Breast Cancer Treatment - Chemotherapy and Hormonal Therapy, Part 2
A new era of options has emerged, and, where previously doctors had one standard option for hormonal treatment of early-stage breast cancer, doctors now have several alternatives and sequences, so it is important to have a detailed discussion with your medical oncologist about what options are best for you.
Chemotherapy for early-stage breast cancer is determined by level of risk based on size of the tumor; the presence or absence of lymph node involvement; and certain features of the cells, seen only under the microscope, associated with more aggressive cancers. The medical oncologist will also take into consideration a woman’s age and any medical conditions she may have. In situations in which there is no disease in the lymph nodes, chemotherapy options include four cycles of AC, which is doxorubicin (Adriamycin) and cyclophosphamide (Cytoxan) or six cycles of CMF, which is cyclophosphamide, methetrexate, and 5-fluorouracil (5-FU). The cycles are typically every three weeks.
In situations in which the lymph nodes are involved, doctors generally recommend longer regimens of chemotherapy. Some treatment plans last six months and include AC followed by paclitaxel (Taxol) or CAF (cyclophosphamide, Adriamycin, and 5-FU).
In 2003, a large study was published that looked at using the same doses of drugs as in AC followed by Taxol but giving them every two weeks instead of every three weeks, a strategy called dose-dense treatment. In order to give the chemotherapy every two weeks, growth factor support was necessary. The side effects were not considerably greater but the reduction in risk of relapse and the survival were improved. Other options for women with node-positive cancer include TAC (the docetaxel [Taxotere], Adriamycin, and cyclophosphamide) or combinations substituting epirubicin for Adriamycin.
The ideal chemotherapy combination continues to be an area of active research, so be sure to ask about clinical trials that may be appropriate for you. Even if you choose not to participate, a discussion of active clinical trials can help you gain a better understanding of why certain drugs are recommended and what side effects can be expected.
To summarize, systemic treatment may be: a hormone medication alone for the lowest risk, estrogen receptor-positive women; chemotherapy alone in estrogen receptor-negative patients; or both chemotherapy and hormonal therapy in estrogen receptor-positive patients considered moderate to high risk. Chemotherapy is given first; after chemotherapy is completed, hormonal treatment can start. (Radiation, if it is planned, also follows completion of all chemotherapy but can be given simultaneously with hormonal treatments.)
Some patients at extremely low risk of cancer coming back (less than 10 percent) may choose not to have systemic treatments of any kind. You and your medical oncologist will decide based on your health and age, your risk of cancer coming back, and the degree of benefit you can expect to derive from any given treatment. These are difficult decisions, but the ultimate decision is yours.
Locally advanced breast cancers involve skin or muscle and are approached differently than early-stage breast cancers. For example, it is necessary to shrink the tumor before surgery can be done, usually by using preoperative or neoadjuvant chemotherapy or hormonal therapy. This means that chemotherapy is given first to reduce the tumor as much as possible, and then a mastectomy is done. When the wound heals, radiation to the chest wall follows. The same chemotherapy medications and combinations are used in these cases as are used for early-stage breast cancer.