Breast cancer is in transition-from an acute disease that killed quickly to a chronic disease that can be managed, much like diabetes or heart disease.
Today's longer survival rates have come about using mostly "old-fashioned" drugs. With the recent emergence of more targeted "smart" drugs, the outlook is for even greater emphasis on maintenance treatment, meaning ever greater pharmacy involvement, from community to hospital to specialty pharmacists.
Treatment by stages
For early-stage breast cancer, the current standard treatment is breast conservation surgery. "We remove only the tumor itself, a procedure called lumpectomy or segmentec-tomy. And then we radiate around that," Luu said. For most women with stage I or II breast cancer, breast conservation therapy is as effective as mastectomy in terms of putting off local recurrence.
About 15% of women with breast cancer are not candidates for breast conservation, so mastectomy is their only surgical option, according to Cynthia Drogula, M.D., medical director and breast surgeon at Baltimore Washington Medical Center. "The reasons a woman might need a mastectomy include: a very large tumor in a smallish breast; multifocal disease-tumors in more than one location in the same breast; inability to get clear surgical margins; or contraindications to adjuvant radiation therapy." (A surgical margin is healthy tissue around the tumor removed for examination.) Also, she said, some women who actually are candidates for lumpectomy choose to have a mastectomy for personal reasons.
What oncologists worry about, Luu said, is distant recurrence, or the cancer returning in other parts of the body. About two-thirds of the recurrences are distant. "That's why we introduce adjuvant drug therapy." Three different categories of drugs are considered for adjuvant therapy: chemotherapeutic, hormonal, and targeted.
In most cases, adjuvant therapy works best when combinations of drugs are used together. While studies have shown which combinations are most effective, decisions about specific drugs for any given patient will depend upon prognostic factors, the woman's menopausal status, her general health and personal preference, ongoing clinical trials, and the medical center providing treatment. "Best" drug combinations also continue to change with new drug approvals and research findings.
Luu explained some of these changes and options for chemotherapy: "In the 1970s and 1980s we did CMF-cyclophosphamide, methotrexate, and 5-fluorouracil (5-FU). In the '80s we moved to doxorubicin, which is an anthracycline, and cyclophosphamide. Then during the '90s we introduced the taxanes-paclitaxel or Taxotere (docetaxel, Sanofi-Aventis) on top of Adriamycin/Cytoxan [AC]."