New view of breast cancer


Doctors who treat women with breast cancer are glimpsing the possibility of a vastly different future. After years of adding more and more to the regimen - more drugs, shorter intervals between chemotherapy sessions, higher doses - they are now wondering whether many women could skip chemotherapy.

If the new ideas are validated by large studies, such as two that are just beginning, treatment of breast cancer would markedly change. Today, national guidelines call for giving chemotherapy to nearly every one of the nearly 200,000 women whose breast cancer is diagnosed each year. In the new approach, chemotherapy would be mostly for the 30 percent of women whose cancers are not fueled by estrogen.

So far, the data are tantalizing but the evidence is very new and still in flux. And no one can yet say for sure which women with hormone-dependent tumors can skip chemotherapy.

It could be a decade before the new studies, one American, one European, provide any answers.

"It's a slightly uncomfortable time," said Dr. Eric P. Winer, who directs the breast oncology center at the Dana-Farber Cancer Center, which is affiliated with Harvard. "Some of us feel like we have enough information to start backing off on chemotherapy in selected patients, and others are less convinced."

Dr. John Glick, director of the Abramson Cancer Center of the University of Pennsylvania, notes that current treatment guidelines were based on results of large randomized clinical trials. And the recent studies indicating that some women can skip chemotherapy are based on an after-the-fact analysis of selected clinical trials. "We're in an era where evidence-based medicine should govern practice," Glick said.

For women with breast cancer, the uncertainty is excruciating. Faced with a disease that already causes doubt and anxiety, they are confronted with incomplete data, different opinions from different doctors and choices that seem almost impossible: Can they - or should they - give up a treatment when all the answers are not in and they have what could be a fatal disease?

"There's a real problem," said Barbara Brenner, who has had breast cancer and is the executive director of Breast Cancer Action, an advocacy group. "We finally tell people at the end of the day, `You're going to get a lot of information. Trust your gut; nobody has the answers.'"

Doctors are also concerned. It took two years before the National Cancer Institute and its researchers could even agree on a study design to test the idea that many women might safely forgo chemotherapy.

The study, which will start enrolling patients at the end of this month, will involve women whose cancers are fueled by the hormone estrogen and have not spread beyond the breast. They will be randomly assigned to have the standard treatment, chemotherapy followed by a drug such as tamoxifen that starves tumors of estrogen, or to skip chemotherapy and only have drug treatment.

In Europe, researchers are planning a similar study but it will include women whose cancer has spread beyond their breasts into nearby lymph nodes.

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