Who Gets Chemotherapy?

Doctors use many factors to determine who receives chemotherapy, hormonal (anti-estrogen) therapy, or a combination of both. A test called Oncotype DX may be able to help you make choices about treatments. These factors are:

• key features of the particular cancer, including tumor size and grade, hormone receptor status, rate of tumor cell growth, oncogene expression, and lymph node involvement
• individual patient profile (age, general health, location of tumor, whether or not there are enlarged lymph nodes under the arm)
• stage of the disease
• menopausal status (whether you are still menstruating or had already stopped menstruating when the cancer was diagnosed)
• risk/benefit factor of the treatment. Your medical oncologist will weigh the risks that you face from cancer versus the long-lasting benefits you could realize from the chemotherapy or hormonal (anti-estrogen) therapy, taking into account the treatment's side effects and your general health picture.

As you and your doctor analyze the information from all of these factors, you'll discuss several widely accepted treatment guidelines. Remember that in determining who receives chemotherapy, every individual's case is different and requires specific consideration by a medical oncologist.

• Chemotherapy is never recommended for non-invasive, in situ cancers, which have nearly no risk of metastasizing (spreading to other parts of the body). Effective treatment targeting the breast, rigorous observation, and follow-up are critical. Anti-estrogen therapy is usually considered for its protective effect on the remaining breast tissue.
• In general, doctors tend to recommend more aggressive treatments in women with invasive breast cancer who are pre-menopausal (still menstruating). Breast cancer in these women tends to be more aggressive, and chemotherapy is usually required in order to achieve the best results.
• Chemotherapy is almost always recommended if the lymph nodes are involved, regardless of the size of the tumor or menopausal status.
• Chemotherapy is usually recommended for pre-menopausal women if the tumor is invasive, has not spread to the lymph nodes, and is one centimeter or more in size. With these factors present in a post-menopausal woman, chemotherapy would be seriously considered.
• Chemotherapy MAY be recommended to women (especially pre-menopausal women) who have a combination of favorable and less-than-favorable cancer characteristics—for example, if the tumor is invasive, is confined to the breast, is smaller than one centimeter, but has one or more unfavorable "personality features".

Hormonal therapy in addition to chemotherapy

• Hormonal (anti-estrogen) therapy should be considered in any PRE-menopausal woman whose cancer is estrogen-receptor-positive. Decisions about chemotherapy and hormonal therapy are coordinated. Some women get chemotherapy alone, others hormonal therapy alone, and still others get both forms of treatment.
• Chemotherapy in addition to hormonal therapy may help lower the risk of recurrence for some estrogen-receptor-positive cancers that also have unfavorable factors. For example, a new test (not yet widely available) shows the levels of "invasion factors" uPA and PAI-1 in the cancer. High levels are considered unfavorable. Another new test called Oncotype DX helps assess risk of recurrence in women with hormone-receptor-positive disease who have completed a course of treatment with tamoxifen. For women at high risk, adding chemotherapy may be beneficial.
• Women with estrogen-receptor-NEGATIVE cancers (the tumors do not need estrogen to grow) will do as well with chemotherapy alone as they would if they followed chemotherapy with hormonal treatment.
• Hormonal therapy is recommended to nearly all post-menopausal women with estrogen-receptor-positive or progesterone-receptor-positive breast cancer.
• Many women may get chemotherapy and hormonal therapy regardless of menopausal status.