American cancer society wig

Part II

Editor's Note: In the first part of this article (February 2002 SEP), Dr. Hughes discussed mammography and early diagnosis, breast-conserving surgery, and radiation and hormonal therapies.

Chemotherapy Adds to Survival

What else can be done to help keep the cancer from coming back? Combinations of chemotherapy drugs can be given to attack any remaining cancer cells that may be lurking in a woman's body.

"Cancer chemotherapy has made a difference," said Dr. A. Marilyn Leitch of the University of Texas, "but the benefits are greater for those with the highest risk of relapse." So if chemotherapy cuts the risk of recurrent cancer by 30 percent, the "bang for the buck" would be a lot more for someone with a 50 percent chance of recurrence (overall 15 fewer in 100 women) than someone with a 10 percent chance of recurrence (overall 3 fewer in 100 women). As a rule, younger women with spreading to the lymph nodes (who are most likely to have the cancer come back) get the most help, with about 12 percent improvement in survival at ten years. Older women see less benefit, with 2 to 6 percent better survival at ten years.

Chemotherapy involves taking four to six monthly cycles of combinations of cancer-fighting drugs. A woman often has a long-term IV catheter implanted under the skin, through which she receives the treatments. Recent studies have shown that treatment combinations which include one of the powerful, but more toxic, anthracycline family of drugs (such as doxorubicin) have given women a slightly better chance of survival over those that did not use this family of drugs, with fewer monthly cycles.

But chemotherapy is no walk in the park. This was the hardest part for Lisa Schmidt, a 45-year-old breast cancer patient.

"I felt so bad for four days after I got the chemotherapy treatments. Later, my hair started to fall out," she says. Hair loss is a common side effect of chemotherapy that women should be prepared for. A custom-dyed wig helped Lisa get through this difficult time: "It really did help me to feel better," she says. She received it from an organization that helps cancer survivors by giving makeup and hair advice (www.lookgoodfeelbetter.org).

Other side effects of chemotherapy include fatigue, nausea or vomiting, and susceptibility to infection. The anthracycline drugs may also lead to heart damage, so the dosage given has to be carefully monitored.

New treatments are being tested for women who have breast cancer that has recurred or is already widespread when it is diagnosed, such as the taxane family of drugs, including Taxol (paclitaxel). Also, stem cell transplants are being tried along with higher doses of combination chemotherapy. Whenever possible, experimental treatments should be used in the setting of a clinical trial, for the sake of future generations of women with breast cancer.

A Personal Decision

Every woman with breast cancer is different. Many things come into play when deciding on a course of treatment, such as her age and health, the appearance of the cancer, the stage, the receptors, and her personal feelings about the treatment and about preserving her breast. Together with her physician, each woman must decide what course of action is right for her.

Actress Suzanne Somers surprised some of her fans when she recently decided to forgo chemotherapy for breast cancer and try an herbal treatment, Iscador. An extract of mistletoe, this substance is toxic to cells and has some activity as a stimulant to the immune system. It hasn't been found to improve survival in breast cancer. As of now, none of the alternative treatments have yet made a convincing case for use in breast cancer. But many drugs that are used originate from plants, like the vinca alkaloids (vincristine and vinblastine) from periwinkle and the taxanes (paclitaxel and docetaxel) from the Pacific yew tree.

Can a Pill Prevent Breast Cancer?

An amazing thing came to light when tamoxifen was used to treat women with breast cancer: the "anti-estrogen" drug prevented new breast cancers from forming in the other breast. This preventive effect has been put to the test in women with increased risk of breast cancer, such as those with a family history of breast cancer. Tamoxifen was found to slash the number of women developing breast cancers by half. The cancers prevented were those carrying the estrogen receptors (ER+) marker.

But tamoxifen isn't a magic bullet. It has other effects, some good and some bad. Like estrogen, it seems to strengthen bones and improve cholesterol levels. On the down side, it promotes buildup of the uterine lining, which leads to double the risk of uterine cancer. There is also triple the risk of blood clots that break off and travel to the lungs (pulmonary embolism). In one large trial of high-risk women who used tamoxifen, for every 1,000 women there were 21 fewer breast cancers, but three more uterine cancers and two more serious blood clots than in untreated women. So, you can see that for high-risk women, the scales balance in favor of taking tamoxifen.

Tamoxifen brings hope for prevention of breast cancer in women with the gene mutations BRCA1 and BRCA2 who face a 50 percent or more risk of getting breast cancer during their lifetimes. These mutations are found in less than one percent of the general public, but are increased among women whose relatives have breast cancer, especially when there is also ovarian cancer in the family. They are more concentrated among some ethnic groups, such as Ashkenazi dews.

Although having both breasts removed (prophylactic mastectomy) may seem radical, it has also been found to be successful at helping these women live longer. Testing for the gene mutations is possible by a blood test; this is especially important for those who think they are at high risk because of multiple numbers of close relatives with breast or ovarian cancer.

But a big question remains: if tamoxifen can prevent breast cancer in high-risk women, should it be used for the tens of millions of women whose risk of getting the disease is average? Or is it just a trade-off, where risk of breast cancer is replaced by risk of another disease that could be just as bad?

MORE on "Designer" Estrogens

Thus began the search for SERMs (selective estrogen receptor modulators) that prevent breast cancer but would be safer for women to take, specifically one that does the good things estrogen does for women (like making their bones stronger and decreasing their cholesterol levels and risk of heart disease) but avoids the bad effects (like a risk of uterine cancer and blood clots).

Hopes are running high for raloxifene (Evista), a SERM FDA-approved for treatment of osteoporosis. The much-awaited MORE (Multiple Outcomes of Raloxifene Evaluation) study on over 7,000 women showed that raloxifene treats and prevents osteoporosis; it was also noted to reduce breast cancers by over 70 percent. The higher risk of uterine cancer was not seen. But serious blood clots were increased by two to three per 1,000 women in those taking raloxifene, compared to the control group. This side effect has also been seen with birth control pills and postmenopausal hormone replacement therapy.

Stay tuned for more on this subject as the STAR (Study of Tamoxifen and Raloxifene) study compares the two SERMs head to head in 22,000 women. The Web site cancertrials. nci.nih.gov has information about this and other trials.

"We have enrolled about 11,000 women so far," said Dr. Leslie Ford of the National Cancer Institute's Division of Cancer Prevention. This study will provide more information about how the two drugs compare on safety and breast cancer prevention. Other SERMs are in the research pipeline also.

"In the meantime, women who have low bone density after menopause may consider taking raloxifene," said Dr. Ford. Chances are that their breast cancer risk would fall substantially. "But if your main concern is high breast cancer risk, tamoxifen is the gold standard for that and is the FDA-approved medicine for prevention of breast cancer."

Hormone Replacement Therapy (HRT) and Breast Cancer Risk

After menopause, a woman's body makes less of the female hormones estrogen and progesterone. These changes cause her to start losing bone mass, which can lead to osteoporosis, and increases her risk of developing heart disease, hypertension, and stroke. Hot flashes and vaginal dryness are other signals of the hormone imbalance of menopause.

So there are good reasons to replace the hormones. But taking estrogen causes a buildup in the uterine lining, so any woman who hasn't had a hysterectomy also has to take progesterone.