Today I went to the NBC studios to do an interview with Brian Williams for his Nightly News show. We talked about what a new study, published today in the New England Journal of Medicine, tells us about how best to use chemotherapy to treat breast cancer—and why the more we learn about tumors the more we learn about which chemotherapy benefits which tumor types.

 

What’s crystal clear is that the treatment of breast cancer is growing up. Initially all women were treated the same, one size fits all, and we were glad to save a few lives despite of the side effects of the therapy. Then we figured out that some tumors were sensitive to hormones and some were not, and that only those that were responded to hormone manipulation. More recently, a test called Oncotype DX has been developed that allows us to distinguish which women with ER-positive tumors will benefit from chemotherapy and which will not—and thus don’t need it.

The second significant determinant of treatment was Her2 status, which tells us who will benefit from Herceptin and who will not.

The study I spoke with Brian Williams about looked at 1500 women with node-positive breast cancer who had taken in part in a study in the 1990s that had randomly assigned them to receive doxorubicin (brand name Adriamycin) plus cyclophosphamide (brand name Cytoxan) followed by four cycles of paclitaxel (brand name Taxol)—the regimen commonly referred to as AC followed by T.

The researchers were able to get samples of these women’s tumor tissue, which had been frozen and saved, to analyze it for HER2 status. (Herceptin had not yet been approved and tumors were not tested for HER2 status when this trial took place.) They found that women with HER2 positive tumors benefited from paclitaxel, regardless of their estrogen status. However, women with HER2-negative, ER-positive breast cancer—the most common type of breast cancer—gained little from having paclitaxel added to their chemo regimen.

The researchers are encouraging other scientists to look at past Taxol studies and to see if these also show that HER2 status makes a difference. This is significant because, obviously, not only do we not want to give women a drug that they won’t benefit from, but because Taxol frequently causes neurological side effects, such as numbness and tingling in the hands and feet that can last for months or years after treatment ends. Another recent study published in the Journal of Clinical Oncology gives us even more information about which chemotherapy is best for women whose tumors are HER2-positive. This study showed us that within the HER2 category there are women whose tumors also overexpress another gene that is called Topo II. This group of women (about 8% of women whose tumors are HER2-positive) apparently does best when they get chemotherapy that includes an anthracycline, like Adriamycin, as well as Herceptin. In contrast, women whose tumors are HER2-positive but don’t also overexpress Topo II do just as well with a non-anthracycline drug.

Why is this important? Anthracyclines are known to cause cardiac damage, some of which can show up even long after the treatment is over. Adding Herceptin to Adriamycin compounds this damage, and so identifying women who could use an alternate combination is important in limiting the consequences of treatment. In addition it may be that women with HER2- negative tumors could use another drug, like cytoxan that has less long-term effects on the heart.

We are entering a new stage in breast cancer treatment, where we have choices. Since there are 2.4 million women living with breast cancer the long-term effects of therapy should be important in determining the best choice!

What does this mean to a woman newly diagnosed? She should get a second opinion about her chemotherapy treatments. She should ask questions, not only about what the benefits of the treatment will be but also the risks and whether there are alternative treatments that might have less long-term side effects. Many doctors are creatures of habit and we sometimes need to jolt them out of their routine to get them to incorporate the latest data into their practice.

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8 Responses to Breaking Chemo News

  1. eyschiff says:

    This issue is so timely for me. I have node negative, ER-positive breast cancer (Stage 1c) and am trying to decide if I should do chemo and hormonal therapy or just hormonal therapy. My Oncotype score is 24 which puts me in the intermediate risk category. I have met with 2 oncolgists and one recommends chemo plus hormonal therapy and the other recommends homonal therapy only. Has anyone else faced this dilemna and what did you decide?

  2. dawndrevers says:

    I too am in the same situation as you. node negative, ER-pos Stage 1b with an oncotype score of 26. I now have 2 docs recommending no chemo and 1 definitely pushing chemo. i also work as an oncology nurse and tend to see patients that are much sicker than the norm so have a distorted view. I suppose by now you have made your decision. I’m hoping to decide this week. I have my radiation planning soon if I decide against the chemo so I have a bit of a time line. So hard to know. My oncologist asked what keeps me awake at 2AM? Is it fear of a recurrence or fear of chemo? Right now I’m leaning toward no chemo but still sitting with it. I hope you are feeling ok with whatever you ‘ve decided

  3. MaryCappello says:

    I was diagnosed with estrogen receptor positive, HER2 negative cancer with lymph node involvement–exactly the category affected by this study. The report broke the night before I received my last A/C chemo treatment, and two weeks before I was to start Taxol. We brought the report to the oncologist, who read it over the weekend, and went over the pros and cons of continuing with the Taxol. Didn’t seem to be many pros, so we decided to skip the Taxol and go right to radiation therapy. Going elsewhere for a second opinion, but don’t expect to be persuaded that it’s a good idea to do the Taxol after all. We’re now wondering–how many oncologists are letting their patients know about this, if they are in a crucial stage of their chemo? Would we have been notified had we not seen the report ourselves on the news? Are oncologists going ahead with Taxol while they wait for the follow-up studies to confirm this study?

    Would be interested to hear if others are in the same situation as this.

  4. Dianne says:

    I have been diagnosed with a 2.1 cm tumor, her2 positive, weakly ER positive, PR negative, no lymph nodes involved. I had IDC – I believe it was in situ, in the right breast only but had a bilateral mastectomy anyway on Sept 9, 2008. Also my tumor was a grade 3 which is typical I guess if one is her2 positive. What would be the best chemo regimen for me? I have to make the decision this week. Also why can’t I have the oncotype dx test? Are there any tests for women with my diagnosis similar to oncotype dx?

  5. Kathy says:

    I was diagnosed in December 2007, ER+, Stage 2b, multiple quadrants and had a bilateral mastectomy in January 2008. Pathology came back with a finding of bilateral cancer. I contracted MRSA on the right side, which was resistant to Vancomycin. Long story short, I spent an additional four months trying to heal. Finally, Cubicin worked and I underwent chemo shortly thereafter – Cytoxin and Taxol. I have been through hell ever since. I went through eight surgeries in nine months because I lost the skin on the right side due to the infection. (Latissimus Muscle Flap) I have cognitive problems and my immune system is compromised either to the chemo, MRSA, anesthesia or the drugs. I finally got implants in April 2009. I am still undergoing reconstruction and hence still have my job. If you can avoid chemo and survive, I would take the Tamoxifen and forget it. I took it for six months and quit when I finally got an honest answer from my oncologist. My quality of life is more important that a mere nine percent points. I was in very good health prior to diagnosis, I could actually deal with stress and multitask, routinely exercised and my weight was and is healthy (I wear a size 4/6). If you can avoid surgery and survive – do it. Due to the MRSA and the lat flap, I now have nerve regeneration pain – see if they will ever explain that to you – so now I see an acupuncturist too. I cannot find anything on the CDC, American Cancer Society or this site regarding the long-term effects of chemo on the immune system. I have found information regarding “chemo brain.” If anyone else has experienced problems with the immune system, I would love to know what I can do about it. Thank you.

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  7. Jenny says:

    Exceptional, I passed this on to a comrade of mine, and he actually bought me lunch because I found this for him, so let me rephrase: Thanks for lunch.

  8. Sherrie says:

    Diagnosed in early Mar 2011 with stage 3 IDC breast cancer. Very aggressive at 84%. I chose bi-lateral mastectomy with reconstruction. Neg sentinal lymph node with removal of 10 on right side. Very painful and terrified at chemo future. Dr wants me to start with 6 cycles on AC followed by 12 cycles at 1 week of Taxol. No radiation because I have RA an autoimmune disease. At same time as taxol, they want me on Her2 trial study to see if there is any long term improvements for future patients. They predict no benefits for me. I am a Triple negative. Their first test for only positive or negative, but her2 is actually graded at 0/1+/2+/3+ where 0=true negative and 1+ and up is really positive. On the original grading 0/1+/2+ are all considered negative. Now they want the 1+ and 2+ people on this new trial. Herceptin chemo will run for 1 year. Trial will be followed for 10 years. I’m concerned with heart issues on Adriamyacin and Herceptin and additional issues with my autoimmune disease and with lymphadema issues. I’m also very afraid of other side effects impacting my job as I’m a very busy web designer with a heavy schedule. Any suggestions or recommendations from anyone? My first AC chemo cycle is on 4/20/11.

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