Evaluating Chemotherapy and Surgery for Breast Cancer Treatment
Except with certain types of breast cancer (such as inflammatory); or in certain cases where advanced cancer has generated a tumor so large that it needs to be reduced in size before surgery is possible, the usual order of treatment is surgery, followed by chemotherapy. It makes sense, doesn’t it? First, remove the tumor, the largest, most evident piece of cancer. Then, do a mop-up action with chemo, killing any cancer cells left in the breast; or, if you’ve had a mastectomy, any lurking cancer cells in other parts of your body.
That may be changing. A conference held this spring at the National Institutes of Health in Bethesda, Maryland, sponsored by the National Cancer Institute, focused on preoperative chemotherapy (See Dr. Kevin Knopf's Sharepost on neoadjuvant chemotherapy), and the panel of experts concluded giving chemo before surgery to a much wider range of women could be a good thing, perhaps. And the main benefit would appear to be not survival rate, but quality of life.
Julie R. Gralow, a University of Washington medical oncologist speaking at the conference, noted that preoperative chemo has long been the norm for the scenarios mentioned above. She took a conservative stance in the matter of more preoperative chemo for more women, noting that, “In earlier stage breast cancer, preoperative chemotherapy is neither better nor worse from the standpoint of overall survival compared to postoperative chemotherapy.”
However, Laura Michaud, a clinical pharmacist speaking from the University of Texas M.D. Anderson Cancer Center in Houston, which has become an early adopter of preoperative chemo for an increased number of patients, said that it may be a quality of life issue. “The hope is that you give the therapy and you shrink the tumor so that you won’t have to do as much surgery,” she said. She added that by shrinking the tumor first, more women are able to undergo breast-conserving surgery: e.g., a lumpectomy instead of a mastectomy. And the vast majority of us would probably agree: a lumpectomy is preferable to a mastectomy. It’s easier surgery, a shorter recovery time, less expensive, and, most important, allows you to keep your breast.
Another reason to try preoperative chemo advanced at the conference is to be able to measure its effect on the cancer while the tumor is still in place. If you start a course of chemo and can actually see that it’s doing its job -- the tumor is shrinking –- you know you’re on the right track. If the tumor doesn’t respond, you can switch to different drugs. If you wait till after surgery to administer chemo, then you have no way of knowing if the “cocktail” you’re taking is working on your particular cancer. Makes sense, yes?
Maybe, maybe not. Eric Winer, director of the Breast Oncology Center at Boston’s Dana-Farber Cancer Institute, said that thus far trials haven’t supported the theory that you can start with one type of chemo and, if it’s not working, successfully switch to another. He added that perhaps the “failure to obtain benefit” may be due to the fact that the second drug treatment is “simply inadequate.” But Norman Wolmark, chairman of the department of human oncology at Drexel University College of Medicine in Pittsburgh, said that the latest data from some ongoing trials shows that “If we now look at disease-free survival for young women under 50 years of age, we see there is certainly a trend in [favor of] preoperative chemotherapy when compared with postoperative chemotherapy.” He added that the trend is just that: a trend, without enough statistical evidence to draw a certain conclusion.
As usual, it’s wait and see. But the day when a woman routinely has a mastectomy because her tumor is too large for a lumpectomy may become a thing of the past. Stay tuned.
Published On: June 20, 2007