New breast-cancer approach shortens recovery time
Around the country, many breast-cancer doctors are beginning to make a simple change in the timing of chemotherapy that can produce dramatic results. Instead of giving patients cancer treatment every three weeks, they’re giving the same dose of drugs every two weeks. That means women receive the same total amount of therapy, but they’re finished in just 16 weeks, instead of 24. This “dose-dense” method is also being studied for lung cancer and a type of lymphoma. While the treatment time is shorter, it appears that women live longer. In a 2,000-patient study, 82 percent of the women in the dose-dense group were cancer-free after four years, compared with 75 percent in the three-week group. How much benefit an individual woman gets from the treatment depends on her overall risk of relapse, but for most, the treatment appears to add about five to 10 percentage points to her chances of staying cancer-free.
The method is a long way from being accepted as the standard treatment for breast cancer, but it is increasingly being offered as an option, particularly among doctors on the East Coast. The pivotal study was led by doctors at Memorial Sloan-Kettering Cancer Center in New York, where the treatment now is widely used. At the Mayo Clinic in Rochester, Minn., more than half of breast-cancer patients now receive dose-dense treatment, although it ranges from 20 percent to 80 percent depending on the doctor.
The more-intense therapy is now possible because of new growth drugs that stimulate a patient’s bone marrow to produce infection-fighting white blood cells. Without the drugs, the body needs at least three weeks to recover between treatments, but with them, the body’s immune system can weather the next round of toxic drugs far sooner. Amgen, the Thousand Oaks, Calif., firm that makes the growth drugs, says its audits of chemotherapy practices around the country show that use of dose-dense therapy has increased fivefold in the past six months.
“It has taken hold here,” says Charles L. Loprinzi, professor of medical oncology at Mayo Clinic. “There are still lots of unanswered questions. … But I think it’s appropriate that it ought to be discussed.”
While the method is being widely studied, not everyone is ready to start using it. Despite the shorter overall treatment time, some oncologists think it’s actually far tougher on the patient. In the study, the dose-dense therapy was actually less toxic to blood cells. But doctors say women, nonetheless, appear to feel more fatigued and the growth drugs sometimes cause bone pain. “I always felt the paper that was published underestimated how the women were going to feel,” says Vered Stearns, an oncologist who is studying the method at the Johns Hopkins Kimmel Cancer Center in Baltimore.
Doctors at University of Texas M.D. Anderson Cancer Center in Houston aren’t using the treatment at all, because they’re waiting to see whether the better survival rates continue to hold up over time, says Edgardo Rivera, M.D. Anderson’s head of Breast Medical Oncology. Others wonder whether the intense treatment may produce higher rates of chemo’s long-term side effects – such as leukemia and heart problems – that simply haven’t shown up yet.
But the biggest hindrance to widespread adoption appears to be cost. The usual 24-week chemo regimen costs about $15,000, while the 16-week course with the added growth-factor drugs jumps to about $27,000 to $30,000. Although insurance plans typically pay for the method, doctors and hospitals who treat a large number of uninsured patients – or practices that are under pressure to manage costs – may be less likely to offer it.
Advocates of dose-dense chemotherapy say patients who aren’t being given the option should ask their doctors about it. Currently, the treatment is aimed at women with cancer that has spread to the lymph nodes, but nowhere else. “If it’s a node-positive patient and their doctor hasn’t raised it with them, there’s something wrong,” says Amy Tiersten, associate professor of medicine at New York University and a breast- and ovarian-cancer oncologist. Since the treatment uses standard, proven chemotherapy drugs, she says, it shouldn’t be a big leap for the medical community to embrace it. Patients are “done with the whole rigmarole sooner. … They get back on to their lives in a shorter period of time.”
When doctors suggested 47-year-old New York office manager Emily King consider the shorter treatment, she didn’t hesitate. “To get back two months of my life, that’s a gift,” says Ms. King. “I was just so happy to have it done faster that I didn’t care. I have a six-year-old.”
Ms. King is in the final weeks of treatment, and while it hasn’t been easy, she has managed to continue working, taking just a few days off after each round of chemo.
The method is based on the theory that tumors grow and die according to mathematical patterns. The trick is timing the therapy just right to take advantage of those patterns, allowing the drugs to knock out the maximum amount of cancer possible without taking too much toll on the patient.
Sloan-Kettering doctors are now studying whether a 10-day interval between chemo treatments – cutting the time of treatment to just 80 days – might be the best method for attacking cancer and further lowering the risk of relapse. Larry Norton, head of solid-tumor oncology and senior author of the 2,000-patient study, says his group will soon publish data showing that the added cost of the treatment is worth it.
“Patients are back to work one-third sooner, back to a normal life and that has to be figured into the cost,” says Dr. Norton. “And you’ve got to figure years of life saved – there’s an economic value to being alive.”
AP-ES-10-07-03 1016EDT