Can some early stage breast cancer patients safely skip chemotherapy?

The standard treatment for early stage breast cancer is a good surgery which is then followed by radiotherapy and chemotherapy but can some early stage breast cancer patients safely skip chemotherapy? Here's what doctors have to say

Breast cancer is a major problem in India and it’s increasing day by day as on a yearly basis, around 2 Lakh women are diagnosed with breast cancer each year in India. The second problem is the increasing number of young breast cancer patients in India since a lot of young women who are less than 35 years are getting diagnosed with breast cancer these days.

Can some early stage breast cancer patients safely skip chemotherapy? (Thirdman)

In the western population, breast cancer is more common in elderly but in India more and more young women are diagnosed with breast cancer and unfortunately, early breast cancer constitutes only about 40% of all breast cancers in India whereas it is 80% or more in western countries because they are more aware. They go for screening mammography and for routine screening tests regularly but in India, women are more hesitant to express their problems because they don’t speak much about it or take enough care to get screening tests done instead, prefer to delay it as much as possible and only when they have an advanced tumour is when they come for a check-up.

In an interview with HT Lifestyle, Dr Rajeshwar Singh, Director, Medical Oncology at Panchkula's Paras Hospital, shared, “Breast cancer is not one disease, it is multiple diseases which are affecting the breast. We have positive hormones breast cancer, HER2/neu and Triple negative breast cancer. Out of this, for hormone breast cancer which is caused due to female hormones, we give a special kind of hormone treatment where we suppress female hormones and treatment is effective in those cases. Traditionally, we used to give chemotherapy to all patients with early breast cancer. It was not possible to decide which patients need chemotherapy and which category of patients can avoid Chemotherapy. Chemo is typically given to ensure that cancer does not reoccur.”

He revealed, “Anybody going through chemotherapy has to face certain things - one is the side effects because chemotherapy is a systemic drug and once it goes into the vein it goes to all the cells of the body. It kills the cancer cell but also affects the normal cell in the body and because of that people have side effects in the form of loose motion, vomiting, loss of hair, deficiency of blood components. Not all patients undergo side effects but a few of them do. All these side effects do occur in breast cancer patients who undergo chemotherapy. If the prognostic test score in something like ‘CanAssist Breast’ test is less than 15, those patients are at a low risk of breast cancer and are in no need of chemotherapy and can be treated by hormone therapy or radiotherapy. In this way we can save many patients from the side effects of chemotherapy, and not just the side effects but many elderly patients above the age of 60 can not tolerate chemotherapy and can not afford it also. Nowadays, we have a modality through which we can decide if a patient needs chemo or not.”

However, he said that with advances in science, cancer treatment has evolved. He pointed out, “With the introduction of prognostic tests such as OncotypeDX and CanAssist Breast, we can now know which early stage breast cancer patients benefit from Chemotherapy. In prognostic tests, we take a sample of the tumour and analyse the proteins to figure out the recurrence. The tests give a recurrence score unique to each patient. If the score is above 15.5 then there is a high risk of recurrence whereas if it is less than 15.5 then there is low risk of the cancer coming back. We want to give chemotherapy only to those patients who have a high risk of breast cancer recurrence and not to the low risk patients. There is no advantage of giving chemotherapy to low risk breast cancer patients because hormone therapy is given to all patients, and by giving only hormone therapy we want to see how much a patient can avoid chemotherapy.”

According to Dr Ashish Jakhetiya, Surgical Oncologist at Geetanjali Hospital, “The standard treatment for early stage breast cancer is a good surgery, mostly a breast conservation surgery, which is then followed by radiotherapy and chemotherapy. Traditional indication was that if the tumour was more than 1 or 2 cm, then the patient has to undergo chemotherapy. However, this treatment approach has changed. We are now in the era of precision medicine, where each patient’s condition is different. It’s not a one size fits all approach. The biology and tumour of each patient is different. We cannot apply the same formula/guidelines for everyone or have a blanket treatment for every patient. This is now possible due to the advances in molecular diagnosis. Once the molecular analysis is done, there are many risk prediction or prognostic tests like Oncotype DX, Mammaprint, Endopredict and some of the new and affordable Indian alternatives like ‘CanAssistBreast’ that give good risk prediction score in early breast cancer patients.”

He added, “In early stage breast cancer patients, about 70% of the patients fall into the low risk group which means that these patients can safely avoid chemotherapy because they have a low risk of the cancer coming back. All credit goes to the advances in molecular biology and these prediction tests. These prediction scores have been validated on a good sample size. We are routinely prescribing these tests and the patients who are undergoing these tests and those who can avoid chemotherapy are very happy because there are so many side effects associated with chemotherapy like fertility issues, hair fall, weakness, nausea, neutropenia. There is a significant chunk of patients who can safely avoid chemotherapy if their risk of recurrence is low. As an approximate analysis, I can say that at least 10-15000 female patients in India must be offered these tests because they might be able to safely avoid chemotherapy.”

As we all know chemotherapy is a toxic drug and it has side effects like nausea and alopecia (loss of hair) but Dr Surender Beniwal , Professor and Head of the Department, Medical Oncology at Bikaner's Acharya Tulsi Regional Cancer Treatment and Research Institute comforted that for early stage breast cancer patients, there is an option to avoid chemotherapy. He elaborated, “Nowadays there are a number of tests available that indicate the probability of recurrence and need of chemotherapy in early stage breast cancer. On the basis of that it can be decided whether a patient needs to undergo chemotherapy. These tests do a molecular test on the breast cancer affected tissue and then try to rule out if chemotherapy will help these patients or not. In some types of breast cancer specially hormone receptor positive, we can avoid chemotherapy and give only one or two pills per day with equal or better effect and very less side effects. With these few drugs we can avoid chemotherapy with an equal or better chance of survival than with chemotherapy. We advise these tests to be done for all hormone receptor positive early breast cancer patients. So we can avoid chemotherapy and can also ensure good quality of life for these patients.”

Revealing that before these tests, the doctors had to give the same treatment to all breast cancer patients, be it early stages or advanced stages of breast cancer, Dr Surender Beniwal shared that chemotherapy was a must to avoid the recurrence of the disease. However, with the availability of these tests, doctors can now individualise the treatment. He said, “The most fearful factor of chemo is alopecia(loss of hair), be it men or women. Especially for women it is a more fearful side effect because the very thought of losing hair itself is a traumatizing situation for the woman and as well as her family. Due to these side effects, women tend to not come out of their houses or indulge in any social activities. The other side effects are vomiting, stomatitis in mouth due to which they are unable to eat or drink properly. The other side effect is that chemotherapy itself can sometimes cause secondary cancer. After 4-5 months of treatment it can lead to a different cancer like blood cancer depending upon the chemotherapy given to the patient. To avoid these side effects we tend to not advise chemotherapy to all patients.”