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Presurgery chemo for breast cancer stirs debate
Question of the Day
More breast cancer patients are offered chemotherapy before surgery instead of afterward — amid much debate about how to do it right and when it’s a good option.
Doctors have long known that having chemo first sometimes shrinks an advanced tumor enough that a woman can undergo smaller surgery and keep her breast.
What’s new is the hope that it may help more women with early-stage cancer in a different way — by enabling doctors to switch drugs if the tumor doesn’t respond right away. Wait until after surgery, and there’s no way to measure the drugs’ effect.
Does it really work? Studies show it doesn’t endanger a woman to have chemo before surgery — but so far, the increased chance of survival hasn’t been proven either.
That means whether a woman is offered presurgery chemo depends more on the doctor than on firm guidelines.
“I’m a fan of letting patients know what their choices are,” says Dr. Minetta Liu of Georgetown University Hospital, a proponent of early chemo who estimates that up to 10 percent of her patients choose it presurgery. “You’re not asking them to do something that’s going to have a negative impact on their survival. It just may not help.”
“It should not be used … just because it exists,” Dr. Hudis said.
With breast cancer deaths dropping since 1990, “the notion that we should move to a different strategy should be challenged, he said. “We have uncharted territory.”
More than 178,000 U.S. women will be diagnosed with breast cancer this year. With the improvements in treatment and early detection, many will survive. Still, breast cancer kills 40,000 a year.
Not every patient needs chemotherapy. It depends on the tumor’s size and type, and whether the cancer has begun to spread, determined by checking lymph nodes under the arm.
There are no good statistics on how many women choose chemo first. Most still undergo the treatment after surgery, especially those treated in community hospitals.
But with more specialized cancer centers pushing upfront chemo for earlier-stage patients — and dozens of clinical trials testing different methods — the National Cancer Institute brought together specialists last spring to debate what everyone agrees is a rising trend.
What’s clear: If shrinking a tumor might save a woman’s breast, or offer a markedly smaller lumpectomy, then presurgery chemo is a smart choice. Studies in the late 1990s proved that, and women with large tumors are routinely offered presurgery chemo — including Democratic presidential hopeful John Edwards’ wife, Elizabeth Edwards, who entered a chemo-first clinical trial when her breast cancer was diagnosed in 2004. (Earlier this year, she learned her cancer returned and spread to bone.)
By Andrew P. Napolitano
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