The pendulum is swinging back. Years ago chemotherapy for breast cancer was rare. Later, it seemed everyone received it. Now some are questioning that routine.
When I was a young surgeon in training I did mastectomies for women with breast cancer. Those who had no evidence of metastasis (spread of the cancer) received no other treatment. Those with metastasis received radiation therapy and sometimes chemotherapy.
As experience with chemotherapy increased and new drugs were developed, more chemotherapy was given. Many women with no evidence of metastasis still received chemotherapy after surgery. Today that practice is being re-evaluated.
Lucette Lagnado, writing in The Wall Street Journal, says the shift to less chemotherapy is being called “de-escalation.” Proponents of this shift believe many women have been overtreated with drugs that may have harmed more than helped. They believe chemotherapy should be reserved for those women who have a high risk of the cancer spreading.
This de-escalation has created a rift between those oncologists who support this trend and those who do not. Cancer mortality rates have improved since the late 1980s and some researchers credit chemotherapy for this improvement. Although chemotherapy agents have been in use since the 1940s, current drugs are less toxic than the early days when nitrogen mustard was used. Side effects are less and ways to diminish their impacts on the patients have improved.
Dr. Steven Katz, a professor medicine at the University of Michigan, is a supporter of de-escalation. He says, “Tens of thousands of women were overtreated; they got surgery they didn’t need, they got radiation they didn’t need, and they got chemotherapy they didn’t need.”
Today patients are routinely given genomic testing to determine the behavior of their tumors. A low score means a woman has a good prognosis and won’t benefit from chemotherapy. A high score means a greater risk of recurrence and a need for chemotherapy. A middle score presents the greatest treatment decision challenge.
Katz and Stanford oncologist Allison Kurian published a study in the Journal of the National Cancer Institute. The study was composed of about 3,000 women with early-stage breast cancer treated by some 500 doctors from 2013 to 2015. The study revealed that the use of chemotherapy declined overall during that time from 34.5% of cases to 21.3%.
Other doctors are more skeptical. At New York’s Memorial Sloan Kettering Cancer Center, Dr. Jose Baselga says that while there is data to support forgoing chemotherapy on certain women with early-stage disease – and he had personally been prescribing less – these represent only a small fraction of patients. He believes others will die if chemotherapy isn’t given.
Another study published in The New England Journal of Medicine in 2015 looked at the treatment of over 10,000 women. Of these, 1,626 had early-stage breast cancer with no lymph node involvement. They were given hormonal treatment alone, without chemotherapy. Those with a low genomic test score had “very low rates of recurrence at five years with endocrine therapy alone.”
But others warn of their experience in the past. Dr. Gabriel Hortobagyi, has practiced oncology for over four decades at MD Anderson Cancer Center in Houston. He recalls the years when high percentages of women died from breast cancer. He credits chemotherapy for helping achieve the turnaround we enjoy today. He believes chemotherapy has saved “tens of thousands, maybe hundreds of thousands of lives.” But he stresses, “We have to do it responsibly and on the basis of the highest level of evidence. The worst toxicity is death.”