Section
5
Adjuvant
Therapy for Low-risk Tumors
Sometimes
we neglect using some fairly well-established, reproducible
prognostic factors. The SEER data and the American College
of Surgeons’ National Cancer Database cannot reliably
identify a subset of node-negative patients with tumors under
a centimeter with a long-term survival of less than 90 percent.
There’s
also very good data showing that patients with histologic
grade one tumors that are 1.1 to 2 centimeters have a survival
that’s greater than 90 percent. Patients with grade one
tumors are overwhelmingly ER-positive, so endocrine therapy
is certainly a reasonable choice there. But the added absolute
benefit of chemotherapy in this subset is extremely small,
and sometimes that is not conveyed to women in a way that
they can understand.
Another
group is the special histologic subtypes, most notably tubular
carcinoma, but also mucinous carcinoma. Even a two to three
centimeter tubular cancer has an outstanding prognosis, and,
again, these are all receptor-positive. So, if physicians
look at old consensus guidelines and just go in lock-step
with the greater-than-1-centimeter number, they might potentially
over-treat some patients by using chemotherapy.
We consider
tamoxifen in these patients not only for the treatment effect,
but also the potential prevention benefit in terms of the
contralateral breast. If you add in the stabilization of postmenopausal
bone loss — if not fracture protection — it’s
well worth taking for many patients. If they have some significant
reason not to take it — a history of pulmonary embolism,
DVT, or if they’re 75 years old with a good-prognosis
tumor — we might not recommend tamoxifen, but it should
be considered.
—Monica
Morrow, MD
| Morrow
M. Who should not receive chemotherapy? – U.S.
databases and trials. NIH Consensus Conference on
Early Breast Cancer, 2000. Abstract
Bergh
JC. Who should not receive chemotherapy? –
International databases. NIH Consensus Conference
on Early Breast Cancer, 2000.
Abstract
Fisher
B. Recent NSABP adjuvant studies in primary (stage
one) breast cancer. NIH Consensus Conference on
Early Breast Cancer, 2000.
Abstract
|
| NIH
Consensus Development Conference on Early Breast Cancer,
Final Statement
Full Text
On
the basis of available data, it is accepted practice
to offer cytotoxic chemotherapy to most women with lymph
node metastases or with primary breast cancers larger
than 1 cm in diameter (both node-negative and node-positive).
For women with node-negative cancers less than 1 cm
in diameter, the decision to consider chemotherapy should
be individualized.
|
| NSABP
B-21: Phase III Trial of Adjuvant Therapy with Tamoxifen
vs Placebo, plus Radiotherapy, in the Management
of Patients with Clinically Occult, Invasive, Node-Negative
Breast Cancer Treated by Lumpectomy (closed for
accrual)
Protocol |
|
Eligibility |
Eligibility
Invasive < 1 cm, node-neg, treated
with lumpectomy & ALND |
|
ARM 1 |
XRT + placebo x 5 years |
|
ARM 2 |
XRT
+ tamoxifen 20 mg qd x 5 yrs |
|
ARM 3 |
Tamoxifen
20 mg qd x 5 yrs |
Wolmark
N et al. The role of radiotherapy and tamoxifen
in the management of node-negative breast cancer
< 1.0 cm treated with lumpectomy: Preliminary
results of the NSABP protocol B-21. Proc.
ASCO 2000
Abstract 271
(The
combination of tamoxifen together with radiotherapy
was superior to either treatment alone in controlling
ipsilateral breast tumor recurrence even in this
highly favorable group. Tamoxifen also reduced
the incidence of contralateral breast cancers.)
|
|
SELECT
PUBLICATIONS
|
Bland
KI et al. Clinical highlights from the National
Cancer Data Base, 2000. CA Cancer J Clin
2000;50:171-183.
Full-Text
Diab
SG et al. Tumor characteristics and clinical outcome
of tubular and mucinous breast carcinomas. J
Clin Oncol 1999;17:1442-8.
Abstract
Fisher
B et al. Tamoxifen and chemotherapy for axillary
node-negative, estrogen receptor-negative breast cancer:
Findings from National Surgical Adjuvant Breast and
Bowel Project B-23. J Clin Oncol 2001;19:931-42.
Abstract
Fisher
B et al. Prognosis and treatment of patients with
breast tumors of one centimeter or less and negative
axillary lymph nodes. J Natl Cancer Inst
2001;93:112-20.
Abstract
Lundin
J et al. Omission of histologic grading from clinical
decision-making may result in overuse of adjuvant therapies
in breast cancer: Results from a nationwide study.
J Clin Oncol 2001;19:28-36.
Abstract
|
|
