Doctor HealthHealth Tips

In a puzzling twist, women who have a history of migraine headaches are far less likely to develop breast cancer than other women, U.S. researchers said on Thursday.

The study is the first to look at the relationship between breast cancer and migraines and its findings may point to new ways of reducing a woman’s breast cancer risk, they said.

“We found that, overall, women who had a history of migraines had a 30 percent lower risk of breast cancer compared to women who did not have a history of such headaches,” said Dr. Christopher Li of the Fred Hutchinson Cancer Research Center in Seattle, whose findings appear in the journal Cancer Epidemiology, Biomarkers and Prevention.

Li said the reduction in risk was for the most common types of breast cancers — those driven by hormones, such as estrogen-receptor positive breast cancer, which is fueled by estrogen, and progesterone-receptor positive breast cancer, which is fueled by progesterone.

Hormones also play a role in migraines, a brutal type of headache often accompanied by nausea, vomiting and heightened sensitivity to light and sound. Women are two to three times more likely than men to get migraines.

While it is not exactly clear why women with a history of migraines had a lower risk for breast cancer, Li and colleagues suspect hormones are playing a role.

“Women who have higher levels of estrogen in their blood have higher levels of breast cancer,” Li said in a telephone interview.

And he said migraines are often triggered by low levels of the hormone estrogen, such as when estrogen levels fall during a woman’s menstrual cycle.

Women who get migraines “may have a chronically lower baseline estrogen. That difference could be what is protective against breast cancer,” Li said.

For the study, Li and colleagues analyzed data from two studies of 3,412 post-menopausal women in the Seattle area, 1,938 of whom had been diagnosed with breast cancer and 1,474 of whom had no history of breast cancer. Women in the study provided information on their migraine history.

They found women who had reported a clinical diagnosis of migraine had a 30 percent reduced risk of developing hormonally sensitive breast cancers.

“Migraines are typically most severe among pre-menopausal women,” Li said. “This study was all post-menopausal women.”

He said that suggests the protective effect seen in women who get migraines may have a lasting effect at reducing breast cancer risk.

“While these results need to be interpreted with caution, they point to a possible new factor that may be related to breast-cancer risk,” Li said in a statement.

Breast cancer is the leading cause of cancer death among women worldwide, with an estimated 465,000 deaths annually, according to the American Cancer Society.
By: Reuters

Gamma-linolenic acid (GLA), the essential omega-6 fat that is found in evening primrose, black currant seed, and borage oil, can inhibit the action of the cancer gene Her-2/neu. This gene is responsible for almost 30 percent of all breast cancers.

40-Fold Increase in Effectiveness

When cancer cells that overexpress the Her-2/neu gene are treated with GLA, it not only helps suppress the cancer-causing gene, but also causes up to a 40-fold increase in response to the drug Herceptin (trastuzumab), which is used as part of breast cancer treatment. GLA also selectively affects cancer cells without damaging normal cells.

Good News for Those With an Aggressive Form of Cancer

This is especially good news because patients who possess the Her-2/neu gene also typically have an aggressive form of the disease and a poor prognosis.

GLA is one of two essential fatty acids, which are necessary for the normal functioning and growth of cells, nerves, muscles and organs. GLA is present in evening primrose oil, borage oil, and black current seed oil, among other sources.

Journal of the National Cancer Institute November 2, 2005; 97(21): 1611-1615 EurekAlert November 1, 2005 Northwestern University November 2, 2005

Dr. Mercola’s Comment:GLA is a powerful nutritional tool that is commonly used to treat:

Inflammation
Arthritic pain
Eczema (atopic dermatitis)

Although GLA is an omega-6 fat, it is one of the only ones that many people seem to benefit from by takingit insupplement form. It is frequently the “secret” weapon in resolving eczema and many mystery rashes.

It is important to use GLA with a balanced amount of a high-quality omega-3 fish oil or, at this time of year, cod liver oil. They act synergistically to provide a potent anti-inflammatory combination.

If taken as a supplement, I personally prefer the ones made from evening primrose oil, but borage oil hasa higher concentration of GLA, which means you need fewer capsules, and it tends to be less expensive.

However, it has been my experience that many experts insist on using evening primrose oil, even though it is more expensive, as it seems to provide better overall results. This may be related to the fact that these oils are not pure GLA but also have other oils. Nervonic acid is present in borage oil and may contributeto its lack of benefit relative to evening primrose oil.

Since cancer, not heart disease, is now the leading cause of death for most of us, this is an important issue.If you are interested in radically reducing yourrisk of developing cancerI would recommend the following:

1. Control your insulin levels: Make certain that you limit your intake of processed foods and sugars as much as possible. When your insulin levels are increased you will inhibit the action of an enzyme (delta-6 desaturase) that actually allows your body to produce GLA.

2. Get appropriate amounts of animal-based omega-3 fats and make sure you use cod liver oil if you don’t have regular access to sun exposure.

3. Get appropriate exercise. One of the primary reasons exercise works is that it drives your insulin levels down. Controlling insulin levels is one of the most powerful ways to reduce your cancer risks.

4. Normalize your vitamin D levels with safe amounts of sun exposure. This works primarily by optimizing your vitamin D level. If you have regular access to sun exposure then you should use fish oil, not cod liver oil, as your primary source of omega-3 fats. Ideally, it would be best to monitor your vitamin D levels.

5. Eat according to your metabolic type. The potent anti-cancer effects of this principle are very much underappreciated. When we treat cancer patients in our clinic this is one of the most powerful anti-cancer strategies we have.

6. Have a tool to permanently erase the neurological short-circuiting that can activate cancer genes. Even the CDC states that 85 percent of disease is caused by emotions. It is likely that this factor may be more important than all the other physical ones listed here, so make sure this is addressed. Energy psychology seems to be one of the best approaches and my particular favorite tool, as you may know, is the Emotional Freedom Technique.

7. Only 25 percent of people eat enough vegetables, so by all means eat as many vegetables as you are comfortable with. Ideally, they should be fresh and organic. However, please understand that, frequently, fresh conventionally grown vegetables are healthier than organic ones that are older and wilted in the grocery store. They are certainly better than no vegetables at all, so don’t use that as an excuse. If you are a carb metabolic type you may need up to 300 percent more vegetables than a protein metabolic type.

8. Make sure you are not in the two-thirds of the population who are overweight, and maintain an ideal body weight.

9. Get enough high-quality sleep.

10. Reduce your exposure to environmental toxins like pesticides, household chemical cleaners, synthetic air fresheners and air pollution.

11. Boil, poach or steam your foods, rather than frying or charbroiling them.

Article Source: Health Guidance

There was a time when Breast Cancer was termed to be as a dreaded disease. But things have changed now. If detected earlier, this could be easily treated. Removal of your breast during the treatment of breast cancer can be one of the painful things you would have to go through. It may not be the same case for all patients. With the increasing knowledge about the cures and treatment breast cancer can be treated very easily.

Breast cancer occurs when cell in our breasts known as tumor grow out of control causing damage to the nearby tissues and spreads throughout. These tumors which are cancerous are known as malignant tumors and cause lot of damage to your body. As it takes lot of time for a tumor to grow, it may not be easy to detect the tumor during self exam. But these can be detected with mammograms.

Breast cancers best treatment - early detection. Once, cancer is detected it becomes easier for the doctors and yourself to fight it out. By the age of 20 all women should start doing Breast Self Examination (BSE) it is one of most easiest and earliest ways of detecting cancer. These check ups should be done few days after your periods. You should do this check up at least once a month. A clinical breast exam should be done at least once a year.

Some of the signs to look for, while doing BSE

• A lump found in and around the nipple or underarm
• Change in size or shape
• Nipple discharge or nipple turning inward
• Redness of skin or warmth
• Formation of dimple or change in skin texture

Some of the causes of having breast cancer

Gender: Being a woman is one of the common reasons for suffering from breast cancer. Event though men suffer from this disease too, just being a woman puts you in lot of danger.

Age: As you grow older your chances of having breast cancer increases.

Family history: If somebody in the family has suffered from breast cancer your chances of having breast cancer increases.

Being overweight or obese: If you are an overweight women your chances of breast cancer increases after menopause.

Lack of exercise: Being lethargic and lack of any physical activity leads you towards increasing weight and chances of breast cancer.

Alcohol: Drinking alcohol becomes very risky as it increases your chances of breast cancer.

Methods to Prevent Breast Cancer

• Turn into a vegetarian
• Have plenty of organic food and vegetables
• Avoid red meat and any processed foods
• Avoid alcohol and colas
• You can have something sweet by having Stevia, an herb which is a substitute to any other toxic artificial sweetener
• Having whole grains is very good such as Oatmeal, Kamut and Psyllium, which are a good source of fiber and enters directly into your bloodstream
• Your diet must include wheat, bran and Cabbage as they are very nutritious food which helps to prevent breast cancer
• Garlic, Ginger, carrots, celery, cilantro, parsley and parsnip has some of the highest cancer fighting nutrients. Include them in your daily diet

Article Source: Health Guidance

In breast cancer, cancer cells in the breast tissue divide and grow in an uncontrolled manner. About 20% of breast cancers originate in the milk-producing glands, also called lobules. About 80% originate in the mammary ducts, the milk passages that connect the lobules and the nipple. Cancerous tumors in the breast usually grow very slowly. By the time one is large enough to be felt as a lump, it may have been growing for as long as ten years.

There are two kinds of breast cancer, invasive breast cancer and non-invasive carcinoma in situ.

Invasive breast cancer
Invasive breast cancer is the more serious of the two types. It occurs when abnormal cells from inside the lobules or ducts spread into the surrounding breast tissue. This enables the cancer to spread to the lymph nodes and, in advanced stages, to areas such as the liver, lungs, and bones.

A previous assumption was that breast cancer started as a very small tumor in the breast tissue and grew bigger. It eventually spread to nearby lymph nodes, and then to distant lymph nodes. Finally, it metastasized in other parts of the body. Now, doctors think that cancer cells can spread from the breast through the blood and lymphatic system at early stages of the disease, even though these spreading cancer cells do not always survive.

A phrase that you may hear from your doctor is the term ‘locally advanced’ breast cancer. This is usually refered to as cancer has not spread to another area in the body. However the following issues may have occurred:

• The cancer in the breast may be bigger than 5 centimetres across
• The cancer may have spread into the skin or muscle of the chest, or
• There may be cancer in the lymph nodes under the arm

Locally advanced breast cancer can be any of the above or all of these issues listed. Locally advanced could mean either stage II or stage III breast cancer.

What are the treatments for breast cancer?

Almost all women with breast cancer will have some type of surgery in the course of their treatment. The purpose of surgery is to remove as much of the cancer as possible, and there are many different ways that the surgery can be carried out. Some women will be candidates for what is called breast conservation therapy (BCT). In BCT, surgeons perform a lumpectomy which means they remove the tumor with a little bit of breast tissue around it but do not remove the entire breast. BCT always needs to be combined with radiation therapy to make it an option for treating breast cancer. At the time of the surgery, the surgeon may also dissect the lymph nodes under the arm so the pathologist can review them for signs of cancer. Some patients will have a sentinel lymph node biopsy procedure first to determine if a formal lymph node dissection is required. Sometimes, the surgeon will remove a larger part (but not the whole breast), and this is called a segmental or partial mastectomy. This needs to be combined with radiation therapy as well. In early stage cancers (like stage I and II), BCT is as effective as removal of the entire breast via mastectomy. Most patients with DCIS that have a lumpectomy are treated with radiation therapy to prevent the local recurrence of DCIS (although some of these DCIS patients may be candidates for close observation after surgery). The advantage of BCT is that the patient will not need a reconstruction or prosthesis to appear like she did before the procedure.

More advanced breast cancers are usually treated with a modified radical mastectomy. Modified radical mastectomy means removing the entire breast and dissecting the lymph nodes under the arm. Patients with DCIS that have a mastectomy do not need to have the lymph nodes removed from under the arm. Some patients are candidates for BCT but choose modified radical mastectomy for personal reasons. Your surgeon can discuss your options and the pros and cons of either procedure. Most women who have modified radical mastectomies choose to undergo a reconstruction. There are many different procedures for creating a new breast mound, and you should talk to your plastic surgeon before your surgery to discuss your options and decide on how you would like to proceed. For more information on breast reconstruction, see Breast Reconstructive Surgery Options.

Chemotherapy

Despite the fact that the tumors are removed by surgery, there is always a risk of recurrence because there may be microscopic cancer cells that have spread to distant sites in the body. In order to decrease a patient’s risk of recurrence, many breast cancer patients are offered chemotherapy. Chemotherapy is the use of anti-cancer drugs that go throughout the entire body. The higher the stage of cancer you have, the more important it is that you receive chemotherapy; however, even stage I patients may benefit from chemotherapy in certain cases. In early stage patients, the risk of recurrence may be small, and thus the benefits of the chemotherapy are even smaller. However, the option to receive chemotherapy should be offered to most patients with breast cancer and they can decide if the potential benefits of chemotherapy outweigh its side effects in their own particular case.

There are many different chemotherapy drugs, and they are usually given in combinations for 3 to 6 months after you receive your surgery. Depending on the type of chemotherapy regimen you receive, you may get medication every 3 or 4 weeks; and you may have to go to a clinic to get the chemotherapy because many of the drugs have to be given through a vein. Two of the most common regimens are AC (doxorubicin and cycolphosphamide) for 3 months or CMF (cyclophosphamide, methotrexate, and fluorouracil) for 6 months. There are advantages and disadvantages to each of the different regimens that your medical oncologist will discuss with you. Based on your own health, your personal values and wishes, and side effects you may wish to avoid, you can work with your doctors to come up with the best regimen for your lifestyle.

Sometimes patients have a recurrence of their cancer, or present in stage IV with disease outside of their breast. These patients will all need chemotherapy, and a variety of different agents may be tried until a response is achieved. Sometimes we give chemotherapy before surgery, and this is called neoadjuvant chemotherapy. This is usually reserved for very advanced cancers that need to be shrunken before they can be operated on.

Radiotherapy

Breast cancer commonly receives radiation therapy. Radiation therapy uses high energy rays (similar to x-rays) to kill cancer cells. It comes from an external source, and it requires patients to come in 5 days a week for up to 6 weeks to a radiation therapy treatment center. The treatment takes just a few minutes, and it is painless. Radiation therapy is used in all patients who receive breast conservation therapy (BCT). It is also recommended for patients after a mastectomy who had large tumors, lymph node involvement, or close/positive margins after the surgery. Radiation is important in reducing the risk of local recurrence and is often offered in more advanced cases to kill tumor cells that may be living in lymph nodes. Your radiation oncologist can answer questions about the utility, process, and side effects of radiation therapy in your particular case.

Hormonal Therapy

When the pathologist examines your tumor specimen, he or she finds out if the tumor is expressing estrogen and progesterone receptors. Patients whose tumors express estrogen receptors are candidates for therapy with an estrogen blocking drug called Tamoxifen. Tamoxifen is taken by pill form for 5 years after your surgery. This drug has been shown to drastically reduce your risk of recurrence if your tumor expresses estrogen receptors. However, there are side effects commonly associated with Tamoxifen including weight gain, hot flashes and vaginal discharge that patients may be bothered by. There are also very uncommon side effects like blood clots, strokes, or uterine cancer that may scare patients from choosing to take it. You need to remember that your chances of having a recurrence of your cancer are usually higher than your chances of having a serious problem with Tamoxifen, but the decision to undergo hormonal therapy is a personal one that you should make with your doctor. There are also newer drugs, called aromatase inhibitors that act by decreasing your body’s supply of estrogen; these drugs are reserved for patients who have already gone through menopause. Talk to your doctors about these new therapies.

Biologic Therapy

The pathologist also examines your tumor for the presence of HER-2/neu overexpression. HER-2/neu is a receptor that some breast cancers express. If your cancer expresses it, you usually have a higher chance of having your tumor recur after surgery. A compound called Herceptin (or Trastuzumab) is a substance that blocks this receptor and helps stop the breast cancer from growing. Some patients are candidates for this medicine. Talk to your medical oncologist to see if Herceptin is right for you.

Follow-up testing

Once a patient has been treated for breast cancer, they need to be closely followed for a recurrence. At first, you will have follow-up visits every 3-4 months. The longer you are free of disease, the less often you will have to go for checkups. After 5 years, you could see your doctor once a year. You should have a mammogram of the treated and untreated breasts every year. Because having had breast cancer is a risk factor for getting it again, having your mammograms done every year is extremely important. If you are taking Tamoxifen, it is important that you get a pelvic exam each year and report any abnormal vaginal bleeding to your doctor.

Clinical trials are extremely important in furthering our knowledge of this disease. It is though clinical trials that we know what we do today, and many exciting new therapies are currently being tested. Talk to your doctor about participating in clinical trials in your area.

What screening tests are available?

The earlier that a breast cancer is found, the more likely it is that treatment can be curable. For this reason, we screen for breast cancer using mammograms, clinical breast exams, and breast self-exams. Screening mammograms are simply x-rays of each breast. The breast is placed between two plates for a few seconds while the x-rays are taken. If something appears abnormal, or better views are needed, magnified views or specially angled films are taken during the mammogram. Mammograms often detect tumors before they can be felt and they can also identify tiny specks of calcium that could be an early sign of cancer. Regular screening mammograms can decrease the mortality of breast cancer by 30%. The majority of breast cancers are associated with abnormal mammographic findings. Woman should get a yearly mammogram starting at age 40 (although some groups recommend starting at 50), and women with a genetic mutation that increases their risk or a strong family history may want to begin even earlier.

Between the ages of 20 and 39, every woman should have a clinical breast exam every 3 years; and after age 40 every woman should have a clinical breast exam done each year. A clinical breast exam is an exam done by a health professional to feel for lumps and look for changes in the size or shape of your breasts. During the clinical breast exam, you can learn how to do a breast self-exam. Every woman should do a self breast exam once a month, about a week after her period ends. If you find any changes in your breasts, you need to contact your doctor. About 15% of tumors are felt but cannot be seen by regular mammographic screening.

There are some experimental screening modalities that are currently being studied. These include MRI, ductal lavage, ultrasound, optical tomography, PET scan, and digital mammograms. For more information on these experimental techniques

Am I at risk for breast cancer?

Breast cancer is the most common malignancy affecting women in North America and Europe. Every woman is at risk for breast cancer. Close to 200,000 cases of breast cancer were diagnosed in the United States in 2001. Breast cancer is the second leading cause of cancer death in American women behind lung cancer. The lifetime risk of any particular woman getting breast cancer is about 1 in 8 although the lifetime risk of dying from breast cancer is much lower at 1 in 28.

Risk factors for breast cancer can be divided into those that you cannot change and those that you can change. Some factors that increase your risk of breast cancer that you cannot alter include being a woman, getting older, having a family history (having a mother, sister, or daughter with breast cancer doubles your risk), having a previous history of breast cancer, having had radiation therapy to the chest region, being Caucasian, getting your periods young (before 12 years old), having your menopause late (after 50 years old), never having children or having them when you are older than 30, and having a genetic mutation that increases your risk. Genetic mutations for breast cancer have become a hot topic of research lately. Between 3% to 10% of breast cancers may be related to changes in either the gene BRCA1 or the gene BRCA2. Women can inherit these mutations from their parents and it may be worth testing for either mutation if a woman has a particularly strong family history of breast cancer (meaning multiple relatives affected, especially if they are under 50 years old when they get the disease). If a woman is found to carry either mutation, she has a 50% chance of getting breast cancer before she is 70. Family members may elect to get tested to see if they carry the mutation as well. If a woman does have the mutation, she can get more rigorous screening or even undergo preventive (prophylactic) mastectomies to decrease her chances of contracting cancer. The decision to get tested is a highly personal one that should be discussed with a doctor who is trained in counseling patients about genetic testing. For more information on genetic testing, see Let the Patient Beware: Implications of Genetic Breast-Cancer Testing, Psychological Issues in Genetic Testing for Breast Cancer, and To Test or Not to Test? Genetic Counseling Is the Key.

Certain factors which increase a woman’s risk of breast cancer can be altered including taking hormone replacement therapy (long term use of estrogens with progesterone for menopause symptoms slightly increases your risk), taking birth control pills (a very slight increased risk that disappears in women who have stopped them for over 10 years), not breastfeeding, drinking 2 to 5 alcoholic drinks a day, being overweight (especially after menopause), and not exercising. All of these modifiable risk factors are not nearly as important as gender, age, and family history, but they are things that a woman can control that may reduce her chances of developing a breast malignancy. Remember that all risk factors are based on probabilities, and even someone without any risk factors can still get breast cancer. Proper screening and early detection are our best weapons in reducing the mortality associated with this disease. For further information about breast cancer risk factors, see Breast Cancer Risk Assessment Tool,and Risk Factors and Breast Cancer.

So-called “DES daughters,” born to mothers who used the anti-miscarriage drug diethylstilbestrol during pregnancy, are at a substantially greater risk of developing breast cancer compared to women who were not exposed to the drug in utero.

Reporting in the recent issue of the journal Cancer Epidemiology, Biomarkers & Prevention, a nationwide team of researchers found that DES daughters over age 40 had 1.9 times the risk of developing breast cancer, compared to unexposed women of the same age. They also found that the relative risk of developing the cancer was even greater in DES daughters over age 50, but say the number of older women in their study group is, as yet, too small for a firm statistical comparison.

“This is really unwelcome news because so many women worldwide were prenatally exposed to DES, and these women are just now approaching the age at which breast cancer becomes more common,” said the study’s lead author, Julie Palmer, Sc.D., professor of epidemiology at the Boston University School of Public Health.

She said an estimated one to two million women in the U.S. were exposed to DES, which was frequently prescribed to women from the 1940s through 1960s to prevent miscarriages.

The ongoing study suggests that DES-exposed women are developing the typical range of breast cancers after age 40 at a faster rate than non-exposed women of the same ages. The researchers also found that the highest relative risk of developing breast cancer was observed in study participants from the cohorts with the highest cumulative doses of DES exposure.

Dartmouth researchers Wendy Wells and William Kinlaw are looking into a protein called S14. (Photo by Joseph Mehling ‘69)

William Kinlaw, an associate professor of medicine at Dartmouth Medical School, has been working on a protein called S14 since 1990. Over the past few months, however, the news about S14 has picked up. Through a series of recently published academic studies, Kinlaw and colleagues are ready to pronounce S14 a potential drug target in treating breast cancer.

“Over the past three years, we’ve learned about S14 and its role in communicating information about the nutrient and energy supply to genes mandatory for fat metabolism in breast cancer cells,” says Kinlaw, who is also affiliated with the Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center. “With this knowledge has also come the understanding that most breast cancers have found a mechanism to turn on the S14 gene”.

He explains that these tumors are ‘addicted’ to S14, because it is mandatory for the activation of a group of genes that allow the cancer cells to make fat. Kinlaw and his team have observed that breast cancer cells die if S14 is removed, and their analysis of human breast tumors indicates that S14 is critical for metastasis.

“This makes sense, as fat is a crucial fuel for breast cancers,” he says. “We believe this is particularly so during a tumor cell’s attempt to journey from the breast to other parts of the body, because the normal breast tissue supplies machinery that allows tumor cells to acquire fat from the bloodstream. Our data support the hypothesis that once the cells leave this metabolically friendly breast environment, the ability to manufacture their own fat becomes a make-or-break issue”.

These findings are supported by three recently published articles. First, a few months ago, Kinlaw and his team published a study in the February 1, 2006, issue of Experimental Cell Research that further explored S14’s relationship in driving fat metabolism in breast cancer cells. The scientists discovered that if you inactivate this protein, the cancer cells die. Because of this, Kinlaw explains, S14 may be a new anticancer target for breast cancer patients.

Second, in the July 2006 issue of Breast Cancer Research and Treatment, Kinlaw and fellow Dartmouth scientists Bernard Cole, Peter Morganelli, Gary Schwartz, and Wendy Wells published a study that connected the amount of S14 present in a given clinical breast cancer case to the prediction, with surprising accuracy, of which tumors would recur on long-term follow up. The scientists used a special new antibody made at Norris Cotton Cancer Center in their predictions. Kinlaw says that this study revealed the potential of S14 as a new marker for prognosis in breast cancer, and experiments are now underway to validate this result. Kinlaw has also tapped into the expertise at Dartmouth’s Tuck School of Business, where students formulated this idea as a model business plan for a class project for Gregg Fairbrothers, adjunct professor of business administration and the director of the Dartmouth Entrepreneurial Network.

And finally, the journal Endocrinology invited Kinlaw and his colleagues to review the topic of fat metabolism in breast cancer cells. In the review, which was available online on June 29, the scientists present a new theory of breast cancer metastasis and its relationship to fat metabolism and diet that focuses on S14.

“We’re now working to examine this idea rigorously in cancer-prone mice engineered to lack S14 in the mammary gland, and to find areas on the S14 protein that might be suitable for attack with a drug,” says Kinlaw.