Stage 0 Breast Cancer: When Should You Wait and See?

“In cancer, as in other areas of medicine, early detection can save lives. But the screening tests used to find early tumors also detect disease that would never cause problems – disease you’ll die with but not from. Managing those cases means giving potentially harmful treatment to patients who won’t benefit.

“DCIS, or ductal carcinoma in situ, is the poster child of this dilemma. Before routine mammograms, only about 1 percent of U.S. breast cancer cases were DCIS. Now nearly 65,000 women a year – about 22 percent of those with breast cancer – are diagnosed with DCIS.

“DCIS, also known as Stage 0 breast cancer, is not life-threatening, and not all cases will progress to invasive cancer. But because there is no reliable way to determine which ones will, nearly all DCIS is surgically removed with a lumpectomy or mastectomy (and sometimes the healthy breast is removed prophylactically). Most DCIS patients also are offered radiation and drugs.”


Early Stage Breast Cancer May Not Require Chemo

“Researchers report in the New England Journal of Medicine (NEJM) the strongest evidence yet that some women with early stage breast tumors may not need chemotherapy to effectively treat their cancer. For some women, hormone-based anti-tumor drugs may be all they need to enjoy 98% survival at five years and a 93.8% chance of being free of invasive breast cancer in that time as well.

“The key to identifying these women lies with a gene-based test called Oncotype Dx, which scans 21 genes in the tumor to create a dossier of the tumor’s strengths and weaknesses. The information helps doctors to determine how potentially aggressive, or not, a tumor might be. Allowed on the market as a clinical laboratory test in 2004, it produces a recurrence score from 0 to 100 and helps doctors determine whether women should be treated with chemotherapy. Lower scores generally indicate that hormone-based drug therapies are enough, while higher recurrence scores push physicians to consider chemotherapy to lower the risk of the cancer returning.”


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.”


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.”


Surgery Doesn't Help Women With Early-Stage Breast Carcinoma

“What to do about the non-invasive breast lesions called ductal carcinoma in situ, or ‘stage zero’ cancer, is one of the hottest debates in breast cancer care.

“Because of more widespread screening, more and more women are being diagnosed with DCIS. The condition now makes up 20 percent of new breast cancer cases, according to the American Cancer Society.

“DCIS doesn’t always progress to invasive breast cancer, which is the life-threatening kind. In fact, some physicians and researchers, including a working group convened by the National Cancer Institute, say it’s not accurate to call DCIS a form of cancer at all, and that the terminology is contributing to overly aggressive treatment.”


One in Five Women with Breast Cancer Don't Know About Test Results That Might Help Them Avoid Chemo

“Although 90 percent of women with early-stage breast cancer said they were aware they took a genomic test that identified their level of risk for a recurrence of the disease, one in five didn’t know the results of that analysis, according to a new fact sheet by the UCLA Center for Health Policy Research.

“The test, called gene expression profiling, or GEP, is used by physicians to help guide treatment decisions and can potentially help people avoid unnecessary chemotherapy. One of a number of emerging ‘precision medicine’ genomic technologies, the GEP estimates the activity of specific genes in breast cancer cells, which can help predict whether there is a greater chance for breast cancer to return. Those with a high risk for cancer growth benefit by having chemotherapy as part of their treatment, the authors write, but chemo has no added value for those with a low risk.”


UCSF-led Study Shows Oncotype DX and MRI May Provide Independent Information in Favorable Risk Prostate Cancer

“Genomic Health, Inc. (Nasdaq: GHDX) today announced results from a study led by the University of California, San Francisco (UCSF) showing a broad distribution of Oncotype DX® Genomic Prostate Score (GPS) results among prostate MRI findings, suggesting that these two technologies may provide non-overlapping clinical information in men with localized prostate cancer.

” ‘For the first time, we looked at the association between information provided by a genomic assay and a prostate MRI to better understand the value these two technologies bring to clinical practice,’ said Michael Leapman, M.D., lead investigator from UCSF. ‘These new data show that, in some patients, further risk stratification may be possible, and tools such as GPS may add important biological information to more precisely assess the aggressiveness of a patient’s cancer.’

“In this study, researchers conducted a retrospective evaluation of the statistical association between the Oncotype DX GPS results and contributing gene groups with baseline endorectal MRI in 100 patients with clinically localized prostate cancer. The results showed a large variation of GPS results across MRI findings, demonstrating that Oncotype DX and MRI offer non-overlapping clinical insights in patients with early-stage prostate cancer.”


Oncologist Recs Plus Motivation Package Increases Exercise

“For breast and colorectal cancer survivors, the level of exercise participation is significantly increased for those receiving an oncologist’s exercise recommendations with an exercise motivation package, according to a study published online May 12 in Cancer.

“Ji-Hye Park, Ph.D., from Yonsei University in Seoul, South Korea, and colleagues recruited 162 survivors of early-stage breast and colorectal cancer who completed primary and adjuvant treatments. Participants were randomized into three groups: control (59 patients); oncologist’s exercise recommendations (53 patients); and oncologist’s exercise recommendations with an exercise motivation package (50 patients). The level of exercise participation and quality of life were assessed at baseline and at four weeks.

“The researchers found that 80.2 percent of the participants completed the trial. Participants who received an oncologist’s exercise recommendation with an exercise motivation package significantly increased their level of exercise participation compared with controls in intention-to-treat analysis (47.57 added minutes per week [P = 0.022] and 4.14 additional Metabolic Equivalent of Task-hours per week [P = 0.004]). No increase in exercise participation level was seen for participants who received only their oncologist’s exercise recommendations. Participants who received an oncologist’s exercise recommendation with an exercise motivation package had significantly improved role functioning.”


High TIL Levels Predict Positive Outcomes in HER-2–Positive Breast Cancer

“High levels of tumor-infiltrating lymphocytes served as an independent positive predictive marker for EFS and pathological complete response in HER-2–positive early breast cancer treated with chemotherapy and anti-HER–2 agents, according a secondary analysis of the NeoALTTO trial.

“ ‘Increasingly, oncogenic addiction, in which tumors become dependent on a sole oncogenic pathway for growth, is thought to promote a tumor microenvironment conducive to immune escape,’ Sherene Loi, MD, PhD, of the Peter MacCallum Cancer Centre at the University of Melbourne, and colleagues wrote. ‘Although this had not been shown yet for HER-2 oncogenic signaling, one could speculate that anti-HER–2 therapy may not only work in a cell-intrinsic manner but may also reserve HER-2–induced immunosuppression as a mechanism for action.’

“The NeoALTTO trial included 455 women with HER-2–positive early-stage breast cancer between 2008 and 2010. The researchers randomly assigned patients to neoadjuvant treatment with trastuzumab (Herceptin, Genentech), lapatinib (Tykerb, GlaxoSmithKline) or both.

“Patients received the initial treatment for 6 weeks, followed by weekly paclitaxel for 12 weeks and three treatment cycles of fluorouracil, epirubicin and cyclophosphamide after surgery.”