Kevin Fox MD, is the Mariann T. and Robert J. MacDonald Professor of Medicine and medical director of the Rena Rowan Breast Center at Penn’s Abramson Cancer Center. He treats all aspects of early stage and advanced stage breast cancer researches adjuvant therapy of breast cancer. This post is part two of a three-part series looking at advances in breast cancer prevention, screening, diagnosis and treatment.
For almost a century, the standard of care included removing a large number of lymph nodes from the underarm of most breast cancer patients in an operation called an axillary dissection. This procedure left many patients in pain, disabled, or with a swollen arm.
The sentinel node procedure allows the surgeon to detect the first lymph node in the underarm. If that lymph node contains no cancer, then the surgeon doesn’t need to perform the axillary dissection: if the first lymph node is cancer-free, the other lymph nodes will almost always be free of cancer as well.
Using this technique, hundreds of thousands of patients have avoided unnecessary axillary dissections.
Partial breast radiation describes several techniques in which the radiation is applied only to the portion of the breast where the cancer was found, rather than the whole breast. Until recently, whole-breast radiation had been the standard of care. Partial breast techniques are not appropriate for all women, but are being offered to patients with increasing frequency.
At the present time, radiation oncologists are exploring more targeted, shorter treatment periods in the hope that many patients can finish treatment in as little as three or four weeks, rather than the current six or seven.
Adjuvant therapy describes drug treatments that are given for a period of time after surgery in order to reduce the risk of recurrence or spread of the breast cancer.
Patients may receive several months or years of adjuvant therapy in the form of chemotherapy, hormonal therapy or both.
The most significant advance in the adjuvant therapy of early stage breast cancer came in 2005 in the form of a substance called trastuzumab, or Herceptin®. Trastuzumab is an antibody that attacks HER-2, a protein that is present in large amounts on certain breast cancer cells.
Only 20 percent of breast cancer patients are HER-2 positive (have too much of the protein), but these cancers can be very aggressive and spread quickly and often. Patients treated with this antibody for a year, along with several months of chemotherapy, reduce the risk of their cancer spreading by 50 percent.
Nearly every patient with HER-2 positive invasive breast cancer now receives trastuzumab in addition to chemotherapy..
In 2006, we began using a special test called the Oncotype DX® assay in patients who had cancers that were considered hormone-sensitive, particularly women whose hormone-sensitive cancers has not spread to the lymph nodes.
Oncotype is a diagnostic test that can provide information about the biological activity of the specific tumor. Along with other information, the test results can help in making decisions about whether or not to include chemotherapy in the treatment plan and indicate how likely it is that a woman’s cancer may return in the future.
For many years, patients with hormone-sensitive cancers that have not affected the lymph nodes received both chemotherapy and hormonal therapy. The Oncotype assay enables us to determine which of these women really need the chemotherapy and determine those who can do just as well without it.
Up to 50 percent of women with this type of breast cancer don’t need chemotherapy at all.
Hormone therapy works by blocking the actions of certain hormones that may trigger cancer growth, preventing the body from producing hormones that may trigger cancer growth, or eliminate hormone receptor in the body.
For many years, the drug tamoxifen was prescribed for most women who had hormone-sensitive breast cancers and it was very effective in reducing the risk of recurrence or spread of the cancer.
In late 2001, we began to prescribe a new type of pill called an aromatase inhibitor. Aromatase inhibitors work better in women who have entered menopause at the time they are first diagnosed with breast cancer.
Tamoxifen remains the best choice for premenopausal women with early stage breast cancer.
In general, courses of chemotherapy are now shorter, lasting from 12 to 18 weeks instead of 24 weeks or even longer. Different drugs, particularly paclitaxel and docetaxel, are used in almost every patient who receives chemotherapy. Many of the most dreaded side effects of chemotherapy, particularly nausea and the risk of infection, have decreased considerably as a result of the changes we have made in the last 20 years.
Six new chemotherapy drugs have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of advanced breast cancer since 1992, and several other chemotherapy drugs used for other types of cancer are given routinely to breast cancer patients as well, with some success.
For patients with hormone-sensitive breast cancer, the aromatase inhibitors mentioned above have proven very useful, as has the drug fulvestrant.
Special compounds such as pamidronate, zoledronate, and denosumab are used routinely in women whose breast cancer has spread to the bones. These compounds are not cancer treatments, but protect the bones against the injuries that the cancer can cause.
Read part one this series in breast cancer advancements.
Learn more about breast cancer treatment at the Abramson Cancer Center in Philadelphia.
Watch conference presentations from the 2011 Life After Breast Cancer conference.
Penn's Abramson Cancer Center is a national cancer center in Philadelphia providing comprehensive cancer treatment, clinical trials for cancer and is a cancer research center. The National Cancer Institute has designated the Abramson Cancer Center a Comprehensive Cancer Center, one of only 40 such cancer centers in the United States.
Advances in surgery for breast cancer
Surgeons began using a technique in the mid-1990s called the sentinel node procedure to evaluate whether a breast cancer has spread to the lymph nodes under the arm.For almost a century, the standard of care included removing a large number of lymph nodes from the underarm of most breast cancer patients in an operation called an axillary dissection. This procedure left many patients in pain, disabled, or with a swollen arm.
The sentinel node procedure allows the surgeon to detect the first lymph node in the underarm. If that lymph node contains no cancer, then the surgeon doesn’t need to perform the axillary dissection: if the first lymph node is cancer-free, the other lymph nodes will almost always be free of cancer as well.
Using this technique, hundreds of thousands of patients have avoided unnecessary axillary dissections.
Advances in radiation therapy for breast cancer
Radiation treatments for breast cancer, particularly in those women who do not choose a mastectomy, have also advanced during the last 20 years.Partial breast radiation describes several techniques in which the radiation is applied only to the portion of the breast where the cancer was found, rather than the whole breast. Until recently, whole-breast radiation had been the standard of care. Partial breast techniques are not appropriate for all women, but are being offered to patients with increasing frequency.
At the present time, radiation oncologists are exploring more targeted, shorter treatment periods in the hope that many patients can finish treatment in as little as three or four weeks, rather than the current six or seven.
Adjuvant therapy for breast cancer
Most women who have early stage breast cancer have adjuvant therapy after surgery.Adjuvant therapy describes drug treatments that are given for a period of time after surgery in order to reduce the risk of recurrence or spread of the breast cancer.
Patients may receive several months or years of adjuvant therapy in the form of chemotherapy, hormonal therapy or both.
The most significant advance in the adjuvant therapy of early stage breast cancer came in 2005 in the form of a substance called trastuzumab, or Herceptin®. Trastuzumab is an antibody that attacks HER-2, a protein that is present in large amounts on certain breast cancer cells.
Only 20 percent of breast cancer patients are HER-2 positive (have too much of the protein), but these cancers can be very aggressive and spread quickly and often. Patients treated with this antibody for a year, along with several months of chemotherapy, reduce the risk of their cancer spreading by 50 percent.
Nearly every patient with HER-2 positive invasive breast cancer now receives trastuzumab in addition to chemotherapy..
In 2006, we began using a special test called the Oncotype DX® assay in patients who had cancers that were considered hormone-sensitive, particularly women whose hormone-sensitive cancers has not spread to the lymph nodes.
Oncotype is a diagnostic test that can provide information about the biological activity of the specific tumor. Along with other information, the test results can help in making decisions about whether or not to include chemotherapy in the treatment plan and indicate how likely it is that a woman’s cancer may return in the future.
For many years, patients with hormone-sensitive cancers that have not affected the lymph nodes received both chemotherapy and hormonal therapy. The Oncotype assay enables us to determine which of these women really need the chemotherapy and determine those who can do just as well without it.
Up to 50 percent of women with this type of breast cancer don’t need chemotherapy at all.
Hormone therapy for breast cancer
Even the way in which we use hormonal therapy for early stage breast cancer has changed.Hormone therapy works by blocking the actions of certain hormones that may trigger cancer growth, preventing the body from producing hormones that may trigger cancer growth, or eliminate hormone receptor in the body.
For many years, the drug tamoxifen was prescribed for most women who had hormone-sensitive breast cancers and it was very effective in reducing the risk of recurrence or spread of the cancer.
In late 2001, we began to prescribe a new type of pill called an aromatase inhibitor. Aromatase inhibitors work better in women who have entered menopause at the time they are first diagnosed with breast cancer.
Tamoxifen remains the best choice for premenopausal women with early stage breast cancer.
Chemotherapy for breast cancer
Over the years, the use of chemotherapy for treating patients with early stage breast cancer has changed considerably.In general, courses of chemotherapy are now shorter, lasting from 12 to 18 weeks instead of 24 weeks or even longer. Different drugs, particularly paclitaxel and docetaxel, are used in almost every patient who receives chemotherapy. Many of the most dreaded side effects of chemotherapy, particularly nausea and the risk of infection, have decreased considerably as a result of the changes we have made in the last 20 years.
Advances in treating advanced breast cancer
The treatment of advanced (metastatic or stage IV) breast cancer has seen drastic changes in the last 20 years.Six new chemotherapy drugs have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of advanced breast cancer since 1992, and several other chemotherapy drugs used for other types of cancer are given routinely to breast cancer patients as well, with some success.
For patients with hormone-sensitive breast cancer, the aromatase inhibitors mentioned above have proven very useful, as has the drug fulvestrant.
Special compounds such as pamidronate, zoledronate, and denosumab are used routinely in women whose breast cancer has spread to the bones. These compounds are not cancer treatments, but protect the bones against the injuries that the cancer can cause.
Read part one this series in breast cancer advancements.
Learn more about breast cancer treatment at the Abramson Cancer Center in Philadelphia.
Watch conference presentations from the 2011 Life After Breast Cancer conference.
Penn's Abramson Cancer Center is a national cancer center in Philadelphia providing comprehensive cancer treatment, clinical trials for cancer and is a cancer research center. The National Cancer Institute has designated the Abramson Cancer Center a Comprehensive Cancer Center, one of only 40 such cancer centers in the United States.
