FAQs After Diagnosis: Early Stage Hormone-Positive Breast Cancer

This post is written by ASK Cancer Commons Scientist and Product Team Member Amanda Nottke, PhD. Dr. Nottke regularly provides guidance to patients through our ASK Cancer Commons service.

After a diagnosis of early stage, hormone-positive breast cancer, you may find yourself facing several daunting decisions, such as choosing between the extensive surgery of mastectomy versus a more minor lumpectomy procedure paired with radiation (with all its challenging side effects). And once surgery is complete, what next? Hormone therapy is clearly indicated for many women, but which drug, and how long to take it? And what about chemo—how to know if the tough side effects are worth the possible reduction in risk of recurrence?

Fortunately, there are a wealth of quality datasets available to inform these decisions. Below are some of the questions we get most frequently from patients using our ASK Cancer Commons service, answered according to the latest thinking from scientific literature and our expert physician network. If you are facing your own cancer treatment decisions and would like free one-one-one expert support, please submit your case here.

1. If my doctor has said either mastectomy or lumpectomy plus radiation are appropriate for me, how do I choose?

Many studies have looked at this, and overall the outcomes for mastectomy versus lumpectomy plus radiation are extremely similar (both are effective treatments, so you can instead weigh the side effects of radiation versus the more intensive surgery of the mastectomy). This webpage provides a helpful summary of the pros and cons of mastectomy compared to lumpectomy. Continue reading…

Recommendation to Omit Radiation Therapy After Lumpectomy Is Not Frequently Implemented

“Nearly two thirds of U.S. women age 70 or older with stage I breast cancer who undergo lumpectomy and are eligible to safely omit subsequent radiation therapy (RT) according to national cancer guidelines still receive this treatment, according to new study results. The researchers looked at more than 205,000 cases of breast cancer nationwide, and their study is published as an ‘article in press’ on the Journal of the American College of Surgeons website in advance of print publication.

“After a lumpectomy, also called a breast-sparing or breast-conserving operation, radiation usually is given to the breast to reduce the chance of the cancer returning. However, treatment recommendations changed in 2004 for a select group of elderly breast cancer patients after research found that postoperative RT did not significantly prolong their survival over five years compared with women who received no RT.”

Radiation Tx Boosts Survival in Triple Negative Breast Ca in Older Women

“Adjuvant radiation therapy (RT) after lumpectomy for elderly women with early stage triple negative breast cancer (TNBC) improved overall survival (OS) and disease specific survival (DSS), a retrospective analysis of cases from the Surveillance, Epidemiology, and End Result (SEER) database has shown.

“The review showed that adjuvant radiation was associated with an overall six-fold decrease in any death, as well as death from breast cancer, Sean Szeja, MD, of The University of Texas Medical Branch at Galveston, and colleagues reported in a poster session at the American Society of Clinical Oncology (ASCO) Breast Cancer Symposium (Sept. 25-27).

“Some 23 months after diagnosis, 98.2% of women who received lumpectomy and radiation were alive, compared with 85.6% of those who received lumpectomy alone, the investigators said. In addition, the analysis revealed that breast cancer-related deaths were more common in the lumpectomy only group (6%) compared with the lumpectomy and radiation group (1%).”

Alternative Way to Treat Early-Stage Breast Cancer With Radiation

“Breast-cancer specialists are sharply divided over a new radiation technique that costs less and is more convenient than conventional therapy.

“The technique, known as intraoperative radiation therapy, or IORT, involves administering a single dose of radiation at the same time a patient is having lumpectomy surgery to remove a tumor. A large, randomized controlled trial concluded that IORT has fewer side effects and appears to prevent the return of cancer nearly as well as traditional treatment, in which patients undergo radiation sessions five days a week for up to seven weeks.

“Oncologists with opposing opinions have been debating that conclusion in letters and editorials in major medical journals, including the Lancet and BMJ. Some critics point out that the study found women who had IORT face twice the risk of a cancer recurrence compared with traditional radiation (3.3% versus 1.3% over five years).”

Doubt Is Raised Over Value of Surgery for Breast Lesion at Earliest Stage

“As many as 60,000 American women each year are told they have a very early stage of breast cancer — Stage 0, as it is commonly known — a possible precursor to what could be a deadly tumor. And almost every one of the women has either a lumpectomy or a mastectomy, and often a double mastectomy, removing a healthy breast as well.

“Yet it now appears that treatment may make no difference in their outcomes. Patients with this condition had close to the same likelihood of dying of breast cancer as women in the general population, and the few who died did so despite treatment, not for lack of it, researchers reported Thursday in JAMA Oncology.

“Their conclusions were based on the most extensive collection of data ever analyzed on the condition, known as ductal carcinoma in situ, or D.C.I.S.: 100,000 women followed for 20 years. The findings are likely to fan debate about whether tens of thousands of patients are undergoing unnecessary and sometimes disfiguring treatments for premalignant conditions that are unlikely to develop into life-threatening cancers.”

Hypofractionation of Breast Radiotherapy Associated With Reduced Acute Toxicity

“In an analysis reported in JAMA Oncology, Jagsi et al found that hypofractionation of whole-breast radiotherapy was associated with reduced acute toxicity compared with conventional fractionation.

“The study involved data on physician-assessed toxic effects and patient-reported outcomes in 2,309 patients who received adjuvant whole-breast radiotherapy after lumpectomy for unilateral breast cancer at Michigan Radiation Oncology Quality Consortium sites from October 2011 through June 2014. Patients had to have a comprehensive physician toxicity evaluation within 1 week of completing radiotherapy and at least 1 weekly evaluation during treatment.”

Lymph Node Radiation May Halt Breast Cancer Recurrences

“Two new studies show promising results for the use of radiation therapy to prevent breast cancer from coming back.

“The research shows that when patients with breast cancer received radiation therapy to their lymph nodes – not just the area of the breast where cancer occurred – cancer did not recur in the original site or spread to other parts of the body. Interestingly, the results were the same regardless of whether the cancer had spread to the lymph nodes.

“A group of Canadian researchers at the Juravinski Cancer Center at Hamilton Health Sciences led a study of more than 1,800 women. In a separate project, researchers at Radboud University Medical Center in the Netherlands studied more than 4,000 European women. Results were published online Wednesday in the New England Journal of Medicine.

“All of the participants had undergone a lumpectomy or a mastectomy. The studies then compared recurrence and survival data between a group of women who received radiation to their lymph nodes against those who did not.”

Short-Course Partial-Breast RT Gets High Marks (CME/CE)

“A week-long course of accelerated partial breast irradiation (APBI) after lumpectomy led to low rates of breast cancer recurrence and a 10-year survival of 96%, investigators in a multi-institutional study reported.

“Patients treated with the interstitial brachytherapy protocol had a 10-year actuarial risk of ipsilateral recurrence of 7.6%, regional failure rate of 2.3%, and distant metastasis rate of 3.8%. High-grade disease at diagnosis and positive surgical margins were the only significant predictors of an increased risk of local recurrence.

“The results compare favorably with those associated with whole-breast irradiation that requires 6 or 7 weeks to complete, Mitchell Kamrava, MD, of the University of California Los Angeles, and co-authors indicated in an article published online in Annals of Surgical Oncology.

” ‘While we await the results of level 1 evidence, these data provide valuable information that 5-day APBI in appropriately selected women can be considered as an alternative to conventional 6- to 7-week external-beam whole-breast irradiation (WBI),’ they concluded.”

Rates of Breast-Conserving Therapy for Early-Stage Breast Cancer Have Increased, Study Finds

“The number of women in the US undergoing breast-conserving therapy following a diagnosis of early-stage breast cancer has risen during the past 2 decades, according to a new study published in JAMA Surgery, though the authors reveal there are still barriers preventing women from receiving the treatment.

“After skin cancer, breast cancer is the most common cancer among American women, estimated to affect around 1 in 8 at some point in their lives.

“The majority of women diagnosed with breast cancer undergo some form of surgery, particularly if the cancer is diagnosed in the early stages. The surgical options available include mastectomy and breast-conserving therapy (BCT), or lumpectomy.

“While mastectomy involves full or partial removal of the breast tissue, BCT involves only the removal of the part of the breast containing the cancer.

“There are pros and cons with each procedure. With a mastectomy, a woman may lose an entire breast, while women who undergo BCT may be able to retain the majority of their breast tissue – making it a preferable option for many. However, women who have BCT often need to undergo radiation therapy for around 5-6 weeks following the surgery to ensure any remaining cancer cells are destroyed.”