New Treatments for Early Breast Cancer
The complications of radiation are exceptionally rare, pneumonitis can occur, that happens in about 1 in 1000 women, rib fracture can occur years after the treatment is completed from osteoporosis, soft tissue necrosis is extremely rare and second malignancies are only really an issue in a very very young patient. This is what radiation pneumonitis looks like. This is a CAT scan of a patient who was treated to the left supraclavicular region, you can see the lung is clear here, but there is considerable scarring and fibrosis of this part of the radiated lung. No positive women, the vast majority of the time get chemotherapy with or without tamoxifen depending on their estrogen or progesterone receptor status. This is not a definitive slide, this is just to give you some thought processes so that when a woman walks in your office with a 2 cm mass, you can kind of understand what the sequence of events will be. If the tumor is less than 1 cm, most of the time they get no adjuvant treatment. If the tumor is less than 1 cm, greater than 5 mm they have to look at good versus poor prognostic factors and then they decide chemotherapy no treatment versus tamoxifen and this can be very complex and a very difficult issue. If the tumor is greater than 1 cm the vast majority of the time they get some sort of chemotherapy with or without tamoxifen. The most common regimens used now are Adriamycin and Cytoxan, Taxol is being increasingly used, sometimes CMF is still used. Follow-up after breast cancer may increasingly fall in the hands of the gynecologist, patient’s often seek the gynecologist for their primary care. We recommend ipsilateral mammogram every six months for two years, a contralateral mammogram just like you would normally do every year, a physical examination of the breast every four to six months, usually every four months for the first year.
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It has been my experience that women rarely go back to self breast exam after a diagnosis of malignancy for a whole variety of reasons, so it’s really important for the physician to take the time to do a careful breast exam. Routine imaging and blood work is not needed, it’s still routinely done, however, there are multiple studies showing that chest x-rays, CT scans routinely CBCs and SMAC probably do not ultimately impact on a woman’s survival should her breast cancer recur. Recurrences are detected about a third by self exam, about a third by mammography, but about a third are detected just by the physician’s exam, so it’s especially important for you to examine the breast of a breast cancer survivor.
I would love it if in five years I wouldn’t have to stand up here anymore. We are always looking for the golden eggs that will allow us to prevent breast cancer once and for all. So I thought I would spend the last minute talking about some of the studies that have been done which are leading us in that direction. The NSABP 1 tried to prevent breast cancer in high risk women and they chose tamoxifen which was well defined for early breast cancer versus placebo. This was a huge study, received a lot of national attention, and basically these are the results. If you look at all tumors comparing tamoxifen in the light versus placebo in the orange, tamoxifen decreased the risk of all tumors by half. Most important, it decreased the rate of invasive tumors by about half. If you look at the thousands and thousands of women treated, this resulted in very few actual cancers being prevented, but the statistics were still highly significant. The problem was we were debating did tamoxifen really prevent cancer or did it just treat the early ones because most of the breast cancers that were prevented were estrogen and progesterone receptor positive. Tamoxifen unfortunately increases the risk of endometrial cancer and thromboembolic events, so it probably not the holy grail that we had planned. At about the same time, raloxifene was used for postmenopausal women to prevent osteoporosis, and it’s thought to avoid the estrogenic stimulation of the uterus and low and behold, when they looked at the woman independently who were treated with raloxifene versus a placebo for their osteoporosis, the women that got the raloxifene had a decreased risk of breast cancer. So ongoing trial from NSABP is called the star trial, it is currently accruing women 22,000 postmenopausal women will be accrued and the arms are tamoxifen versus raloxifene and we await the results of that trial.
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