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June 2014 Ask the Expert: Making Treatment Decisions

During the month of June, Sara Tolaney, MD, MPH, answered your questions about how to make informed treatment decisions, find a healthcare team you trust and actively participate in planning your care.

My medical oncologist says I need chemotherapy but my own research says there’s not necessarily a benefit for me. What do people do when they cannot get a second opinion in such a controversial area?

I am terrified of going through radiation therapy and would rather skip it. Would I be making a huge mistake by skipping radiation therapy? I am fearful of all the side effects.

I was diagnosed with stage III TNBC last year and joined a clinical trial. The 3 tumors all completely resolved before surgery but I did not achieve pCR. My oncologist doesn't think I need more chemotherapy. Should I seek a second opinion?

How long is it best to wait after chemotherapy before mastectomy?

Because of my current treatment plan, I will likely be starting radiation 8 months after my diagnosis. Isn't this kind of late to be getting radiation? I feel that undergoing radiation as well may be overtreating me and cause additional side effects.

Is hormonal therapy better than doing chemotherapy and tamoxifen?

What are some side effects of doing ovarian suppression with oral therapy of aromatase inhibitors?

I was on letrozole (Femara) for 7 years and have now been changed to tamoxifen. I have been on this now for 4 months. I was stage III BC 8 years ago and had double mastectomy, chemotherapy and radiation. I have no uterus. Would you have changed my medicine? How long should I be on tamoxifen?

What are the benefits of taking anastrozole after 5 years?

I did not have the BRCA genetic test after being diagnosed with a stage I ER/PR-positive breast cancer 14 years ago. My mother's sister and father's sister both had breast cancer, and my mother was given DES while pregnant with me. Should I have the test performed for my niece and great niece now? 

How can I find a physician who will treatment my Stage 1 ER-positive breast cancer with anastrozole (Arimidex) even though I am premenopausal? I took anastrozole for the past year and had a clean digital mammogram a week ago. My doctor insists I now have to take tamoxifen instead of anastrozole and I don't want to do this.

Question: I have estrogen and progesterone receptor-positive stage IIA breast cancer that appears as both invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS). I’m pretty much in the “grey area.” I had surgery and will have radiation therapy and treatment with aromatase inhibitors.

My medical oncologist says I need chemotherapy but my own research says there’s not necessarily a benefit for me. I can’t get a second opinion and Oncotype DX is not available to me. What do people do when they cannot get a second opinion in such a controversial area?

Dr. Tolaney: Making decisions about which patients with estrogen-receptor positive tumors need chemotherapy can be challenging. The biology of these cancers varies, and some people benefit from chemotherapy and some do not. The Oncotype DX test provides not only prognostic information, but also predictive information about the benefits of chemotherapy for a particular ER+ tumor. Most insurance companies cover Oncotype DX, so I would speak with your oncologist about whether or not this is needed.

It is challenging to provide an opinion about whether or not chemotherapy is needed for you without more information—generally we need to know about your general health and more about the pathology of your tumor (ie. grade, size, whether lymph nodes are involved, etc). If you are unable to go to a different physician for a second opinion, there are online services that also will have your pathology/medical records reviewed, and provide an opinion (ie. Partners Online Specialty Consultations).

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Question: I am 51 years old and have tripe-negative breast cancer and am BRCA1-positive. I had a mastectomy and am undergoing chemotherapy. I had 24 lymph nodes removed; 3 were positive.

I am terrified of going through radiation therapy and would rather skip it. Would I be making a huge mistake by skipping radiation therapy? I am fearful of all the side effects, including damage to my heart and lungs. I am in excellent physical shape and am leaning towards treating my body with nutrition instead of radiation.

Dr. Tolaney: I would highly recommend you consider radiation. Risks of local recurrence after a TNBC diagnosis with 3 lymph nodes involved may be around 25%. I would consider going to an excellent radiation oncology center where the risk of long term side effects is small.

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Question: I was diagnosed with stage III TNBC last year and joined a clinical trial for paclitaxel (Abraxane) with carboplatin (Paraplatin), had a mastectomy with 29 nodes removed, and 33 daily radiation treatments. The 3 tumors all completely resolved before surgery but I did not achieve pCR (pathologic complete response). My oncologist doesn't think I need more chemotherapy or a different type of chemotherapy. I am being treated at a large research hospital. Should I seek a second opinion?

Dr. Tolaney: It sounds like you had a very nice response to the preoperative (before surgery) chemotherapy, which is great. It is, however, hard to know if that is enough chemotherapy as we do not have long term follow-up data from giving a stage 3 TNBC abraxane and carboplatin. Generally, in these situations, I think about giving 4 cycles of AC (Adriamycin and Cytoxan) afterwards in order to make sure I have completed a standard adjuvant regimen for TNBC in patients who are otherwise healthy and have good heart function. That being said, there isn’t a right answer here, and certainly getting another opinion can often be helpful in these situations where there isn’t a straightforward approach.

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Question: How long is it best to wait after chemotherapy before mastectomy?

Dr. Tolaney: Generally we wait about 3 – 4 weeks after the last dose of chemotherapy prior to breast surgery.

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Question: I was diagnosed with triple-negative breast cancer. Because of my current treatment plan, I will likely be starting radiation 8 months after my diagnosis. Isn't this kind of late to be getting radiation? I feel that undergoing radiation as well may be overtreating me and cause additional side effects.

Dr. Tolaney: Generally we do chemotherapy after surgery and then radiation after completion of chemotherapy, so sometimes radiation begins a while after a diagnosis if it takes time to get through the surgery and chemotherapy. There is data to suggest timeliness of initiation of radiation therapy is important, and shouldn’t be delayed from time of completion of chemotherapy (if chemotherapy is given) or surgery (if no chemotherapy is administered).

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Question: Is hormonal therapy better than doing chemotherapy and tamoxifen?

Dr. Tolaney: For an estrogen receptor-positive tumor, hormonal therapy is a critical part of therapy. For some ER-positive tumors, the benefits from hormonal therapy are often larger than the benefits from chemotherapy. Usually tamoxifen results in about a 40% relative reduction in risk of recurrence.

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Question: What are some side effects of doing ovarian suppression with oral therapy of aromatase inhibitors?

Dr. Tolaney: Generally patients experience menopause-like symptoms such as hot flashes, night sweats, and vaginal dryness. Additionally, patients can notice joint aches and pains, decreases in libido, and sometimes, changes in mood. The combination can thin bones and increase the risk of osteoporosis and fractures.

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Question: I was on letrozole (Femara) for 7 years and have now been changed to tamoxifen. I have been on this now for 4 months. I was stage III BC 8 years ago and had double mastectomy, chemotherapy and radiation. I have no uterus. Would you have changed my medicine? How long should I be on tamoxifen?

Dr. Tolaney: We really don’t have good data for long-term therapy with aromatase inhibitors (such as the letrozole) yet. We do have data for patients doing 5 years of tamoxifen followed by 5 years of an aromatase inhibitor ( the MA.17 study) so the way you are doing therapy is really in the reverse order of MA.17. This study demonstrated that adding 5 additional years of hormonal therapy was beneficial.

We also have long-term data for the use of tamoxifen (based on the aTTom and ATLAS trials) that suggests that 10 years of tamoxifen is better than 5 years of tamoxifen in preventing recurrences. So it seems that long-term hormonal therapy is beneficial, and switching to tamoxifen after use of the aromatase inhibitor seems reasonable. Generally I would recommend doing hormonal thearpy to complete 10 years of treatment given that you had a stage III cancer.

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Question: What are the benefits of taking anastrozole after 5 years?

Dr. Tolaney: There are studies that are ongoing to answer this question (MA.17 extension trial and NSABP B-42) but we do not yet know the benefits of long-term therapy with an aromatase inhibitor.

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Question: I did not have the BRCA genetic test after being diagnosed with a stage I ER/PR-positive breast cancer 14 years ago. My mother's sister and father's sister both had breast cancer, and my mother was given DES while pregnant with me. Should I have the test performed for my niece and great niece now? 

Dr. Tolaney: I always recommend that patients with the cancer and afamily history do the testing if it is something they have interest in for themselves and their family. If you had a mutation, then your siblings could consider testing. I would recommend you do testing first (rather than having your nieces get tested now) as they wouldn’t need to do testing if you do not have a mutation. In order to determine what your risk is of having a mutation, I would need some more information (ie. age you were diagnosed, age your family was diagnosed, if there is a family history of ovarian cancer, etc). I recommend seeing a genetic counselor if you want to think about this further.

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Question: How can I find a physician who will treatment my Stage 1 ER-positive breast cancer with anastrozole (Arimidex) even though I am premenopausal? I took anastrozole for the past year and had a clean digital mammogram a week ago. My doctor insists I now have to take tamoxifen instead of anastrozole and I don't want to do this. 

Dr. Tolaney: We do not use aromatase inhibitors in premenopasual patients unless they are receiving ovarian suppression, or decide to have their ovaries removed. If one prescribes an aromatase inhibitor to a premenopausal patient without ovarian suppression, there is a feedback mechanism that actually results in estrogen production, which is the opposite of what we are trying to achieve and could actually stimulate cancer growth. I would strongly recommend considering the use of tamoxifen (or ovarian suppression with an aromatase inhibitor if that is what you prefer).

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Denver, CO  ·  September 13, 2014

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