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 Breast

Clinical Breast Cancer Program
Treatments & Surgical Procedures  Chemotherapy & Radiation


Adjuvant Breast Cancer Treatment

Mortality rates for breast cancer have declined steadily in the U.S. since 1990, resulting in an improvement in survival. The reasons for this shift include mammographic screening, adjuvant hormonal therapy, adjuvant chemotherapy, post-lumpectomy radiation, and expansion of the guidelines for adjuvant chemotherapy to include its use in patients at earlier stages of the disease.

Chemotherapy or hormonal therapies may be used as sole treatments, or they may be used in conjunction with other therapies for other patients. Adjuvant therapy is the use of these drugs after surgery to prevent the growth of cancer cells that may remain in the breast. Studies have shown that by eradicating cancer cells that remain in the breast after surgery or radiation, the use of adjuvant chemotherapy or adjuvant hormonal therapy significantly increases women's chances of long-term survival.

Hormonal therapy

The increase in breast cancer survival is largely due to the benefits of hormonal therapy, such as tamoxifen and aromatase inhibitors (AIs), for the treatment of hormone-sensitive breast cancer. These systemic agents work to either block estrogen from stimulating the cancer cell (tamoxifen), or by reducing the amount of estrogen produced in the body (AIs).

Recent clinical trials have demonstrated that AIs are more effective than tamoxifen at reducing breast cancer recurrences in post-menopausal women, but for pre-menopausal women, tamoxifen is the treatment of choice. Many patients treated at Columbia University Medical Center have participated in national clinical trials to study these treatments and to better understand the optimal duration of their use.

Chemotherapy

Chemotherapy is systemic drug therapy given either in pills or intravenously. By interfering with the ability of cancer cells to split and grow in the body, chemotherapy can help to shrink the size of existing tumors and can help prevent recurrences in patients who have had cancer.

Professional guidelines dating back to the early 1990's recommend that chemotherapy be considered for all women with invasive breast cancer, especially those with positive lymph nodes or estrogen receptor (ER) negative tumors. Despite its ability to help prevent recurrences among women with early stage breast cancer, it is not appropriate for every patient. Determining who should receive chemotherapy is a complex question that involves many factors.

The Comprehensive Breast Cancer currently uses many tools to guide such treatment decisions. A series of tests helps to gauge each patient's risk based on the size of her tumor, its grade (how aggressive it is), whether or not it has spread to lymph nodes, and whether the tumor is hormone-receptor positive or not.

Among the more recent tools available is a test to assess tumors for the expression of genes that are associated with risk of developing breast cancer recurrence in women who have traditionally been seen as low risk, particularly patients with hormone receptor positive, lymph node negative breast cancer. Studies have shown that based upon the expression patterns of these genes, some patients are more likely to experience breast cancer recurrences. Combined with evaluation of the other characteristics above, the profile of gene expression gives a more accurate assessment of a patient's risk of having recurrent cancer. Patients at Columbia are now being offered the opportunity to participate in national clinical trials to determine the efficacy of using risk profiles to predict benefits from chemotherapy in addition to hormonal therapy. Appropriate candidates may also participate in trials evaluating the newest chemotherapy treatments for early stage breast cancer. As an academic institution, Columbia University is committed to continually developing and improving treatments for breast cancer through research. The Clinical Breast Cancer Program is currently leading and participating in studies of many agents to treat different stages of breast cancer.

Columbia's efforts to advance breast cancer treatment include testing novel therapeutic agents to target cancer cells. At this time, the Breast Program's research team is studying chemotherapy in combination with drugs such as vorinostat, Avastin, Herceptin, Zarnestra, and others. In addition, we are studying many drugs in early stages of development to evaluate their potential for the treatment of breast cancer.

Although estrogen- and progesterone-receptor-positive disease can be controlled with hormones for months to a few years, receptor-negative tumors are treated with chemotherapy with a median duration of response of about a year and a median survival of 2 years. Patients should consider participation in a clinical trial if breast cancer recurs particularly when the disease spreads to other organs. However, patients whose tumors have not shrunk when treated with conventional therapy are seldom good candidates for new therapies. A history of breast cancer is often considered a contraindication for the use of oral contraceptives or estrogen replacement therapy, although these issues have never been rigorously tested.

Accelerated Partial Breast Irradiation

Accelerated Partial Breast Irradiation
This figure shows the three-dimensional conformal radiation therapy (3D-CRT) APBI technique. This noninvasive method of delivering APBI uses multiple beams arranged to assure the optimal dose to the lumpectomy cavity while minimizing acute and chronic toxicity.

After undergoing a lumpectomy to remove the part of the breast affected by breast cancer, most women must undergo radiation therapy treatments to eliminate microscopic cancer cells that might remain undetected by clinical examination or breast imaging. The standard course of breast irradiation delivers radiation to the entire breast, and consists of six to seven weeks of therapy given five days a week.

Accelerated partial breast irradiation, or APBI, is a new form of radiation therapy that is under investigation for preventing recurrences in women who have undergone surgery for breast cancer. By focusing the radiation treatment to the cavity where the cancer was removed from the breast (rather than to the entire breast), APBI may be able to shorten the course of radiation from six or seven weeks to just one week.

APBI is delivered directly to the cavity from which the breast cancer was removed, and at much higher daily dose compared to that used during the standard whole breast radiation therapy course. Because the cumulative amount of radiation given during one week of high dose APBI is approximately equal to that delivered during 6-7 weeks of standard daily low dose irradiation therapy, it is believed that the two methods may be equally effective overall at decreasing the risk of recurrence at the lumpectomy cavity.


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