Wednesday, December 11, 2013

For some patients with advanced breast cancer, chemo may be enough and they can be spared from the ordeal of going through surgery and radiation

It’s not been much time when Angelina Jolie initiated a “to go for or not to go for mastectomy” debate after being found with mutation in one of those ‘breast cancer risk prone gene BRCA1’. Well before you decide to go under a knife of surgeon, this could be a worth considering study that just came up from a very experienced physician based in India, which you want to discuss with your team of doctors.  

In a very prestigious AACR meeting currently ongoing in San Antonio, namely “2013 San Antonio Breast Cancer Symposium, held Dec. 10–14” Dr. Rajendra Badwe from Tata Memorial Hospital, Mumbai, India raised many eyebrows when he presented his findings in which he and his team led a study of 350 women with widely spread breast cancers that had shrunk after initial chemotherapy. Almost 50% of these patients went through mastectomy (surgery to remove the breast or the lump plus any cancerous lymph nodes). Rest of them did not have surgery. After about two years, 40 % of both groups were alive, suggesting that just chemotherapy could be enough. Women diagnosed with advanced breast cancer who respond well to chemotherapy get no additional benefit from having surgery and radiation afterwards. However, Dr. Rajendra Badwe, went on saying that options for surgery and radiation can be reserved for patients who need it for palliative reasons.
Targeting a specific area of the body for surgery or radiation is called loco-regional treatment, or LRT. Conventional wisdom has been that women with advanced (Stage 4) breast cancer, in which the disease has metastasized (spread to other organs), are treated only with chemotherapy unless other health issues (among them the relief of pain or other symptoms; the prevention of bone fractures; the tumor causing an open wound) dictate otherwise. In last decade, however, research community divided on into two school of thought on whether or not to use other supplementary treatment modalities such as surgery and radiation so they realized severe need of trials to confirm their theories. To find which of the two treatment methods resulted in the best survival outcomes for patients, Badwe and his colleagues in India, conducted a prospective, randomized, controlled trial funded by Badwe's hospital and the Department of Atomic Energy Clinical Trial Center in India.

Between 2005 and 2013 the researchers enrolled 350 women with metastatic breast cancer whose tumor responded positively to six cycles of chemotherapy. One group of patients received LRT, while the other group did not receive LRT. Both groups were matched for age, tumor size and extent of the metastases, and hormone receptor and HER2 receptor status.

Patients in the LRT group had either a lumpectomy or mastectomy and surgical removal of lymph nodes, followed by radiation treatment. All patients whose breast cancers were hormone-related received standard hormone therapy, regardless of the group to which they had been assigned.While the cancer was well-controlled in women who underwent surgery, that didn't translate into a survival advantage over the women who did not have surgery, Badwe said.The researchers also found a 7 percent excess death rate in patients who received LRT. The finding was not statistically significant, they said, but it aligned with the previous such findings that suggest surgical removal of the primary tumor in patients with advanced breast cancer might trigger the metastases.

“From a clinical practice point of view, as a surgeon I might know when to operate,” Dr. Badwe said. “But most importantly, when not to operate is equally important. “We need to know what the tumor is sensitive to,” Badwe said. “That is of greater value than loco-regional treatment.”

The extra expense of surgery and radiation, and the impact of those treatments on a patient’s quality of life also contribute to the researchers’ position that LRT should be done only within the tenets of clinical trials, he said.

While given the genetic differences between various populations, findings from this study have to be analyzed in that perspective, however, these findings open the door for more research on this aspect and warrant for more efforts towards new targeted therapies. 

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