Some Women with Early Breast Cancer May Not Need Chemotherapy, Study Says

By Andrew J. Roth and Jim Stallard,

Hear medical oncologist Larry Norton explain results of a trial showing that some women with breast cancer may not need to receive chemotherapy.

Summary

New clinical trial results show that women with intermediate-risk breast cancer treated with endocrine therapy alone fared just as well as those treated with chemotherapy plus endocrine therapy. In light of the findings, medical oncologist Larry Norton says that standard practice should change immediately.

In the past several decades, many advances have been made to develop safer and more precise treatments for breast cancer. Chemotherapy remains a cornerstone of care and has extended survival for countless women. For those with a certain type of breast cancer, the standard treatment has been chemotherapy combined with endocrine therapy (also called hormone therapy).

New results from a clinical trial that began in 2006 show that women with intermediate-risk breast cancer may not need chemotherapy. Joseph Sparano of Montefiore Medical Center presented the data at the 2018 annual meeting of the American Society of Clinical Oncology (ASCO).

Intermediate risk refers to the likelihood that a breast cancer will come back or spread after surgery.

Medical oncologist Diana Lake, the principal investigator for this trial at Memorial Sloan Kettering, says the results support a growing body of research showing no chemotherapy benefit for older women. They also provide guidance for treating younger women with the disease.

The trial evaluated more than 10,000 women whose breast cancer was hormone receptor positive and HER2 negative and whose disease had not spread to lymph nodes in the armpit. After surgery to remove the tumor, patients were randomly assigned to receive either chemotherapy and endocrine therapy or endocrine therapy alone. The study found that chemotherapy did not add to the efficacy of endocrine therapy in intermediate-risk patients, especially those older than 50.

We spoke with breast cancer expert Larry Norton, Senior Vice President at MSK and Medical Director of the Evelyn H. Lauder Breast Center, to learn more about the impact of these results and what’s next for research in this area.

The women in this group are considered to be at intermediate risk. Can you explain what that means and how that determination is made?

Intermediate risk refers to the likelihood that a breast cancer will come back — recur — or spread after surgery. In the United States, recurrence risk is most commonly determined with a genetic test called Oncotype DX®. It looks at 21 genes within a tumor sample, and the score falls on a scale from zero to 100.

About the Oncotype DX® Test
This information explains the Oncotype DX® test and answers frequently asked questions about the test.
Learn more

We have known that women who have a recurrence score of ten or lower should not receive chemotherapy because they have an excellent prognosis with endocrine therapy alone. It’s also understood that those with a score greater than 25 should be treated with chemotherapy along with endocrine therapy because it can significantly reduce the risk of the cancer coming back.

But it has been a big mystery as to how people should be treated when their Oncotype DX score is in the range of 11 to 25. This study sheds light on that question.

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What does this study tell us? What do women with breast cancer need to know?

These study results showed us that patients with an Oncotype DX score of 11 to 25 who were treated with endocrine therapy alone had a very good prognosis. This group doesn’t need to undergo chemotherapy.

Over the years, we have made major advances in reducing the side effects of chemotherapy. We used to have a range of symptoms, including nausea, vomiting, and low blood counts. But today, chemotherapy is not anywhere as tough as it used to be. Nevertheless, it is a treatment that involves some side effects, cost, and time, so it is a huge achievement to learn that we can eliminate it for some people.

It cannot be overlooked that the prognosis is very good for women treated with endocrine therapy alone. Though these results apply to a particular subset of people with breast cancer, it’s still a large group — maybe 100,000 people in the United States alone. This is a very large clinical trial, and it was well conducted and well designed, so I expect it to have an immediate impact on patient care.

Patients with an Oncotype DX score of 11 to 25 who were treated with endocrine therapy alone had a very good prognosis. This group doesn't need to undergo chemotherapy.
Larry Norton
Larry Norton medical oncologist
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What are the next steps for this research?

First, I think we need to go back over the tissue samples from patients and try to understand the situation even more. It is being reported that chemotherapy might benefit women who are younger than 50 and have scores higher than 15, for example. Are there biological differences in younger women at intermediate risk compared with women over 50 who are at intermediate risk?

Further, since chemotherapy provides no additional benefit, what else could we add to endocrine therapy to achieve an even better prognosis for intermediate-risk patients? Could we target specific gene mutations associated with breast cancer, like PI3K? Can we teach the immune system to get rid of cancer cells? These are all research projects that we are involved with here at MSK since our goal is 100% eradication of breast cancer.

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Comments

The dr found a tumor in my bother’s through m. He did a biopsy last Thursday and this coming Thursday we will know what kind of cancer. The dr told that he hoped is treatable. Afternoon the results I want to take him to this cancer center. Can you help me

Dear Irma, we're sorry to hear your brother is going through this. Once he gets the diagnosis from his doctor, if he wants to come to MSK he can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment, and best wishes to you and your family.

I had Breast Cancer in 2008. My onco test showed me to be intermediate. Though my oncologist wanted me to have chemo, I chose not to. I had 5 years of Arimidex & 33 sessions of radiation. Now 10 years later I am still cancer free!

Dear Roberta, we're glad to hear you're doing well. Thank you for sharing your story and best wishes to you!

I had breast cancer ...2011..I am also on Arimedex (7 years now), no chemo, no radiation, NO CANCER!

In a country like india, where doing ONCO type Dx costs apprx 4000 US $, by this money one can complete chemotheray, agreed that if is low risk one can avoid cost and side effects associated with chemotherapy, in less affording class.

I was treated with chemo Surgery and radiation for my ER PR positive stage2B lobular breast cancer in Dubai.I am on Tamoxifen and zoladex. I was diagnosed in 2016 March at the age of 43yr 6 Maths age and finished treatment in November 2016. Had a recent PET and am clear.
Need to take an expert advice as do I need to be on zoladex.wht does the latest evidence say about this .

Dear Tejal, we recommend that you discuss this with your healthcare team. If you are interested in arranging a consultation with an expert at MSK, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment, and best wishes to you.

Is Oncotype DX valid with one positive sentinel node to decide on requirement for chemotherapy in premenopausal woman with grade III tumor of 1.6cm with recurrence score of 20 ? Most of the sites talk abut Oncotype DX with negative node involvement. Thank you.

This is something that should be discussed with the patient's medical team. Thank you for your comment.

I am 74 and had ER+PR+ HR- Cancer Grade2 Stage 1 removed OncoType score 13 and 15 Days Radiotherapy.
I was given Letrozole and on second day within 15 mins of taking medication had violent rash from face down arms back down just below waist. This disappeared after 1 hour but oncologist wants me to stop as he has not seen this before. He feels that Tamozifen will be better for me as does not want me to try other AI tablets. I am pleased but nervous that the outcome may not be as good regarding cancer returning elsewhere with Tamozifine. Am I overthinking this?? Thankyou

Dear Sandy, we're sorry to hear that you had these side effects. If you are interested in speaking with a doctor at MSK about what your treatment options may be, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment and best wishes to you.

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