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February 2011 Ask the Expert: Early-Stage Breast Cancer Treatments and Strategies

A diagnosis of early-stage breast cancer can bring up a number of medical and emotional concerns. During the month of February 2011, Living Beyond Breast Cancer expert Minetta C. Liu, MD, answered your questions about the types of treatment for early-stage breast cancer, how to manage symptoms and side effects, how to interpret your pathology report or the feelings and reactions you may have at diagnosis.

You may also be interested in our February teleconference, Coping with a Recent Breast Cancer Diagnosis.

Will tamoxifen be as effective as letrozole (Femara) if I am postmenopausal and my tumor was estrogen positive?

What are the health risks of taking tamoxifen after menopause?

What is your opinion about undergoing four cycles of Taxol treatment after four cycles of Adriamycin and Cytoxan treatment (traditional ACT) given the recent studies that indicate Taxol does not benefit patients with HER2-negative, estrogen-receptor positive cancers? I am inclined to skip the Taxol given the potential long-term side effects.

What is the role of tamoxifen (or other SERM) therapy in treatment of recurrent DCIS for premenopausal women?

At 33 years old, I was diagnosed with poorly differentiated infiltrating ductal carcinoma …. What is the standard protocol for follow-up care after treatment? My doctor does not want to do a lot of test/scans because he states that it does not improve the overall survival rate. I am fearful of a secondary cancer and not catching it early enough. Any suggestions?

How high is the statistical risk of permanent, disabling nerve damage with taxane drugs? I am 51 and healthy with no other illnesses or conditions. But I am very active on a rural property at home and also have a corporate job that is fairly demanding, so I want to try to limit any risks of permanent physical disability.

What can women with early-stage breast cancer do to prevent recurrence/mets?

What is the latest research on “chemobrain” symptoms with aromatase inhibitors? Are there any treatments found to minimize or reverse the cognitive side effects of aromatase inhibitors in women experiencing this?

I was diagnosed with high-grade, triple-negative DCIS with micro-invasions (largest 0.2 cm). No nodes were removed at the time of mastectomy, and no further treatment is recommended. My oncologist strongly recommended against a prophylactic mastectomy. I am a 66-year-old woman who would prefer the peace of mind to vigilant monitoring.

When a woman is diagnosed with breast cancer or ovarian cancer at an early age and has the BRCA1 or 2 gene, and subsequently has a prophylactic hysterectomy and/or mastectomies, how is her future risk for cancer affected?

Question: Will tamoxifen be as effective as letrozole (Femara) if I am postmenopausal and my tumor was estrogen positive?

Dr. Liu: Both tamoxifen and letrozole (Femara) are potentially effective therapies for postmenopausal women with hormone receptor-positive breast cancer. Whether or not one medicine is better than another is impossible to determine for any one individual, and the choice of medicines often rests on considerations for toxicity. For example, some women are intolerant of letrozole because of joint pain or stiffness, and the symptoms improve with a switch to tamoxifen.

Question: What are the health risks of taking tamoxifen after menopause?

Dr. Liu: Tamoxifen blocks the effects of estrogen in some tissues, but promotes the effects of estrogen in other tissues. This explains the benefits and side effects associated with this medicine.

In postmenopausal women, the potential benefits include improvements in bone density. The potential side effects include vaginal discharge, vaginal dryness, hot flashes or night sweats and abnormal liver function test results, as well as the very rare possibilities of venous thromboembolic disease (a disease involving blood clots) and endometrial hyperplasia (an above normal thickening of the uterus) or cancer.

Question: What is your opinion about undergoing four cycles of Taxol treatment after four cycles of Adriamycin and Cytoxan treatment (traditional ACT) given the recent studies that indicate Taxol does not benefit patients with HER2-negative, estrogen-receptor positive cancers? I am inclined to skip the Taxol given the potential long-term side effects.

Dr. Liu: The regimen of Adriamycin/Cyclophosphamide (AC) followed by paclitaxel (Taxol) is considered a standard of care for the treatment of node- positive or high risk node-negative early-stage breast cancer, regardless of hormone receptor status or HER2 status. The studies to which you refer are subset analyses of the main clinical trials and should be interpreted with caution. Please discuss your concerns with your oncologist before making any final decisions about your care.

Question: What is the role of tamoxifen (or other SERM) therapy in treatment of recurrent DCIS for premenopausal women?

Dr. Liu: The actual treatment of ductal carcinoma in situ is local, involving some combination of surgery and radiation. Tamoxifen is considered for prevention with the aim of reducing the risk of a future noninvasive or invasive breast cancer. Raloxifene (Evista) is also classified as a selective estrogen receptor modulator (SERM), but there are no data to support its use in ductal carcinoma in situ.

Question: At 33 years old, I was diagnosed with poorly differentiated infiltrating ductal carcinoma …. What is the standard protocol for follow-up care after treatment? My doctor does not want to do a lot of test/scans because he states that it does not improve the overall survival rate. I am fearful of a secondary cancer and not catching it early enough. Any suggestions?

Dr. Liu: The standard of care regarding follow up after a diagnosis of early-stage breast cancer is a thorough physical examination, review of symptoms and routine blood work (including liver function tests). These are typically completed every three months for the first two years and every six months for the next three years. After five years, follow-up is extended to once a year.

Annual mammography is recommended for women who undergo breast conservation. Blood tumor markers and radiographic studies (CT scans, bone scans, PET scans, etc.) are usually not recommended in the absence of clinical findings or symptoms that suggest a recurrence. Patients should report all new and persistent symptoms to their oncologists, who maintain a very low threshold for pursuing additional evaluation as needed.

Question: How high is the statistical risk of permanent, disabling nerve damage with taxane drugs? I am 51 and healthy with no other illnesses or conditions. But I am very active on a rural property at home and also have a corporate job that is fairly demanding, so I want to try to limit any risks of permanent physical disability.

Dr. Liu: Taxane medicines are associated with the potential to cause neuropathy, or numbness, tingling, increased sensitivity and/or tenderness in the hands and feet. The frequency of neuropathy varies from one taxane to another, but the symptoms are typically mild, have little to no impact on daily activities and resolve at some point after the completion of therapy.

The likelihood of permanent debilitating neuropathy is very low in the setting of early-stage breast cancer. The key is to report all potentially related symptoms during the course of treatment so your oncologist can adjust the taxane dose or treatment schedule and/or begin supportive medications promptly.

Question: What can women with early-stage breast cancer do to prevent recurrence/mets?

Dr. Liu: All women with early-stage breast cancer should consider lifestyle modifications as an additional strategy to reduce the risk of developing recurrent breast cancer. These lifestyle changes do not need to be drastic and parallel recommendations for promoting good general health, including maintaining a normal body mass index, daily exercise, a low-fat diet, limited alcohol intake and avoiding excessive stress. The role of vitamin D supplements, soy or other phytoestrogens and various breast health diets remains controversial.

Question: What is the latest research on “chemobrain” symptoms with aromatase inhibitors? Are there any treatments found to minimize or reverse the cognitive side effects of aromatase inhibitors in women experiencing this?

Dr. Liu: “Chemobrain” is a term that applies to changes in concentration or memory that occur during or after cancer treatment. These bothersome changes are often subtle to observers; in fact, many individuals affected by chemobrain will score well on formal cognitive tests.

The underlying cause is unclear and likely involves multiple contributing factors, including medications, fatigue, sleep disturbance, premature menopause and anxiety or stress. In most cases, these changes are temporary. Treatment therefore focuses on managing the symptoms until they resolve.

Referral to a neurologist who specializes in the diagnosis and treatment of conditions related to concentration and memory may be helpful. If the symptoms are associated with a specific aromatase inhibitor, switching to another aromatase inhibitor or to tamoxifen may prove beneficial as well.

Question: I was diagnosed with high-grade, triple-negative DCIS with micro-invasions (largest 0.2 cm). No nodes were removed at the time of mastectomy, and no further treatment is recommended. My oncologist strongly recommended against a prophylactic mastectomy. I am a 66-year-old woman who would prefer the peace of mind to vigilant monitoring.

Dr. Liu: Prophylactic mastectomy, removal of the opposite, noncancerous breast, is not medically indicated for women with ductal carcinoma in situ (DCIS) in the absence of other risk factors for contralateral breast cancer, or the occurrence of a second, independent primary breast cancer in the other breast. Risk factors may include a strong family history or a known BRCA1 or BRCA2 mutation. Nonetheless, women may elect to have a prophylactic mastectomy after a therapeutic mastectomy. This choice is usually based on one of the following:

  • the desire to avoid the stress and anxiety associated with the need for mammograms and other screening breast imaging studies and possible future breast biopsies; OR
  • the desire to undergo reconstructive surgery on both sides to maintain symmetry.

It is important to understand that these are individual choices, and thorough discussion of the pros and cons with your oncologist and breast surgeon is necessary.

Question: When a woman is diagnosed with breast cancer or ovarian cancer at an early age and has the BRCA1 or 2 gene, and subsequently has a prophylactic hysterectomy and/or mastectomies, how is her future risk for cancer affected?

Dr. Liu: BRCA1 and BRCA2 mutation carriers are at a higher risk of developing breast cancer, ovarian cancer and other malignancies. Bilateral mastectomy will significantly reduce the risk of developing a new breast cancer, and preventivesalpingo-oophorectomy, which means removing the ovaries and fallopian tubes, in women over the age of 35 will reduce the risk of both ovarian cancer and breast cancer.

These risk reducing surgical strategies are optional, and some mutation carriers opt to maximize screening methods instead. Discussion with your oncologist, surgeon and a genetics counselor is advised.

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