Breast Cancer: When is Less Treatment Better?

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.