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.
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.
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.
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