The first step many women take when being treated for breast cancer is a major one: surgical removal of the tumor. But growing evidence points to the fact that delaying surgery in favor of other treatments might actually have some benefits.
Stretching back thousands of years, to the beginnings of breast cancer treatment, the first, best, and formerly only treatment was surgical: removal of the cancerous tumor.
Makes sense, right? It’s like burning off an early melanoma, or having an operation to remove bone spurs; go in and physically remove the source of the problem.
Breast cancer "surgery" has a brutal history. In ancient Egypt, it consisted of nearly always fatal cauterizations of the spots where breast cancer tumors had broken through the skin. Eighteenth-century surgeons used liquor and a piece of wood to bite on (to stifle screams) when operating on their breast-cancer patients; President John Adams’ daughter died of breast cancer, after undergoing such surgery.
As late as the 1970s, surgeons were routinely removing not just the tumor from a woman’s breast, but a big part of her chest, including breast, skin, chest muscles, and underarm lymph nodes.
Science has made great strides since then. Many women now have breast-conservation surgery (lumpectomy), a simple same-day procedure that preserves nearly all of the breast. Even those having a mastectomy (removal of the entire breast) often get to keep their skin, their figure (thanks to reconstruction) - even, in some cases, their nipple.
Still, from the earliest recorded mentions of breast cancer until very recently, surgery has remained the fist step in treatment.
But that could be about to change.
Some oncologists are starting to believe that treatment of cancer prior to surgery - via chemotherapy and/or hormone therapy - has its advantages. Assessing the current landscape, Dr. Matthew Ellis of Washington University in St. Louis says, "There’s a rush to surgery in what is actually a very chronic illness." He adds, "We need to educate surgeons and patients that it’s not in their best interest to remove the tumor the moment the patient comes into the office." (Van Epps, 2012)
What reason do Ellis and others like him have for taking this radical stance, a belief that flies in the face of thousands of years of history?
Research data. There are enough oncologists who’ve been prescribing hormone therapy and/or chemotherapy for their patients prior to surgery; and it’s been going on over enough time, for a body of results to be gathered and analyzed. Initial studies show that there’s no survival benefit for removing a cancerous tumor right away, as opposed to treating it first with other methods - a process called neoadjuvant therapy.
Not only is the survival benefit the same; there may also be some value in identifying whether or not a certain treatment will work on the type of cancer the patient has.
For instance, long-term hormone therapy with an aromatase inhibitor (AI; e.g., Arimidex) is routinely prescribed for post-menopausal women with hormone-receptive cancer. Unfortunately, it’s not effective for some women; their cancer returns.
However, if hormone therapy is given prior to surgery, it’s possible to track the tumor’s response in real time. If the tumor shrinks, the drug works; if it doesn’t, the oncologist realizes this particular patient will need a different type of long-term treatment.
Another plus? Being able to avoid a mastectomy, with all its potential risks. In a recent study, fully half of the women who were told they needed a mastectomy were able to have breast-conservation surgery instead, after their tumor shrank in response to taking an AI.
For the approximately 20% of women diagnosed with HER2+ breast cancer, help may be on the way sooner rather than later. In news announced Sept. 10, the drug pertuzumab (Perjetaâ„¢), already approved for women with metastatic HER2+ cancer, has been placed into an accelerated approval process by the FDA for use by all women with an HER2+ diagnosis, to shrink their tumors prior to surgery. Used in combination with chemotherapy and Herceptin, nearly 40% of women in a small study showed apparent eradication of their tumors - an 86% improvement over current treatment methods. The FDA will issue its decision on final approval Oct. 31.
Researchers are hoping more oncologists adopt the practice of neoadjuvant therapy prior to surgery. Why? Because being able to track tumor response to hormone therapy in real time provides valuable data in the quest to discover why some women don’t respond to therapy, either initially or after time.
The more your oncologist knows about the biology of your cancer - and the sooner s/he knows it - the more personalized and specific your treatment can be.
And the more personalized your treatment, the greater its chance of success.
Breast cancer. (2013, July 27). Retrieved from https://en.wikipedia.org/wiki/Breast_cancer Van Epps, H. (2012, Fall). The estrogen effect. Cure, 11(3), 45.
PJ Hamel is senior digital content editor and food writer at King Arthur Flour, and a James Beard award-winning author. A 16-year breast cancer survivor, her passion is helping women through this devastating disease. She manages a large and active online survivor support network based at her local hospital and shares her wisdom and experience with the greater community via HealthCentral.com.