What Types Of Breast Cancer Should Be Treated With Chemotherapy
Almost all women with HER2-positive cancers still need some amount of chemotherapy. And women with triple-negative tumors still need a relatively intensive course of chemotherapy, Dr. Lustberg says.
Chemotherapy may also be used to treat certain larger HR-positive cancers that have spread to lymph nodes, even if the tumor is estrogen-positive. “Specialized testing can determine which of these breast cancers will benefit from chemotherapy,” Dr. Lustberg says. Because of the personalized therapy made possible by these predictive biomarkers, the use of chemotherapy in lymph node-negative and positive HR-positive cancers has decreased in recent years, with excellent clinical outcomes.
Some Cases Keep Me Up At Night
Dr. Doshis oncologist, Dr. Eric Winer of the Dana-Farber Cancer Institute, gave her good news: A genetic test of her tumor indicated she would not get any significant benefit from chemotherapy. Hormonal therapy to deprive her cancer of the estrogen that fed it would suffice.
But as much as Dr. Doshi dreaded chemotherapy, she worried about forgoing it. What if her cancer recurred? Would chemotherapy, awful as it is, improve her outcome?
She got a second opinion.
The doctor she consulted advised a very aggressive treatment, Dr. Doshi said a full lymph node dissection followed by chemotherapy.
She had multiple conversations with Dr. Winer, who ended up discussing her case with four other specialists, all of whom recommended against chemotherapy.
Finally, Dr. Doshi said, my husband said I should just pick a horse and run with it.
She trusted Dr. Winer.
Her struggles mirror what oncologists themselves go through. It can take courage to back off from chemotherapy.
One of the most difficult situations, Dr. Winer said, is when a patient has far more advanced disease than Dr. Doshi did hers had spread to three lymph nodes but no further and is not a candidate for one of the targeted treatments. If such a patient has already had several types of chemotherapy, more is unlikely to help. That means there is no treatment.
It falls to Dr. Winer to tell the patient the devastating news.
What Tests Are Used To Determine If A Patient Can Benefit From Chemo
Genomic profiling tests can help determine if a cancer is likely to return and whether or not some patients with small, early cancers will or will not benefit from chemotherapy.
There are many of these tests, and the two most common ones are Oncotype DX and MammaPrint, Dr. Lustberg says, adding that both are FDA-approved. The tests analyze a sample of a cancer tumortaken from a biopsy or a surgical specimenlooking for the activity of certain genes that can affect the likelihood that a patients cancer will grow or spread.
The following patients may be eligible for the Oncotype DX test:
- Youve recently been diagnosed with Stage I, Stage II, or Stage IIIa invasive breast cancer
- The cancer is estrogen-receptor-positive
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Survival Rates Are Tripling For Lung Patients
When Dr. Roy Herbst of Yale started in oncology about 25 years ago, nearly every lung cancer patient with advanced disease got chemotherapy.
With chemotherapy, he said, patients would be sure to have one thing: side effects. Yet despite treatment, most tumors continued to grow and spread. Less than half his patients would be alive a year later. The five-year survival rate was just 5 to 10 percent.
Those dismal statistics barely budged until 2010, when targeted therapies began to emerge. There are now nine such drugs for lung cancer patients, three of which were approved since May of this year. About a quarter of lung cancer patients can be treated with these drugs alone, and more than half who began treatment with a targeted drug five years ago are still alive. The five-year survival rate for patients with advanced lung cancer is now approaching 30 percent.
But the drugs eventually stop working for most, said Dr. Bruce Johnson, a lung cancer specialist at Dana-Farber. At that point many start on chemotherapy, the only option left.
Another type of lung cancer treatment was developed about five years ago immunotherapy, which uses drugs to help the immune system attack cancer. Two-thirds of patients from an unpublished study at Dana-Farber were not eligible for targeted therapies but half of them were eligible for immunotherapy alone, and others get it along with chemotherapy.
When Oncologist Stops Chemo
If you decide to stop chemotherapy, make sure you continue to feel relief from symptoms such as pain, constipation, and nausea. Making Your Decision · Questions to Ask Your Oncologist · Life After Chemotherapy. Cancer treatments can help stop the growth or spread of cancer. However, sometimes treatment doesn’t work well or stops working.
A person may want to stop chemotherapy for a while or completely. This may be due to adverse side effects, treatment seems to be ineffective, or for other reasons. Your oncologist considers these issues when determining what treatment options may benefit you and if you can tolerate it. Breaks are common in cancer practice, and for both patients and oncologists, pausing with a reevaluation plan can be a much less threatening discussion than stopping chemotherapy altogether.
Your oncologist might suggest that you talk to a social worker or attend a support group with others who are facing similar decisions. Now may be the time to do some things you’ve always wanted to do and stop doing things you don’t want to do anymore. You can learn more about the changes that occur when curative treatment stops working, and about planning ahead for you and your family, in Advance Directives and Approaching the End of Life. Review the recommendations of the American Society of Clinical Oncologists and Choosing Wisely as you make this decision.
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Concerns About Chemo And Your Natural Defenses
A growing population of adults are choosing to refuse chemo is based on the way in which it works. Chemotherapy does not kill your immune system as claimed, but it can harm it temporarily. The potential for this side effect is well known and the oncologist will prepare for it and monitor your immune system closely throughout treatment. This is a large part of the reason why, if you do choose to elect chemotherapy, your blood will be closely monitored through tests during your treatment. This concern is not unfounded but it is debatable, as the effects on your immune system end shortly after the round of chemo does.
Considering A Clinical Trial
At any point during your treatment, you may consider asking your doctor whether a clinical trial is an option. A clinical trial is a research study that tests a new treatment in people. It proves that it is safe, effective, and possibly better than the standard treatment you may already have had. Many clinical trials require that you have few or no previous treatments. Because of this, it is best to ask about clinical trials early in the treatment process. Joining a clinical trial may be a better option for your second-line treatment than a standard treatment. Your health care team can help you review all clinical trial options that are open to you.
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Thinking About A Second Opinion
When faced with deciding whether to continue cancer treatment, some patients or their loved ones may want to get a second opinion. Even when you place full trust in your doctor and cancer care team, you might wonder if another doctor could offer something else or more information. It’s normal to think about talking to someone else, and your doctor should support you if you decide to get another opinion. Remember that your cancer care team wants you to be sure about the decisions you make. You can read more in Seeking a Second Opinion.
If Cancer Treatments Stop Working
Cancer treatments can help stop cancer from growing or spreading. But sometimes treatment does not work well or stops working.
Maybe treatment ended a while ago and was successful at first, but cancer has come back. Or maybe one type of cancer treatment has stopped working and the cancer has kept growing. If this happens, your doctor might say your cancer has advanced or progressed. There may or may not be other treatment options. But when many different treatments have been tried and are no longer controlling the cancer, it could be time to weigh the benefits and risks of continuing to try new treatments.
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How Do We Know That Less Or No Chemotherapy Really Is Enough For Her2
Early in the 2000s, trastuzumab , a monoclonal antibody, was introduced to treat women with relatively advanced cases of HER2-positive breast cancer, and it was successful, Dr. Winer explains.
Suddenly, women with relatively advanced forms of breast cancerwith lymph node involvementwere doing exceptionally well, he says. So, then we asked ourselves: If you have a very small HER2-positive breast cancer and no lymph node involvement, do you still need such complex chemotherapy treatments? In a study published in the New England Journal of Medicine almost a decade ago, we demonstrated that one could give a limited course of chemotherapy along with trastuzumab and achieve outstanding results.
Is There A Type
There is not a vast amount of research on people who refuse conventional treatment for cancer, according to Professor Saunders. This group of patients is more sceptical about medicine and are therefore less likely to want to participate in a scientific trial, she said.
But its not one size fits all, said Professor Saunders. This is not one group of people. There are different motivations and nuances.
For some, its a very specific reason such as a religious or a psychiatric condition. But the larger group is actually well educated, younger, healthier, fitter, and they have a high need for decision-making control.
An Australian study from 2012 suggested that one in four cancer survivors has used alternative treatments and dietary supplements but no Australian research is tracking numbers to see if refusal of conventional treatment rising.
Danielle Spence, the head of cancer strategy and support at Cancer Council Victoria, agrees that the reasons for refusal are quite broad. She urges health professionals to take the time to understand what those issues are.
It can be misconceptions and myths or cultural misinformation, Ms Spence said. It can be stigma. Some people dont have a relationship with a GP. They might be too embarrassed to come forward. Some people might not be able to stop working or caring for children.
A lack of health literacy combined with fake news on social media makes it difficult to reach those who are hesitant about conventional treatment.
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Saying No To Your Oncologist Is Sometimes The Right Thing To Do
Cancer is a dreadful disease. Just dreadful. Make no mistake: I have tremendous respect for the awesome doctors who treat patients afflicted with it day after day. Still, paradoxically, I cant help but notice that some of them have just as hard a time as do other doctors with caring for patients at the end of their lives. I believe a large part of their difficulty stems from the ridiculously dysfunctional either/or approach to palliative care and hospice were stuck with in this benighted country.
The problem is that in order to qualify for hospice, patients must not only have a certified life expectancy of less than six months, but they must also not be undergoing any active treatment for their malignancy. When you stop to think about it, though, this is actually quite discriminatory. We dont require people on hospice with other diagnoses to discontinue their life sustaining medications. Patients with COPD are allowed to continue their bronchodilators CHF patients dont have to stop their ACE inhibitors and digoxin. But if a cancer patient wants to qualify for hospice, they have to forgo curative treatments like chemotherapy.
So what if the oncologists call it palliative chemo instead? That still sounds too much like giving up, and that is something that too many oncologists are loath to do. Not only to do, but to even think about. I actually heard one oncology colleague of mine tell a mutual patient, Im in the business of hope.
Treatment : Supportive Care
Supportive cancer care can be an effective complement to standard treatment, helping to minimize the physical and emotional stress of cancer treatment.
For example, psychotherapy and massage therapy can help ease patients anxiety as they cope with a diagnosis acupuncture can be beneficial for pain relief and nutrition counseling can keep a patient from losing too much weight during treatment and keeping their body as healthy as possible.
Other types of integrative medicine include the following:
Aromatherapy Hypnosis Mindfulness meditation
Anything you can do to keep a patient mentally and physically well while they handle the stress of having cancer is beneficial, Budds says. Its just one of the growing set of tools we have to help our patients deal with cancer. Weve come a long way in recent years.
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Talking With Your Health Care Team
It is important to talk with your health care team about your care throughout the treatment process. Being an informed, involved patient, asking questions, and talking about your preferences will help you and your health care team work together better. Also, it will make you feel more confident about your treatment choices.
Bring a list of questions to your visits to help guide the talk. It will help you make sure your doctor addresses all of your concerns. You may want to print the list below or for an e-list and other tools to use during your visit.
Here are examples of the types of questions you may want to ask:
What is the current status of the cancer?
Has the cancer grown and/or spread since my first treatment?
Are other treatment options available?
Would you recommend starting a new treatment?
Would you recommend participating in a clinical trial?
Should I consider not having a new type of treatment at this time?
What will happen if I choose not to have another type of treatment?
Who can help me if Im worried about managing the costs related to my cancer care?
Who can help me understand what parts of my care are covered by my insurance?
If you and your doctor decide on second-line treatment, you may consider asking the following questions:
Find more questions to ask the health care team.
If Another Treatment Is Available
If you have cancer that keeps growing or comes back after one kind of treatment, its possible that another treatment might still help shrink the cancer, or at least keep it in check enough to help you live longer and feel better. Clinical trials also might offer chances to try newer treatments that could be helpful.
If you want to continue to get treatment for as long as you can, its important to think about the odds of further treatment having some benefit , compared to the possible risks and side effects. Your doctor can help estimate how likely it is the cancer will respond to treatment you might be considering. For instance, the doctor might say that more treatment might have about a 1 in 100 chance of working. Its important to have realistic expectations if you do choose this plan. The possible benefits, risks, side effects, costs, schedule of treatments and visits, and effect on quality of life should always be considered and discussed.
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Life After Chemotherapy Stops
Discuss any physical symptoms that youre having as well as any emotions that are troubling you. Your oncologist might suggest you speak with a social worker or attend a support group with other people who are facing similar decisions. Remember, you are not alone in this.
Accepting that you may have reached the limit in your care can cause more anger, sadness, and feelings of loss. Use this time to discuss your wishes with your family and friends. Think about how you want to spend time with them.
Some people decide that finishing lifelong goals or taking an overdue vacation is a better way to spend time than coping with more chemotherapy treatments.
Life Expectancy When Chemo Stops Working
What is your life expectancy once chemo stops working? This is a common question, and its one that concerns patients and their families for a variety of reasons. When a cancer patient is approaching the end of their life, there are many details that will need to be considered. Families may have important religious rites to perform, and sometimes travel arrangements must be made.
Many different factors will determine how much time a patient has left, and this is true for any of us whether we have cancer or not. The type of cancer, the stage of the cancer when it was first diagnosed, the treatment a patient has received, the patients physical and emotional health, and the specific type of cancer will all play roles when it comes to how much time someone has to live.
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Questions To Ask Your Doctor About Chemotherapy
Patients are sometimes reluctant to ask questions, but I tell my patients that any question is an important question when it comes to their cancer care. Oncologists deal with cancer every day, but it’s all new to the patient. Getting your questions answered will help you make informed decisions about your care.
Think about your questions before your appointment. Write them down and bring them with you. I also recommend bringing a family member or friend to take notes during the appointment because its easy to get overwhelmed by information.
Here are some questions to consider asking your doctor about chemotherapy:
- What drug or drugs are you recommending?
- Whats the goal of this treatment?
- How long will I be on it?
- How do I receive it?
- How often do I have to come in? Can someone come in with me?
- If Im taking this drug at home, where do I store it? How often do I take it? What if I forget to take it?
- What are the potential side effects? Are you going to give me anything ahead of time to deal with them?
- Am I likely to have long-term side effects from this drug?
- Who do I call if Im at home and I have a question?
- What kind of support is there to help me through this treatment?
- Is there any support for my caregivers?
If you think of more questions after your appointment, call back and ask them.
If you start chemotherapy and your experience is different from what you expected, talk to your care team. They may be able to make changes that help you.