Postmenopausal Women With Breast Cancer May Be Able To Avoid Chemotherapy

For many people, considering the possibility or the reality of chemotherapy is the worst part of cancer treatment. Everyone has heard horror stories about nausea, GI upset and hair loss. Being reassured by our doctors that times have changed, and that most people get through the months of treatment with manageable side effects, does not always help our anxiety. I have been working in Cancer World long enough to remember when we gave everyone a small plastic emesis basin as they prepared to leave the Infusion Unit. We knew they likely would need it before they reached their car in the garage. Now, really and truly, many people never vomit through a whole course of treatment — thanks to really excellent anti-nausea drugs.

This was the first large randomized trial that proved that some women with positive lymph nodes can do well without chemotherapy.

Even better news, however, is the increasing knowledge about who needs and will benefit from chemotherapy and who can safely avoid it. A study presented recently at the virtual San Antonio Breast Cancer Symposium reported the results of the RxPONDER study. Over recent years, there has been a trend towards more newly diagnosed women being able to do well without chemotherapy. As doctors have better understood characteristics of tumors and risk assessment, it has been possible to consider each situation and make the best recommendation. This new study indicates that women with Stage II and III ER-positive breast cancer who have 1 to 3 positive axillary lymph nodes and an Oncotype DX score of 25 or lower can safely be treated with only hormonal therapies.

This was the first large randomized trial that proved that some women with positive lymph nodes can do well without chemotherapy. The Oncotype DX is a genomic test that examines 16 cancer-related genes to determine the risk of recurrence for women with ER-positive breast cancer. It has been used to evaluate the need for chemo (vs. only hormonal treatment) for node negative women for more than ten years, but this is a major step forward to include women who have positive lymph nodes. In the comparison of post-menopausal women with node-positive cancers who did and did not receive chemotherapy, the survival was almost the same: 91.6% and 91.9%. Among pre-menopausal women, however, there was a greater difference: 94.2% vs 89%.

Clearly this is important information that will help oncologists and their patients make difficult treatment decisions. Even with some reassuring numbers, choosing to opt out of chemo is scary for some women. No one, whatever the statistics, ever gets a promise about survival from cancer, but most of us want to increase our chances however we can. If, for example, one is told that she has a 98% chance of staying well without chemo, that would be reassuring for many people. Others, however, worry about being one of the two out of a hundred women who are not lucky. Any of us who have been diagnosed with cancer have already fallen on the wrong side of the numbers at least once; it can be tough to think we will be more fortunate in the future.

Chemotherapy always brings risks and toxicities. There can be long-term serious side effects in addition to the malaise, GI issues, hair loss and more that accompany the months of treatment. Chemotherapy also always brings the psychological reassurance that we have done everything possible to keep cancer away in the future. When I talk with women who are struggling to make this decision, I always bring up two considerations:

• For you, what would be the worst possible outcome? For some, it would be not having chemo and having the cancer return and always wondering if it would have been different if you’d had chemo. For others, it would be having the chemo and still having the cancer return and always wondering if life could have been easier and better. Once the worst possible outcome has been identified, my advice is to make whatever choice avoids that possibility.
• The second is easier: What will help you sleep better both tonight and three years from now?

If someone is stuck and unable to make a choice, I offer up my grandmother’s strategy. This has zero scientific evidence to support it, but it often helps. Her suggestion for any tough decision was to flip a coin. It does not matter how the coin falls; what matters is how your gut feels about which side lands up. Listen to your body.

And then, after thoughtful discussions with your doctors, move ahead and try to never second guess your actions.