Who needs chemotherapy?

By Dr. Robert Pluenneke on August 27, 2008 1:36 PM | | Comments (1786)

When a patient is first diagnosed with cancer, one of the more difficult aspects of an oncologist’s job is determining which patients might benefit from chemotherapy.  No place is this more keenly felt than in breast cancer patients.  Each year, hundreds of thousands of women are diagnosed with breast cancer.  Many of them receive chemotherapy based on a perceived risk of the disease returning.  In the past, we have used critical characteristics, and information from the path report to determine whether a patient would be considered at high enough risk to benefit from chemotherapy.  This is not always accurate and some women receive little or no benefit from chemotherapy. This, however, is changing with new tests that allow us to better characterize a woman’s breast cancer and help determine whether she would be a patient that would benefit significantly from chemotherapy.  One such test is the Oncotype DX test that has been developed by Genomic Health.  This test uses a series of genes that have been identified within breast cancer cells. Whether these genes are activated (or present) within a breast cancer has been shown to be able to predict a possible outcome in patients with breast cancer.  This allows us to look at a particular patient and get a better handle on what her true risk of relapse may be.  With more certainty and more confidence we are able to avoid the side effects of chemotherapy. 

Two examples of how this test helps oncologists are represented by two different patients that I have seen over the last 2 weeks.  The first woman is a young woman who is in her early 40’s. Her sister developed breast cancer approximately five years ago.  She had an abnormal mammogram and underwent biopsy, lumpectomy & sentinel lymph node biopsy. The pathology revealed a small, less than a centimeter tumor with no lymph nodes involved.  My initial recommendation to her was that this tumor could likely be handled without chemotherapy.  However, I recommended that we have the Oncotype DX test performed.  The Oncotype DX test came back with a very high possibility of reoccurrence. This result allowed me with confidence to counsel her that her risk is significant( as high as possibly 30-40% chance of this cancer coming back).  With this information, it was easier to recommend chemotherapy.  The second patient was a lady who was in her late 40’s, with a very similar sized tumor and early stage tumor.  In this patients case her Oncotype DX came back very low and I felt very comfortable treating this lady with just anti-estrogen therapy and avoiding the toxicities of IV chemotherapy. 

These types of tests are the wave of the future.  Our ability to be able to determine which patients are at greatest risk for relapse will continue to be further defined as additional tests become available.  These types of tests will be seen within the next few years in colon cancer and possible in prostate cancer.  This should allow us to decrease the amount of chemotherapy that we give to patients and to treat our patients with more accuracy and confidence.  These tests are one of the most exciting advances in the treatment of cancer and they makes me look forward to increasingly improved outcomes in cancer patients.

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