Shifts in Standards of Care
I have been in the business long enough to have observed several enormous shifts in the standard of care for women with newly diagnosed breast cancer. There was a period about ten years ago when women with high risk breast cancer (usually meaning inflammatory breast cancer or a large tumor/many positive lymph nodes) were sometimes treated with a bone marrow transplant. When the studies of that treatment were released, it was learned that particularly aggressive treatment was no more helpful than standard adjuvant therapy. That is, women did equally well both ways. I have personally experienced one of the transitions. In 1993, the usual chemotherapy, and what I had, was oral CMF (some women received all IV CMF which was considered slightly less aggressive and easier to tolerate). By 2005 and my second breast cancer, the standard of care had moved to CA, sometimes given in a Dose Dense (every 2 weeks) fashion sometimes followed by Taxol (with DD or weekly). Again, that is what I had.
Now there is a major report in the Journal of Clinical Oncology by DiLeo and Oakman from Proto, Italy. (As an historical aside, the guru of CMF was also from Italy) that is appropriately titled " Ode to a Past Emperor". This editorial describes the new study and the likely approaching change from CA followed by Taxol to A and paclitaxel followed by Taxol. There are some serious design flaws in the study, and the authors are careful in their comments and clear in their recommendations. Th central point is not the particular chemotherapy regimen, but the reality that we know more and more about the biology of tumors, and treatments are increasingly personalized and selected to be helpful for a particular individual. It is impossible, however, to read this editorial without sensing that "The times...they are a changing."
Here is a quote and then a link to read more:
During the past 10 years, breast cancer research has been revolutionized
by demonstration of heterogeneity in biology, clinical behavior,
and treatment response. In 2000, a landmark publication revealed
genetic heterogeneity in breast cancer, with distinctive gene expression
portraits allowing classification into molecular subtypes.1 In 2002, a
px 0.0px; font: 9.5px Helvetica;">pivotal report highlighted heterogeneity in chemotherapy efficacy,
with estrogen receptor status as a discriminator of chemotherapy
benefit.2 Furthermore, in 2006, multigene signatures were reported to
predict chemotherapy benefit in node-negative, estrogen receptor
(ER) -positive breast cancer.3 Current appreciation of this heterogeneity
does not support the one-size-fits-all assumption inherent in
many prior chemotherapy trials. Yet, to date, evidence for subtype
chemosensitivity is largely derived from retrospective analysis of these
studies. Thus, whereas the old generation of clinical trials has been
pivotal in shaping our adjuvant chemotherapy approach, the rule of
the old empire has come to a close. The era of breast cancer as a
homogenous disease is no more.