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Good news can seem hard to come by when you're facing a diagnosis of breast cancer. But Elaine Lapinsky, 48, of Kresgeville, Pennsylvania, felt she had finally heard some when she learned she could have five days of intensive radiation therapy after her lumpectomy instead of the conventional seven weeks of daily treatments. "My diagnosis had been such a shock and my life had already been disrupted so much. I was excited to hear I might be able to finish treatment quickly," says Lapinsky, whose children were ages 13 and 17 when she got breast cancer three years ago.
Shortly after being diagnosed, Lapinsky had had a lumpectomy, but it failed to remove all the cancerous tissue. Disappointed, she sought out another specialist for a second operation. He happened to be participating in a nationwide trial of five-day partial breast irradiation, a technique that had been well studied in patient trials but didn't have an established track record, as had traditional radiation. Still, after hearing him out and doing her own reading, "I felt confident that it would be an effective alternative in my case," Lapinsky says. "Plus, not having to make the 45-minute drive to the oncologist's office, each way, every day, for seven weeks was a huge draw. I so much wanted to be done!"
After her five-day treatment, Lapinsky felt no fatigue, a common side effect of traditional radiation, and she was left with just a smattering of tiny, permanent red marks on her breast. Today she remains free of breast cancer. Her experience illustrates how, for the more than 200,000 American women diagnosed with breast cancer each year, there's more hope than ever. "In terms of treatment, we are constantly making huge jumps forward, not just in how well we can fight the disease, but in the quality of life women can have," says oncologist Kimberly Blackwell, MD, an assistant professor of medicine and radiation oncology at Duke University Medical Center, in Durham, North Carolina.
But you shouldn't rush to try something new -- in fact, you shouldn't rush at all when it comes to making any treatment decision, says Dr. Blackwell. "I can't emphasize enough how important it is to take your time! Look into all your options, weigh pros and cons, and carefully explore what's right for you. Only then, with the help of your doctors, should you choose a treatment plan."
With that advice in mind, here's the lowdown on six promising new options for treating breast cancer. All of them have been well researched for efficacy and safety among patients, but because these treatments are new, they aren't as time-tested as older therapies. These innovations won't be right for every patient, but use this guide to talk with your doctor about the technologies that might help you win the breast-cancer battle.
What it is: A five-day treatment that delivers radiation directly to the pocket where your original tumor was removed by surgery -- the area in which cancer is most likely to come back. Unlike conventional radiation therapy, in which an external beam is targeted over a large area of your entire breast (just like a diagnostic x-ray for a broken bone, say) and which requires a much longer, physically draining course of treatment, the most widely used form of PBI is delivered internally. A "balloon" attached to a tube that leads to the outside of your breast is placed inside the cavity. For each treatment, a radioactive "seed" is inserted into the tube and then travels to the balloon, where it delivers a prescribed dose of radiation to the specific site of the original tumor. The balloon and tube can be inserted in a doctor's office in less than 15 minutes using local anesthetic; removal, which occurs as soon as you're done with your treatment, is just as easy. The most common side effects are some breast tenderness and mild burns on the skin.
In a study conducted at William Beaumont Hospital, in Royal Oak, Michigan, women treated with five days of PBI did just as well over the course of five years as those treated with a seven-week course of external beam radiation. "It will take another eight to 10 years of follow-up study on patients before we have definitive data on how PBI compares with traditional radiation," says Martin Keisch, MD, radiation oncologist at Mount Sinai Medical Center, in Miami Beach, Florida, "although all the evidence so far suggests this shorter, more targeted approach is just as effective."
Who can consider it: Someone with early-stage breast cancer that hasn't spread to more than two lymph nodes and who has chosen breast-conserving lumpectomy with radiation instead of a mastectomy. To find a doctor who does PBI (and to learn more about the procedure, including details about how it feels to have the balloon inserted), go to www.proximatherapeutics.com, a Web site sponsored by the company that makes the most widely used form of PBI, called MammoSite. Since it was approved by the FDA, in May 2002, more than 2,000 physicians have been trained to use the technology and more than 9,000 patients have been treated.
What it is: A new test that can help determine whether you're likely to experience a cancer recurrence and therefore benefit from chemotherapy. Each year more than 50,000 women are diagnosed with hormone-sensitive breast cancer, which relies on estrogen to grow. But researchers have long known that a substantial number -- perhaps as many as 50 percent -- of these women are at low risk for the cancer to return to begin with and therefore may not need to go through the discomfort and side effects of chemotherapy, which include fatigue, nausea and vomiting, decreased appetite, hair loss, mouth sores, and infertility.
The test, also called Oncotype DX and available since January 2004, analyzes 21 genes, the majority of which are key to the growth and spread of cancer cells. On the basis of an analysis of tissue collected during your biopsy, your risk of recurrence is assessed and given a score. A score of 17 or below is considered low risk; 18 to 30, intermediate; 31 or higher, high risk.
In a retrospective study sponsored by the National Cancer Institute, in Bethesda, Maryland, involving 668 patients, women with high scores reaped a 25 to 27 percent drop in recurrence risk over 10 years, while women with low recurrence scores saw little, if any, benefit from the addition of chemotherapy. "The test helps take a lot of the guesswork out of a treatment decision," says Sheila E. Taube, PhD, associate director of the institute's cancer-diagnosis program.
Who can consider it: Women with early-stage, lymph-node-negative, hormone-receptor-positive cancer. Your doctor can tell you if your cancer fits this description, since all breast cancer tumors are checked for stage (which describes the cancer's size and how far it has spread), lymph-node status (whether the cancer has spread to the lymph nodes under your arms), and hormone-receptor status (an indication of whether the cancer needs the hormone estrogen to grow). To learn more about the 21-gene test, click on "Oncotype DX" at www.genomichealth.com. The test is pricey -- $3,450 -- so find out whether your health insurance will cover it before you request it.
What it is: An accelerated schedule of chemotherapy in which you receive treatments every two weeks instead of the typical three. Research indicates that more frequent exposure to the drugs may kill more cancer cells and result in better cure rates. But since a high dose at shorter intervals can cause a risky decline in infection-fighting white blood cells, patients receive a drug called filgrastim to boost immunity during therapy.
A multicenter study of 1,973 women found that those who received this condensed chemo were 26 percent less likely to have cancer recur after four years compared with those who got standard therapy. "The treatment was very well tolerated, too," notes Diana E. Lake, MD, a medical oncologist and breast cancer specialist at Memorial Sloan-Kettering Cancer Center, in New York City. "Patients on the dose-dense regimen didn't have more severe side effects than those who got chemotherapy every three weeks."
Who can consider it: Any woman with early-stage cancer. If a woman has a very large mass, however, she might consider having dose-dense chemotherapy to shrink the tumor before having surgery, "allowing for greater breast conservation when the mass is removed," Dr. Lake says.
What it is: A drug previously reserved for treating only advanced breast cancer that latches onto and kills cancer cells that make too much of a protein called HER-2 (human epidermal growth factor receptor 2). About 20 to 25 percent of breast cancer patients are HER-2 positive, which makes their tumors more aggressive, faster growing, and far likelier to return after chemo than those whose cancers are HER-2 negative.
In two recent studies involving more than 3,300 early-stage, invasive, HER-2-positive breast cancer patients, those who received Herceptin along with standard chemotherapy were 52 percent less likely to have their cancer return compared with those who only received standard chemotherapy. "It is the best data I've ever seen in my career," says Sandra M. Swain, MD, chief of the cancer therapeutics branch at the National Cancer Institute. "Herceptin is truly a major life-saving advance for women who are HER-2 positive."
Herceptin is given intravenously, usually once every three weeks for a year (the same schedule used for most chemotherapy, although chemo rarely lasts for more than three to six months). Since Herceptin appears to cause little damage to normal healthy cells, it usually has minimal side effects (some nausea and fever, which usually subside after the first treatment). The downside: Congestive heart failure is about 4 percent more common among Herceptin patients than those receiving chemotherapy alone.
Who can consider it: Virtually any woman who has cancer in her lymph nodes and tests HER-2 positive, according to Dr. Swain. Testing for HER-2 is usually done on tumor tissue at the time of diagnosis. If it wasn't, your doctor can request that the test be performed on a stored tissue sample (most pathology labs keep "archives" for several years). Also, if you have completed chemotherapy recently (within the past six months) and are HER-2 positive, talk with your doctor about beginning a year's treatment with Herceptin.
What it is: A supplemental treatment in which microwave energy is used to raise a tumor's temperature, stimulating blood and oxygen circulation. This, in turn, maximizes the entry of radiation or chemotherapy drugs into the tumor, destroying more cancerous cells while preserving healthy tissue.
In a recent study led by researchers from Duke University Medical Center of 109 women whose cancer had returned in their chest wall after undergoing mastectomy, those who were given HT in addition to standard radiation experienced total disappearance of their tumors at a rate nearly three times that of patients treated with radiation alone. Another Duke study involving 21 women with advanced breast cancer who had HT along with high-dose chemotherapy administered directly to their tumors (via a fat globule) found that most patients experienced a significant reduction in tumor size. In some, the tumor was reduced enough that they could choose lumpectomy instead of mastectomy. And in a few cases, the HT treatments completely eliminated the tumors.
Who can consider it: Up to 21,000 women each year who experience a return of cancer in their chest wall after a mastectomy. When this happens, the cancer is at an advanced stage and there aren't many other treatments that can target the chest wall, so HT plus radiation is practically a must. "It's an important option that represents a real opportunity for hope," says Dr. Blackwell. Most major cancer centers now offer HT plus radiation for these patients. The combination of HT and chemo to shrink early-stage cancer tumors, however, is still considered experimental. Several U.S. cancer centers in addition to Duke University are participating in clinical trials of HT on early cancers; ask your doctor to direct you to studies in your area.
What they are: Drugs that help prevent cancer comebacks in women whose cancer is estrogen-sensitive. Women take aromatase inhibitors in the same way they would take tamoxifen -- in pill form after they have finished surgery, chemo, and/or radiation. But unlike tamoxifen, which works by blocking cancer cells from getting access to estrogen, aromatase inhibitors lessen the amount of estrogen the body produces. Therefore, they are approved only for women who have already gone through menopause.
In a recent study of more than 8,000 women, those taking letrozole (one of three aromatase inhibitors available; the other two are anastrozole and exemestane) for five years had a 19 percent lower risk of breast cancer recurrence and a 27 percent lower risk of the disease spreading to distant parts of the body compared with those who took tamoxifen for five years. "We still have a lot to learn about the best way to use these drugs," says Dr. Lake, who notes that it isn't known if one aromatase inhibitor is better than another or if it's better to give tamoxifen for five years and then switch to an aromatase inhibitor.
Who can consider them: Postmenopausal women with hormone-receptor-positive cancer (it doesn't matter whether your menopause came on naturally or your treatment jump-started it). If you still have periods, the standard of care is still five years of treatment with tamoxifen. Aromatase inhibitors may speed up bone loss in some women, so you may also need 1,000 to 1,500 milligrams of daily calcium or possibly a prescription drug, such as Fosamax, to help prevent bone thinning. Side effects of the aromatase inhibitors also include hot flashes and muscle aches.
Within the next 10 years it's possible that women could have their breast tumor wiped out by freezing the tumor -- in the doctor's office, without general anesthesia and with virtually no side effects, except for brief swelling and tenderness afterward. Such cryosurgery is being tested at multiple hospitals across the country. Using ultrasound for guidance, a surgeon places a "cryoprobe" (a needle with a tip that gets extremely cold) through a small incision in the skin so that it sits at the center of the cancer site. An ice ball forms around the tumor, destroying it (just as frostbite destroys healthy skin tissue). The probe is removed, then a bandage is placed over the incision site.
Amazingly, freezing cancer cells also appears to stimulate an immune response that helps fight a cancer comeback. "When you kill cells with cold, you leave their proteins in place," says Michael S. Sabel, MD, a leading cryosurgery researcher and assistant professor of surgery at the University of Michigan Comprehensive Cancer Center, in Ann Arbor. "There is evidence that suggests that the immune system recognizes these proteins and begins to destroy cancer cells that express them elsewhere in the body."
The method is currently being used only in women with small, early cancers; plus, until more definitive data is collected, all "ice surgeries" are followed up with conventional surgery to insure a woman's chances at beating breast cancer aren't compromised by an experimental treatment.
The National Cancer Institute expects to approve a trial of cryosurgery by late fall or early 2006. To learn more, e-mail Dr. Sabel at firstname.lastname@example.org; be sure to include "LHJ" in the subject line.
Originally published in Ladies' Home Journal magazine, October 2005.