Ask-the-Expert Online Conference: Updates From the 2009 ASCO Annual Meeting

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Ask-the-Expert Online Conference

The Ask-the-Expert Online Conference called Updates From the 2009 ASCO Annual Meeting featured Nick Robert, M.D. and Beth Baughman Dupree, M.D., F.A.C.S. answering your questions about the newest findings on risk, screening, treatment, and more.

Editor's Note: This conference took place in June 2009.

Important trials regarding systemic treatment?

Question from Beth: Dr. Robert, as a medical oncologist, obviously you have specific opinions as to where the future of breast cancer systemic treatment is going. From the most recent ASCO meeting, what do you feel are the one or two most important trials that are either beginning or that we have information on regarding breast cancer?
Answers - Nicholas Robert, M.D. The meeting of ASCO is a very big meeting, about 30,000 members. There are so many abstracts submitted, it is hard to go through all of them. For a long time we've heard about triple-negative breast cancer and the dismal prognosis, especially with metastatic disease. This year was a triple-negative breast cancer good news story. In a small study led by Joyce O'Shaughnessy where we gave chemotherapy to women with a triple-negative profile, we found that we could improve the outcome by adding a drug that was chosen on a basis of biology. We found that with the good response rate, we improved the time before recurrence, and we also found that we actually improved survival. What's so exciting about the findings is that it was based on the biology we think is specific to the triple-negative subtype. Knowing that biology, we added a new drug, the PARP inhibitor, and we found encouraging results. However, we need more information on this approach, and we hope that this summer we can reproduce these results in a bigger study. We hope that if these results are reproduced, we can begin to think about using this approach in the early phase of breast cancer in patients with this triple-negative profile. The other study that I'd like to mention was one I was involved in, the use of the drug Avastin (chemical name: bevacizumab). When adding that to different chemotherapy regimens, we improved the results for patients with metastatic breast cancer. This study took a novel approach, and what it means to patients is that we now have more options to treat patients with metastatic breast cancer, which we hope translates into better control of their cancer for a longer period of time, so they will have a better quality of life.

Other antidepressants for premenopausal women taking Tamoxifen?

Question from Jenna: Are there other types of antidepressants (other than SSRIs and SNRIs) that a premenopausal patient can safely take with tamoxifen? Have they been extensively studied for interaction?
Answers - Nicholas Robert, M.D. The drug is Effexor (chemical name: venlafaxine) and it’s been shown to be effective. It is used a lot to reduce hot flashes and it does not have a significant impact on tamoxifen. But Effexor is an antidepressant and can be used at higher doses to treat depression.

Pain studies or medication for pain from expanders?

Question from PamT: Have there been any pain studies on women who have bilateral mastectomies with expander placement? I'm 11 days post my third expansion. My doctor never offered to do smaller increments of saline. He doesn't think I need anything stronger than over-the-counter meds, but I'm still in pain. What can I do? And do women whose chest muscles are more toned have more pain?
Answers - Beth Baughman DuPree, M.D., F.A.C.S. It's very common for women to complain about chest tightness and pain during the expansion process. In addition to anti-inflammatories, I recommend the use of a muscle relaxant for my patients, specifically Skelaxin (chemical name: metaxalone), as this medication can help with the pain from the stretching of the muscle that occurs in the expansion process. I do not believe that there have been any studies that show that women whose chest muscles are more toned are prone to more pain. After surgery with bilateral tissue expanders having been placed under the pectoral muscle, I use the analogy and explain to my patients that it's as if they did 1,000 chest presses without taking a break. The combination of Motrin and Skelaxin, although it has not been scientifically proven in a randomized trial, has become our standard postoperative pain regimen for patients undergoing mastectomy and immediate reconstruction with either expanders or implants. I also recommend for my patients that during the expansion process they premedicate with Skelaxin the night before they are due to see the surgeon for expansion, and follow through for 24-36 hours afterwards. This has become a popular regimen in my practice with my partners and all of our plastic surgeons. The patients have discussed this at the breast cancer support group and said to make sure for the patients to ask for the expansion cocktail if it is not pre-written for them. There are many muscle relaxants on the market, and we have found that this one in particular has less central nervous system effects and the best benefit for the patient overall.

PARP inhibitor trials at University of Pennsylvania?

Question from Kelly: I would like further information on getting into the PARP inhibitor trials being done at the University of Pennsylvania.
Answers - Beth Baughman DuPree, M.D., F.A.C.S. I would suggest, Kelly, that you call the University of Pennsylvania and ask for the Department of Medical Oncology. Tell them you'd like to speak to a clinical trials nurse, and that individual should be able to connect you with the principal investigator at the university in order to be able to determine whether or not you are a candidate for the trial.

Changing the way we think about anthracyclines?

Question from AmyR: Are we changing the way we think about anthracyclines in regards to certain types of breast cancer?
Answers - Nicholas Robert, M.D. The answer is yes, we are. We're doing a national trial comparing an anthracycline-based regimen and a non-anthracycline-based regimen. The rationale for this trial is that there is good information obtained from other studies where the retrospective analysis has been made. We find that the patients who benefit from the anthracyclines had tumors that were HER2-positive. This has been a recurrent finding and we are currently doing a clinical trial in patients with HER2-negative breast cancer where they either receive a regimen called TAC (Taxotere [chemical name: docetaxel], Adriamycin [chemical name: doxorubicin], and Cytoxan [chemical name: cyclophosphamide]) that contains the anthracycline Adriamycin, versus TC, which does not. This trial has been recently modified to add another question as to the role of Avastin in the treatment of early breast cancer with a treatment arm that consists of TC with Avastin. This is an ambitious clinical trial with a pool of 5,000 women and it really requires the support of many people including women who are diagnosed with breast cancer to participate in this clinical trial. All our advances in breast cancer when it comes to medical oncology are done through the process of clinical trial. So we are encouraging women who are eligible to participate in this trial to answer this question.

New oral medications for advanced breast cancer?

Question from KayD: Are there new oral drugs available for advanced breast cancer (besides Xeloda)?
Answers - Nicholas Robert, M.D. In terms of chemotherapy agents, the answer is no. The good news about Xeloda is that in the trial that was presented at ASCO, when you combine Xeloda (chemical name: capecitabine) with Avastin, you improve the outcome of these patients with better outcome of their cancer. So Xeloda -- which is attractive because it not associated with nausea or hair loss -- now appears to be a better drug when you combine it with Avastin.

Research on progesterone-positive breast cancer?

Question from Deirdre: Is there ongoing research as to exactly what PR+ means to breast cancer? We all know that ER+ means that the lesion is fed by estrogen, but when I look up PR+ it states that the lesion is affected by progesterone but not that it feeds the cancer. Can you explain where the research is on progesterone and breast cancer? Thanks!
Answers - Nicholas Robert, M.D. The progesterone receptor, we think, is positive when there is an impact on the functioning estrogen receptor. In patients where both receptors are positive, we think that hormonal/endocrine therapy will be more effective. There is an uncommon subset of tumors where the estrogen receptor is negative and the progesterone receptor is positive. We think in that group there are still some benefits to using hormonal treatments, although the benefit is less.

Opinion on vitamin D and breast cancer?

Question from Jo-Ann: You read so much about the effect of vitamin D to prevent further breast cancer. Do you have an opinion on this?
Answers - Nicholas Robert, M.D. As someone who's originally from Canada, there was some pride when an observation was made from some Canadians in Toronto that there was a relationship between low vitamin D levels and breast cancer recurrence. However, with more people looking at this relationship, it is less clear that there is a relationship between low vitamin D and breast cancer. In these observations, there is an impression that having a normal amount of vitamin D is good for general health, and has an impact in terms of bone health. So in my practice, I do check vitamin D levels. If they are very low, I encourage patients to increase the amount of vitamin D, but one has to be cautious not to give too much. One also has to be careful that we at this point don't know that replacing vitamin D will have an impact on how someone will do with their breast cancer diagnosis.
Beth Baughman DuPree, M.D., F.A.C.S. In July 2007, in the New England Journal of Medicine, a review article seemed to spur a very large push for evaluation and treatment of patients' vitamin D levels. Many studies had been looked at prior to that and felt that possibly the cancer was the cause of the low vitamin D, as opposed to the low vitamin D levels being linked to an increased risk of developing breast cancer, colon cancer, and other medical disorders. Patients who live far north of the Equator and who have less sun exposure may have lower levels of vitamin D and the exact relationship is still something that we don't understand completely. We have begun testing all our patients at diagnosis and have found a significant number of patients who are deficient in their level of 25-hydroxy vitamin D. Since vitamin D-3 cannot be obtained through drinking milk, we recommend either sun exposure, which can create Vitamin D through the skin, or more importantly supplementation just to get the vitamin D level back into the normal range of somewhere between 35 and 55 nanograms/ml. I do not believe that vitamin D is the magic bullet that some people believe it can be in the prevention of breast cancer, but I think that having our levels within a normal range can certainly help with normal cellular functions. Vitamin D deficiencies have been associated with the ability to have ingrowth of blood vessels into tumors, and since some of our targeted therapies such as Avastin work to stop the ingrowth of blood vessels, an association can certainly be present but I believe still needs further investigation.

Subgroups within triple-negative breast cancers?

Question from PhoebeJ: Do we have further knowledge about subgroups within the triple-negative breast cancers?
Answers - Nicholas Robert, M.D. In terms of triple-negative breast cancer -- that is, defined by patients who are ER-negative, progesterone-receptor-negative, and HER2-negative -- this is not a uniform group. There are some patients who have a basal cell type. There are some patients who have a mutation in BRCA1, and in the future as we begin to do genomic studies on a more regular basis where research will support what is important to do, we will find that the triple-negative group, just like breast cancer, is composed of multiple subsets. The hope many of us have as we develop a better understanding of the different subsets of breast cancer is that we will be able to match systemic treatments that are more specific to each subset.

Studies on ginger to reduce nausea?

Question from Hal: The use of a ginger extract to help control nausea has been in the news lately. What was discussed at the conference if anything?
Answers - Nicholas Robert, M.D. Ginger has been known for a long time to potentially be helpful for nausea. I think many of us felt that was really for mild nausea. However, there was a stimulating small study suggesting that ginger extract may have a role in controlling nausea. It will be important to extend this observation to see how well this really works, compared to the many drugs that we have available already for controlling nausea during chemotherapy.
Beth Baughman DuPree, M.D., F.A.C.S. Ginger ale has long been used in the post-operative period as one of the beverages of choice and with all of the possible beverages that could be consumed, it's believed that the ginger in the ginger ale has been helping to alleviate nausea well before we knew how potent it could be.

Vaccine for non-HER2 cancer survivors?

Question from JGordon: Are we going to have a vaccine for non-HER2 cancer survivors in the near future? Are we doing Phase II or III clinical trials?
Answers - Nicholas Robert, M.D. The idea of a vaccine and cancer has always been an exciting one. If we could just vaccinate patients against cancer. Unfortunately, in breast cancer, approaches to date have not been successful. There was a recent large trial in metastatic breast cancer that many groups were involved in, which unfortunately was not successful. This included patients with HER2-negative breast cancer. We are looking at another trial that will include HER2-negative breast cancer in the metastatic setting, and if this trial is positive, we could consider a similar approach in early breast cancer.

Benefit from taking antioxidant supplements?

Question from Chess: Breast cancer survivors are said to take higher doses of antioxidants. Is there any research to support this strategy? What research, if any, has been undertaken to discover whether there is any benefit from taking supplements? Where do promoters of supplements get their "evidence"?
Answers - Nicholas Robert, M.D. The issue of supplements is compounded by the absence of well-designed clinical trials. Unfortunately, much of the information is testimonial in nature. The rationale for these approaches does have some biological basis, but as we have learned with other good ideas, they must be tested in a prospective fashion. Unfortunately when this is done, ideas like high-dose vitamin C did not prove to be of value. In terms of antioxidants, the limited data that does exist is not encouraging. What further complicates this whole field is the quality of the product tested. Supplements are not well regulated to guarantee quality. My recommendation is to avoid supplements while receiving active systemic treatment, and if there's an interest in using supplements, to be cautious and use them moderately. There exists already in the National Cancer Institute a department that supports studies with supplements, and I would encourage participation in such trials.
Beth Baughman DuPree, M.D., F.A.C.S. This brings up a very, very important issue that you must be completely forthcoming with your treating physician about anything you are taking, whether it is prescription, over the counter, or thought to be some type of herbal or vitamin supplement. Many of our treatments, including anthracyclines and radiation therapy, kill cancer cells by creating a formation of free radicals. Because one of the mechanisms of antioxidants is to stop free radical formation, the last thing we want to do is inhibit potential beneficial effects of the treatment we are giving by adding excess antioxidants into the body during the time of certain chemotherapy and radiation treatments. Once the initial treatment of the cancer is complete and patients are beginning the process of trying to live a healthier lifestyle, the recommended doses of vitamins and antioxidants should not be taken in excess of what the FDA recommends. I do encourage my patients to eat a healthy diet in which many antioxidants will come from the foods that we eat. Supplementation can be used just as the word says, to supplement, not in place of healthy food choices. So be certain that you discuss with your physician any medications, supplements, or herbs that you are taking during your treatment.

Prophylactic mastectomy for LCIS?

Question from awb: Do you feel BPMs are indicated for LCIS or is close monitoring/tamoxifen a safe alternative?
Answers - Beth Baughman DuPree, M.D., F.A.C.S. Bilateral prophylactic mastectomies have many indications but this is certainly a decision that would need to be made in conjunction with several other factors such as genetic predisposition (such as carrying the BRCA1 or 2 gene), family history, and certainly the number of previous biopsies that have yielded results of either LCIS or atypical ductal hyperplasia. Tamoxifen and the drug Evista (chemical name: raloxifene) have been shown in the STAR trial to be effective at decreasing the incidence of developing a breast cancer by approximately 48%. With the prophylactic surgery, there is still approximately a 2% risk of developing a breast cancer even with removal of the breast. In my personal practice, if a patient is requesting prophylactic surgery with a history of LCIS, I would go through an extensive process of education, medical options, and certainly have them understand the overall risks and benefits as well as obtaining a psychological assessment to be certain that this was the appropriate treatment for that patient. If this is something that you are considering, it is very important to absolutely understand what the surgery and reconstruction entail, and what your other medical options are such as anti-estrogen therapy with tamoxifen, close clinical monitoring, and digital mammography alternating with bilateral breast MRI. And in addition, maintaining a healthy body fat, exercising, and a healthy diet.

Do estrogen-receptor-positives really have to give up wine?

Question from Sharon: Please, please address this for those of us who are estrogen receptive, after 5 years of organic eating, and on Arimidex, do we really, really have to not have our wonderful glass of wine at night? Or every night? Ugh. Have given up everything else... no red meat, etc.
Answers - Nicholas Robert, M.D. There is a concern about the use of alcohol intake and the risk for breast cancer. As a matter of fact, a recent study suggested women should avoid alcohol altogether. My interpretation is that the use of alcohol should be moderate at best. That translates into a glass of wine, for example, with dinner. There is an interesting observation that was made by the Harvard School of Public Health in their studies, where they found that the association between alcohol and breast cancer was reduced by taking folic acid. However, for other health reasons, the use of alcohol (even that good glass of wine) should be tempered by moderation.
Beth Baughman DuPree, M.D., F.A.C.S. Postmenopausal women in particular who drink 2-3 glasses of alcohol per day increase their risk of developing breast cancer by approximately 40%. Women who drink half a glass of wine a day increase their risk of breast cancer by approximately 6%. We know there is an association and as with everything in life there are risks and benefits. Many of my patients feel as though they have to give up several things in their life through the process of adequately treating their breast cancer. I feel we need to create balance in our lives and a glass or two of wine per week is most likely not going to significantly change someone's risk of a new or recurrent breast cancer. But I don't believe that women, especially with estrogen-driven breast cancers, should be drinking significant amounts of alcohol on a daily basis. As for the folic acid study, I've had several patients return to my office and ask if they could increase their alcohol consumption if they're willing to take folic acid. I said it was promising, but that I would still recommend moderation.

Thermography or alternate screening method for dense breasts, family history?

Question from Colleen: What can you tell me about the effectiveness of thermography breast exams as an alternative to mammograms? Any new research on that? I'm 66 with a history of dense breast tissue and a sister with breast cancer at age 45. Thank you.
Answers - Nicholas Robert, M.D. In your situation, what is recommended is an annual digital mammogram which is more sensitive than the conventional film mammogram that was used for many years. In a patient with a family history of breast cancer, one should consider a breast MRI, which is more sensitive than a digital mammogram. You should also seek genetic counseling to determine your risk. This will help assist in obtaining a breast MRI. In addition, it is important to consider strategies to reduce the risk of developing breast cancer including what we have already discussed about alcohol intake, but also in terms of being close to one's ideal body mass, which can be achieved with a combination of diet and exercise. Unfortunately, thermography (which was a test that was being explored when I was a resident over 30 years ago) still is an area which, in my mind, is a study, and not to be considered a routine screening method for detecting breast cancer.
Beth Baughman DuPree, M.D., F.A.C.S. Women who obtain screening mammography do not prevent the formation of a breast cancer. But through screening mammography and early detection, we can prevent death from breast cancer by diagnosing cancers in either a pre-invasive phase or very early phase. Mammography has clearly been shown through screening studies to decrease the death rate from breast cancer by approximately 40%. There are no such prospective randomized trials looking at thermography as a widespread screening tool. Therefore I do not recommend it in my patients as their method of screening. It is difficult at times to interpret the results; therefore it is not something that is routinely used in our clinical breast practice.

New prognostic indicators for breast cancer?

Question from Rebbie: Are there any new prognostic indicators for breast cancer?
Answers - Nicholas Robert, M.D. In terms of prognostic factors, there is some very exciting work in metastatic breast cancer evaluating so-called circulating tumor cells. This test may be helpful in monitoring patients who are being treated for metastatic breast cancer; however, some of us think what might be more exciting is the ability to understand better the status of a patient being treated for metastatic breast cancer by evaluating cellular characteristics of the cells. To date, this remains an area of study but the hope is that for some patients with metastatic breast cancer, so-called “interrogating” the circulating tumor cells might prove of value in determining specific treatments. This thinking is in concert with an increasing interest to understand better the biology of breast cancer. Again, talking about metastatic breast cancer, the interest is that doing repeat biopsies of the tumor may be of therapeutic benefit.
Beth Baughman DuPree, M.D., F.A.C.S. As a surgeon, when a patient's cancer recurs, we will always opt to re-biopsy the tumor in order to determine whether the patient's estrogen, progesterone, and HER2 status has changed.

Role of meat and dairy in development of breast cancer?

Question from TinaT: Does consuming meat and dairy play a role in the development of breast cancer? I am a 1-year survivor, and along with other survivors, have given up meat and dairy. Is there any research that backs this information?
Answers - Nicholas Robert, M.D. The concern about the consumption of meat and dairy is a concern both about the consumption of animal fat and the consumption of calories. There is a growing literature to support that not only breast cancer survivors but all of us moderate our intake of both animal fat and calories. In terms of not only cancer prevention, but in terms of general overall health, the more careful we are with our diet, and the need to add exercise to avoid weight gain, the better the health outcome. So for the breast cancer survivor, the limited use of meat and certainly being careful about calories is a worthwhile strategy.
Beth Baughman DuPree, M.D., F.A.C.S. It has been clearly shown that exercise of at least 3 hours of cardiovascular type per week can decrease the risk of developing a breast cancer by approximately 18%. When you look at diet and exercise combined together, if you are taking in more calories than you are burning, there is more substrate for your body to be able to keep as fat stores. Because fat is a source of estrogen production, obviously having higher fat stores can be detrimental, especially for estrogen-driven breast cancer and for women at high risk of developing breast cancer. Many women do not understand that, although their ovaries are thought to be one of the only sources of estrogen production, that we have an enzyme that is very powerful in our adrenal glands called aromatase that is very effective at producing estrogen sources from our body's fat stores. So I do not tell my patients that they have to stop eating meat or dairy sources. I believe it's far more important to, once again, practice balance in this aspect of cancer prevention and treatment. As a society, particularly in the U.S.A., the level of obesity has become an epidemic. If you want to have an idea of this larger picture, the Center for Disease Control has an excellent resource that can show you the map of the U.S. and the relative levels of obesity over the last 50 years. The take-home message from this is not that you need to stop eating meat or dairy, but that you need to take a look at your overall level of health and well-being, and once again, practice moderation and not necessarily abstinence.

Research on Herceptin as maintenance medication?

Question from marejo: Any trials done or research done into using Herceptin as a maintenance drug? I am 4 years out (HER2 positive, stage 2B) and often wonder why we couldn't use Herceptin as a bi-yearly or yearly maintenance protector.
Answers - Nicholas Robert, M.D. The issue about how long to give Herceptin (chemical name: trastuzumab) in the adjuvant setting remains unclear. The standard now is to give Herceptin for 1 year. Interestingly, there is a small study where Herceptin was given for only a few weeks, and there was a benefit. There is a much larger study evaluating 1 year of Herceptin vs. 2 years. The results of that study are still pending. There has also been the strategy of using another drug that interferes with HER2, the target for Herceptin. This is an oral drug called Tykerb (chemical name: lapatinib) and there has been a study completed where this drug was given to patients after completing their standard treatment. This was given to some patients 2-3 years after their diagnosis. We will see from this study whether there is any benefit from this approach. There is a new study using another HER2-targeted drug which will be given to women with early breast cancer who have been treated with Herceptin, and they will be given this new drug. We will be able to see if there is any benefit to giving additional treatment to patients who had HER2-positive tumors. So right now, the standard is 1 year of Herceptin but you should know that people are looking at other approaches to see if we can improve the outcome for patients who have been diagnosed with HER2-positive breast cancer.

Where is research on triple-negative breast cancer?

Question from Sally: The comments on triple-negative breast cancer were short and to the point. They did not come across as particularly hopeful. Can you share where the research is with these types of cancer, and how much it is being studied? Since it is less common, many of us with this diagnosis wonder how much effort is being given to these types of cancers.
Answers - Nicholas Robert, M.D. The comments about the new treatment of triple-negative breast cancer with a PARP inhibitor were meant to be very hopeful. Frankly, for those of us involved in breast cancer treatment, this was the most exciting information we've heard about triple-negative breast cancer for some years. We hope that this approach using PARP inhibitors will not only be of benefit for women who are being treated for metastatic breast cancer, but also for women with early breast cancer. One of the frustrations in cancer or any research is the amount of time it takes to develop better therapies. You should know that the triple-negative breast cancer subset has been a subject of many clinical trials, and it has attracted the attention and interest of many clinical investigators. Many of us feel that the term triple-negative really reflects our ignorance about the biology of this subset because we know there are positive features, features that we can target, that can potentially be used for therapies that will improve the outcome of this patient subset.
Beth Baughman DuPree, M.D., F.A.C.S. As a surgeon who has been in private practice for nearly 20 years, I have patients in my practice who still come back to see me on an annual basis, alive and well, without evidence of disease, having had triple-negative tumors. For many of these women, at the time of their diagnosis, these tumors did not seem to have a particularly ominous prognostic aspect. Ever since we developed the drug Herceptin that has singled out tumors that express the HER2 receptor, we have now moved on to the next category of tumors looking for targeted therapies. Because ER-positive tumors have had over 20 plus years of the benefit of anti-estrogen therapy such as tamoxifen with further advancements in medications such as the aromatase inhibitors, the tumors designated as triple-negative breast cancers have now become the tumors for which we want to identify a therapy that can specifically target them as we have done in ER-positive and HER2-positive patients. As recently as 10 years ago, patients with HER2-positive tumors were felt to have a more ominous prognosis. But in the short course of a decade, we have changed that aspect. Additionally, patients with triple-negative tumors are often the patients to whom now, as surgeons, we will offer neoadjuvant chemotherapy or chemotherapy prior to surgery in order to be able to downstage tumors and also begin systemic treatment as early as possible. We cannot change the biology of the tumor that is presented to us, but sometimes we can change the way in which we choose to approach the treatment of the tumor. It's unfortunate that this tumor subset gets its name because it doesn't express estrogen, progesterone, or the HER2 receptor and therefore in its name is the word "negative," inasmuch that carries a stigma of having something negative. As we move forward in clinical research, hopefully we will be able to find a targeted therapy that is equally effective on this subset of tumor so we can be in an online chat in a few years talking about a different subset or a different specific aspect of breast cancer that needs our attention.

How to use current therapies to best benefit?

Question from Rich: Considering there is suggestion from cancer stem cell researchers that therapies that attack rapidly dividing cells can stimulate cancer stem cells, how does one use currently available therapies for actual benefit?
Answers - Nicholas Robert, M.D. The issue of stem cells in breast cancer has become a field of great interest. The thinking is that there are certain cells in a tumor, called stem cells, that are responsible for resistance and we may need a different strategy to eliminate stem cells. However, these concerns, which are right now more theoretical than fact, should not discourage us from using effective therapies that attack highly proliferative breast cancers. If you look at the experience of treating hormone-receptor-negative cancers, which tend to be more proliferative than hormone-receptor-positive cancers, you notice that chemotherapy is more effective in these hormone-receptor-negative cancers. At this time, it would be a mistake to avoid regimens that are effective against proliferative cancers. With that said, we look forward to understanding better the stem cell biology and how it relates to different breast cancers.

New data and recommendations for aromatase inhibitors?

Question from PJ: What's the latest data on aromatase inhibitors, and the number of years you should take them for maximum effectiveness?
Answers - Nicholas Robert, M.D. The current recommendation for the use of aromatase inhibitors is five years. In my practice, if I have a patient who started on tamoxifen and they're switched over to an aromatase inhibitor, I recommend 5 years of the aromatase inhibitor. But frankly, we don't know how long to give aromatase inhibitors. The duration of 5 years is the duration of how long we give tamoxifen. There are studies looking at the duration of how long to give an aromatase inhibitor. One study in which we were participants has already completed the accrual to try to answer that question, and we hope that in 2 or 3 years, maybe sooner, we'll have an answer on the duration question. I would recommend for anyone who's on an aromatase inhibitor and is coming up to their 5 years, it would be a reasonable discussion based on the stage of their early breast cancer to speak to their medical oncologist about the duration of the aromatase inhibitor they are taking, and if possible to take part in a clinical trial to try to answer this question.

What do you most HOPE to hear about at next year's ASCO?

Question from samita: What do you most HOPE to hear about at next year's ASCO?
Answers - Beth Baughman DuPree, M.D., F.A.C.S. That I don't have to be a breast surgeon anymore!
Nicholas Robert, M.D. There is something we haven't talked about tonight, which is the use of intravenous bisphosphonates. There was some exciting work from Austria that suggests the use of intravenous bisphosphonates, especially the use of Zometa (chemical name: zoledronic acid), could reduce the risk for recurrence of metastatic disease. There is a much larger study addressing this same question that hopefully we will hear about at next ASCO to provide more information on the potential benefit of intravenous bisphosphonates in early breast cancer. We know that the use of bisphosphonates is important to preserve bone health in postmenopausal women; it would be very exciting to learn that it can also reduce the risk of breast cancer recurrence.

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