Finding Your Compass

New research and tools illuminate the multiple treatment paths faced by patients with early-stage invasive breast cancer.

One evening about 18 months ago, Debjani Dutta stepped out of the shower, rubbed herself down with moisturizer—and felt a small lump on her right breast. It was a crazy time for the family. Dutta’s boys were 5 and 7. The roof on their home in Fremont, California, needed replacing. She had a meeting early the next morning. And then, she found a lump.

“My heart almost stopped beating,” Dutta says today. “I tell you, that was about the scariest moment of my life.” Dutta, 38, a scientist at Genomic Health, had been working for five years on Oncotype DX, a genetic assay of tumor tissue used to help women, doctors, and researchers understand a breast cancer patient’s risk of recurrence and response to chemotherapy.

“I knew what it could be,” Dutta says. Her mind whirred. Was it cancer? If so, would it be estrogen receptor-positive or negative? What stage? What level of HER2 gene expression? Any positive lymph nodes? How many? The answers, Dutta knew, could dramatically change her prognosis and course of treatment—if it was breast cancer.

It was—stage 1C estrogen receptor-positive, HER2-negative, invasive ductal carcinoma.

Treatment for early-stage breast cancer (stages 1 and 2) has entered a bewildering era, even for experts such as Dutta, with new drugs on the horizon, old drugs under scrutiny for use in particular types of patients, new diagnostics based on tumor genetics, and new treatment regimens.

But with the confusing proliferation of tests and treatment options also comes specificity. Researchers are beginning to learn who will benefit from each treatment option—from chemotherapy and hormonal therapy to more targeted anti-cancer drugs—and who will not.

That’s important, because as more women live for many years after breast cancer, researchers following them are realizing that some cancer treatments themselves carry long-term risks of heart disease and secondary cancers. Why accept those risks if the characteristics of the tumor—or the patient’s own genes—suggest she’s not likely to benefit?

“The goal is to erase the unwanted and unnecessary use of chemotherapy,” says Paul Goss, MD, PhD, director of Breast Cancer Research at Massachusetts General Hospital and a professor at Harvard Medical School. “It’s almost like a teacher punishing the entire class of children instead of finding that one person that whispered. We’ve been punishing the whole class, not knowing who the culprit is. But we are gradually moving toward personalized medicine.”

Clinical trials for new therapies or treatment regimens often begin with high-risk patients or those with more advanced tumors, which makes it difficult for doctors to apply that data to other types of patients and cancers. Several clinical studies evaluating early-stage breast cancer genetics and treatment regimens won’t deliver results for several more years. So for now, controversies emerge as researchers and clinicians try to extrapolate from studies focused on larger tumors to figure out what’s most likely to work best for early-stage patients, and least likely to cause complications.

Talk about this article with other patients, caregivers, and advocates in the Breast Cancer CURE discussion group.
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