Breast Cancer Treatment Options-Expanding, Confusing
Elizabeth Tracey, Medical Writer
In looking back, one of the most noteworthy aspects of Ann Fonfa's diagnosis with breast cancer was her almost total lack of fear. "I remember finding the lump myself by doing a breast self-exam in December of 1992," Ann says. "This was after having had a clinical exam by a physician just 2 months earlier. But when I went in for the mammogram and ultrasound, I was not afraid. I had no expectation of cancer."
A series of missed diagnoses and incorrect treatments resulted in several lumpectomies, two mastectomies, and an ongoing relationship with an oncologist. Ann's NOTE: This is not quite accurate. Invasive lobular does not show up on mammograms and I never got involved with any oncologist. My second surgeon is my 'case' manager.
Unfortunately, Ann did have cancer. It also resulted in Ann developing the Annie Appleseed Project, a breast cancer support organization, as well as a Web site, www.annieappleseedproject.org, for which Ann regularly travels around the country attending medical meetings and posting the latest information about breast cancer.
One of those meetings took place at the National Institutes of Health in Bethesda, Maryland, early in November 2000. Treatment options available to women who have had surgery for their breast cancer and are now eligible for follow-up therapy--so-called adjuvant therapy--were discussed.
Experts at the conference said the group of women likely to be looking at adjuvant therapy would probably enlarge considerably as better detection catches them earlier in their disease, before breast cancer has spread. Such women have what is called localized disease. Their treatment will usually start with either removal of the tumor only, known as lumpectomy, or removal of the entire breast, known as mastectomy, followed by radiation. At this point, treatment options expand.
"I was rather disappointed to note that since the last consensus conference 10 years ago there's really not much that's new," says Helen Schiff, a colleague of Ann's and a breast cancer survivor and advocate. "Most of what was discussed seemed to be pulling back from therapies that appeared promising initially, such as the use of Taxol [generic name paclitaxel], and there seemed to be a number of very small gains. I guess what we need to remember is that not many gains are that big, but they all add up."
Taxol's relative lack of benefit was one of the big issues at the conference. The drug came on the scene several years ago and has since been used in many types of cancer, including lung, ovarian, and breast. Taxol is used in combination with other agents for disease that is severe or has spread, but the hope was that it would have a benefit in localized breast cancer.
"From my point of view, I'm disappointed that the results weren't more positive," says Peter Ravdin, MD, PhD, associate professor of oncology at the University of Texas Health Sciences Center in San Antonio and a presenter at the conference. "Between these results and the contraindications, and side effects seen with Taxol, I'm going to have to seriously consider in clinical practice where things stand."
Side effects of Taxol can be severe, including numbness and tingling in the hands and feet, muscle aches and pains, and loss of all body hair, including eyebrows and eyelashes. The medicine must be given by injection, resulting in added inconvenience to people receiving it, and it is also quite expensive.
Side effects are not a side of anything--Ann Fonfa
"Side effects are not a side of anything," says Ann. "When I look at results of a study, I can usually see that those unwanted effects, when combined, occur in a majority of the women in the study. This should be noted."
Other breast cancer advocates, including Rebecca Garcia, PhD, vice president of the Susan G. Komen Breast Cancer Foundation, also express concerns about the use of Taxol. "We conclude that at the present time, we can't really recommend Taxol in the adjuvant setting," Garcia says. "We aren't saying women should change what they are currently doing, but use of the drug does not appear to offer any benefits. Additional research is clearly needed."
Women with localized breast cancer should be offered chemotherapy, however, since it does have clear benefits and improves survival for most women, according to a consensus panel. In addition, breast cancer cells should be tested for the presence of a marker on their surface called an estrogen receptor. Those women whose tumors have the marker should receive hormonal therapy as part of their adjuvant therapy. This often means taking the drug tamoxifen (brand name Nolvadex) for a period of 5 years.
Two other issues received a great deal of attention at the conference:
Many breast cancers occur in women aged 70 or older, in whom the best strategy for treatment is not yet known.
Only a very small percentage of women with breast cancer participate in clinical trials.
Patricia Eifel, MD, professor of radiation oncology at the M.D. Anderson Cancer Center in Houston and the conference chairperson, says, "We just don't know how women with breast cancer who are over the age of 70, and who frequently have other health problems, should best be treated. Studies addressing this issue are urgently needed."
Right now, only about 3-4% of women who are diagnosed with breast cancer enroll in a clinical trial.
Right now, only about 3-4% of women who are diagnosed with breast cancer enroll in a clinical trial. "The faster you can do the trials, the faster you can get the results," says Dr. Ravdin. "Typically, studies on adjuvant therapy take about 3 years to recruit patients, then continue for about 5 years to assess results," says Dr. Ravdin. "If you could reduce the time it takes to recruit enough patients you could assess therapies much faster."
Dr. Eifel concludes, "Clinical trials over the past 10 years have contributed an enormous amount of new information about adjuvant therapies. Women with breast cancer have more treatment options and a better chance of surviving their disease than ever before. At the same time, making treatment decisions has become a more complex process for them and their physicians due to a growing list of effective options."
Elizabeth Tracey is a freelance medical writer.
Reviewer: Beth Israel Deaconess Medical Center. Reviewed for medical accuracy by physicians at Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School. BIDMC does not endorse any products or services advertised on this Web site www.cbshealthwatch.com.
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