By Harold Burstein
WebMD Live Events Transcript

What are your therapy goals? How do you choose the treatment for metastatic breast cancer that will best allow you to reach your goals? We covered these issues and more when WebMD and the Y-ME National Breast Cancer Organization presented a discussion with oncologist Harold J. Burstein, MD.

The opinions expressed herein are the guest's 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: This event is brought to you by Y-ME National Breast Cancer Organization, through grant support from Eli Lilly and Company. Lilly and Y-ME have had no influence over the content presented at this event. This Live Event is an interactive session in which Harold Burstein, MD may express his opinions about breast cancer and its treatment. Lilly and Y-ME do not necessarily share Burstein's views or opinions. His statements may contain information that is not part of the FDA-approved labeling for the products discussed. Please consult with your doctor for complete information about treatment choices.

Moderator: Hello, Dr. Burstein. Welcome to WebMD Live. Let's talk about some of the treatment goals a patient might consider when faced with metastatic breast cancer.

Burstein: The goals of treatment are to:

Prolong life
Alleviate symptoms related to the cancer
Allow women with advanced breast cancer to be as functional as possible for as long as possible

We do not generally speak about curing advanced breast cancer. Some women will do well for a very long time but we generally expect that over time most women will succumb to their disease. So our goal is to keep the cancer at bay and to allow patients as full a life as possible for as long as we can.

Member: If you don't believe you can cure advanced breast cancer, what is the point of invasive procedures or toxic treatments?

Burstein: The treatments that we have available now can certainly help in many instances to control the tumor and to relieve symptoms related to the cancer. Women are living longer than ever before, despite having breast cancer. In fact, there will be some exciting data being presented at the National Cancer Meetings in May showing that over the past decade we are doing better, or women are doing better and living longer with advanced breast cancer. Increasingly, it is a disease we talk about "managing" as though it were diabetes or another chronic medical condition.

That said, we have to be very respectful of the trade-offs between toxic treatments and improving duration and quality of life. One of the other big trends in the past decade has been a movement away from more intense high-dose chemotherapy and towards less toxic ways of giving chemotherapy. So we think we are helping women do better and better, and there is a growing list of treatment options for women that gets larger each year. That is why it makes great sense to treat these women even if we fall short of ultimately curing their disease.

Moderator: How can you help a woman prioritize her goals when different treatments have varying side effects and outcomes?

Burstein: That's not an easy question to answer, and truthfully, the art of being a breast oncologist is to get to know patients and to develop a relationship with them that allows both the doctor and the patient to better understand over time what the natural history of the breast cancer will be, and what this particular patient wishes and will accept in the way of side effects or treatment preferences.

It's not something that you can usually figure out on the first visit. But it is something that over time the doctor and the patient learn to work on together.

Moderator: Can you please define the primary types of treatment for advanced breast cancer?

Burstein: There are three major categories of treatments for advanced breast cancer:

Hormone Therapies. These all work by altering the hormonal milieu and are effective only in those patients whose tumors express hormone receptors like the estrogen receptor.
Chemotherapy. Chemotherapy can be effective for any type of advanced breast cancer, and there are many, many types of chemotherapy to choose from.
Biological Therapy. Right now, the only approved biological treatment for advanced breast cancer is Herceptin, which targets tumors that are HER2 positive.

There are other supportive types of medical treatment. For instance, we often use bisphosphates such as Aredia or Zometa in women with breast cancer that has spread to their bones. So in putting together a treatment program for a given patient, we take into account where their disease has gone, such as the bone, and the biological features of their tumor, such as the estrogen receptor status and the HER2 status, and we try to tailor the treatment options to the patient based on those features.

Member: What is the "cutoff" point for suspending treatment of metastatic breast cancer?

Burstein: That's a hard question to speak about too generally. Because of the heterogeneous nature of breast cancer, some women may receive a very large number of treatments for their advanced disease, sometimes up to six or seven chemotherapy regimens, but other women might end up receiving only a few.

With the medical team, the woman and her family usually can recognize when the treatments are no longer working and when the burden of treatment is becoming greater than the likely benefit. That is when it is no longer appropriate to continue therapy. That doesn't mean that she is not seen by her doctors, but rather the focus shifts more towards treating her symptoms and assuring her comfort, and less on directly treating her tumor. This is why it is very important to have a solid relationship between the patient and medical team.

Moderator: How do you suggest a woman go about finding an oncologist to work with, since that seems to be key to quality of life with mets [metastatic breast cancer]?

Burstein: Most oncologists are pretty experienced with managing breast cancer. In a typical oncology practice, about one-third of the routine work of a medical oncologist involves caring for women with breast cancer. Having said that, and I cannot say this without sounding self-serving, I actually believe women with breast cancer are best served in dedicated comprehensive breast cancer programs. That's where medical oncologists and surgeons and radiation oncologists all work together on a daily basis to care for such women.

Most of the studies in medicine suggest that the best treatment outcomes are found in places with the greatest experience, and I suspect that's true for breast cancer as well. However, there are terrific doctors everywhere and as I said, most oncologists are familiar with this disease and I think that if you have a strong relationship with your medical team, that really is a critical piece of optimal care.

Member: I have been diagnosed with breast cancer and am considering treatment options including chemotherapy -- is there a treatment option that won't cause me to lose my hair?

Burstein: I suspect this is a question about early-stage breast cancer, not so much about advanced breast cancer. For treatment of early-stage breast cancer, most of the standard chemotherapy regimens do cause significant alopecia or hair loss. A regimen called CMF is still given sometimes to women with early-stage breast cancer and is likely to cause significant hair loss in only half of the patients who receive it.

For treatment of advanced breast cancer, there is a growing number of treatment regimens that do not cause significant hair loss. These include capecitabine, vinorelbine, and some other chemotherapy drugs.

Member: Is there a therapy routine for patients after chemotherapy to deal with depression and other side effects?

Burstein: There isn't as much data as we would like on how best to recover after chemotherapy. There are studies that have shown that a moderate exercise program can lessen fatigue and depression after chemotherapy for breast cancer. And I have found that women who can participate in a moderate exercise program -- 15 to 30 minutes of low impact exercise a day --often find this helpful in recovering from the side effects of chemotherapy.

Member: I have stage IV mets. In my sternum, it has calcified already, borderline. I am 40 years old. Should I have a hysterectomy or shots to keep my ovaries shut down? Estrogen positive, with high S phase, second time getting cancer. First time breast stage 2 and went four and a half years. Now the above. Many have considered hysterectomy versus the shots, because there are more medications in your body, so is it better since I am 40 to have the hysterectomy?

Burstein: For premenopausal women with estrogen receptor-positive breast cancer, ovarian suppression can be a very important part of treatment for metastatic disease. This, in fact, was first shown over 100 years ago, when doctors in England showed that advanced breast cancer could respond to oophorectomy. Nowadays, we have several ways of making a woman who is premenopausal, postmenopausal. These include medical treatments with shots given once a month or sometimes once every three months, using medicines called GnRH agonists. Some of the brand names include Lupron or Zoladex.

Another approach is to have the ovaries surgically removed, which is, of course, permanent. We think that either approach is equivalent in terms of how the disease is likely to respond. So the decision often comes down to questions of patient convenience and preference. Either strategy is a reasonable one for younger women with ER-positive breast cancer.

Member: My mother has stage 4 mets; her concern is to be as pain-free as possible; she'd rather feel no pain than be aggressive and prolong her life; she is 68; what would be her choices to for treatment?

Burstein: The important point about advanced breast cancer is we treat it on the biology of the tumor. We need to know the estrogen receptor status and the HER2 status of the tumor in order to bring the right treatments to bear on it. Every woman with advanced breast cancer needs to make sure that her tumor has been tested for the estrogen receptor and the HER2.

We hear from many patients that they do not want to be in pain. The good news is that effective cancer therapies can help alleviate pain and can prolong life. Some women may benefit from radiation therapy to focal areas of bone pain. We often use bisphosphates to also help control bone pain. Finally, of course, there are traditional pain medicines, and oncologists are pretty good, but not great universally, at using pain medicines to make sure that women with advanced breast cancer are comfortable and leading a life of dignity as they want.

There is a growing discipline within oncology called palliative care, where people have particular expertise in management of pain and end of life care. When I have patients who have very challenging and refractory pain needs, I call on my colleagues with that background to help me better manage them.

Usually for women with advanced breast cancer there are opportunities to both make sure we are treating their pain from the tumor and to treat the cancer directly, particularly earlier in the course of their advanced illness.

Member: I have been diagnosed with infiltrating ductal carcinoma. My lymph nodes were negative (my tumor was 1 cm), yet I am being treated with epirubicin, cytoxan and FU5 (I think!). I will then have radiation and tamoxifen treatment. Is chemotherapy usually given to women with negative lymph nodes and tumors the size mine was?

Burstein: The role of chemotherapy in treating good prognosis, node-negative breast cancer remains somewhat controversial. Current guidelines suggest that most young women (premenopausal) and many women up to age 60 or greater who have tumors of 1 cm or greater are potential candidates for chemotherapy. However, in many instances the benefits of chemotherapy are quite small because the overall prognosis is so very good.

We spend a great deal of time talking to such women about the realistic benefits and risks of treatment, and work with them to make a decision that makes most sense for that woman, taking into account her age, her other medical problems, her risk of recurrence for this breast cancer, and her personal preferences.

Member: Is there any place for alternative medicine in dealing with advanced breast cancer? It seems to me that things like massage and stress reducers like meditation, healthy diet can be helpful, but I'm wondering about any herbal treatments.

Burstein: We know that a tremendous fraction of patients with advanced breast cancer are interested in alternative therapies. In fact, probably the majority of our patients with advanced disease are pursuing some strategy to help them do better beyond what the doctor is prescribing. This can be massage, dietary changes, exercise, nutritional or herbal supplements, acupuncture and so forth.

I'm always interested in knowing what my patients are doing, and there are a few herbal supplements that might be more toxic or interfere with other cancer treatments. Most of these things, however, are pretty safe. And many of my patients tell me that they feel better being engaged with these health practices, and sometimes that they even relieve specific problems such as nausea, fatigue, or pain.

That said, in the academic literature, there are few data to tell us whether or not these types of alternative therapies change the natural history of breast cancer, nor whether such practices really help in the way that their advertising or marketing claims suggest.

In general, I encourage my patients to:

Eat a well balanced and nutritionally sound diet.
Get mild to moderate degrees of exercise or activity as their symptoms allow.
Take a regular multivitamin.

Beyond that, it really is up to the patient, and there are no data to provide guidance.

Member: Is it possible to have a good quality of life during breast cancer treatment, especially chemotherapy? You always hear about the horrible side effects.

Burstein: Yes. There is an increasing recognition of the importance of quality of life during cancer treatment. There are new drugs that can help reduce the anemia and fatigue associated with treatment and our repertoire of nausea medicines and pain medicines continues to get better. Many of my patients will lead very productive, very rewarding lives while receiving chemotherapy.

Now this is not universal. There was a New Yorker cartoon a year or two ago where the woman is in her doctor's office and says, "I don't think the medicine is working for me, I'm not nearly as happy as the people in the ads." Obviously the ads make it seem too easy. But truly, many women flourish during chemotherapy treatment, and these are the kinds of things that doctors and patients work on together all the time.

Member: My original tumor was HER2 negative but apparently there was part of the tumor that had cells HER2 positive and I had to have chemo a second time. How does this happen and what percentage of breast cancer patients, if any, does this happen to?

Burstein: HER2 testing is a technique that is not in its infancy, but is still not mature. Most of the time, here I mean 85% of the time, the original test and any subsequent tests are concordant. Occasionally it does happen that on subsequent testing a discordant result is seen; that is, a tumor that was considered HER2 negative now seems to be HER2 positive or vice versa.

In such instances we usually order a FISH test, which is a useful tiebreaker for deciding whether or not the tumor really is HER2 positive. We think that most of the discordant results are artifacts of imperfect testing technology.

In general, we don't think that the tumors themselves change over time; thus, a tumor that is originally truly HER2 negative, we tend to think of being HER2 negative for the life of the patient. However, since we have only been doing widespread HER2 testing for a few years now, we certainly do not know all we need to know about test results, and sometimes you just have to use your best clinical judgment.

Member: How accurate are PET scans?

Burstein: PET scans are a new way of measuring whether or not cancer has spread to other parts of the body. For breast cancer patients, we have traditionally relied on CT scans and bone scans. Occasionally a PET scan can provide additional information that can help clarify whether or not a finding on a CT scan, for instance, is really cancerous, and sometimes a PET scan can find very occult deposits of cancer.

However, as of April 2003, it is not a test I use routinely in clinical practice, and there is a great deal of variability in the quality of the PET scans and their interpretation. SO if you get a PET scan, it is very important to know how reliable the particular radiologist and scanner are.

Member: How reliable is the CA-27-29 blood test?

Burstein: The CA-27-29 test is of mixed usefulness in advanced breast cancer. Some women will have tumor only in their bones or other places in the body that are difficult to see on conventional CT scans. For such women, the CA-27-29 marker -- if elevated -- can let the doctor and patient know how the tumor is responding if the X-rays are equivocal. But not everyone's tumor expresses the CA-27-29 marker, and if there are other things to follow, such as lymph nodes or skin lesions or conventional X-ray findings, those tend to be more reliable a gauge response to treatment than is the CA-27-29 marker.

Moderator: Dr. Burstein, we are almost out of time. Before we wrap up for today, do you have any final comments for us?

Burstein: For women with breast cancer, the past 10 years really have provided great progress. There are more and more treatment options and patients are genuinely doing better. There is still much work to be done, and there are great opportunities for clinical research and progress. Hopefully, that will continue and patients should stay tuned to the web, to the newspaper, and to their doctors, because there really are things happening in cancer research that are making a clinical impact in the near term.

Moderator: Our thanks to Harold Burstein, MD, and thank you members for joining us today. For more information, please read I Still Buy Green Bananas, available from the Y-ME National Breast Cancer Organization website at www.y-me.org.