Targeting Adjuvant Chemotherapy
This is an important article from the Journal of Clinical Oncology about the use of adjuvant chemotherapy in early breast cancer. I have been in the business long enough to recall various trends and their eventual reversal or change. For example, I remember an alert from the NCI in the early 1980s that suggested that all node negative patients should still receive adjuvant chemotherapy. The evidence from a study then in progress was so strong that the study was stopped early, and this bulletin circulated. Obviously, in subsequent years and studies, more specific guidelines were developed, and doctors are much better at figuring out who will benefit from these drugs. The availability of the Oncotype DX test for women with ER positive, node negative breast cancer has been an enormous help in determining who needs chemo and who is likely to do just as well with "only" hormonal treatments.
Here is the beginning of the editorial and then a link (to a PDF) to read more:
Targeting Adjuvant Chemotherapy: A Good Idea That Needs to Be Proven! Daniel F. Hayes, Breast Oncology Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI
The success of adjuvant therapy in reducing recurrence and mor- tality has been established for endocrine therapy, chemotherapy, and more recently, trastuzumab1-3. Indeed, Berry et al have suggested that at least one half of the remarkable reduction in breast cancer mortality observed over the last 30 years can be attributed to widespread appli- cation of adjuvant systemic therapy. The Oxford Worldwide Overview of early breast cancer trials, conducted by the Early Breast Cancer Trialists Collaborative Group (EBCTG) demonstrated definitively that, without respect to subgrouping, chemotherapy appears to reduce breast cancer recurrence and mortality by approximately 30% and 20%, respectively.
However, this success does not come without a price. All oncologists and their patients recognize that chemotherapy is almost universally associated with bothersome adverse effects and occasionally with life-threatening toxicities (approximately 1% in most cooperative group trials), as well as enormous direct and indirect financial costs. In this regard, breast cancer is arguably the paradigm for personalized cancer care. Clinicians can confidently use the highly validated biomarkers estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) to withhold endocrine and anti-HER2 therapies from patients who are so unlikely to benefit that the risks and costs of treatment cannot be justified.
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