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Remove lines from master cylinder and plug hose in master cylinder. The shop is doing it complete with heads and a list of the "good" stuff, - RV cam with entire new kit of lifters spings etc. This request is consistent with Executive Order , issued on January 18, , which instructs agencies to ensure the objectivity of any scientific and technological information used to support their regulatory actions. The granule cell layer of animals exposed to ppm appeared qualitatively normal. A sophisticated sighting and magnification system allow the user to precisely set parallax and zenith angle. Festo Introduces the DDLI Pneumatic Actuator for Servo Positioning and Force Control The new DDLI servo-pneumatic actuator from Festo delivers precise dynamic movement of large loads up to kg horizontally and 60 kg vertically — and cycle times up to 30 percent faster than comparable standard pneumatic actuators.

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The models suggest a retreat of the spruce-fir zone and an advance of the southern oaks and pines. In any case, our results show that species will have a lot less pressure to move their suitable habitats if we follow the path of lower emissions of greenhouse gases.

Our predictions of increase in range potential future suitable habitat are very likely to be overestimates of the actual ranges that would be achieved by the end of this century, as migration of most species will not keep up with relatively abrupt changes in climate, unless humans get seriously involved in moving species.

This comparative study, a first of its kind as far as we know, standardizes outputs from three unique forest landscape models across spatial four regions and temporal , , scales, a range of climate scenarios PCM B1 and GFDL A1fi , species 30 total, most common species; region totals varied from 15 to 24 , and evaluation metric future: Standardizing in this manner enables an increased understanding of underlying drivers of differences across models that use diverse approaches and assumptions.

Hereafter, we refer to the two sets of model projections as "unrefined" and "refined" niche model projections. The unrefined projections define the future locations of the climatic conditions in which the species is found today and thus areas that are likely to be climatically suitable , whereas the refined projections define the areas that are likely to be climatically suitable in the future and, given the effects of soils, interactions between plant functional types, the effects of CO2 enrichment, and fire, will likely support the plant functional type to which the species belongs.

What It Means to Nursery Managers and Tree Planters" is an excellent short introduction intended for landscapers and their clients, urging that planting for climate change become integral to the profession. The authors Williams and Dumroese distinguish 3 types of assisted migration: Florida Torreya is the illustrated example of type 3.

This paper by Susan March Leech et al. It was published 2 years after field experiments began for British Columbia's Assisted Migration Adaptation Trial , and is a superb overview of that effort.

Crucially, it sets the Canadian practices within the context of global climate initiatives in forestry. Climate Change Response Framework The Framework is a collaborative, cross-boundary approach among scientists, managers, and landowners to incorporate climate change considerations into natural resource management.

It provides an integrated set of tools, partnerships, and actions to support climate-informed conservation and forest management. Six Framework projects see map left encompass 19 states in the eastern USA , including 14 National Forests and millions of acres of forestland. Each regional project interweaves four components: Learn more about how the components interact to build a flexible, scalable, and effective strategy.

Climate Change Tools and Approaches for Land Managers 2nd edition, Map left shows dots for all the forest management institutional partners whose experiences in using the USFS climate resources have contributed to this second edition. Beginning as a pilot program in northern Wisconsin, this highly collaborative effort expanded to several ecoregional projects across the midwest and northeast United States. It builds off of two fundamental ideas. First, because climate change inherently adds complexity and un- certainty to the process of making forest management decisions, there is no single "answer" for how managers should address climate change in management.

Additionally, differences in existing management goals and values will naturally result in a diversity of adaptation actions. Rather than providing recommendations or prescriptive actions, we designed a flexible approach that accommodates a diversity of management goals, forest ecosystems, ownership types, and spatial scales Swanston and Janowiak Given the need to consider incomplete information and to "learn by doing," adaptive management principles are well-suited for incorporating climate change considerations into management.

Although no active management is currently planned in these stands, swamp white oak Quercus bicolor and bur oak Quercus macrocarpa were identified as two potential species that could be planted in lowland hardwood forests to maintain forest cover if intervention was deemed necessary.

These species are not currently present on the property but can be found in localized areas in northern Wisconsin, which would represent a small degree of assisted migration. Forest Service Although "assisted migration" is rarely mentioned in this report, the need for it is evident, particularly in the description of how the species mix is expected to shift: Boreal species such as quaking aspen, paper birch, tamarack, and black spruce are projected to decrease in suitable habitat and biomass across the assessment area.

Species with ranges that extend to the south such as American basswood, black cherry, northern red oak, and eastern white pine may increase in suitable habitat and biomass across the assessment area. Although "assisted migration" is only slighted mentioned in this report, it will be apparent to all knowledgeable readers that such assistance will be vital in this region. Notably, the boreal tree species with their southern-most current ranges in this region will greatly diminish or entirely wink out, so more southerly species will need to be introduced to ensure multi-layer forest health.

These species are currently very common across the landscape and play a dominant role in many forests, and the reduction of suitable habitat for these species may affect a large portion of northern Wisconsin and the western Upper Peninsula. Report excerpt at right: Balsam fir, black ash, paper birch, and tamarack also have low modifying factor scores, suggesting that there are life-history traits or biological stressors that may cause these species to lose even more suitable habitat than the model results indicate.

A given species will not necessarily be able to migrate to newly available habitat and colonize successfully, however. Species not currently present in the assessment area would require long-distance migration, whether intentional or unintentional, to occupy suitable habitat in the assessment area. Because the Great Lakes and the Straits of Mackinac present substantial barriers to migration, southern species may be even less able to occupy suitable habitat in the eastern Upper Peninsula.

Habitat fragmentation and the limited dispersal ability of seeds could also hinder the northward movement of the more southerly species, despite the increase in habitat suitability.

Most species can be expected to migrate more slowly than their habitats will shift. Of course, human-assisted migration is a possibility for some species and is expected to become tested and used during the next decades.

Click left chart for a short pdf by the forestry extension service, Michigan State University. USDA regional report A major transition in forest composition is not expected to occur in the coming decades.

Global warming is expected to occur with strong latitudinal differences: Projected shifts in habitat suitability for P. Red, yellow, blue and green represent lost, threatened, persistent and emergent habitat, respectively. Approximately 56 per cent of the contemporary distribution is predicted to be lost or threatened habitat by Mapped projections indicate the shift in the trailing edge encompasses the entire managed boreal forest in Canada.

Emergent suitable habitat totalled 28 per cent. Projections of the ecological genetic model into the climate of the decade centered on indicate the challenge for forest management is in assuring a timely transfer of trailing edge populations to the future location of the climates for which they are optimally suited.

Seed deployment zones for P. Each zone identifies a geographic area defined by two non-overlapping confidence intervals 7. Where and when to plant long-lived tree species in a rapidly changing climate may be one of the most significant and perplexing components of forest management. Historically, geographically-based seed transfer guidelines have been used in reforestation to manage the risk of maladaptation. Under a rapidly changing climate, however, the traditional guidelines lead toward increasing maladaptation as stands age.

An updated paradigm for seed transfer guidelines is an explicit acceptance of proactive transfer in anticipation of future climatic conditions such that there is a calculated initial elevated risk of maladaptation in an attempt to optimize adaptation over the life of the stand. The projected redistribution of western seed deployment zones by Figure 7B are not as geographically disparate as in eastern Canada. But, the loss of habitat in interior Alaska and along the Mackenzie River corridor down through Alberta could eliminate suitable climatypes before they provide seed for reforestation.

Consequently, there should be a sense of urgency in building a robust seed bank. Movement of genotypes to much colder climates may result in poor seedling survival and suboptimal growth due to frost damage. Rather, we recommend moderate scale transfers among breeding regions that are supported by both appropriate climate differences and population performance from field trials. For example, a transfer from central breeding region D1 northwest into region G2 represents a 1.

This transfer also results in slightly better performance of introduced D1 material compared to the local G2 sources Table 3, 1. Genotypes adapted to warmer region D1 temperatures would be safe to transfer under current climates and additionally be suitable under warming of mean annual temperature by 0. Given the uncertainty of future climate projections, methodological limitations inherent to provenance and progeny testing, and the need for planting stock to survive current climate conditions, assisted migration prescriptions should likely avoid very large transfer distances.

While results from experimental seed transfers in provenance and progeny trials may be among the most valuable information to develop climate change adaptation strategies, the data is not without problems. Genotypes tested in field trials may not have experienced rare climate events such as unseasonal or extreme cold temperatures in the boreal north.

Thus, good growth observed in populations transferred to colder climates may not necessarily reflect their long-term fitness. Another technical limitation of genetic field test is that competition in older trials may exaggerate genetic differentiation of genotypes.

We therefore recommend that transfers should generally be moderate approx. Such restrictions could gradually be relaxed to allow for longer distance transfers as the climate continues to warm. Only the top-performing families should be chosen for assisted migration prescriptions. As an alternative climate adaptation strategy to seed transfer among breeding regions, Table S1 may also be used to remove genotypes from local breeding populations, if their climate sensitivity is indicated by performing poorly when transferred to warmer breeding regions.

USFS Assisted migration underway! February news article: Forest Service researchers that the cause was due to climate change. With climate change, there has been less snow on the ground to insulate the shallow roots from extreme temperatures.

And with less snow on the ground, frozen roots have led to the decline of 60 to 70 percent of trees covering , acres in Alaska and British Columbia. Researchers also believe that yellow cedars may thrive in areas outside of where it has already migrated, leading to the hope that assisted migration may restore the dwindling population of these trees. However, there is also concern that assisted migration may cause yellow cedars to become an invasive species.

Nevertheless, a trial planting of yellow cedars in Yakutat has been successful with a first-year survival rate of more than 90 percent. What change in the environment triggered tree death in previously healthy forests? A chronology of the natural his- tory of yellow-cedar helps put forest decline into temporal context. The location of Pleistocene refugia Carrara et al. An ongoing population-genetics study will address this hypothesis for yellow-cedar.

At one location near Petersburg, Alaska, cedar pollen became abundant about years ago Ager et al. The Little Ice Age c. The ages of mature yellow-cedar trees, whether they are dead or still living, indicate that most of them regenerated and grew to their canopy status in existing forests during the Little Ice Age Hennon and Shaw , Beier et al. It was during the Little Ice Age that yellow-cedar became more abundant at lower elevations, where it would later be most vulnerable to decline.

The onset of yellow-cedar decline coincided with the end of the Little Ice Age Hennon et al. A large pulse of yellow-cedar mortality occurred in the s and s Hennon and Shaw during a notably warm period of the Pacific Decadal Oscillation Mantua A conservation strategy for a climate-sensitive species needs to consider the manner in which past, current, and future climates affect the various ecological traits and life stages of that species.

Because climate changes through time, the adaptive range of species becomes a moving target, and a conservation strategy must be dynamic. Climate is expected to impact each tree species in a unique manner; therefore, there is a need to model each species individually Iverson et al.

Our conceptual approach is to integrate snow cover and drainage in order to identify unsuitable, suitable, and potential new habitats for yellow-cedar. Specifically, we nested soil drainage within favorable climate envelopes, with an emphasis on adequate snow-cover levels, to define habitat suitability as the foundation for a conservation and management strategy for yellow-cedar figure 7. One species that might substitute for yellow-cedar in the maladapted zone is western red-cedar Thuja plicata [Donn ex D.

Don] , which grows in some of the declining yellow-cedar forests at lower elevations in Alaska and British Columbia, south of latitude 57 degrees N. Western redcedar is a calcium-accumulating, decay-resistant, long-lived tree of commercial value that is prized by the local indigenous people. Its bark and wood properties, including wood chemistry, differ from yellow-cedar's, but the two trees have some ecological redundancy and offer similar ecosystem services.

The northern range extent and elevational limit of western redcedar suggest that future warmer climate conditions will favor this tree in Alaska, which also appears to be the case in coastal British Columbia Hamann and Wang More knowledge is needed on redcedar's adaptation to the same freezing injury that afflicts yellow-cedar before intensive efforts of promoting redcedar in declining forests would be justified Schaberg et al.

When favorable climate develops beyond its existing range, yellow-cedar may be particularly slow to migrate because of its low reproductive capacity Harris The previously mentioned genetic study is designed to test the Holocene migration of yellow-cedar, which we suspect is slow and still proceeding toward the northeast. Yellow-cedar is absent from much of the widespread forested wetland in these areas, even though the conditions appear to be favorable for yellow-cedar and may have been so for thousands of years.

Yellow-cedar may benefit from some assistance in migration to speed the colonization of new habitats as the climate warms. Assisted or facilitated migration is the deliberate movement by humans of genotypes and species into areas in which the projected climate is believed to be associated with high probabilities of persistence.

These activities can be controversial, because widespread movements of species can be interpreted as fostering the introduction of invasive species that could bring unanticipated consequences.

Assisted migration may be required for species with narrow resource requirements or poor dispersal ability Warren et al. As a cautious step, we conducted a trial planting of yellow-cedar near Yakutat, Alaska, an area of discontinuous occurrence for yellow-cedar but still within its range limits; Hennon and Trummer to test the survival and growth of yellow-cedar where it did not previously grow.

New USFS technical report: A conservation and management strategy for yellow-cedar in Alaska is presented in the context of climate change. This document has four sections. Section 1 covers the ecology and silvics of yellow-cedar, as well as other background information. Section 2 outlines knowledge on the extensive mortality to yellow-cedar, including the role of climate. Section 3 describes opportunities for the conservation and active management of yellow-cedar on lands that are considered either suitable or unsuitable for yellow-cedar.

Section 4 uses risk models and yellow-cedar distribution data to evaluate, quantify, and map areas of habitat suitability for yellow-cedar, both now and predicted through the year Yellow-cedar at risk of forest decline by the end of the century varies considerably by geography in coastal Alaska.

Some areas are already heavily affected by decline, and risk is not expected to increase appreciably. Other areas are currently unaffected but are expected to develop decline. Still other areas are expected to remain healthy. This report provides a vulnerability assessment and the scientific foundation for conservation and active management of yellow-cedar on suitable and vulnerable lands.

Must say very impressed! A lot has changed since high school, I am 20 years old now and 5 months away from shipping out for basic training for the military cant enlist until braces are off.

Now couple years later terrible diet, virtually no excersise, and no supplements. I am 6foot 1 and pounds. Not chubby at all but def fat has hidden my 6 pack away: As I said I have a few months to jump back on board and I am dead serious about getting in the best shape of my life. I just bought YMCA membership and signed up for swimming lessons. I want to bulk up with some serious muscle mass and burn some of this 22 percent body fat and get it back down to healthy level.

Or will I need to make adjustments? Most people need to make some adjustment or another, as everyone is a little different. Yep, the workout shake will still work. Just stick with a single dose—for now at least. Hope you decide to join us man! What would you suggest? We live in Toronto too. Seems like a great place to train at! Fish oil timing is one of those cases. This program sounds awesome! And man, looking at this site just makes me so excited to join and try!

Thanks for the heads up Oliver! Hey Shane, thanks for your reply. I noticed that you have updated the links, but not all of them. The ones of whey protein and Maltodextrin are still invalid. Do you mean what do we mix the powders with? Some of our guys use milk though and use a bit less whey and maltodextrin so that it has the same overall nutrient breakdown. I only weigh 47kg.

Can you please suggest me a good one. They seem to be broken right now, as bodybuilding. Sorry for the confusion! So which one will give me better result. Still working on it! Hi Shane, thanks for the great post here. The info you guys provide has been very helpful in my quest to gain weight. I just started using the fish oil that you have recommended thanks for the links and you were right, this stuff is really quite easy to take.

However, I just read a study which links omega 3s to a higher risk of prostate cancer. I was wondering if you have read this study yet? I figured I will talk to my doctor about this one before continuing with the omega supplements. Oh man that study has been making waves! Interestingly enough, fish oil actually reduces your chance of getting prostate cancer in several other ways: Aaaaand keep in mind that MOST studies still show that consumption of omega 3s reduces your risk of prostrate cancer!

The media is always coming out with sensational stuff like this, as this new research is shock worthy and increases readership. Thanks Shane, what a great article! As a ectomorph struggling to put on weight this is very helpful. I was going through the comments and must appreciate the fact that you take the time to answer all questions your readers have.

Most of my doubts got clarified as I went through your answers. No problem Misha, glad it helped! And this post is broscience all the way. Just eat and lift heavy. My legs could use a lot more work though. I looking to gain another 10 to 15 pounds of muscle.

I train for strength as well for definition. You may not be a hardgainer at all, just a poor eater! You sounds like a good fit for this program, yeah. We can definitely bulk up the stilts, and nothing will do a better job of giving you a strong balanced physique than squats and deadlifts!

Hey Shane, what is your opinion on oatmass as an alternative to maltodextrin? Or, rather, blended oats, as they are essentially the same, right?

This stuff is working! However, Ive gained unwanted fat in my middle section, and thighs, where that was never happening in the past. I weigh now around lbs. I still appear skinny to most, but I may be average. Do youvthinkbthos program is right for me? Most guys have a bit of this or that mixed in, often in the form of carrying a little bit extra around the middle hehe.

Now, here comes the problem: Does you guys or any one of your clients ever got ANY stretch marks on your skin due to rapid muscle building? A lot of us ectomorphs have stretch marks from growing UPwards though. A lot of us take to puberty by rapidly shooting sky high instead of getting muscular, it seems. It awes me how much you guys are into this for us, ectomorphs.

The past two weeks I merely stood at my current weight. I want to have the leanest possible bulk ever cutting being an ectomorph? I know what you mean. By super leanly bulking you can always maintain your strength of being lean while adding on the new strength of being strong and healthy.

You need to gain weight to grow, so a calorie surplus is your friend! I like to track using the vein on my bicep. I take creatine with some food and use whey after workout but how to use dextrose and maltodextrin: Shane, I read that you use 15g of Creatine when you try to gain some weight.

Is this true or is our maximum of creatine as being an ectomorph much higher? Yeah I used to take 15g of creatine spaced out over a couple hours. Some creatine might have been flushed out, yeah. Hey Shane I wanted to know other than the days im working out and making that double dose shake, should i be having just a regular whey protein shake the days im off?

And is having all that protein healthy for you? Universal Torrent is a pretty good gainer, although once you start having several servings at once the cost quickly adds up! The maltodextrin they load the stuff with costs them pennies and costs you several dollars. I figure may as well just buy it yourself, mix your own perfect ratio, and save a bit of money. Can trim the doses down and fiddle with things if you ever decide to cut or anything. Getting your protein from a variety of sources is best, and yep whey protein is a totally valid place to get it.

I get more than enough there. Can you refresh the links of the lists of supplements please. Thanks in advance for your reach article that helps me a lot. Lets say will I have to increase my protein intake overtime?

And I also read that your body absorbs about 25g of protein in an hour so what would be the point of doubling your protein intake if it would all be converted into waste? I am looking forward to stop drinking Gatorade as it contains quite a lot of sugars, and buy maltodextrin instead as it looks much healthier, thank you Shane for your time and keep it up!

Your site is great. Thanks for the kind words Juan! Comments like yours are why I love writing blog articles so much. Gold Standard is sweet.

ON is a good company. Bananas are sweet too, and a great source of vitamins and minerals as well as being a good source of carbs. I think Gatorade is made out of sucrose, which contains fructose. Fructose is absorbed very differently from glucose and not necessarily in a beneficial way. Not the best thing to be taking in high doses while training. I mean bananas have so many amazing things going for them. If you like the flavour of Gatorade, you could try adding a scoop of Xtend to your drink.

You can buy flavouring like citric acid separately too. Yep, you can develop an intolerance from eating too much of anything, really! If your body can only absorb 25g of protein in an hour then drinking more than 25g of whey in an hour will just mean that it takes longer than an hour to digest all of the protein!

If we just peed calories out if we ate them too fast that would be the best news ever for chubby guys and gals, who, presumably, could eat entire cakes just fine so long as they ate them quickly enough. I use a protein shaker 20oz. You could drink 1 in the change room beforehand, 1 in the gym and 1 after. Thanks Shane for all the help and advice. Can i make this with milk or is the taste not gonna be as good?

Also how much milk would you use if you use 28 oz of water? You could probably make it with milk so long as you feel good while drinking it. Could be that fat soluble vitamins, like vitamin D, work better in whole fat milk. Shane im sure you answered this somehwere but since carbo gain doesnt have a scoop how do you measure out a serving size? Or how many scoops would i use if i used the scooper from the gold whey box. The tub should have nutrition information on the side … but who weighs their food?

Right now Jared and I are trying waximaize maltodextrin is way more enjoyable — waximaize seems to be the twin of corn starch and it came with a scoop. And can you help me choose the best creatine brand? Dextrose tastes like milk sugar, and waximaize tastes like cornstarch — up to your taste buds!

Might be better for the teeth, too? Have it right after you finish your workout. That will double the dose and give you some extra calories and extra protein to play around with. No need to double the creatine, although you could! I am 17 years of age. I know eating more and being beastlier in the kitchen is easier said than done, so just take it day by day and try to build up progressively better and better habits! After all your gains, do you still take supplements?

I mean, when people reach their goals in terms of bodyweight, do they stop taking supps easily? I ask because in my country supps are overtaxed, so I see it as an investment, instead of a cheaper alternative to food.

I stress constantly about it, and I just been thinking about anything that could help me with building muscle drug-free is a go, so supplements are my first choice. Buuut… people become hostage to this shit. I wonder if it would be possible to drop naturally, with ease, them once I packed those 20 lb.

Would you guys mind telling me a little about your thoughts and experiences? I used to wonder that all the time myself. Ergogenic supplements SuperPump, NO xplode, jack3d, etc: I felt like I went from being superman to a weak old man when I stopped training with them.

The homemade ones are very cheap, and, for MOST people, cheaper than their whole food equivalents. You can accomplish your gains and then use very minimal dosages or stop using them entirely. Gainers QuickMass, Serious Mass, etc: Kind of useless to begin with and massively overpriced. Food replacements, like whey protein: Stuff like fish oil you might want to take forever. Stuff like vitamin D is tricky to get naturally, as you need to be outside a lot to encourage your body to synthesize enough of it.

Most people need to supplement with it or drink milk, which is fortified with it. Anyway, the short answer to your question is no: If nutritious whole food is cheaper and more accessible for you and you have the appetite to eat it then you could forget about supplements altogether!

Good luck gaining your final 20!! Supplements are still cheaper than most whole foods, but not as cheap as you might think. It is still cheaper taking malto than buying whole food price per calorie , but in the specific case of whey and pre-wo, they are way off the range.

Yeah, that helped a lot! So, did you stop taking supps entirely now that you reached your final weight? I really like it, and I like having goals to work towards. I still take supplements. It sounds like things are different where you live — I do know that food in Canada is expensive relative to other countries — but whey here in Toronto is muuuch cheaper than, say, chicken breasts, steak or ground meat.

If you call it a supplement I also absolutely adore coffee! I have a nice hot mug before pretty much every workout and love it pretty heartily. As for your creatine questions: Not everyone gets water retention from creatine. All the extra muscle you built while on it … that will stay. How much lean mass can you expect to gain? I went in an added a bunch of studies to the creatine section today.

Well, that was the original plan. To be completely honest, I did take around g of malto after workout days for a few weeks and gained some weight. Not that much, though, never passed on my max weight. Maybe 1 or 2 lbs. VERY slowly, way slower than I would see elsewhere.

One thing is the scale moving slowly, other thing is the scale not moving at all! Had problems with whey concentrate, might try isolate. Focus on moving up your weight on the scale each week instead i. Now that you have my info, my questions: Do you recommend otherwise, and how many servings per day and when is the best time? Please mention the creatine servings too. I noticed last year, although not sure, that briefly taking Whey with milk induced mildish stomach pains.

Also, how much cardio should I do? Is a minute session good enough? I usually go start with 1 set wide pull-ups, 1 set push-ups, then 1 set dumb-bell chest-press, 1 set crunches. REST, repeat 3 times. I substitute the chest-press with the lat pulldown on alternate days, and also include bicep curls, and traps sometimes, and holding a dumbbell while squatting. What do you suggest overall, and how is my plan looking? Where would I be in 3 months? You live in a place where you pretty much only have access to fish, green vegetables and eggs?

Sounds like some sort of super-health haven! As for creatine, you want around 6g a day. Your body needs about 3g per day, but we lose a few grams when we take it. We do some dynamic stretches, a few mobility drills and practice our lifting technique at the beginning of every training session. Different programs are constructed in different ways. As for a specific workout program for you, I would follow one made by an expert!

You could use our program which I obviously think is the best one out there ever , or any other number of great programs out there. Definitely thinking about joining the program but have some questions about what I can expect in your program. Nevermind — the email bounced from the account you have attached to your comment.

Shoot us an email at us bonytobeastly. Hey shane i was wondering how many scoops of the carbo gain using the scooper from the gold standard whey is equivalent to 1 serving?

If i am trying to put on a good amount of weight do you sugesst using the 3x dose? A whey scoop holds about 30g 24 of which is protein. For every nice full scoop of whey you put in the drink, put 2 kind of wimpy scoops of maltodextrin in.

As for how much you should take, I would let your abs decide. I handle them well, as do most naturally lean super skinny dudes, so a triple dose works well for me. Start with a single, scale it up. Thanks a lot man that def helps…Il be putting in 4 wimpy scoops of cargo gain then for a double dose!

Are you drinking this concoction only on workout days? If so, does this mean your daily caloric intake swings quite a bit between workout days vs. Yes and often yes! We seem to respond pretty well to cycling carbs and calories. You could skip a snack or shrink the serving sizes of some meals, etc.

Excellent article with studies. I read most of them and went out to buy the 8 lbs of Maltodextrin. I went to research more into Maltodextrin and came across this study http: Our diets DO affect our gut flora, and the healthier and more balanced our diet tends to be the healthier and more resilient that flora tends to be.

WebMD is telling me that these foods commonly cause symptoms to flare up:. Currently, it is unclear how environmental factors contribute to the development of disease. Dietary studies in both mouse models and humans demonstrate large shifts in the composition of the microbiota dependent on diet [16], [25], [26], [27].

Likewise, human studies comparing obese and lean twin pairs demonstrated changes in Bacteroidetes prevalence and a decrease in microbial diversity in obese individuals [47]. The last line says: If these individuals carry other risk factors for CD genetic variants of anti-bacterial response genes such as ATG16L1 or NOD2, for example , this may result in the development of disease in these susceptible individuals.

These findings describe a potential disease mechanism linking the ubiquitous dietary additive MDX to microbial changes in the intestine of CD patients and suggest a novel therapeutic area for the prevention and treatment of inflammatory bowel disease.

You are also, of course, perfectly welcome to play it safe and get your carbs from somewhere else! What changes did you make in the October update? I might have a bad memory, but could it be that you had glutamin in there before? If so, why did you drop it? Hey LJ, the changes are prrretty small.

We added in a little excerpt from Alan Aragon, explained the methods behind our madness a little more clearly, and we added in a couple more reference studies. Last month we made a slightly more significant change though — we added a TON of new studies, we switched over to recommending Amazon.

Amazon is one of the few sites that stocks it. Consume lots of easily digested proteins, carbs and calories surrounding your training and in general … but still get the majority of your calories from minimally processed nutritious whole foods. Creatine is the most powerful legal muscle-building supplement out there, and it also happens to be cheap, healthy and very very well researched for decades now.

Fish oil helps you get a more balanced fat intake and it has a bunch of promising effects on your health and body composition. Vitamin D is a fat soluble vitamin, so taking it alongside a fat like fish oil allows it to be properly absorbed.

Vitamin D fortified whole milk is another effective way to get your vitamin D in. Anyway for now i was really hoping if you could help me anyway with some tips, having just bought some malto and whey i made my first post workout drink of double dose, and for 30 mins afterwards i felt pretty sick lol. I train 3 times a week doing all the major compound lifts, I eat around calories a day but it seems nothing is paying off right now, being stuck at this size is becoming really disheartening, really knocking my confidence man.

I was wondering if maybe you had any tips for me, tired of being this skinny where i can see my hip bones lol.

Being in the UK is great. One of the strongest and most helpful guys in the community, Steve, is British. Yeah some people handle the drink better than others. The best thing though is to get a really firm grasp on the fundamentals of lifting and eating to build muscle. Shane I think you saved my life… I started bodybuilding a few times, never really bulk any weight… So this time I was determined to use steroids… Gladly I found your website.

Now I would have a question… In my country gainers are much more cheaper than protein, so I will use Serious Mass. The serving size is gr. Could you tell me please how much sould I take during a day, and if I must take-it in non-workout days too?

I have some financiar issues, but when I will overcome those, definitely I will sign up for your program. Gainers are usually cheaper than protein but more expensive than maltodextrin. Buying protein and maltodextrin and mixing it up yourself is often cheaper.

Definitely the same idea — the ingredients in Serious Mass are first maltodextrin and second protein albeit a blend. Whole foods will be markedly better. I just noticed the new pictures that u put up of yourself..

I wud also like to share that i gained 5 more kgs since i last messaged you so i weigh in at My aim is muscle gain especially in the arms. Can i mix whey or a protein blend and mix it up with milk, bananas and peanut butter to achieve the same effect as Serious Mass? Have you used Serious Mass or Combat before? Musclepharm Combat 4lbs blend or Serious Mass 12 lbs? Keeping in mind my aim of muscle gain and of-course cost effectiveness.

Eagerly waiting for your reply. No, the effect would be different. Weight gainers do work for ectomorphs — they provide carbs, protein and calories, after all. Man, I felt like such crap after taking them. Bananas are badass at building muscle. Same deal with peanuts and milk — totally badass in all kinds of subtle ways in addition to being great sources of macronutrients and calories.

As for gaining in your arms, stay tuned! A lot of us skinny guys have long lanky arms and struggle with catching them up myself included , even after gaining a bunch of proportional weight. Thanx a lot man! Is it really needed or is it available in a sufficient quantity in the protein drinks or gainers? Also do u guys use them? Also i would like to make some requests.. Can you please also make a page where you review various supplements in a video form and discuss about its effectiveness, cost effectiveness and profile?

Please upload some videos showing the proper form and movements with which exercises should be done.. Please upload some pictures of your own transformation over the years and last few months.. No need to worry about them. I bought a little tub today to give it a try. The other is caffeine. It makes a pretty potent pre-workout supplement. No need to get fancy — a cup or two of coffee is fine.

We downplay vitamin D a bit here too. You really do want to get your vitamin D levels in order. Hi Shane, I Have been drinking the shake for about a month now and still cant seem to gain any weight. I use 2 scoops of the whey and 3 scoops of the carbo gain using the whey scooper. Any recommendation of what I can do to increase my weight gain?

Nothing worse than pouring money into all kinds of supplements and not getting anything out of them at all. Did you read the beginning of the article? Taking supplements without first mastering the fundamentals is like upgrading the engine of a car that has no fuel in it.

Shane I want to buy the program. Can you tell me how many days a week are you at the gym for the program? We train three times per week, each workout lasts about an hour, and we hit each major muscle group each time. As you know already my budget is very tight me and my dad are building a bench , and I also found a very cheap maltodextrin in my country more than half of the price of NOW Carbo Gain — the one that you recomended.

BUT here is the description:. You always want to buy from respected brands — ideally big companies that are getting tested by independent consumer labs. We need enough protein, not as much protein as possible. Check this article out:. With that said their numbers seems a little off.

It also very much depends on your goals. That article seems to be trying to be controversial. I mean, you can get your protein from chicken or protein powders. Thanks for taking the time to read this, you guys rock! I will see you guys on the beastly side next month after my payday LOL! It takes many hours for things to pass through your intestines, so absolutely no worries of it coming out the other end that quickly after you ingest it!

I have at least 5 meals per day with at least 3 being lots of white rice as it opens up my appetite too. Coupled with mg of vitamin daily, I gained about 20 pounds of lean muscle mass.

As Shane mentioned before, things will really change. People are taking me much more seriously now not that they are shallow but in a natural human reaction kinda way. Our pyshique and confident attitude plus aura we exude really tells alot about us. Being is no biggie to me yet but it made all the difference when everyone who knew you WILL notice and the compliment they give only serve as further motivation. Thanks for sharing man. Either dextrose or maltodextrin would be fine, although this one certainly tastes much better!

Hey Shane, good blog! Now I have this question:. I use dextrose instead of maltodextrine. Whats the difference between using dextrose in the shake instead of fine powder oats?

Is it better to use dextrose in the training shake and fine oats after training or vice versa? A friend of mine also uses amino acid tablets instead of amio acid powder. Which one do you recommend for an ectomorph?

Whats your thought on this ZMA supplement? Dextrose and maltodextrin are both fine. Both are rather quickly digested sources of glucose. Both are easy on the appetite, too, since their fibre content is, well, non-existent. Powdered oats are cool too, and a lot of our Australian members go that route, for some reason.

Less easy on your appetite perhaps? You could definitely go for powdered oats. I would recommend protein powder for an ectomorph, not BCAAs. See the beginning of the article. Coffee is great pre-workout! Creatine you can take whenever, so I usually just mix it into my workout drink or have it with breakfast.

Tier One Pre-Workout Supplement. Ideal dose of caffeine, ideal dose of the best brand of creatine and the ideal dose of beta-alanine which is promising but not very well studied. How many calories do you estimate you were eating when you gained your first 20 pounds? And did you use supplements then? I really have no idea how many calories I was eating. I could have saved myself some time, money and trouble had a I bought supplements, but back then I was eating tons and tons of whole foods — lots of chicken, fish, whole grain bread, cheese, milk, potatoes, etc.

In retrospect, even just whey would have helped a ton. Preparing all that meat was expensive and a huge hassle, and the chicken and fish leftovers I was warming up in the microwave tasted pretty awful ….

When is the proper time to take this shake? Is it hours before going to the gym or during your workout? Also, should i be taking another shake after my workout? With 30 grams of protein and 5 grams of creatine? I have taken this shake once before with 30 grams of protein, 60 grams of Cyto Carb and 5 grams of creatine and the shake seemed kind of thin, should i be increasing my dosage? So yep, that would take care of the nutrient timing benefits. Infiltrating lobular carcinoma of the breast.

DiCostanzo D et al. Prognosis of infiltrating lobular carcinoma. An analysis of "classical" and variant tumors. Histological variants of infiltrating lobular carcinoma of the breast. Fisher ER, et al. Tubulolobular invasive breast cancer: Weidner N, Semple JP. Pleomorphic variant of invasive lobular carcinoma of the breast. Eusebi V, et al. Pleomorphic lobular carcinoma of the breast: An aggressive tumour showing apocrine differentiation.

The significance of signet-ring cells in infiltrating lobular carcinoma of the breast. Developing a Prognostic index for ductal carcinoma in situ of the breast. Are we there yet? Silverstein MJ, et al. A prognostic index for ductal carcinoma in situ of the breast. Prognostic classification of breast ductal carcinoma in situ. Intraductal carcinoma ductal carcinoma in situ. Holland R, et al. Microcalcification associated with ductal carcinoma in situ: Semin Diagn Pathol ; Ductal carcinoma in situ: Leal CB, et al.

Ductal carcinoma in situ of the breast; histological categorization and its relationship to ploidy, and immunohistochemical expression of hormone receptors, p54, and c-erbB-2 protein. Sneige N, et al. Ductal carcinoma in situ treated with lumpectomy and irradiation: Douglas-Jones AG, et al.

A critical appraisal of six modern classifications od ductal carcinoma in situ of the breast DCIS: Consensus conference on the classification of ductal carcinoma in situ. Modern Pathology ;11 2: Immunohistochemical detection of steroid receptors inbreast cancer: J Clin Pasthol ; Immunocytochemical estrogen and progestin receptor assays in breast cancer with monoclonal antibodies. Histopathologic, demographic and biochemical correlations and relationship to endocrine response and survival.

Pertschuk LP, et al. Estrogen receptor immunocytochemistry in paraffin embedded tissues with ER1D5 predicts breast cancer endocrine response more accurately than HSpgamma in frozen sections or cytosol-based ligand assays. Andersen J, et al. Immunohistochemical estrogen receptor determination in paraffin-embedded tissue. Prediction of response to hormone treatment in advanced breast cancer. Goulding H, et al. A new immunohistochemical antibody for the assessmnet of estrogen receptor status on routine formalin-fixed tissue samples.

Human Pa thol ; If history and physical examination are normal, other staging investigations may not be necessary. If there are any abnormal findings, these should be further investigated as appropriate. If the patient presents with locally advanced breast cancer large tumour, node positive or inflammatory breast cancer, the risk of metastatic disease is higher.

Staging prior to any treatment bone scan, chest CT or x-ray, abdominal CT or US and, laboratory investigations including liver enzymes should be considered. In the absence of symptoms suggesting metastatic disease, staging should be done postoperatively based on final pathology. Staging of breast cancer is based on final pathology. In asymptomatic patients with newly diagnosed cancer, the following staging investigations are recommended based on the pathologic staging: Baseline tumour markers including CEA, CA and CA should only be considered as part of the initial staging for patients with metastatic disease.

If normal, they need not be repeated, unless there is a documented or suspected progression. Other than these investigations, prior to chemotherapy, a hematology and chemistry panel should be done to rule out bone or liver metastases and to ensure adequate marrow, hepatic and renal function.

Diagnostic radiologists, medical oncologists, pathologists, radiation oncologists and surgeons typically attend these conferences. The clinical history, physical examination, pathology slides and diagnostic imaging studies are reviewed and management options are discussed. Family physicians and surgeons are welcome to attend these conferences. Patients with breast cancer should be supported in their decision-making about what treatment pathway is best for them.

The information in this section of the Cancer Management Guidelines is our current approach to patients with breast cancer. It is not intended to be a comprehensive manual on breast cancer and its treatments nor is it intended to imply that the approach given here is the only acceptable approach. People with a suspected diagnosis of breast cancer should undergo percutaneous core biopsy , to confirm the pathology.

Patients with a new diagnosis of non-metastatic breast cancer should be referred initially to a surgeon with experience in breast cancer surgery for assessment regarding operability and discussion of surgical options.

The breast should be imaged with a mammogram and ultrasound, and if these investigations are non-diagnostic, an MRI of the breast should be carried out. Biopsy of any suspicious abnormalities found on imaging should be done. Recommendations for radiation and systemic therapy are based on the pathology of the underlying breast cancer.

A margin of underlying breast tissue should be excised with the nipple-areolar complex to evaluate for an associated in-situ or invasive cancer. Axillary staging is not initially required in the context of breast conserving therapy. Mastectomy represents a surgical option. A referral to plastic surgery for reconstruction of the nipple-areolar complex should be considered. Appropriate management of pure DCIS requires detailed mammographic evaluation of the breast to obtain an assessment of the preoperative extent of the lesion.

Close cooperation and communication between the radiologist, surgeon, pathologist and oncologist is crucial to ensure adequate local therapy in patients treated with breast conservation. Treatment for patients with concomitant microinvasive and invasive disease should be based on the presence of the invasive disease, as discussed in separate sections.

Sentinel lymph node biopsy is advised for patients undergoing mastectomy for DCIS due to the possibility of an invasive component in the final surgical specimen. DCIS is a non-obligate precursor of invasive disease. At present, all patients with pure DCIS are offered treatment. Patients with pure DCIS may be treated with breast conserving therapy or mastectomy. Patients undergoing breast conserving surgery including partial mastectomy, lumpectomy, wide excision, or excisional biopsy with a positive margin defined by ink on DCIS after surgery should undergo wider local excision.

A 2-mm margin is associated with a decreased risk of in-breast tumor recurrence compared to narrower margins. Margin widths greater than 2 mm do not confer a significant benefit in local control compared to a 2 mm margin and thus re-excision for margins wider than 2-mm should not be routinely carried out 2. Clinical judgment should be utilized for determination of the need for re-excision in patients with a smaller negative margin width 0.

Radiotherapy reduces the incidence of in situ and invasive breast recurrences after breast conserving surgery by half. Radiotherapy should optimally start once healing from the partial mastectomy is complete, generally within 10 weeks of partial mastectomy.

If post-operative problems occur, including hematoma, large seroma, infection, breast edema with erythema, or wound dehiscence occur, the start of radiotherapy may be delayed to allow resolution. There is no randomised trial evidence showing detriment to delay the start of radiotherapy however, retrospective data from British Columbia shows that there is no detriment to delay up to 20 weeks after BCS for patients with invasive disease 7 , which likely also applies to DCIS.

Radiotherapy planning and prescription is similar to those with invasive disease and are described separately. Women with very diffuse areas of DCIS e. The use of adjuvant hormonal therapy is somewhat controversial. No randomized trial has shown an improvement in survival with tamoxifen. Contraindications to tamoxifen are discussed more thoroughly below.

The role of adjuvant aromatase inhibitors is not clearly established. A randomized study of adjuvant tamoxifen versus anastrozole in women with DCIS treated with lumpectomy showed that anastrozole offers a similar degree of benefit and similar number of side effects as tamoxifen, although the side effect profile differed.

American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. Epub Sep Effect of radiotherapy after breast-conserving surgery for ductal carcinoma in situ: Breast-conserving treatment with or without radiotherapy in ductal carcinoma in situ: Effect of tamoxifen and radiotherapy in women with locally excised ductal carcinoma in situ: Intervals longer than 20 weeks from breast-conserving surgery to radiation therapy are associated with inferior outcome for women with early-stage breast cancer who are not receiving chemotherapy.

Breast Cancer Res Treat. Epub Aug 9. Nomogram for predicting the risk of local recurrence after breast-conserving surgery for ductal carcinoma in situ.

Evaluation of a breast cancer nomogram for predicting risk of ipsilateral breast tumor recurrences in patients with ductal carcinoma in situ after local excision. A population-based validation study of the DCIS Score predicting recurrence risk in individuals treated by breast-conserving surgery alone. Use of this term is controversial. Most modern authors regard this as indicating a high risk for the development of infiltrating carcinoma in either or both breasts. The risk for subsequent carcinoma is not confined to the segment of the breast involved by the in situ change.

The risk to each breast is approximately equal and approaches fifteen percent within ten to fifteen years. When LCIS is identified on an excision specimen, re-excision is not required, although should be considered in pleomorphic LCIS if the margin is not adequate. Patients can be given the option of either careful follow-up or occasionally, bilateral mastectomy with or without immediate or delayed reconstruction. Tamoxifen was shown to decrease the risk of invasive cancer in women with LCIS in the NSABP prevention trial using tamoxifen 20 mg daily for 5 years, although there was no improvement in survival.

Tamoxifen can be considered if breast cancer prevention is the primary goal. Classic LCIS behaves as an indicator lesion for higher risk of breast malignancy in any region of the breast. When detected in isolation, PLCIS has a pattern of recurrence more similar to a precursor lesion such as DCIS with a higher risk of malignancy within that region of the breast.

There are no randomized trials that describe what margin should be achieved with surgery or the efficacy of adjuvant breast radiotherapy in the setting breast conserving surgery for PLCIS. It is recommended that patients with PLCIS on biopsy have excision to rule out additional pathology and achieve clear margins for PLCIS and should also have a discussion regarding the possible benefits of adjuvant breast radiotherapy or more definitive breast surgery.

T3N0 Updated February Management of Invasive Breast Cancer Invasive breast cancer requires multimodality management that is specific to the stage of the disease. Definitive treatment of early invasive breast cancer is surgery.

Typically, the primary tumor is excised and axillary lymph nodes are removed for staging. The decision of when to proceed to surgery and which procedure is best for an individual patient has become more complicated with the options of neoadjuvant chemotherapy and immediate breast reconstruction, and with changing recommendations for radiotherapy and chemotherapy.

Sequencing of breast cancer treatment is more commonly done with multidisciplinary input. A general overview of breast cancer surgery is outlined below and additional information on special circumstances, such as young women, elderly patients, pregnant patients, and male breast cancer are found in following sections.

Breast conserving surgery BCS, lumpectomy, partial mastectomy or segmental mastectomy or breast conserving surgery plus radiotherapy has been shown in multiple randomized control studies to be equivalent to mastectomy in terms of survival and breast cancer outcomes for patients with early-stage disease 1,2. Additional strategies such as oncoplastic lumpectomy resections and tumor shrinkage with Neoadjuvant Chemotherapy NAT can increase the number of patients eligible for BCS. MRI is not recommended in the routine assessment of unilateral breast cancer as there has been no improvement in survival or repeat surgery rates by using MRI and the additional investigations and findings can result in delay or overtreatment to the known cancer.

Patients with a positive margin should be evaluated for further surgery. Patients having BCS should be referred to radiation oncology as radiotherapy significantly lowers the risk of in-breast recurrence in the setting of BCS. However, there is a group of patients felt to be at low risk of recurrence with BCS alone who may be spared radiotherapy. The addition of a radiation boost to the tumour bed reduces the risk of IBTR. However, re-excision to obtain negative margins may reduce IBTR more than using a radiation boost.

The use of systemic therapy also minimally reduces IBTR. Those with positive margins have double the risk of IBTR compared to those with negative margins. There is conflicting data regarding the risk of IBTR with close margins.

Most of the randomized trials of breast conservation with radiation vs mastectomy were in the context of no tumour seen at ink at pathologic examination of the resection specimen, although retrospective studies demonstrate an increased IBTR with both positive or close margins. There is no evidence that re-excision alters survival compared to radiotherapy boost. The degree of survival impact of either, in the setting of close margins in particular, is expected to be small, or negligible, particularly in the absence of other risk factors.

For patients with a high systemic failure risk e. It may also be reasonable to accept a higher risk of IBTR in patients for whom further local breast surgery would result in an unacceptable cosmetic result, but for whom there is a strong desire to avoid a mastectomy, or if medical problems preclude further surgery. In these situations, a radiation boost would likely be used, albeit this can also affect the cosmetic outcome.

Guidelines for Re-excision and Radiation Boost following breast-conserving surgery. For patients with invasive disease, invasive or in situ disease at the margin will be treated in the same manner. The definition of a negative margin is no tumour at the inked margin. A positive margin is defined as tumour touching ink. In British Columbia, a close margin is currently defined as less than 2 mm margin.

Re-excision to obtain negative margins is recommended for patients with positive margins. A radiotherapy boost is usually recommended in the setting of a close margin. Patients with close or positive margins who decline re-excision should be advised that the risk of IBTR is increased. Early consultation with a radiation oncologist is recommended if there is uncertainty about whether re-excision is recommended.

This will facilitate a timely re-excision. Re-excision should be carried out prior to adjuvant radiation but does not need to occur prior to systemic therapy. If, after this, it is still not possible to accurately determine the margins, then the margins should be treated as unknown in which case a re-excision or radiation boost is generally recommended. Total mastectomy TM is defined as the removal of entire breast. Skin sparing mastectomy SSM is used in conjunction with immediate breast reconstruction and studies have shown no increased recurrence risk with use of this technique When assessing a patient for a NSM, considerations include location of the tumor, nodal status and need for radiotherapy, and tumor biology.

Total Mastectomy TM, SSM, NSM is an option for patients with early stage breast cancer particularly for patients with contraindications to radiotherapy or desire to avoid radiotherapy, patients who would have a poor cosmetic outcome with breast-conserving therapy or those with multicentric disease or associated diffuse, extensive DCIS. Mastectomy should also be considered in those who continue to have positive margins of invasive disease after multiple breast-conserving surgeries. Axillary surgery provides important prognostic information and can improve regional control for some patients with invasive breast cancer.

Traditionally, level I and II axillary node dissection ALND had been the standard of care for all patients with invasive breast cancer. Axillary lymph node dissection is recommended 12,13,14,15,16,17 Surgical Breast Tumor group consensus in the following situations: Inflammatory breast cancer Occult breast cancer presenting as axillary node metastasis Clinically node positive axilla, confirmed by FNA or core biopsy in a patient for whom neoadjuvant chemotherapy is not planned Axillary nodes that remain positive after neoadjuvant chemotherapy Axillary recurrence following previous breast cancer treatment.

Level 1 and 2 axillary dissection is generally recommended for those with three or more pathologically positive sentinel nodes and those at high risk for gross residual nodal disease after sentinel node procedure e.

It is recommended that surgeons report breast cancer procedures using this template to facilitate communication of relevant details to other care providers. The specimen removed at partial mastectomy must be oriented by the surgeon. At least two boundaries should be marked with sutures of different color or length so that the specimen can be oriented in three dimensions e. With a correctly marked specimen the pathologist will then be able to make an accurate estimate of the size of the tumour-free margin and to identify the location of any margin thought to be inadequately excised.

If the margin is inadequate in a location where it is possible to improve the situation surgically, then a re-excision should be carried out. For a modified radical mastectomy, axillary end should be marked for orientation so that the location as well as the number of nodes removed and involved by malignancy can be ascertained.

Patients who require a mastectomy to treat unilateral breast cancer often enquire about contralateral prophylactic mastectomy CPM. A detailed history and family history is required to assess the risk of a contralateral breast cancer CBC. For the average woman the risk of CBC is less than 0.

Systemic treatments also reduce the risk of CBC. CPM in an average risk woman does not improve cancer outcomes. As such, CPM is not recommended for women with unilateral breast cancer. A Canadian expert consensus statement on this issue is a work in progress. The link will be posted here once it is available. All women undergoing mastectomy should be offered a reconstruction and referral to a plastic surgeon if they are clinically candidates.

Reconstruction can be performed at the time of mastectomy immediate reconstruction or as a second procedure delayed reconstruction. Options for reconstruction include autologous tissue vs implant reconstruction. Current review of breast reconstruction is found in the Surgical Oncology Network Newsletter Spring Fisher B, Anderson S, Br yant J et al Twenty year follow up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.

N Engl J M ed ; Twenty year follow up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med ; Preoperative MRI and surgical management in patients with nonpalpable breast cancer: Epub Dec Schnitt, Armando Giuliano et al.

Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. Sentinel lymph node resection compared with conventional axillary lymph node dissection in clinically node-negative patients with breast cancer: Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases.

Sentinel lymph node biopsy for patients with early-stage breast cancer: American society of clinical oncology clinical practice guideline update. Accessed April 21, Judy C. Annals of surgical oncology. October , Volume 23, Issue 10, pp — https: Patients treated with breast conserving surgery BCS; lumpectomy, partial or segmental mastectomy for stage I or II breast cancer should have a consultation with a Radiation Oncologist regarding the role of radiation therapy RT.

RT to the breast following BCS reduces the risk of breast recurrence and lowers the risk of systemic recurrence and breast cancer death. RT should follow BCS unless contraindicated due to patient comorbidites, limited patient life expectancy, patient desire to avoid RT, or in selected low recurrence risk situations see below.

If post-operative problems occur, including hematoma, large seroma, infection, breast edema with erythema, or wound dehiscence occur, the start of RT may be delayed to allow resolution. In such cases or to accommodate patient convenience, there is no randomised trial evidence showing detriment to delay the start of RT until 20 weeks after BCS.

If the patient receives adjuvant chemotherapy, then RT should follow the chemotherapy and start approximately weeks after the last intravenous chemotherapy. Trastuzumab as a single agent may be delivered concurrently with radiation therapy.

Adjuvant hormonal therapy may be commenced prior to or after RT. Randomised trials have shown improved local control with a boost of RT to the surgical bed following tangential RT for selected patients.

Patients who might be spared radiation therapy after breast conserving surgery. Such women should be informed that RT will further decrease the risk of breast recurrence, but that the absolute benefit of RT on long-term survival is small.

Accelerated partial breast radiation therapy following breast conserving surgery. Randomized trials of partial breast RT compared to whole breast RT have completed accrual but will not report cancer endpoints for several years. Whole breast RT remains the standard local treatment following breast conserving surgery. Partial breast RT using external 3-D conformal external beam RT has been shown to increase the risk of breast pain and induration at the primary site.

Where available, patients undergoing accelerated breast radiation therapy should be treated as part of a defined, clinical trial protocol. Partial breast RT may be considered in particular circumstances, e. Some patients treated with mastectomy with negative nodes may benefit from adjuvant RT.

This benefit is significant, even for patients with only a moderate risk e. Timing of Adjuvant Radiotherapy: Timing is as described above post BCS for node-negative patients. Effect of radiotherapy after breast-conserving surgery on year recurrence and year breast cancer death: Epub Oct Tamoxifen, radiation therap y, or both for prevention of ipsilateral breast tumor recurrence after lumpectomy in women with invasive breast cancers of one centimeter or less.

Vinh-Hung V, Verschraegen C. Breast-conserving surgery with or without radiotherapy: Pooled-analysis f or risks of ipsilateral breast tumor recurrence and mortality. J Natl Cancer Inst. Breast conservation is a safe method in patients with small cancer of the breast. N Engl J Med. Impact of a higher radiation dose on local control and survival in breast-conserving therapy of early breast cancer: Whole-breast irradiation with or without a boost for patients treated with breast-conserving surgery for earlybreast cancer: Epub Dec 9.

Role of a gy boost in the conservative treatment of early breast cancer: Results of a randomized clinical trial in lyon, france. Late cosmetic results of short fractionation for breast conservation. Tamoxifen with or without breast irradiation in women 50 years of age or older with early breast cancer.

A positive margin is not always an indication for radiotherapy after mastectomy in early breast cancer. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy.

Danish Breast Cancer Cooperative Group 82b trial. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: Effect of radiotherapy after mastectomy and axillary surgery on year recurrence and yearbreast cancer mortality: Epub Mar Erratum in: Does locoregional radiation therapy improve survival in breast cancer?

J Clin O ncol. Adjuvant systemic therapy has been demonstrated to reduce the risk of cancer recurrence and improve survival. Adjuvant systemic therapy with either chemotherapy or hormonal therapy should be offered to women according to the treatment policies as defined in Adjuvant Systemic Therapy.

These policies are reviewed continuously by the provincial breast systemic policy group and updated accordingly. The systemic management of invasive non-metastatic breast cancer is complex. The management of locally advanced and of metastatic breast cancer is discussed separately.

The prognosis for a patient following treatment of early breast cancer varies according to their age, co-morbidities, and the stage and the biomarker profile of their cancer. The majority of patients with early breast cancer will be cured with appropriate multi-disciplinary therapy. Invasive breast cancer can be divided into three broad groups that influence systemic treatment decisions: Within each of these groups, treatment recommendations are also influenced by patient age, co-morbidity, and personal preferences, as well as the stage and other histopathologic features of the cancer.

The majority of advances in the management and improvements in the cure rates of early breast cancer have come from successful completion of scientifically rigorous clinical trials. Patients should be given the opportunity to participate in clinical trials if available for their stage and type of breast cancer. Hormone receptor positive breast cancers express estrogen receptors ER and or progesterone receptors PR, PgR on their nuclei, as evinced by immunohistochemical IHC assay.

There are two main immunohistochemical scoring systems used by the province to describe the degree of ER and PR expression. The Allred score is made up of a measure of the intensity of the IHC stain and the percentage of cells which take up the stain for the receptor. A simpler scoring method is often used in which the hormone receptor staining strength is expressed from 0 no staining to 3 strong, ubiquitous staining.

Cancers with an IHC score of 0 or an Allred score of 2 or 0 do not benefit from hormone receptor targeted therapy. Cancers with an Allred score of 3 have weak staining in a small percentage of cells, and the benefit of therapy targeted at the receptor is debatable in this setting. The decision to treat cancers with an Allred score of 3 with hormone therapy should be individualized. The current standard of care for most premenopausal women is 5 years of hormone therapy. Women who remain premenopausal after 5 years of tamoxifen may derive a small additional survival benefit from continuing tamoxifen to a total of 10 years.

For postmenopausal women, there are several hormone therapy options. Compared with 5 years of tamoxifen, the use of an aromatase inhibitor for either five years, or for 2. Menopausal women completing five years of tamoxifen should consider an additional years of an aromatase inhibitor or of tamoxifen if unable to tolerate aromatase inhibitors , depending on the recurrence risk of the original cancer.

This is associated with a modest disease free survival improvement over stopping therapy at five years, and for women with node positive breast cancer, a small survival gain. Ongoing studies are examining whether longer than 5 years is beneficial if the first five years of therapy included an aromatase inhibitor.

The choice of treatment strategy must take into consideration patient co-morbidities and drug side effects, as well as the absolute recurrence risk associated with their cancer. Disease characteristics Hormone therapy T1N0 grade 1 Tamoxifen for 5 years, unless not tolerated or contraindicated Any of. Contraindications to starting or continuing Tamoxifen Issue Type of contraindication Notes Personal DVT, PE Absolute Unless patient anticoagulated for duration of tamoxifen use Close family history of DVT, PE Relative Coagulation studies may rule out a familial hypercoagulable state making tamoxifen safer Newly diagnosed Endometrial cancer Absolute Patients should discontinue tamoxifen permanently if they develop endometrial cancer while on tamoxifen.

Patients with remote history of low stage curatively treated endometrial cancer may safely take tamoxifen Severe depression Relative Tamoxifen may exacerbate depression Patients taking buproprion Wellbutrin , fluoxetine Prozac , or paroxetine Paxil Relative These drugs are metabolized by the same enzyme which metabolizes tamoxifen to its active metabolite endoxifen.

Whether this is clinically important is controversial. Each case must be considered individually balancing the potential benefits and risks of switching to a different antidepressant. Patients who can safely and easily switch to a different anti-depressant are encouraged to do so. Chemotherapy may be indicated for some hormone receptor positive breast cancers in addition to hormone therapy and local management.

The decision to recommend chemotherapy is based on a number of patient and tumor factors weighed together. In general, if the cancer exhibits any or several of the characteristics listed below, the benefits of chemotherapy should be considered: None of these features alone or in combination mandates the use of chemotherapy.

The decision making process is complex and involves balancing the potential benefits of adjuvant chemotherapy with the potential harms side effects and must be considered on a case by case basis. Other important factors in this decision making process include patient factors such as age, life-expectancy, and co-morbidities. Patient preference and willingness to accept chemotherapy side effects must also be considered.

Cancers without any of the above features arising in very young women 35 and younger may still warrant chemotherapy, as young age is an independent adverse prognostic factor. Recurrence risk assessment tools such as Adjuvant! Online can facilitate discussion with patients and illustrate the probable benefits of hormone therapy and chemotherapy in individual cases.

There are several tissue based prognostic tools which may be of value in guiding management recommendations for some women with node-negative, ER-positive and HER-2 negative breast cancer. This score provides an estimated risk of breast cancer recurrence over 10 years in the context of appropriate locoregional management and 5 years of hormonal therapy.

Furthermore, retrospective analyses suggest that only cancers with a high RS 31 or higher derive additional protective benefit from chemotherapy. These may not be the same as criteria established by other jurisdictions.

At present a provincially funded Oncotype Dx Assay can only be obtained through consultation with a Medical Oncologist and with compassionate access program CAP approval. Patients may choose to pay for the test through their own means; their medical oncologist can facilitate the process. There are numerous active adjuvant chemotherapy regimens. The choice of regimen drugs, doses, and number of cycles should be evidence based whenever possible.

The standard regimens available to Oncologists practicing in British Columbia can be found on the chemotherapy protocol, breast webpage. Postmenopausal who are relatively young and fit may be considered for the same chemotherapy regimens as for premenopausal women with similar cancer stage and grade.

There are a number of adjuvant chemotherapy regimens that do not incorporate anthracyclines. These are particularly good choices for patients at risk for cardiac injury. Patients with significant cardiac co-morbidities should undergo left ventricular ejection fraction assessment prior to initiating chemotherapy. Patients with an LVEF that is below the institutional lower limit of normal should not receive anthracycline based chemotherapy.

Anthracyclines may also be best avoided in patients with multiple cardiac risk factors even if they have a normal LVEF. Estrogen receptor ER and progesterone receptor PgR , by ligand-binding assay compared with ER, PgR and pS2, by immunohistochemistry in predicting response to tamoxifen in metastatic breast cancer: A Southwest Oncology Group study.

Int J Cancer ; Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and year survival: Endocrine therapy plus zoledronic acid in premenopausal breast cancer. N Eng J Med ; Is chemotherapy necessary for premenopausal women with lower-risk node-positive, endocrine responsive breast cancer?

Breast Cancer Res Treat ; Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial. A randomized trial of letrozole in postmenopausal women after five years of tamoxifen therapy for early-stage breast cancer. Meta-analysis of breast cancer outcomes in adjuvant trials of aromatase inhibitors versus tamoxifen.

J Clin Oncol ; Systemic treatment of early breast-cancer by hormonal, cytotoxic, or immune therapy: Anastrozole alone or in combination with tamoxifen versus tamoxifen alone for adjuvant treatment of postmenopausal women with early breast cancer: Is chemotherapy alone adequate for young women with oestrogen-receptor-positive breast cancer?

A multi-gene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer. Gene expression and benefit of chemotherapy in women with node-negative, estrogen receptor-positive breast cancer. Taxane-based combinations as adjuvant chemotherapy of early breast cancer: HER2 and response to paclitaxel in node-positive breast cancer.

All breast cancer cells have some HER2 receptors. This confers a more aggressive natural history to these cancers, which also more frequently have grade 3 than other grade histology. In BC, all breast cancers should be tested for Her2, usually on the core biopsy, although any specimen, including archival tissue, can be used.

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