Fewer women to receive chemo for breast cancer
By MARILYNN MARCHIONE
The Associated Press
SAN ANTONIO — For years, doctors have known exactly what to do with breast cancer patients like Eva Ossorio: Poison them.
Blasting women with toxic chemicals was considered the best way to save their lives. The bigger the cancer or the more it had spread, the more vile liquid doctors pumped into their veins to try to kill it.
But there has been a sea change in the last year.
Guidelines recently adopted in Europe and similar ones unveiled this weekend at a conference in Texas will result in far fewer women getting chemotherapy in the future.
The new advice calls for choosing a treatment based on each woman’s particular type of tumor.
“In the past, we made all decisions based on how big the tumor was and whether the lymph nodes were involved. If you had a lot of cancer, you got treated one way, and if you had a little cancer, you got treated another way,” said Eric Winer of the Dana-Farber Cancer Center in Boston.
Under the new rules, hormone status — whether a tumor’s growth depends on estrogen or progesterone — becomes the single most important factor in picking treatment.
That is why Ossorio, 62, a nurse in San Antonio, last week was started on a hormone blocker rather than the chemotherapy she formerly would have received for her relatively large tumor. She was relieved.
“I don’t care if I die tomorrow. I decided I didn’t want chemotherapy,” she said.
Patients have reason to dread it. Chemotherapy is a sledgehammer, killing all rapidly dividing cells whether they are out-of-control cancerous ones or healthy ones that naturally grow quickly, like those lining the mouth and stomach. That is why chemotherapy causes hair loss, nausea and mouth sores.
But the worst part is, it only helps about 15 percent of those who get it after the usual surgery to remove their tumors.
About 25 percent get worse despite chemotherapy. Sixty percent would have been fine with hormones alone.
“For the vast majority of patients, we probably overtreat,” said William Gradishar of Northwestern University in Chicago.
“It’s not that chemotherapy is not of value. It’s that the value is smaller in women with hormone-driven disease,” said Robert Carlson, a Stanford University physician who led the U.S. guideline-writing group. “We’re trying to determine if the benefit is so small that we should not be recommending chemotherapy.”
Several developments in recent years help doctors pick who really needs it.
First is the realization that breast cancers have different causes, arise from different types of cells, are driven by different genes, and tend to be different in women before or after menopause.
For example, three-fourths of postmenopausal women with breast cancer have tumors fueled by estrogen, called ER-positive disease. Drugs that block this hormone, like tamoxifen and a newer class of medications called aromatase inhibitors, work against those cancers — whether they have spread to lymph nodes or not.
On the other hand, women before menopause often have tumors that are ER-negative and orchestrated by bad genes. Hormones don’t help in that case. These women benefit most from chemotherapy.
If hormone drugs are ball-peen hammers compared to chemotherapy, a medication like Herceptin is an even more refined tool. It focuses on the one-fourth of breast cancers that have too much of a protein on cell surfaces called HER-2 and leaves healthy cells alone.
A woman’s HER-2 status is the next factor doctors will consider, after hormone status, in choosing treatments under the new guidelines.
New high-tech laboratory tests help doctors sort it out. They measure the activity of dozens of genes and reveal which ones are most active and what treatments would work best.
The new guidance was developed by the National Comprehensive Cancer Network, a group of cancer treatment centers, in cooperation with the American Cancer Society.
New guidelines say that doctors should change the way they decide how to treat breast cancer.
- Old and new: Previously, chemotherapy was advised if tumors were bigger than 1 centimeter or had spread to lymph nodes. Now, hormone blockers are advised if estrogen or progesterone is making the tumor grow. Herceptin is recommended if women have the bad gene that that medication targets.
- Bottom line: Fewer women will get chemotherapy, and more will get hormone treatments and Herceptin.
- On the Web: The new guidelines developed by the National Comprehensive Cancer Network are at http://www.nccn.org/.
About the National Comprehensive Cancer Network
The National Comprehensive Cancer Network® (NCCN®), a not-for-profit alliance of 25 of the world's leading cancer centers, is dedicated to improving the quality and effectiveness of care provided to patients with cancer. Through the leadership and expertise of clinical professionals at NCCN Member Institutions, NCCN develops resources that present valuable information to the numerous stakeholders in the health care delivery system. As the arbiter of high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers. The primary goal of all NCCN initiatives is to improve the quality, effectiveness, and efficiency of oncology practice so patients can live better lives. For more information, visit NCCN.org.
The NCCN Member Institutions are:
- Fred & Pamela Buffett Cancer Center at The Nebraska Medical Center
- City of Hope Comprehensive Cancer Center
- Dana-Farber/Brigham and Women's Cancer Center
Massachusetts General Hospital Cancer Center
- Duke Cancer Institute
- Fox Chase Cancer Center
- Huntsman Cancer Institute at the University of Utah
- Fred Hutchinson Cancer Research Center / Seattle Cancer Care Alliance
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
- Mayo Clinic Cancer Center
- Memorial Sloan Kettering Cancer Center
- Moffitt Cancer Center
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
- Roswell Park Cancer Institute
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
- Stanford Cancer Institute
- University of Alabama at Birmingham Comprehensive Cancer Center
- UC San Diego Moores Cancer Center
- UCSF Helen Diller Family Comprehensive Cancer Center
- University of Colorado Cancer Center
- University of Michigan Comprehensive Cancer Center
- The University of Texas MD Anderson Cancer Center
- Vanderbilt-Ingram Cancer Center
- Yale Cancer Center/Smilow Cancer Hospital