Early Stage Treatments -- Joyce Ann O'Shaughnessy, MD.-- Oct. 31, 2002.

Last Editorial Review: 10/23/2003

WebMD Live Events Transcript

Finding and treating breast cancer in its earliest stages is the key to winning the battle against this disease. What are the options for early intervention? How do you evaluate your choices and make the best treatment decision? Joyce Ann O'Shaughnessy, MD, joined us on Oct. 31, 2002, to answer treatment questions.

The opinions expressed in this transcript are those of the guest 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 to WebMD Live. We'll be discussing "Beating Back Breast Cancer: Early Stage Treatments." Our guest today, Joyce Ann O'Shaughnessy, MD, will answer your treatment questions. Welcome Dr. O'Shaughnessy.

O'Shaughnessy: I'm glad to be here.

Member: Dr. O'Shaughnessy, I am scheduled for breast cancer surgery, but first I will receive chemotherapy. I am supposed to get four cycles of doxorubicin and cyclophosphamide. Then I will get four cycles of docetaxel. Then surgery. I'm told that the addition of the docetaxel before surgery is a good idea. Does that sound right?

O'Shaughnessy: Yes. That certainly does sound right. We have very good evidence now that adding docetaxel (Taxotere) doubles a woman's chances of not finding any cancer in her breast at surgery. Furthermore, the docetaxel can increase a woman's overall survival from her early breast cancer. I very commonly recommend the AC (Adriamycin, Cytoxan) followed by Taxotere for women who are receiving pre-operative chemotherapy.

Member: I've just been diagnosed with node-positive, early-stage breast cancer; what are my best options?

O'Shaughnessy: For node positive breast cancer in the U.S. most women are treated with Adriamycin, Cytoxan, and either Taxol or Taxotere. The recent study of Taxotere along with Adriamycin and Cytoxan shows a significant reduction in the risk of breast cancer recurrence with the addition of Taxotere as well as a significant improvement in survival rates for women with one to three positive lymph nodes. Taxol following AC chemotherapy appears to improve survival in node positive breast cancer patients, particularly those who have estrogen-receptor negative breast cancers. And so for most women who have node positive breast cancer, they will benefit from receiving both Adriamycin and either Taxotere or Taxol with a significant improvement in their chances of long term overall survival.

Member: I had a biopsy last week on a mass located only through ultrasound very close to my breastplate. The results came back positive and I see my surgeon later today. What questions should I be asking him and how will I know if he is applying the latest technologies and treatments?

O'Shaughnessy: The main question is whether your surgeon will recommend a lumpectomy or mastectomy. We have new data that spans over 20 years showing that a lumpectomy with radiation therapy to the breast provides exactly the same overall survival for women, as does a full mastectomy. So, a woman whose breast cancer can be completely removed by lumpectomy should strongly consider this option as it is definite that it is as effective as mastectomy, provided the margins are negative for cancer, meaning the cancer has been completely removed.

Many surgeons are offering a sentinel lymph node biopsy, which is considered to be a state-of-the-art technique. I would recommend you ask your surgeon about a sentinel lymph node biopsy. I would ask the surgeon if your breast cancer tissue will be sent for HER2 testing, which many of us consider to be a standard diagnostic test on the breast cancer. If your cancer is of the size that the surgeon recommends a mastectomy to you, you can ask him or her about the possibility of using chemotherapy before the surgery to shrink down the cancer and whether this might give you the opportunity to have a lumpectomy.

Member: Before I was diagnosed I had an ultrasound that showed a thickening of the uterus. So when I was diagnosed in January 2000, I refused tamoxifen due to that reasoning on my part, plus I was told I was in gray area anyway to take it ... opinion please?

O'Shaughnessy: I am not able to give you a strong recommendation about whether tamoxifen would be of benefit to you without having a chance to review your pathology reports. However, as a general rule, I am a strong advocate of tamoxifen because tamoxifen has been shown to twice as effective as chemotherapy regarding preventing breast cancer recurrences and saving women's lives from early breast cancer that is estrogen receptor positive. A thickened uterus is not necessarily a reason not to take tamoxifen and to be safe, a biopsy of the uterus lining could be performed to document that there is no evidence of early abnormal cells.

The new drug Arimidex is an alternative to tamoxifen for postmenopausal women, and does not appear to cause any stimulation of the uterus or uterine cancer. Because I believe very strongly in the importance of hormonal therapy with tamoxifen or Arimidex for hormone-receptor positive breast cancer, I would strongly urge you to discuss these options with your oncologist now that we have the promising data and FDA approval of Arimidex for early breast cancer.

Member: I keep reading about something called adjuvant therapy. What is that, and what do I need to know about it?

O'Shaughnessy: Adjuvant therapy refers to the treatments that are given to cancer patients after their cancer has been removed by surgery. For breast cancer, adjuvant therapy refers to chemotherapy and hormonal therapies such as tamoxifen or Arimidex, which treat the woman's entire body. The purpose of adjuvant therapy is to kill any cancer cells that may have come loose and invaded out of the original cancer in the breast and may have spread to parts of a woman's body such as her bones, liver, or lungs. Most often any small metastases would only be a small clump of cells and would not be seen on even the best x-rays, such as CT scans or bone scans. However, adjuvant therapy is given to most women with breast cancer because there is a risk even with negative lymph nodes that cancer cells have left the breast and traveled to different areas in a woman's body.

Member: I thought tamoxifen was just a guarantee for the cancer not to recur in the breasts?

O'Shaughnessy: Tamoxifen is a life-saving medication and is my very favorite drug of all time for breast cancer because I save more women's lives from breast cancer with tamoxifen than any other drug. The primary purpose of tamoxifen is to kill off cancer cells that may have spread in a woman's body, and to save her life from breast cancer. A secondary benefit is to prevent breast cancer in her other breast. Unless a woman has a history of blood clots in her legs or lungs or a recent stroke or heart attack, the benefits of tamoxifen far outweigh any risks. I beseech you to talk to your doctor or to consider another consultation with a different doctor about tamoxifen.

Member: I am 55 years old and have breast cancer in my family on both grandmothers. On my last mammogram (one month ago) they found a 8mm x 8mm x 5mm spot. I have had an ultrasound that showed the spot to be 3mm x 3mm x 2 mm. It is solid. They said the change in size might be due to the compression of the mammogram. They have advised me to have a follow-up mammogram in six months. Should I be getting a second opinion? I know this is very small but I am concerned.

O'Shaughnessy: It is always a good idea to follow your instincts. If you would feel more comfortable with a second opinion, I would urge you to obtain one.

Member: Dr. O'Shaughnessy, I read on breastcancer.org about a benefit of a new combination therapy that came out this year. It has to do with a standard chemotherapy called FAC. They talked about an alternative combination that now may be better. Can you tell me what they're talking about?

O'Shaughnessy: The new treatment you are referring to is called TAC, which is a combination of Taxotere, Adriamycin, and Cytoxan. In a very large study in women with node positive breast cancer, TAC was found to significantly reduce the risk of breast cancer recurrence three years after diagnosis, compared with FAC, a chemotherapy regimen we have been utilizing for more than 20 years. Most importantly, in women with one to three positive lymph nodes, TAC reduced the risk of dying from breast cancer by 50% compared with FAC treatment. This very substantial benefit was seen in women whose breast cancers were either estrogen-receptor positive or negative. This very important study represents a huge advance for women with breast cancer, and as a result, many breast cancer specialists are offering women treatment with either TAC or AC followed by Taxotere.

Member: In March, I was diagnosed with stage I breast cancer with 1.1 cm lesion. I had a lumpectomy and six and a half weeks of radiation. My lymph nodes were clear with no sign of cancer. I am currently on tamoxifen. Would I have been better off by doing chemotherapy as well to increase my chances of not having a recurrence?

O'Shaughnessy: This is a very important question, and it is a gray zone where different oncologists might offer different opinions. The question of whether you would benefit from chemotherapy would depend on a very careful review of your pathology report to assess several features of your breast cancer. Although I am not able to give you my opinion about whether chemotherapy would be helpful for you, I would suggest that you obtain at least two opinions about this as you may be in a gray zone, meaning that there is no definitive right or wrong answer to this question. The important thing is for an oncologist to tell you what the absolute benefit to you would be regarding avoiding breast cancer recurrence with the addition of chemotherapy so that you can decide for yourself whether you want to have chemotherapy or not.

Member: I am a 38-year-old woman who is scheduled for a mastectomy with reconstruction. I am led to believe that I caught this early and that my prognosis is very good. According to the ultrasound my tumor is 1.8 cm at its largest point. My question: Are there other options besides chemotherapy for a person in my situation as an adjunct therapy?

O'Shaughnessy: Most 38-year-old women who have a 1.8 cm breast cancer will benefit from combination chemotherapy regardless of whether the lymph nodes are positive or negative. In Europe, node negative women who have very strongly estrogen-receptor positive breast cancers and who are young are treated with suppression of their ovaries with an injection given monthly called Zoladex in combination with tamoxifen.

However, in the United States, we generally treat young women with chemotherapy followed by tamoxifen if her breast cancer is estrogen-receptor positive, and with Zoladex if her menstrual periods return and she has positive nodes. The effectiveness of chemotherapy is particularly pronounced in women who are pre-menopausal. Therefore, I would urge you to pursue both chemotherapy and optimal hormonal therapy to maximize your chances for being cured from breast cancer. The results with optimal chemotherapy and hormonal therapy are generally extremely good for women with 1.8 cm breast cancers.

Member: I just went back for a second mammogram, due to a change from the previous year's view. I have been told that I have "microcalcifications" in both breasts. I will be scheduling another mammogram in six months. Is there an explanation of this symptom and how it may relate to breast cancer, if at all? I'm very concerned and scared!

O'Shaughnessy: Some microcalcifications have a classically benign appearance on mammogram, and it is very safe to follow them carefully with repeat mammograms every six months for a few years, and then returning to yearly mammograms if the benign microcalcifications do not change.

These classically smooth and larger benign microcalcifications do not increase a woman's risk for breast cancer. The fact that they have appeared in both breasts makes it less likely that these microcalcifications are of concern. Some microcalcifications are small, multiple, irregular in shape, and clustered together, and these are more worrisome for breast cancer. I believe strongly in the power of a second opinion and would urge you to take your mammograms to another breast-imaging center or to your primary doctor who will send them to another breast radiologist for a second opinion.

Member: What are the most recent breast-conserving treatments for breast cancer stage I and II and does breast conserving surgery have a lower efficacy regarding eradication of the disease and recurrence than the more radical modalities?

O'Shaughnessy: The standard of care for breast-conserving surgery remains a lumpectomy obtaining at least several millimeters of normal breast tissue around the lumpectomy without any of the margins around the lumpectomy involved with cancer or with ductal carcinoma in situ.

Newer treatments such as cryosurgery or radio frequency ablation are still investigational and are quite early in their clinical development. Following lumpectomy with clear margins, the standard of care remains whole breast radiation therapy with a boost of the radiation to the lumpectomy bed. This treatment is highly effective and is associated with about a 5% to 8% risk of in-breast tumor recurrence over 10 years. If a woman's breast cancer is estrogen-receptor positive, tamoxifen will reduce the risk of in-breast recurrence down to a risk of 2% to 3% over 10 years.

Newer treatments such as radiation therapy called brachytherapy, which involves the placement of radioactive seeds in the breast, cuts the duration of radiation therapy from approximately five to six weeks down to five days. However, brachytherapy is still early in its clinical development and only women with very small, node-negative breast cancers who have widely clear margins and whose breast cancers were not too close to the skin are good candidates for brachytherapy at this time.

Member: Can you tell me the reason chemotherapy is sometimes given before surgery if the cancer is early stage and hasn't spread?

O'Shaughnessy: For small breast cancers, in general, women have a choice about whether to have surgery first and then chemotherapy or whether to have chemotherapy first and then surgery. Right now there is not a compelling reason to prefer one method over another for small breast cancers that can be removed by lumpectomy.

Chemotherapy given before surgery is still in 2002 most commonly given for women who either have large breast cancers that cannot be completely removed with surgery and the chemotherapy is given to reduce the size of the breast cancer and make a mastectomy feasible and to increase the chances of obtaining clear margins at the time of surgery. Some women receive pre-operative chemotherapy because they are very highly motivated to preserve their breast and their breast cancer is too large at the time of diagnosis to permit a successful lumpectomy. It's clear that giving chemotherapy before surgery will allow 10% to 15% of women to have a lumpectomy who were not originally eligible for this lumpectomy. This approach is safe and effective provided clear margins are obtained at surgery and provided the woman receives breast radiation therapy.

Moderator: Dr. O'Shaughnessy, we are almost out of time. Do you have any final comments for us today?

O'Shaughnessy: We have made steady progress against breast cancer over the last 25 years by providing state of the art chemotherapy and hormonal therapy to women with early stage breast cancer following breast surgery. Most recently, the newer chemotherapy agents, Taxotere and Taxol, have provided substantial improvement in women's overall survival from breast cancer. The new hormonal agent Arimidex appears very promising and we hope that the next several years will show us that Arimidex is more beneficial than tamoxifen for early breast cancer.

It is important for all women who are newly diagnosed with breast cancer to obtain several opinions about adjuvant therapy and to pursue the therapies that will give them the highest long-term survival rates.

Our research group in U.S. Oncology has recently launched a new adjuvant breast cancer clinical trial, which we hope will further improve the survival of early breast cancer patients. In this study, patients are randomized to receive either AC followed by Taxotere or to AC followed by Taxotere and Xoloda. We are very confident that AC followed by Taxotere offers women the best current hope for long term overall survival from breast cancer and we have an excellent rationale for postulating that combined Taxotere and Xoloda may be even more effective than Taxotere in prolonging survival and curing women from breast cancer.

The pace of research is very rapid with new advances reported for early stage breast cancer nearly every six months. The future remains bright and I fully expect that the cure rate from breast cancer will continue to steadily improve over the next several years.

Moderator: We are out of time. Thanks to Joyce Ann O'Shaughnessy, MD, for joining us today. To learn more about breast cancer, be sure to explore all the breast cancer info here at WebMD, including our message boards and live chats. Thanks, and be well!

O'Shaughnessy: Thank you for chatting with me today.

This event was sponsored by Aventis Oncology. Aventis Oncology may have determined the selection of the speaker or topic of this event. Joyce Ann O'Shaughnessy is a member of the Aventis Oncology Speakers Bureau. However, the views expressed by the speaker during this event are those of the speaker and do not necessarily represent the opinions of the sponsor.

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