Study questions multiple breast cancer therapies

Long-term breast cancer survivors who undergo chemotherapy or take the anti-cancer drug tamoxifen or both after surgery report more physical problems than do women who undergo surgery alone, according to a large study conducted at Georgetown University Medical Center and UCLA’s Jonsson Comprehensive Cancer Center.

In the past decade it has become standard practice to treat even women with smaller tumors that have not spread to other organs aggressively with multiple therapies, particularly if they are under the age of 60.

Doctors have maintained that surgery to remove cancerous tissue, followed by so-called adjuvant therapy – chemotherapy and chemopreventive drugs – offers the best chance of achieving a cure and preventing a recurrence.

Typically women with stage I and stage II cancers – small tumors confined to the breast or to underarm lymph nodes – undergo four to six months of post-operative chemotherapy, often combined with five years of tamoxifen (brand name Nolvadex), a drug that has been shown to prevent a recurrence of breast cancer while possibly increasing risk of endometrial cancer.

But the new study of 763 cancer-free women diagnosed before 1993, published last week in the Journal of the National Cancer Institute, found that adjuvant treatment may cause long-term physical side effects years after diagnosis while only modestly boosting the chances of remaining cancer-free.

“I was kind of surprised that there was a long-term effect from chemotherapy and tamoxifen,” said Patricia A. Ganz, a professor of medicine at UCLA who is the lead author of the study. The NCI report is the latest in a series of long-term studies of more than 1,000 breast cancer patients. “But most people would never trade survival” for a potential risk of earlier death or recurrence, even with fewer side effects.

“I would suspect that there is a toll from treatment” of other diseases as well, Ganz added, saying that researchers are beginning to study the long-term effects of treatment for other cancers, such as Hodgkin’s disease.

All participants in the study completed a 42-page questionnaire at home.

Regardless of the treatments they endured, they reported high levels of health, emotional well-being and physical functioning five to 91/2 years after diagnosis.

The most pronounced disparities were in the realm of physical functioning – such as the ability to exercise – and on a scale that measured overall quality of life. Women who had surgery alone reported higher levels of physical functioning and overall quality of life than those who underwent adjuvant therapy. The latter group also reported more sexual side effects, such as pain during intercourse, than the surgery-only group.

“Many of these treatments are not without costs,” said Jan Platner, a breast cancer survivor who is director of administration for the National Breast Cancer Coalition, a Washington-based lobbying and advocacy group. “And if you’re going to have these side effects for 30 years and [adjuvant therapy] confers only a small survival advantage,” women should be informed of that.

Knowledge of the risks and benefits of adjuvant therapy, Platner said, is particularly important for younger women with breast cancer, who usually receive the most aggressive treatment on the theory that their cancers grow faster.

“There continues to be this huge debate among great minds … “Gee, should we hit ’em with everything up front or should we save something for later?’ ” Platner said.

Ganz said some research suggests that women with the tiniest cancers – those smaller than one centimeter – could forgo adjuvant therapy without sacrificing their chance of disease-free survival. “Those people already have an excellent prognosis,” she said.