Breast Cancer: When is Less Treatment Better?

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Eric Winer, breast cancer

Eric Winer, MD, director of Breast Oncology.

By Eric Winer, MD

When a woman learns she has breast cancer, and she has cancer treatment available to her, it is only natural that she and her doctor would choose a powerful course of action. And in many cases, this approach makes sense.

However, aggressive treatments often come with consequences. Bigger surgeries lead to bigger and more frequent complications. Advances in reconstructive techniques are a blessing for the woman who needs to have a mastectomy, but reconstruction comes with its own consequences. Radiation therapy, chemotherapy, hormonal therapy, and many of the new targeted therapies can also result in complications, some more than others.

Increasingly, we are worried about overtreatment for breast cancer, particularly for small, non-aggressive tumors, which account for a sizeable number of breast cancer cases. New data suggests there may be gentler approaches, particularly for many of these early stage cancers.

As breast cancer doctors, our two greatest challenges are finding better treatments to help prevent the 40,000 deaths from breast cancer in the U.S. every year, and figuring out who, on the other end of the spectrum, is getting exposed to needless risk and toxicity.

Eric Winer, breast cancer, Sandy Cassanelli

Winer and his patient, Sandy Cassanelli, discuss treatment options.

Less surgery. Even though breast-conserving techniques (lumpectomy followed by radiation therapy) are just as effective as mastectomy for most cancers, we are finding that more women – especially young women – choose the more extensive surgery, often in combination with reconstruction. Research at the Susan F. Smith Center for Women’s Cancers is exploring why, and helping women make the most informed decisions about lumpectomy vs. mastectomy.

In fact, many recent advances have allowed women who might otherwise need a mastectomy to undergo a lumpectomy. Improved imaging technologies help physicians determine which patients are the best candidates for conservative surgeries. Drug treatments (neo-adjuvant therapy) can shrink tumors in some women prior to surgery, so a more limited procedure can be performed.

Less radiation. Recent studies have shown that shorter courses of radiation are as effective as the standard 6-7 week course for many patients. The doses administered each day are a little higher, but treatment can often be completed in four weeks or less.

Less toxic drugs. An Oncotype DX test, which examines tissue from the tumor after surgery, can help predict the likelihood of cancer recurrence and, more importantly, tell us a great deal about the value of chemotherapy for a given patient. Increasingly, we are using Oncotype and tests like it to determine which patients have the most favorable prognosis and who can be spared the toxic effects of chemotherapy.

Many of our new medicines for breast cancer – early stage or advanced – are “targeted” drugs tailored to the molecular composition of the cancer, including genes and proteins, and are sometimes less toxic than chemotherapy. We are studying various combinations of targeted drugs in hope of reducing the risk of recurrence and doing so with limited side effects.

One recent victory was our finding that women with small (stage I), HER2-positive breast tumors, who received a combination of lower-intensity chemotherapy and trastuzumab following surgery, were highly unlikely to have the cancer recur within three years of treatment. For these women with early stage HER2+ breast cancer, this kinder and gentler regimen has become a standard approach.

A group of drugs called antibody drug conjugates (ADCs) are in clinical trials, and we are excited about their ability to deliver a potent chemotherapy drug directly to tumor cells, allowing very little chemo to enter the bloodstream. One example is T-DM1 (trastuzumab), a very well-tolerated drug for HER2+ breast cancer with very few side effects.

I personally am very hopeful about what’s to come. A woman who has treatment options available to her can, with her doctor, choose the best path for her type of cancer and her personal preferences. For some patients with breast cancer we need to find more effective treatments, but for many others we need to sort out which treatments are unnecessary so we can spare her the side effects from cancer treatment.

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3 thoughts on “Breast Cancer: When is Less Treatment Better?

  1. Dear Paula,
    I am sorry you are going through this ordeal. As you might imagine, I take care of many, many women with stage 4 breast cancer. I don’t see this as an either or choice. We have two major challenges. The first is to eliminate the 40,000 deaths from breast cancer that we see each year in the United States. We do have many clues about which women are far more likely to have recurrences and can benefit from aggressive treatments. We also know that even those aggressive treatments are just not enough for many women…some may need a totally different approach. Millions of dollars are invested into new approaches every year, and with the combination of precision medicine and immunotherapy, we hope to be in a very different place 5 years from now. But at the same time, we know for certain that overtreatment remains a problem. Here we also have many clues. In fact, we know that for some women, backing off on treatment is entirely safe. We urgently need to back off on treatment when it is toxic and unnecessary. That said, we usually do opt and recommend more, rather than less, when the situation is at all unclear. I don’t think you and I disagree with only exception – I think we know a little more than you may suspect and we are ready to move away from a one size fits all approach to breast cancer. If we can help you in any way, let us know.

    Eric Winer

  2. Having been diagnosed stage 4, with metastases to my lungs, liver and bones almost three years ago, my long-term outlook is not very hopeful today. I participate in groups with women whose first bout of cancer was anywhere from months to years ago (well over the three years you indicate as a significant landmark), who followed a variety of treatments, lifestyles, etc. Nobody can tell me why I went from healthy to Stage 4 in the 18 months between mammograms. Nobody knows why I respond to some chemos for my type of BC and not others. Likewise nobody can tell my friends why their cancer came back while other women’s didn’t. Nobody can tell any of us why some women will survive for 10 and more years with stage 4, while others will succumb in less than a year. In short, Dr. Winer, nobody can tell us anything, because nobody seems to know. So I don’t wonder why women – especially young women – chose the more aggressive treatments. It’s because when you’re in your 30s or 40s (or even 50s, like me) statistically significant phrases like “highly unlikely” and “three years” hold no significance when weighed against the overall lack of knowledge and our lives, dreams and plans. And while I am extremely sympathetic toward women having unnecessary treatments, perhaps more research dollars should be spent on real cures for stage 4, rather on how to avoid over treating stage 1. Because once no woman or man has to fear dying of stage 4, which accounts for those 40,000 deaths you mention, I am certain they will feel safer in opting for the gentler treatments at stage 1.

  3. This is a very helpful and informative article. As a 2 time cancer survivor (Hodgkin’s Lymphoma 1989 and Breast Cancer 2014), I can tell you the choices of treatments definitely come with their own set of risks. More than likely my breast cancer was a long term side effect of my mantle radiation I had in 1989. While the treatment was the top choice to treat my Hodgkin’s, it left me with numerous long term issues. Happily, though, it allowed me to be where I am today. I would say trade-offs are the main thing. You have to do what is right for you at the moment, which can be overwhelming at the time. I appreciate having some information to share with others who question why I did not undergo chemo for my breast cancer. I did have the oncotype DX test which led us to the treatment of an estrogen inhibitor. Each person is unique and so is the treatment course. Sometimes I have to remind myself of that when I hear what other people are doing to treat their breast cancer. Did I do enough? Should I have done something different? It can be nerve-wracking and scary, but in the end I made a decision with the help of my Dana-Farber doctors that was the best choice for me.

  4. Having been diagnosed stage 4, with metastases to my lungs, liver and bones almost three years ago, my long-term outlook is not very hopeful today. I participate in groups with women whose first bout of cancer was anywhere from months to years ago (well over the three years you indicate as a significant landmark), who followed a variety of treatments, lifestyles, etc. Nobody can tell me why I went from healthy to Stage 4 in the 18 months between mammograms. Nobody knows why I respond to some chemos for my type of BC and not others. Likewise nobody can tell my friends why their cancer came back while other women’s didn’t. Nobody can tell any of us why some women will survive for 10 and more years with stage 4, while others will succumb in less than a year. In short, Dr. Winer, nobody can tell us anything, because nobody seems to know. So I don’t wonder why women – especially young women – chose the more aggressive treatments. It’s because when you’re in your 30s or 40s (or even 50s, like me) statistically significant phrases like “highly unlikely” and “three years” hold no significance when weighed against the overall lack of knowledge and our lives, dreams and plans. And while I am extremely sympathetic toward women having unnecessary treatments, perhaps more research dollars should be spent on real cures for stage 4, rather on how to avoid over treating stage 1. Because once no woman or man has to fear dying of stage 4, which accounts for those 40,000 deaths you mention, I am certain they will feel safer in opting for the gentler treatments at stage 1.

  5. Dear Paula,
    I am sorry you are going through this ordeal. As you might imagine, I take care of many, many women with stage 4 breast cancer. I don’t see this as an either or choice. We have two major challenges. The first is to eliminate the 40,000 deaths from breast cancer that we see each year in the United States. We do have many clues about which women are far more likely to have recurrences and can benefit from aggressive treatments. We also know that even those aggressive treatments are just not enough for many women…some may need a totally different approach. Millions of dollars are invested into new approaches every year, and with the combination of precision medicine and immunotherapy, we hope to be in a very different place 5 years from now. But at the same time, we know for certain that overtreatment remains a problem. Here we also have many clues. In fact, we know that for some women, backing off on treatment is entirely safe. We urgently need to back off on treatment when it is toxic and unnecessary. That said, we usually do opt and recommend more, rather than less, when the situation is at all unclear. I don’t think you and I disagree with only exception – I think we know a little more than you may suspect and we are ready to move away from a one size fits all approach to breast cancer. If we can help you in any way, let us know.

    Eric Winer

  6. This is a very helpful and informative article. As a 2 time cancer survivor (Hodgkin’s Lymphoma 1989 and Breast Cancer 2014), I can tell you the choices of treatments definitely come with their own set of risks. More than likely my breast cancer was a long term side effect of my mantle radiation I had in 1989. While the treatment was the top choice to treat my Hodgkin’s, it left me with numerous long term issues. Happily, though, it allowed me to be where I am today. I would say trade-offs are the main thing. You have to do what is right for you at the moment, which can be overwhelming at the time. I appreciate having some information to share with others who question why I did not undergo chemo for my breast cancer. I did have the oncotype DX test which led us to the treatment of an estrogen inhibitor. Each person is unique and so is the treatment course. Sometimes I have to remind myself of that when I hear what other people are doing to treat their breast cancer. Did I do enough? Should I have done something different? It can be nerve-wracking and scary, but in the end I made a decision with the help of my Dana-Farber doctors that was the best choice for me.

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