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Most patients opt for breast-saving cancer therapies

University Of Chicago : 27 October, 2002  (Technical Article)
As a family nurse practitioner, Marlene Sefton knows about breast cancer. Almost five years ago, she got to know about it personally, when invasive cancer was found in her left breast.
Only 42 at the time, Sefton was relieved that the disease was at an early stage and that she was eligible for a lumpectomy. Also called breast-conserving surgery, lumpectomy involves removal of only the cancerous lump and the surrounding area of normal tissue. Now 47, Sefton said she chose a lumpectomy after asking her surgeon many questions about how it compares with a mastectomy, which removes the entire breast.

'What I wanted to know most was my chance of recurrence with each treatment,' said Sefton, a Chicago resident. 'Of course, I preferred the lumpectomy, but only if that, along with chemo and radiation, gave me a high cure rate and low recurrence rate.'

Long-term survival rates show no difference between women who have a mastectomy and those who choose a lumpectomy with radiation therapy, the National Institutes of Health reported in 1990. Thus, the NIH said therapy that preserves the breast is preferable for treating stage 1 and stage 2 breast cancers. Today most U.S. women with breast cancer, 60 to 70 percent, choose breast-conserving therapy, according to Dr. David P. Winchester, an Evanston surgeon and a spokesman for the American College of Surgeons.
'The vast majority of women diagnosed with breast cancer are candidates for breast-conserving surgery followed by radiation therapy,' said Dr. Francine Halberg. She is a radiation oncologist in Greenbrae, Calif., and a spokeswoman for the American Society for Therapeutic Radiology and Oncology.

Still, it's not for everyone. The National Comprehensive Cancer Network, an alliance of cancer centers, advises against lumpectomy in certain cases. If the cancer is larger than 2 inches or is in two or more quadrants, or parts, of the breast, the woman might not have a good cosmetic result. Breast-conserving therapy also is not recommended for women who have a connective tissue disease, such as lupus or scleroderma, or who are pregnant and would require radiation therapy while pregnant.

Radiation a must
Radiation therapy is a necessary part of breast-conserving therapy, Halberg said. The cancer recurs four times more often in women who do not undergo radiation treatment after lumpectomy, she said. Without radiotherapy, women increase their chance of dying of the cancer by nearly 9 percent, according to study results published earlier this year in the Journal of the National Cancer Institute.

Halberg believes that many women who are candidates for lumpectomy do not want it because they have misconceptions about radiotherapy.

'Many people associate chemotherapy side effects with radiation therapy,' Halberg said. 'But there is no nausea, vomiting or hair loss with radiation therapy.'

The most common adverse effect of radiation treatment is fatigue, and it usually does not prevent women from doing their normal activities, Halberg said.

Some women may not want radiation therapy because of the length of treatment. The standard course of radiation therapy for breast cancer in the U.S. is 30 to 33 treatments of the entire breast over six to seven weeks, Halberg said. Researchers are studying risks and benefits of an accelerated dosage schedule or treatment of only part of the breast, which cuts the length of treatment to as short as two weeks.

'We'd love to treat women in shorter times, so they can get on with their lives,' Halberg said. 'But we need very long follow-up to make sure accelerated radiotherapy or partial breast irradiation is as safe and effective as what we're doing today.'

The goal of radiation therapy is to get rid of cancer in the breast. Chemotherapy destroys microscopic cancer cells that may be hiding elsewhere in the body if the breast cancer has spread into the breast tissue. A woman also may receive hormonal therapy if her cancer cells are estrogen receptor-positive, meaning they need estrogen to grow. These cancers often will respond to hormone therapy that blocks the receptor sites, such as the anti-estrogen drug tamoxifen. This drug decreases the chance of recurrence of estrogen-sensitive breast cancer, said Dr. Gini Fleming, a medical oncologist at the University of Chicago Hospitals.

'It's overwhelmingly clear that five years of tamoxifen treatment is a huge benefit,' Fleming said. Tamoxifen is still the standard treatment of estrogen-sensitive breast cancer despite promising results of new drugs called aromatase inhibitors, Fleming said. This class of drugs, which includes anastrozole (brand name Arimidex), letrozole (Femara) and exemestane (Aromasin), blocks estrogen production and is effective only in postmenopausal women.

Early results from several large studies suggest that breast cancer is less likely to recur in postmenopausal women who take an aromatase inhibitor after treatment with tamoxifen for five years or less, the National Cancer Institute reported this year.

'There is clearly an effective new category of drugs that may be superior, but we don't have long-term follow-up of aromatase inhibitors,' Fleming said.

Recurrence a possibility
Drawbacks of aromatase inhibitors are that they are expensive and may cause osteoporosis. However, they do not increase the risk of endometrial cancer, blood clots or stroke.

Although many therapies are available to decrease the risk of recurrence, they cannot prevent it, not even mastectomy. 'A lot of women think if the breast is removed, there is no chance of recurrence, but that's not true,' Winchester said.

Studies show a 1 or 2 percent rate of local recurrence (in the skin or muscle of the area of the mastectomy) after removal of in situ, or non-invasive, cancer, the American Cancer Society reports. Local recurrence after mastectomy for invasive breast cancer ranges from 4 to 14 percent, according to a review of six studies published in the cancer society's Cancer Journal for Clinicians. The same article showed a 3 to 20 percent local recurrence rate after lumpectomy and radiation therapy.

Sefton, the nurse practitioner, had radiation therapy and hormonal therapy after lumpectomy. She also decided to have chemotherapy, which her doctors recommended because of her relatively young age.

'It's such an individual choice,' Sefton said of her treatments, which were, she added 'all about percentages, am I going to beat this?'
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