Chemo or radiation for all tumors?
Meet the Experts
Jennifer Griggs, M.D., M.P.H. is a medical oncologist specializing in the treatment of breast cancer, with a a special interest in cancer survivorship, patient-physician communication, and quality of care for women with breast cancer.
Question from Jennifer: Is it still the opinion of many that small, early breast tumors do not get chemo or radiation, or is it now going towards ALL breast cancer patients be given some type of chemotherapy or radiation?
- Answer —Jennifer Griggs, M.D., M.P.H.: Breast cancer is treated with several different types of treatment, as you know. Although the stage of the cancer, that is, the size of the tumor and the involvement of lymph nodes, is very important in helping us decide treatment, also important is the biology or "personality" of the cancer. We might be more aggressive in treating an 8 mm cancer than we would be in treating a 2 cm cancer. What I mean by that is if the 8 mm cancer has very busy cells with a high grade and is negative for the estrogen receptor and positive for HER2, I would be more inclined to offer that patient chemotherapy than I would be somebody with a slow-growing 2 cm tumor that is ER-positive and negative for HER2.
We have additional help in making tumor therapy decisions in some patients with a technology called genomic profiling. This is a test done on the primary tumor and does not require any additional surgery or bloodwork. The tumor is sent for tests that further define the tumor's personality. There are several brand names for this test. The one used most often at this point in the U.S. is OncotypeDX. This test, again done on the breast cancer tumor already removed, returns a risk of recurrence score, and further defines the tumor's likelihood to come back elsewhere in the body. The test right now is only used in patients who have negative lymph nodes and whose cancer is positive for the estrogen receptor. If the patient has a tumor that does not fit those two criteria, the Oncotype test or other genomic assays cannot at this point be said to be helpful. The decision about radiation therapy depends on the patient's tumor size, the type of surgery she has, and the lymph node involvement.
For most women who have a lumpectomy (also called breast conserving surgery), radiation after surgery is considered standard of care. Omission of radiation therapy is associated with a higher risk of recurrence in the breast and surrounding lymph nodes. There are some women for whom radiation therapy can probably be safely omitted. Women who are 70 years old or over, who have small tumors with a slower growing personality, and who had a good surgery with nice wide margins tend to gain less from radiation than other women. And a woman may decide after consultation to reserve radiation therapy for the future if she indeed has a recurrence in the breast.
To answer your question, yes, women with small tumors very often are offered chemotherapy and radiation therapy, again depending on many of the factors I discussed above.
One interesting study that came out of San Antonio this year was a study looking at women who had a small number of lymph nodes involved (1-3 involved) who had tumors positive for the estrogen receptor. In 2 studies, the genomic profiling technology that I described above was shown to help predict which patients would have recurrent breast cancer. While we're certainly not going to start at this point using the genomic profiling assays to decide who does and who does not get chemotherapy with 1-3 positive nodes, additional studies that show the same thing will undoubtedly expand indications for this assay or test. But none of us is willing to not give chemotherapy to women with positive nodes on the basis of this test alone.
On Wednesday, December 19, 2007, our Ask-the-Expert Online Conference was called Updates from San Antonio 2007. Jennifer Griggs, M.D., M.P.H. answered your questions and shared the newest research presented at this year's San Antonio Breast Cancer Symposium.
The materials presented in these conferences do not necessarily reflect the views of breastcancer.org. A qualified healthcare professional should be consulted before using any therapeutic product or regimen discussed. All readers should verify all information and data before employing any therapies described here.
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