. For someone who was yelling 2 posts ago about using relative numbers to exaggerate findings, its quite hypocritical. 4 patients, while unfortunate, are not enough to change medical practice

You and I both know that claiming "40%" rate of heart failure for 4 out of 8 patients is disingenuous

Risk estimates for heart failure at one year are therefore much more precise than those for heart failure at five years, because they are based on many more people.

Not quite. The problem you run into here is not giving enough time for heart failure to develop. CHF from chemo is very real, esp from anthracyclines. I see it regularly--but sometimes it takes more than a year to develop, so you'll actually underestimate the true incidence

what you really need is a large trial, robust enough that even if you have some loss to f/u, death, etc, you still have plenty of data in which to make reliable estimates

We both know 4 of 8 doesn't cut it.

And the larger trials that were done on elderly patients like this showed a much lower rate of CHF, and I suspect that the small sample size of this trial is the reason, plus the dubious diagnosis of heart failure

When I said "more precise" I obviously meant "more precisely estimating the risk AT one year," not "more accurately reflecting what these women may suffer over the rest of their lives." In a small group or subgroup, even if an effect is so huge as to be significantly significant, confidence intervals are very broad. That means that you don't have a good estimate of what the "true" size of the effect would be (if you could magically obtain and analyze data for all such patients who would ever exist), because just one more or one less person in your group being diagnosed by chance could make a big difference to the apparent size of the effect. If you have more people in a group (here, the earlier years of follow-up, the younger age groups, etc.), a couple of chance events more or less makes less difference to the observed effect size.

Does that mean that the authors' whole rationale for believing the combo regimen is especially toxic depends upon eight coin-flips? No, because remember that there were much larger age groups who showed the same effect. The 272 women under 55 who got that regimen suffered an adjusted 7.5% cumulative heart failure rate, which is gigantic for women of that age, 16.36 times that of women under 55 who got no chemo. If you supposed that half of those diagnoses represented incompetence by cardiologists or general practitioners, their real risk would still be 8 times higher than that of the no-chemo group. Combining all age groups, the adjusted cumulative 5-year rate of heart failure was 20% - recall, as we discussed, that that is an absolute risk - in the combo group of 442 people, versus 4.5% in the "other chemo" group and 3.1% in the "no chemo" group. There are certainly some categories of breast cancer patients who will see reduced death rates if they use SOME type of chemo, but are there many for whom this particular regimen is so much more effective than any other that it can outweigh the excess deaths that would be caused if one-fifth of them got heart failure? Maybe there are certain cases for which that's true, but surely the burden of proof is on the prescriber.

When I said "more precise...

I don't really follow what you are trying to say in this paragraph. Significantly significant?

No, because remember that there were much larger age groups who showed the same effect.

Again, the purpose of a study is to quantify results. If your diagnostic algorithms are not accurate, the numbers cannot be trusted.

No one is saying chemo induced CHF does not happen. Ive seen it multiple times in my admittedly short career so far. But this study, which does not even use echo to define CHF within the study is bad. And the media, for blowing up the result of what is essentially a subgroup analysis containing a whopping 8 patients is ridiculous

So you can quote all the numbers from it you want. I think the evidence for those numbers is lacking. I think relying on a diagnostic algorithm with such poor PPV is weak

s deaths that would be caused if one-fifth of them got heart failure?

Only if you believe the numbers from this one study, and disregard every study ever done before it. And you close your eyes to the fact that we have no idea how CHF was diagnosed. Then yes

Well, others with more grasp of statistics will get my first point.

I don't think that the media should have buried alarming numbers from two subgroups simply because they were small (38 and 8 women); however, I do agree that they should have qualified them.

I don't know if there are clinical trials of this two-drug regimen vs. placebo in elderly women that showed lower risks in 5-year follow-up (please feel free to cite any). If there were, they involved only selected patients. This, being a retrospective study based on medical records (and not a prospective clinical trial), examines what happens to a broader and sicker population of real-world women. Side effects usually prove to be higher in real-world studies. These women's diagnoses were not assigned in the course of a research study, but in the course of the regular clinical practice of the doctors they saw. I know very well that doctors are known to dish out phony diagnoses, but I don't believe it happens at this rate.

Well, others with more grasp of statistics will get my first point.

Not so fast. Anyone who says "significantly significant" may have a good grasp of statistics, but their hold on the English language is a bit more tenuous. Unfortunately, both are needed to convey your point.

two subgroups simply because they were small (38 and 8 women);

If you don't think 8 patients is too small of a sample size, then your grasp of statistics is also tenuous. Do you know about power in regards to studies? What is the power needed to show a significant result with a good p value? You think its 8? Really? Then prove it, because saying something does not make it so

I don't know if there are clinical trials of this two-drug regimen vs. placebo in elderly women that showed lower risks in 5-year follow-up (please feel free to cite any)

There is a large retrospective trial of medicare patients. I'll pull it when im less busy

I know very well that doctors are known to dish out phony diagnoses, but I don't believe it happens at this rate.

Your belief is irrelevant. The PPV speaks for itself

Yes, that single superfluous word was some sloppy editing on my part. I will not waste my time compiling a retaliatory list of grammatical and spelling errors in your past posts, because it would be utterly irrelevant to the issue of whether your beliefs are supported by evidence.

This was, as I keep saying, not a clinical trial but a retrospective analysis of medical records. Of course, if there had been more than 8 over-75s getting the combo treatment, the exact harm done to that subgroup would have been more precisely defined. This was not within the control of the researchers; where real-world studies are concerned, that's life. Since heavy-duty chemo is seldom appropriate for the very old, it is GOOD that the review of records didn't identify large numbers of elderly patients who had received it - that is an indicator of rational behavior by the practicing oncologists who treated these patients. Regardless, the subgroup size of 442 total women using that regimen is plenty large enough to find a seven-times-greater risk of heart failure diagnosis to be statistically significant. If you dispute that, feel free to explain numerically why it is not so. Otherwise, I think we have beaten this dead horse long enough.

Im glad youve seen the light and abandoned the 40% number

17% risk attributable to dual chemo....despite my unrefuted remarks about the poor PPV and lack of echo in the diagnosis of CHF, I think that is a reasonable number

compared to the >80% 5 year mortality rate of untreated breast cancer I think thats not too shabby

http://www.ncbi.nlm.nih.gov/pubmed/10797344

Wow, you are a cold hearted person and way off topic.

To activate the immune system into an extra boost to handle these cells would be the way to go. I have always felt awkward with poisons (chemo), mutilations ( surgery) and burning (radiations) as we evidently damage the body to extremes as in many cases, there is nothing left that will survive. Baby steps .....after all these years, it seems almost futile. Our ways of life are evidently toxic.

Here is what I believe: Each and every one of us will live exactly as long as we're supposed to, regardless of what we do or don't do. The only thing that could change, if we improved (or not) our lifestyles, treatments, medicines, diets or anything else would be the quality of our individual lives. If I don't die of cancer, I could die of heart disease or any number of other things. If I lead a perfectly healthy lifestyle, don't smoke, don't overeat, exercise regularly and sleep well, I might step into the street and get hit by a bus. Or maybe get shot in a drive-by shooting. At any rate, I will die precisely when I'm supposed to. It's the quality of my life that will be affected by the other variables, not the length. As I said, this is what I believe. You can believe whatever makes sense to you.

I believe in UFO's!

Where did you get this idea? Have you not heard of the National Cancer Institute? Roswell Park Memorial Institute in Buffalo, NY over 100 years old. Dr. Park was given a grant to find the cure for cancer. That cancer center is now 100 years old. Do you know how many MDs and PhDs have worked there over all those years looking for a cure? Do you know how many people around the world, in and out of the government, are looking for cures, treatments and causes for cancer? So don't blame the pharmaceutical industry....they would love to find the meds to cure cancer which would in turn help their profits.

Also did you know they have found cancer (tumors) in mummies? So cancer has been around thousands of years?

Best wishes with your surgery and possible treatment.

To 1026AP: I am so sorry. I am a breast cancer survivor and was diagnosed 3 years ago. It does feel daunting and overwhelming to be diagnosed and quite scary, but I promise you that you will get through it. I did a double mastectomy, chemo A/C and herceptin and radiation. I'm not going to lie, some days are really difficult. Other days won't be so bad. You are much stronger than you realize and there are (unfortunately) a lot of women who understand what you are going through. I will keep you in my thoughts and prayers. My best wishes for a speedy recovery. We are all cheering for you! Love to you.

I hope everything works out for the best for you.

Doctors make a lot of money squeezing breasts in mammogram machines that provide annual cancer-causing radiation doses. Then, they make more money removing benign lumps from breasts.

Doctors make a lot of money squeezing breasts in mammogram machines that provide annual cancer-causing radiation doses. Then, they make more money removing benign lumps from breasts.

they also save a lot of lives doing it

But I guess thats not good enough for some people...

wishing you the best outcome. I belong to an online cancer survivors network.. I think the link is csn.cancer.org.. or just google cancer survivors network. Anyhow, it's a great site with lots of friendly people and you can read, ask questions., it really has a wealth of information. Breast cancer has it's own discussion board (it's one of the largest, sadly) They even have discussion boards for caretakers, emotional support, etc. Good luck to you!!

Why have you not researched your cancer and available treatments at National Cancer Institutes webside cancer.gov or another good source of accurate information American Cancer Society at cancer.org?

It's a waste of money. Why not shift some of the dollars to men's health ? Why should Grandpa live fewer years than Grandma ? Is Grandpa a lesser being ?

Why are you commenting about a disease and it's patients when you obviously don't care?

The real truth is nobody survives life.

John Howell - just hope that you never get a cancer diagnosis because then you will get a real 'wake-up' call about surviving 'these conditions' and I bet you will be screaming and pleading the loudest for a cure and that you want to live and not die. So, unless you or a family member have experienced cancer and its aftermath, 'Shut-up'...

Then I suppose you don't go to a doctor at all. Your faith will cure you of everything and if not, well, you were suppose to die anyway. I believe that is how the people in the third world live.

Let me please inform you that standard treatment is standard because it works for the majority of people. These treatments are tried by many doctors at many centers often around the world with hundreds if not thousands of people. They get a somewhat standard results which means that they can predict a fairly standard response. Let me also comment the people in the cancer field meet annually both MDs and PhDs to discuss and to review what is going on in the field. The cause, the treatment and cure for cancer is not secret. If you are going to someone who thinks his secret treatment is the best, there is a reason it is secret....it's phony.

Sorry to tell you but most of the doctors in that book are quakes that the oncolgists have been trying to get them to stop practicing medicine. These doctors are not telling the truth and won't let anyone duplicate what they are doing to verify their results. That means they are hiding something.....the patient didn't really have cancer, the treatment is voodoo, the cure can't be verified by the tests. Standard treatment means that doctors around the world can use that treatment and expect the same cure or results.

And we keep advocated early detection to cure slow-growth cancers

breast cancer is not "slow growth".

body will likely cure on its own if it has a strong immune system

Tell that to the 40,000 women that died of breast cancer last year. Wait, you can't. Because they died

Are you going to try and tell me ALL of them had a weak immune system?

our cure rate hasn't really improved in 50 years,

Our survival rate has increased by 30% over the past 20 years

http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-029771.pdf

we'll look back on these crude treatments for cancer and see them as absurd

I think your opinion is absurd, and I don't even need to wait 5 minutes to know that

Most breast cancer occurs after 50 years old. So, I recommend going to a geriatric doctor, who will explain to you what you can do to over-come fatigue, tiredness, muscle pain, etc. when over 50 years old. These symptoms are common in this age group. The main issue is the lack of absorption of nutrients, since the pH changes in the digestive system.

For example:

1) A little vinegar in salad dressings to change pH.

2) Potassium issues for muscle cramps - Almonds, bananas etc.

3) Calcium issues for fatigue - need to add foods with more calcium or a supplement (be careful with supplements - body is not used to then entire dose being taken once a day - body is programmed to deal with calcium in small doses with the slow process of digestion).

Work with your doctor. He/she will be very helpful.

Have a nice Labor Day! :)

nonsense, all of it. I suspect you are making it up or are delusional