Oncologists at the 2013 San Antonio Breast Cancer Symposium learned about several studies that will help them make decisions about the best treatments for people with metastatic breast cancer.
Surgery for Stage IV women. In the years I have participated in support groups for breast cancer, one of the questions that pops up frequently has been why a woman whose cancer has spread beyond her breast would not have a mastectomy. Almost everyone else with breast cancer has a lumpectomy or a mastectomy. It seems like this group of women whose cancer has reached the most serious stage would need to have the source of their cancer removed.
The standard answer has been stopping chemo or other systemic treatments long enough to do surgery would allow the cancer in a woman’s vital organs to have a chance to grow. There is even a school of thought that removing the original tumor somehow spurs its daughters elsewhere in the body to greater growth. So for many years surgery was not an option for women with metastatic breast cancer.
However, as women survived longer and their systemic treatments worked well enough that they were stable or showed no evidence of disease, practice began to change a bit. Some doctors decided that in those cases, a mastectomy made sense. The situation has been confusing to women with metastatic breast cancer because some were receiving surgery, and others weren’t. Women who sought a second opinion about what to do often received conflicting opinions. The research studies that oncologists base their opinions on looked at results after treatment and had different conclusions; however, the best way to compare treatments is to randomly assign patients to two treatments to see which is more effective.
Now two new randomized studies are helping to provide more information on which to base these decisions.
Researcher Rajendra Badwe, M.D., director of the Tata Memorial Hospital in Mumbai, India, led a randomized trial dividing women into two groups. In addition to chemotherapy, some women also received surgery and radiation. This is called loco-regional treatment (LRT) in medical speak.
Dr. Badwe and his team studied 350 women from 2005 to 2013. They matched the 173 women who received surgery and radiation with the 177 who did not for age, tumor characteristics, and the extent of disease’s spread. “We found that there was no difference in overall survival between those who received LRT and those who did not receive LRT,” Badwe said.
A Turkish study led by Dr. Atilla Soran found similar results. However, in that study there was a survival benefit if the breast cancer had spread to the bones.
There may still be a role for surgery or radiation for metastatic women if they have bone metastasis or if the cancer breaks through on the skin causing ulcers. The important information for you to know if you are a metastatic patient trying to decide whether to have surgery is is that it is still a complicated issue you will want to discuss carefully with your doctor, but that the evidence currently suggests that there is no need for you to lose your breast.
The drug dasatinib (trade name Sprycel) combined with letrozole (trade name Femara), delayed disease progression for women with hormone receptor-positive, HER2- negative metastatic breast cancer in a clinical trial. Dasatinib is a drug used for leukemia, but it blocks a protein that is believed to help breast cancer spread to the bones. If you are a hormone receptor positive and Her2 negative metastatic patient, you could ask your doctor whether you are a candidate for participation in the next set of trials for this drug.
CTC Testing. Metastatic breast cancer patients are usually in treatment for the rest of their lives. Doctors will put women on a treatment plan until it no longer appears to be working and then switch to a different drug. Knowing when to change can be tricky. Researchers were hoping that they could track how effective a drug is by measuring the number of tumor cells circulating (CTC) in a patient’s blood, but a recent study found that is not the case.
Jeffrey B. Smerage, M.D., Ph.D., clinical associate professor at the University of Michigan Comprehensive Cancer Center in Ann Arbor led a study looking at this issue. He said, "We concluded that CTCs are not a good marker in helping to decide when to switch between chemotherapies. It had been hoped that switching would both increase the chances of being on an effective therapy and decrease the exposure to toxicity from less effective or ineffective therapies, and as a result it had been hoped that this early switching would result in improved survival and time to progression.”
The study did find that the number of circulating tumor cells (measured by a simple blood test) seems to be a valid predictor of how well a metastatic patient will do. Dr. Smerage and his colleagues found “the group of patients with elevated CTCs at both baseline and 21 days [after starting their first chemotherapy] has a worse prognosis with regard to both time to progression and overall survival.”
Patients will want to discuss the implications of this study for their own situation. It seems to me that it could help patients who are trying to decide whether to continue treatment. Those who have low CTC at the time of diagnosis or whose CTC levels respond well to chemo may want to persist with chemo. It’s all too easy for a patient with a stage IV diagnosis to think that death is near and decide to forego treatment. This study gives another way to measure prognosis. Of course, it is important to remember that statistics only measure what happened to a group of people and can’t predict what will happen to an individual. But those facing hard decisions now have one more piece of information to help them.
Ramucirumab. A promising drug did not work as well as hoped. Early data had suggested that a combination of ramucirumab and docetaxel might work well in metastatic breast cancer, but a clinical trial led by John R. Mackey, at the University of Alberta, Edmonton, Canada found that it was not successful. Ramucircumab did improve survival for colon and gastric tumors.
Current statistics suggest that 30% of breast cancer patients will become metastatic at some point, so this news is important for every breast cancer patient. Metastatic breast cancer remains a stubborn disease, but new drugs and treatments are prolonging life. It would be wonderful if all the research presented at the San Antonio Breast Cancer Symposium proclaimed big breakthroughs, but sometimes it is almost as important to know what doesn’t work. Avoiding a needless mastectomy and being able to make better decisions based on a simple blood test can improve a patient’s quality of life.
Bankhead, C. “Surgery No Help in Metastatic Breast Cancer.” Medpage Today. Dec. 14, 2013. Accessed Dec. 16, 2013 http://www.medpagetoday.com/MeetingCoverage/SABCS/43441.
Kuznar, Wayne. “Ramucirumab Does Not Prolong PFS in HER2-Negative Metastatic Breast Cancer” OncLive. Dec. 13, 2013. Accessed Dec. 16, 2013 http://www.onclive.com/conference-coverage/sabcs-2013/Ramucirumab-Does-Not-Prolong-PFS-in-HER2-Negative-Metastatic-Breast-Cancer.
“New Drug Combination Delayed Disease Progression for Subgroup of Women With Metastatic Breast Cancer” Accessed Dec. 16, 2013.
“Patients With Metastatic Breast Cancer May Not Benefit From Surgery and Radiation After Chemotherapy.” American Association for Cancer Research. Dec. 11, 2013. Accessed Dec. 16, 2013. http://www.aacr.org/home/public--media/aacr-press-releases.aspx?d=3236.
“Switching chemotherapy does not improve survival in metastatic breast cancer patients with CTCs.” Medical News. Dec. 16, 2013. Accessed Dec. 16, 2013 http://www.news-medical.net/news/20131216/Switching-chemotherapy-does-not-improve-survival-in-metastatic-breast-cancer-patients-with-CTCs.aspx.
Published On: December 16, 2013