​Let's Answer Your Questions...with Dr. Ray Chu

upfront with information and explaining things to people. I'm honored to have been part of Shannon's treatment team as a resurgeon, and so I'm your guest host today, and so this is a good time to put some more information out there. With a breast cancer aware this month, So I've been giving some questions from listeners and readers about cancer and I'm going to do my best to answer them. So someone wrote in what's the difference between stage three and

stage four? So cancers to the body are staged, and it generally involves the idea of how far outside the organ of origin things are. So like a lung cancer that spreads to the other lung or lymphotes outside the lung or to other organs. Stage four generally means like a totally different organ, like a lung cancer that spreads the liver, or breast cancer that spreads to the brain. That's usually the difference between the stage three and a

stage four. Someone asks what does a cancer look like when you operate on them, So they all actually look a little bit different, and sometimes even for a breast cancer, they can look a little different. It depends a little bit on how aggressively something is growing. Sometimes things are pretty vascular and growing and really pushing brain around a lot, and once in a while you have ones that are a little bit more slower growing and encapsulated and kind

of round. You typically can tell the cells look very different, doesn't look like normal brain at all. When you see a tumor and it has some color and texture differences. Sometimes a tumor can be a little bit firmer than regular brain, so you can carve out that pathway, that line between the brain tumor and the normal brain. Rarely there can be hemorrhage associated with it, So sometimes you can operate within this blood clot and then you find

tumor tissue to remove. Sometimes a tumor can be cystic. Sometimes the cells can create some fluid and you want to take all that out, and sometimes there's a little bit of a wall to be removed. Sometimes really it just makes fluid that pushes on the normal brain. So we use all these kinds of differences to try to help us remove everything we can. Most of the time when we're there at surgery, between things we use to

help us, like MRI guidance and an operating microscope. We use this big microscope that offers a lot of illumination and a lot of magnification. We can see the edge of the tumor. There are always a few cells left behind that we can't see that there are actually smaller than you can see in the microscope. So typically people need some amount of radiation around the surgery. Sometimes we do that afterwards. Sometimes if it's a very small spot, we think our targeting is better if we do a

small doser radiation beforehand and then do surgery. Also, if we're at surgery and any cells escape if someone already had radiation, we think that those cells as not really that viable, not that alive, So sometimes we would take all that into account that there's cells there. But one part of the question is is can you see cells spread in the brain. You really can't see the exact cells. They have to be large enough to be a tumor.

Sometimes we use other adjuncts at surgery, like there's not as many interopreative MRIs like tak an MRI in surgery, and really you can't operate inside an MRI safely right. Many surgical tools are some type of metal, and even if you choose one that doesn't create a lot of magnetic signal, kind of dangerous to do that. But sometimes we use an ultrasound because you can use an ultrasound right on the brain itself and see as you're working

that you took all the tumor out. So those are some of the things we use to make sure we do our best job. Someone asks how long does it take for cancer to metastasize, so they offer the spread of timing days, weeks, months, or year. So most cancers don't spread in days. So it is rare that we can find someone that has had a new diagnosis of a cancer and they'll have several sites of the disease at the same time, but it usually still would be something over time has spread to that not usually days.

I've definitely seen people where it can be diagnosed with a cancer like a breast cancer and a brain metastis. At the same time, I've also seen people where it can be more than five or more years since they're cancer diagnosis before something happens. There's a lot we think that has to do with how much people fall up with their doctor and get appropriate scans and things and appropriate treatment, and we usually can find little changes happening

before there's widespread disease. That once in a while it's people who don't quite keep up all the imaging or kind of disappear a little bit from the oncologists and start taking some strange therapies that sometimes they can come back with a lot of things going on. But it is part of why for a lot of cancer you really use the term remission. Like when people have had a lot of treatment and things are quiet and we still watch them with some visits and scans, they can

be in a remission. And for many of these cancers, it's hard to use the word cure. Care would imply we shake your hand and give you a U and say go live your life. Don't get another test again. I mean, we do worry that things can rear their ugliheads again. So sometimes I even have people, you know that I've been following for more than a decade, just making sure that they stay out of trouble. See, does weight have anything to do with the likeli of getting cancer?

I'm not aware of some that's super clear for that. I mean, we do think of both how people respond to a disease and its treatments might have a little bit to do with health, you know, like some amount of focus on exercise and diet. It's not really that there's something as simple as a tumor starvation diet. I've had someone before where the spouse the patient on the tumor strivation diet. The only thing starving was the patient. The pumber can find a way to grow, So it's

not as simple as the diet. Sometimes in the Internet people even talk about, oh, sugar feeds cancer, And there's a little bit to that. I mean in your bloodstream. Also, your body makes glucose to feed the brain, right, it doesn't your brain doesn't run on protein purely, so you can't really eliminate sugar from everything. And clearly it's one thing to say, you know, nobody needs three slices of chocolate cake to day, but sugar from fruits it is always going to be a part of a good diet.

And so sometimes too, when people are going through surgeries and treatments, they deserve a treat here and there. You know, to deny someone all twreats doesn't always help quality of life. Part of our goal should be quality of life, not just pure quantity of belief. There's a question about itchy nipples as a sign of breast cancer. Well, I'm going to be the best one to go into all of those as a neurosurgeon, but I haven't heard that one before.

That's a big warning sign. Note Okay, someone asks what is the best case scenario when a patient goes to you to get a tumor removed? So many times what we look at is this distinction between a solitary brain metasis or several brain fantast disease. And while Shannon actually had a couple spots there, a lot of them are very small. There was one major one, and so sometimes we think if there's one major metastasis and we perform surgery, that we're attacking like the major side of disease in

the body. There is this part too that taking some tumor out from the current disease state really helps. To the hero on cologist dart Piro, it really helps give us both an idea for sure that we're seeing tumor. Also it gets another chance for us to look the molecular signas to their tumor case. It changes the idea of any targeted therapy or immuni therapy. So with her, fortunately we were able to remove that safely and she did well with surgery. She was pretty tough. She's been

through a few surgeries, so she is pretty tough. And then we're able to treat the other tiny sites with radiation and she spawned well to that. So in Sham's case, there was this big advantage that we took with surgery that her brain was quiet for a long time, and really what we thought was going on with her is that she had systemic disease. That was the problem. I

remember actually when we did our podcast together. Neurologically, she was doing great, her brain was terrific, she was speaking well, she was thoughtful, but she said I kind of have this new pain and that they were kind of working that up and it was that worry, that sign that something else is going on on the body. The pain was on the body, her brain was doing fine. There is that advantage in the brain that most of the time,

between surgery and radiation we can control metallic disease. It doesn't always happen exactly the same and the rest of the body, and so sometimes looking again at that molecular signature helps guide us onto the next step. Once in a while. It's that thing that we think of the removing a solitary brain metastasis is kind of like resetting the clock. Like if you took all the people with lung cancer with and without brain metastases, clearly the survival

would be different. But we think that if we have someone with really one metastas that we can remove safely and give focused radiation to the edges there, we kind of reset the prognosis clocked, almost as if they didn't have that metastasis in the first place. And then clearly when you have someone with several metastasy, you don't have

that advantage. Sometimes when we operate on people with several metastases, we operate on one or two of the largest ones that might be hard to treat with radiation or ones that are very symptomatic. For example, there could be one really pressing on the most area and with like a lot of swelling. That someone has weakness, and if we can take that out, we can make them stronger. So we plan those surgeries to help quality of life, but it may not always change their prognosis if they're multiple

metastasies different than that solitary scenario. Those are some of the ways we look at try to make the best of a situation for a patient and keep them healthy. Someone asked, how soon can you tell of a surgery was a success? In general, you know a lot about surgery within the first twenty four hours, so you know, if I would know if a patient is neurologically worse or not, that if things like brain swelling or bleeding or even stroke, which is a risk of surgery. It's

an uncommon risk. I mean, when you tinker with the brain for surgery, a stroke can happen about one percent of the time you perform kind of surgery. We would know that generally in the first twenty four hours. There is partly a different sun of success in terms of like does a tumor grow back in things, but usually between surgery and focus radiation, we can prevent a tumor

from coming back at that. One side part of our job later with multiple rain and arize is to look at the rest of the brain to make sure there are no other sense. Okay, someone asks, are there natural foods that keep cancer away? Well, it's a little bit unclear. There are some studies that you'll see that talk about either the rate of cancer or the response to cancer and evolvays some things, but it's not really clear enough

that there's a particular food that does that. Now, clearly there's probably a part of us as Americans eating like regular food and you know, fresh fruits and vegetables and things that are from cooking, and there's probably an amount of processed foods that we're a little bit not in control of exactly what's in there and sugar content and stuff like that. But I wouldn't as necessarily say that there's one super particular thing that people should tank see.

When breast cancers be on the point of treatment, what does a patient actually die from It can depend, so it's a little bit more rare for people to succumb

to brain metastases. Usually we can control them between surgery and radiation and sometimes Now there are targeted agents for breast cancer, a number of different targeted medicines that can get into the brain a little bit or when people qualify for immunotherapy, right, so chemotherapy being medicines that hurt tumor cells a little bit different than immunotherapy, medicine to stimulate your immune system to fight the tumor better. Not all cancers have a good signal that they would respond

to immunotherapy, but they can. And then even if therapy can get into the brain, sometimes we even use it on primary brain tumors, so sometimes that can be the stuff that really helps fight things. I guess the second part of that is the cancer is the cancer yourself. For organ failure, so not most people really die pure organ failure. So real organ failure we're like your kidney

shutting down, your liver shutting down. Happens when people have some type of an infection and you know, bloodstream infection called sepsis. Most of the time, when breast cancer patients start to peter out, it's that the disease is growing and just taking a toll on their body for their energy reserves. And making them sick. It can be some organ involvement. It's not usually totally organ failure. Can you tell when someone only has a few weeks left to live?

Yes and no. I mean sometimes you get a sense on someone who really feels that their energy is very depleted and they don't feel well. They haven't responded to the therapy. Once a while, when people have limited ability to speak, they can still tell you what they want and feel like they're going through. When people sometimes just gradually want to do less and eat less than that can be a sign they know there are things going on that are not going in the right direction. But

sometimes it's hard. Like humans, we have this weakness in prognostication. We can't always pull the future out Like I want my crystal ball to be working, but it's really well, like a crystal ball that has some cracks in it. Things like that. See, cancer treatment can weaken the body of the immune system, So how do we know whether it's doing more good than harm. Well, some of that is and really seeing people and try to balance the

quality of life. So more and more it's the priority to make sure people have a good quality of life and not really just you hammering them with treatments to get more quantity of life. So as people are fatigued or have different medical side effects from treatment, sometimes we will dose reduce the treatment. And sometimes even if the treatment was roughly working, if it's hurting someone more than

it's helping, we may have to change that. So it's a lot of contact with a good doctor and making sure we stay in touch about side of and things. Should someone with cancer exercise, absolutely so, we both think that that's good for your mental health, but the whole idea of just oxygenation and stimulating the good cells in the body, right, We think that exercise and movement is good for the immune system and helping you fight the tumor.

In general, there's no disease that I know of where strict bed rests for prolonged times is good and lots and lots of bedrests put you at risk for other problems. So when people are in the hospital after surgery it can't walk around very well. We do various things to stimulate their blood from being too thick and getting blood clots. There are squeezers we put on the legs are rarely if it's days later. Some people even need light blood thinner to make sure they don't develop these blood clots

and things like that. When you're under prolonged bed rest, then there are risks for blood clots and it can be dangerous. Also cancer in general, we think cancervations are a little more prone to blood clots than others, even more so, like strict bed rest can be a risk for cancervations. As it true you qualify for lifetime disability if you're diagnosed with cancer, I'm unaware of that being

the case. I think there are definitely people with different insurance policies, and then there's a part where it can depend where you are in your cancer course. Certainly someone has more and more metastics than unable to work in things like that. There's things that for disability, but not an automatic you know, the first sign of cancer, it is not an automatic lifetime disability. Do I think anything about deodorant in cases of breast cancer. I haven't heard

that one either. I haven't heard any breast cancer oncologists recommend that everyone stops deodorant. I don't know that that's the one. I certainly appreciate it when patient's were deodorant. Do you think the metal insides women's brass could potentially be a factor causing breast cancer. That one's a tough

one for me. I'm not sure I would call myself the expert in that, but I'm unaware of any type of recall, and you know, this country is pretty safe with that stuff, so I think if there are any real evidence for that, it would be something that'd be changed pretty quickly. Also, you know, I assume they're talking more like the underwire than like the class and stuff like that, which sometimes the classes are in the back. But I'm not aware of anything that says that the

metal has anything to do with it. So once in a while we meet patients that have a couple of preset ideas in their head about what cancer is like and what to do or not to do. Sometimes you're worry that people with mentastass might feel that there's nothing that can be done. But we're better and better at this over the years, and even since I started at Cedar Sina twenty years ago, things are different than before, so things are more treatable. We have better tools at surgery,

have better treatments, more targeted agents and immunotherapy. So it wasn't like that when I started that. We had people brame my task diase around for a long period of time, but now there are there are people that I have even past ten years with a diagnosis or brain metast disease. It's different than it used to be. Sometimes we meet people that are a little bit reluctant for different treatments

like radiation. So people are scared by the dea of radiation and probably more than scared by the idea of radiation or their brain. Part of what we do for target radiation is that we focus really tightly around the tumor target, and then we distribute the beams of radiation around multiple parts of the brain such that each part of the brain can tolerate the dose. So it's kind of like if you have two flashlights focus on a target.

It's more intense at the center, but if you do that thousands of times, you get this intensity at the tumor site, but the rest of the brain gets very little radiation at all, And so we do to try to make it safe. I mean, clearly, there's always a little bit of risk with things like radiation, but we try to limit that risk as much as possible, keep

the brain as healthy as possible. It is better than it used to be that we can target these things more precisely, really the sub millimeter accuracy than we used to. Sometimes we meet patients that are very reluctant to treatment, and there are lots of people out there with stories on chemotherapy. I think that some of these stories are really older stories. I think it's tricky to go on the internet sometimes, not that I don't want people to read.

I always appreciate what people read, just we have to take everything with a grain of salt. And on the Internet it's a lot harder to tell what your source of information is. You know, in a store, it's very easy to tell the difference between the Wall Street Journal and the National Enquirer. But on the Internet it's different.

So sometimes we're really just reading some one person's particular response to all the stuff, and you know, rarely people aren't even telling you all the things and telling you the total truth. Right, So generally get a little bit better information from curated sites like them American Cancer Society or our website I think has good information. Sometimes we want to gauge that and really weigh the source of the information. Even your favorite restaurant has a bad review somewhere,

that doesn't mean that you don't like it anymore. And then I think the one difference too is that the chemotherapies have gotten better. So really in this umbrella of chemotherapy are more and more targeted therapies. As we do more testing and find more molecular signatures of these cancers, sometimes we can find a particular driver that we can develop a drug to. So some targeted therapies will take advantage of that hurt to our cells and get into

them in a certain way because of that. One example for a breast cancer is people that are hurt too positive that there are targeted agents for that that this her too positive is a different little different than a triple negative breast cancer, and we can use different treatments for some of these people. I think another major improvement over time has been this idea of immunit therapy. So immunotherapy is medicine to emulate your immune system or fight

a tumor better. There's a lot of tumors that try to hide from the immune system, and primary brain temors can hide from the immune system by both down regulating signals that our immune sysm uses to detect foreign things like tumors, and it also sends out signals to suppress your immune cells. But the goal of immuni therapy is medicine to try to stimulate that to reverse itself. I guess I should clarify. There is like medicine immune therapy,

there's also cellular imunotherapy like vaccines. Vaccines oftentimes are taking tumor proteins and stimulating them with your immute white blood cells to fight them better. But it's a little harder to do all that stuff. It requires to recent surgery. And then there's a part where the immune systems you have to raise cells to develop into ones that recognize

foreign proteins and things versus you know, medical emunit. Theor wich is a medicine we can give you, but sometimes we have to sit down a lot with patients and really try to give as much information as we can and dispel some of these myths that are out there. Well, it's been a pleasure to sit down with you and answer great questions. Keep your questions coming, you want to

help you answer them. In the spirit of Breast Cancer Awareness Month, make sure you keep up with mammograns merely checkups. This is doctor Cheu, see you next time.