Chemotherapy may not be for every cancer patient

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Should every woman who develops breast cancer be treated with chemotherapy?

One of the most controversial topics in medicine today is “Should every woman who develops breast cancer be treated with chemotherapy?”.  Even more important, should chemotherapy be used as much as it is for most cancers?   Specifically, because I have dealt with breast cancer more than any other cancer I want to use this as my example.  OBGYNs are the doctors who find breast cancers most frequently when they are doing yearly breast exams and when they order yearly mammograms.  As a gynecologist, I would break the news to my patient, then refer her to a breast surgeon who would manage the rest of her care, including surgery and often times, chemotherapy.

When I first started practice in the 80s, these surgeons believed of course, in surgery and it was generally severe and traumatic to the patient.  Over time, surgery for breast cancer has become less radical.  In the past, most patients with breast cancer received radiation or chemotherapy and rarely were allowed to avoid either.  Slowly this has become less of a requirement for patients with breast cancer, however most women I talk to are convinced to take chemotherapy, “just to be careful to kill the breast cancer cell that were too small to remove with surgery.”.  Because of the increase in early detection, surgeons get patients with early smaller cancers and patients can often have the same survival with or without chemotherapy, however my patients are still talked into chemo by their surgeons because “It is just to be careful”.  Today we are talking about the risk of “being careful “and why this line of reasoning is no longer reliable as well as not always good for you!

Many oncologists are avoiding chemotherapy for early-stage breast tumors. The average number of newly diagnosed women with breast cancer has dropped from 35% down to 21%, and more are treatable with surgery.

Half of the doctors today are questioning whether or not women diagnosed with breast cancer are being over treated.  The issues most women fear when they think of chemo is being sick, losing their hair, and feeling sick from the chemo for long periods of time that they cannot go to work or care for their families.  The doctors who are concerned about the risks of chemo have a much greater worry–we worry about the long-term effects of chemo such as the appearance of other cancers from suppression of the immune system, and heart and kidney damage from chemo that leave many women in a state of disease the rest of their lives.

Unfortunately, chemo seems to be recommended to most women with breast cancer even if it will only improve their chance of survival by < 0.01%.  Chemo can help fight cancer tumors, but the poisonous side effects can be deadly, and include leukemia, heart failure, neuropathy, and infertility as well as premature menopause. Even the oral tumor medications like tamoxifen put a patient at high risk of uterine cancer.  I prefer the new drug, Arimidex and Letrozole, which work in a completely different way from tamoxifen and pose protection for the uterus and not risk!

Cancer mortality rates have improved dramatically since the late 1980’s, and some of this is due to chemo and radiation.  However, those numbers do not account for the women who developed other life-threatening diseases that cause their death secondary to their cancer treatments.  because of these risks of chemo has set doctors in a direction of dividing patients and medications into genetic types, so that the right patient gets only the medication that will work for them.  This is a type of “smart-chemo-bomb” technology which decreases risk and secondary disease for patients who do need chemo!  Doctors are now refining their treatment strategies with genomic testing and a better understanding of tumor biology is drastically reshaping the way breast cancers are treated. With genomic testing, a tumor is given a score, a low score means a woman has a good prognosis and won’t benefit from chemo. A high score means she needs chemo and a mid-range score means there needs to be careful thought and analysis before deciding on the treatment. Genetics of the tumor also directs which type of chemo should be used for that tumor, and the patient’s genetics specifies which chemo may cause her damage, and which she can tolerate.

There is a war going on between factions of doctors who treat breast cancer patients with one side saying chemo is necessary for all or most patients, and those that believe only the tumors who have metastasized should require chemo. This debate is called the “de-escalation” debate. A debate over decreasing shot gun treatment for all patients with a certain disease to a more individual treatment with less is more mentality.

Remember, for older, larger, and metastasized tumors, chemo after surgery is often still the treatment of choice. But the point seems to be to make a careful decision based on available tests rather than just agree to the most drastic treatment, when in a panic over the diagnosis. Dr. Baselga worries about “pack behavior” making clinical decisions based on wishes instead of data. When one examines the data, one can make better choices.  At the end of the day, an informed patient is the goal. The patient should be able to participate in making good decisions for good health care choices.

A paper published in the New England Journal of Medicine in 2015 gave de-escalation supporters powerful ammunition. In a study of more than 10,000 women, 1,626 who had early-stage breast cancer with no lymph node involvement were given hormonal treatment (Tamoxifen, arimidex, and Letrozole) alone, without chemotherapy.

The study, led by Joseph Sparano, an oncologist and professor of medicine at Albert Einstein College of Medicine, found that those with a low score also had “very low rates of recurrence at five years with endocrine therapy alone.” In other words, they did fine without chemotherapy.

“There is clearly a need for addressing the toxicities of the treatments,” Dr. Hortobagyi says, “but we have to do it responsibly and on the basis of the highest level of evidence. We can’t simply go out and say, ‘As of tomorrow, I will go and give half the chemo,’ in the absence of evidence that [it] would work.”

Besides, he adds, “The worst toxicity is death.”


This Health cast was written and presented by Dr. Kathy Maupin, M.D., Bio-identical Hormone Replacement Expert and Author, with Brett Newcomb, MA., LPC., Family Counselor, Presenter and Author.  

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