Breast Cancer Treatment Update

WebMD Live Events Transcript

When you are diagnosed with breast cancer, you want the best possible outcome. But what are your treatment options? It can be confusing: surgery, radiation, hormone therapy, immune therapy, chemotherapy, clinical trials, even alternative therapies. We turned to Marisa Weiss, MD, of breastcancer.org for answers about what treatments are available. She joined us on Oct. 27, 2004.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Welcome back Dr. Weiss. If you were diagnosed today with breast cancer, what would be the first options you would explore for treatment?

WEISS:
Upon a breast cancer diagnosis, it's important to stop and do all the tests and studies necessary to define the nature and extent of the problem. This means getting a careful mammogram study, possibly an ultrasound test -- and possibly an MRI scan of the breast. Usually a biopsy comes next. The tissue removed is analyzed in the pathology department and a report is generated.

Information comes back in bits and pieces, so you need to wait until all the key information is back before you can make any final treatment decisions. This information includes:

  • Tumor size
  • Grade (how much the cancer cells look similar to or different than normal cells)
  • Hormone receptors
  • Margin status (was the whole cancer removed or were tumor cells up against the edge of the tissue that was taken out)
  • HER-2 status and a few more things

In addition, your doctor will need to evaluate the lymph nodes to see if any are involved, and if they are, you'll want to know how many. Your doctor also might order other tests of different parts of the body.

When this information is back you have a good idea of what the nature of your problem is so you can pick the best treatments for you. This will involve a decision about how to treat the breast, either by mastectomy, which removes the whole breast, or lumpectomy followed by radiation to the remainder of the breast tissue, or under certain circumstances, radiation may be directed to only part of the breast.

Decisions will be made also about the potential need for systemic treatment (treatment to the whole system/body), which includes chemotherapy, immune therapy (like Herceptin), and hormonal therapy. You will be meeting with a lot of doctors from each of these specialties to come up with a combined treatment plan that is most likely to work best for you.

MEMBER QUESTION:
Is it important to be treated at a teaching hospital in a large urban center to get the best treatment? We are out in the middle of nowhere and I am concerned that the latest treatments may not be available in our small hospital.

WEISS:
That's an excellent question. You can get state of the art treatment at many community hospitals. The best way to figure out if this is possible or not is to have an evaluation at the community hospital and then at the teaching hospital. Find out what technology is available in the community hospital. Get the names of the specific doctors that are there and find out if they are specialists in breast cancer and where they trained. Ask around to family and friends and coworkers. Pretty quickly you will find out where the best care is available.

If it's very hard for you to get your care at the teaching hospital at least you can get a treatment plan designed by that hospital and you can have it put in place at the community hospital.

"Generally a second opinion is very useful. It is an opportunity to get more information so that you can have a better understanding of what your situation is."

MEMBER QUESTION:
I'm getting so much information from medical people I can't keep it straight. How am I supposed to sort it all out and make a decision? This is my life and I can't keep it all together.

WEISS:
Go to breastcancer.org. It is a special place on the Internet where we provide the best medical information in an easy to understand manner. For sure, the information is overwhelming at a time when it's hard to concentrate and think straight.

Ask your doctors to write their recommendations down on a piece of paper so that you can be sure that you heard them correctly. Bring these papers from one doctor to the other. Ask them to work on the same page and then go to breastcancer.org and get more information that will help you understand and get comfortable with the information so you can arrive at a decision you are comfortable with.

MEMBER QUESTION:
Do you recommend getting a second opinion when first diagnosed with breast cancer?

WEISS:
Yes. Generally a second opinion is very useful. It is an opportunity to get more information so that you can have a better understanding of what your situation is and what options you have. You can bounce one doctor's opinion off the other and this can be quite helpful.

Sometimes, however, a second opinion can introduce confusion if the second doctor disagrees with the first doctor. You might seek out a third opinion in order to figure out what to do, or you can circle back to your primary care doctor and ask him or her to help you.

MEMBER QUESTION:
Are AC and Taxol a good choice for ER-negative breast cancer?

WEISS:
Both of those drugs are very effective chemotherapy agents. They can be used together or in combination with other agents. There is a whole "alphabet soup" of medicines you will start to hear about. Usually the options provide effective treatment with minimal differences between them.

Besides Taxol that you referred to, there is another drug that is very effectible and might even be more powerful, called Taxotere.

MEMBER QUESTION:
Are there any clinical trials for ER-negative breast cancer?

WEISS:
There are many clinical trials for women such as you. Usually the trials start upon your initial diagnosis. If you're already in the middle of a treatment course, it may be too late to enroll in a clinical trial for your current situation. For some women who develop metastatic disease, they may be eligible for a number of different clinical trials, despite what prior treatment they had.

MEMBER QUESTION:
You said that you have to start clinical trials from the beginning. How do I find out what trials are available and decide what I should try? Having just been diagnosed, I am still trying to absorb so much information.

WEISS:
Find out from your cancer center what trials are available there. You can go to 1-800-4-CANCER to learn about other trial opportunities. You can also go to cancer.gov. At breastcancer.org we have these links for you.

MODERATOR:
And we have a clinical trials message board on WebMD.

MEMBER QUESTION:
Do you feel PET scans are good for follow-up?

WEISS:
PET scanning can be helpful in finding early signs of metastatic disease in someone who is at significant risk for having this possible outcome. It is an expensive test that is only available in relatively few centers. It may be hard for your insurance company to pay for it. This is because, so far, a woman's survival from metastatic breast cancer is not extended by finding metastases a little bit sooner through PET scanning, compared to finding it a little bit later because of new symptoms. You have to talk to your doctor about this.

"Tumor markers are not recommended by the professional societies of oncologists, because they can be unreliable and misleading."

MEMBER QUESTION:
What should I consider before deciding between lumpectomy and mastectomy? I want the least amount cut away, but don't want any cancer left in me.

WEISS:
Lumpectomy and radiation to the remainder of the breast is equally effective as mastectomy in a woman who has one cancer in the breast that is smaller than two inches, or four or five centimeters, that is completely removed with clear margins. Each large international study has demonstrated that these two treatment options are equal for these women. This is also true for women with lymph node involvement.

Mastectomy most likely represents the best treatment approach for women with:
  • A cancer that is bigger than 5 centimeters that did not shrink down with chemo
  • Multiple cancers in the same breast that can't be removed with clear margins
  • Inflammatory cancer (a type of breast cancer that diffusely involves the whole breast)
  • Skin involvement

Sometimes after mastectomy radiation is needed. This is true if your cancer is over 5 centimeters and there are four or more positive lymph nodes or if the margin of resection is positive.

MEMBER QUESTION:
What about tumor markers? My oncologist doesn't feel I need them at this point.

WEISS:
Tumor markers are not recommended by the professional societies of oncologists, because they can be unreliable and misleading. Sometimes the marker can be elevated without any problem being present. Sometimes the markers can be normal and you have a problem present.

If you are someone with metastatic disease and your marker is high, then getting markers can be useful as a measure of your response to therapy. For example, if you are taking hormonal therapy and your markers drop, that shows a good response to treatment. If you remain on hormonal therapy and the markers start to climb, it may signal the need to modify your treatment plan.

MEMBER QUESTION:
Does the location of the tumor in the breast affect prognosis?

WEISS:
Generally no. Most cancers in the breast happen to be in the upper outer quadrant, but there is no clear correlation between location and prognosis.

MODERATOR:
What are the latest drugs available? Do you see anything new coming that looks really promising?

WEISS:
There are all kinds of new drugs that are coming out.

  • Taxotere, which has been around for a while, is showing efficacy for new groups of patients.
  • There's a new drug that will probably become available next year, called Lapatinib, which is an immune treatment that works against the HER-2 and EGFR receptors.
  • There are new hormonal therapies around the corner.
  • Medicines are coming that work to block blood supply to cancers.

Sign up for the email updates at breastcancer.org to make sure you find out about these therapies as soon as they are available.

MEMBER QUESTION:
Have any peer-reviewed studies been published about alternative therapies?

WEISS:
Many women are interested in complementary and alternative medicine and wish they could integrate these treatments into their conventional treatment. Unfortunately, it is hard to get the money together to fund research in this area, because there are very few products that could be sold to recapture the money invested in the protocol.

We do know that mindful measures can help improve quality of life. Some examples:

  • Support groups
  • Stress reduction
  • Prayer
  • Meditation
  • Touch therapy massage

We don't know if they extend survival. We are trying to learn more about herbal therapies as well as vitamins and supplements.

MEMBER QUESTION:
I am coming up on my first year follow-up and am trying to stay on top of this. What tests to you recommend?

WEISS:
High quality mammography and possibly MRI scanning. If your breasts are hard to examine physically and if mammography was not helpful in finding your first diagnosis, then MRI scan may be very helpful to get, along with mammography. You might choose also to be followed by a specialized team of experts in breast health.

MEMBER QUESTION:
Are there any new drugs coming out for ER-negative? It seems like all the drugs benefit ER-positive.

WEISS:
In fact, chemotherapy works best in women with hormone receptor negative disease. So any new chemotherapies are likely to benefit someone like you. For women with hormone receptor positive disease, they will get less benefit from chemotherapy. Instead, they need to depend more heavily on hormonal therapies.

"If your breasts are hard to examine physically and if mammography was not helpful in finding your first diagnosis, then MRI scan may be very helpful."

MEMBER QUESTION:
If your mother had breast cancer at 60 and your sister had it at 46, what would you recommend to the next sister in line (me - age 37)?

WEISS:
You should get a baseline mammogram now and ask your doctor if the mammogram was reasonable to interpret. Sometimes mammograms in younger women are hard to read because there's so much active gland tissue that can easily obscure a cancer that could be present. If the mammogram was reasonable to read, your doctor may recommend that you start with annual mammography, even now.

I would also recommend that you see a genetic counselor to find out if there is an abnormal gene present in your family. Knowing this could help tailor your treatment plan for you. An MRI scan could be very important if your family history proves to be significant, or if a genetic abnormality is present. This test should be done at a center that is experienced with this modality.

MEMBER QUESTION:
What is the best hormone therapy for receptor-positive disease?

WEISS:
There's no "right" answer to this question.
  • If you are after menopause, and you are choosing hormonal therapies, Arimidex is probably your best option.
  • If you are on Tamoxifen and have been on that drug for two or three years and you are post menopausal, then switching over to an aromatase inhibitor may be beneficial. These medicines include Arimidex, and Aromasin.
  • If you are about to finish a five-year course of Tamoxifen, and you are postmenopausal, you may consider starting Femara and extend your protection with a five-year course of this drug.

Talk to your doctor about these options and look at breastcancer.org for all the information you need.

MODERATOR:
Before we wrap things up, do you have any final words for us, Dr. Weiss?

WEISS:
Thank you for tuning in. Be sure to sign up for email at breastcancer.org. Be sure to prepare your questions ahead of time before you go to the doctor so you can use your time most effectively. Thank you for the opportunity to be of help.

MODERATOR:
Our thanks to Marisa Weiss, MD, for joining us. For more information please visit breastcancer.org. And be sure to visit the WebMD message boards to ask questions of our online health professionals and to share questions, comments, and support with other WebMD members.



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