Some women get too little chemo

Study shows patients with early breast cancer are often undertreated

December 13, 2003|By NEW YORK TIMES NEWS SERVICE

A new study of 20,000 women with early breast cancer found that more than half did not receive the recommended schedule of chemotherapy. That deviation may have put them at risk for worsening of the disease or recurrences that could have been avoided.

Often, doctors delayed therapy or cut back the dosage out of concern about side effects.

"I think the intention here is good, to not make patients sick," said Dr. Gary H. Lyman, an author of the study and an oncologist at the University of Rochester. He said doctors were tempted to cut back or postpone chemotherapy in many types of cancer when they saw people suffering from side effects. But, he warned, "patients need to be aware that if their treatment is compromised too much they may lose in the long run, with the disease coming back."

It is not known whether the women in the study suffered as a result of reduced treatments; that kind of follow-up was not part of the study.

Writing in the Dec. 15 Journal of Clinical Oncology, Lyman and his co-authors describe their findings as alarming, particularly in light of growing evidence that the odds of curing breast cancer are highest when patients complete a full course of chemotherapy within a certain period of time. "Women who get less have a significantly higher risk," Lyman said.

A researcher who was not part of the study, Dr. Larry Norton, head of medical oncology at Memorial Sloan-Kettering Cancer Center in New York, said he was surprised and disturbed by the widespread failure to stick to a treatment schedule.

"This should remotivate both doctors and patients to be sure both dose rate and level are adequate," Norton said.

The issue is not just the total amount of chemotherapy, but also its timing - what doctors call "dose intensity." The concept applies to other diseases and treatments as well. For instance, someone with strep throat might need to take four antibiotic capsules a day for 10 days to cure it. If a patient decided to take the same total number of capsules over 20 days instead of 10, or to take three a day instead of four for the 10 days - decreasing the dose intensity - the treatment might not work as well, perhaps not at all.

People commonly take chemotherapy in cycles: they are treated every day for a week or so, take a few weeks off and then start again. A common reason for delaying the next cycle or reducing its dose is a lowering of white blood cell counts, which can predispose patients to infection. Lyman and his colleagues say that doctors should make more use of drugs called colony stimulating factors to keep up the white cell counts and help patients get through the full-strength treatment.

The study was paid for by Amgen, which makes a widely used colony stimulating factor, Neupogen. The drug is expensive and can add $20,000 or more to the cost of treatment.

Lyman said that the study was the researchers' idea, not Amgen's and that the company had no influence on the results.

Dr. Daniel Haller, editor of the oncology journal and a professor of medicine at the University of Pennsylvania, said that editors and scientists did not think the authors had a conflict of interest.

"Frankly, we live in the real world, and much if not most of the exciting biology and even standard chemotherapy work is coming from industry, and we're struggling to deal with that in an honest fashion," Haller said.

The study analyzed the medical records of about 20,000 women who were treated in 1,243 community oncology practices around the United States. When the researchers compared the treatment that the women actually received with the standard regimens, they found that more than half received less than 85 percent of the recommended dose intensity.

Previous studies have found that such reductions can increase the risk of recurrence and death.

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