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VAREN BLACK: Hi, I'm Varen Black, and welcome to our webcast.
When a woman is first diagnosed with breast cancer, the main goal on her mind is to remove the tumor as quickly as possible. But equally important is what's called "adjuvant therapy," which is used to catch cancer that may have spread to other parts of the body.
Now, joining me to discuss this therapy -- and its importance -- is Dr. William Gradishar, director of breast medical oncology at Northwestern Memorial Hospital. Thank you, doctor, for being with us today.
WILLIAM GRADISHAR, MD: I'm happy to be here.
VAREN BLACK: Doctor, let's start with the role of adjuvant therapy in the management of breast cancer. First of all, let's define "adjuvant therapy."
WILLIAM GRADISHAR, MD: Adjuvant therapy is a form of treatment that follows what we think of as the definitive first-line therapy. So in the case of breast cancer, it's typically removal of the primary breast cancer. And that can take the form of either a lumpectomy or a mastectomy.
And the intention of adjuvant therapy, then, is to follow that in an effort to eradicate microscopic disease that the surgeon isn't able to see or remove. Systemic therapy -- that goes everywhere -- could take the form of chemotherapy -- which is drug therapy that goes through the blood. It could be hormone therapy, which is taken by mouth but then absorbed into the blood and goes everywhere. And the intention, again, is to try and eradicate microscopic disease that might have gotten away from the primary breast tumor.
And then, finally, it should be mentioned that adjuvant therapy can also take the form of radiation therapy. So if a woman has a lumpectomy, and has preserved her breast, radiation therapy is meant to eradicate any microscopic disease that might still remain in the breast.
VAREN BLACK: Doctor, I understand that there are different types. What are they, and can you briefly explain them to us?
WILLIAM GRADISHAR, MD: There are different types of adjuvant therapy. If we focus first on chemotherapy -- again, as I indicated earlier, chemotherapy is drug therapy either given as a single agent or sometimes in combination, sort of a recipe.
And when we use the drugs in combination we often abbreviate the combinations according to the names of the drug. So for instance, CMF, CEF, CAF or AC, the initials stand for the names of the drug. So in the case of CAF, it's cyclophosphamide adriamycin 5FU. The "E" in CEF is epirubicin, etc.
And, again, those have been regimens -- or recipes -- that have been developed after undergoing a large clinical trial development where patients who were very similar were all treated with that recipe versus another or nothing. And it was determined that it did offer an advantage in terms of reducing the risk of the disease coming back, and it did improve survival.
So as a consequence of that, these recipes became what we view as standard options for women with early-stage breast cancer. CMF, CAF, AC, CEF, AC followed by a taxane are all reasonable options that are available to patients -- if they're appropriate to receive adjuvant therapy.
VAREN BLACK: Doctor, some women may have heard of Herceptin. Now, what is it's role in breast cancer therapy?
WILLIAM GRADISHAR, MD: Herceptin is actually a relatively new drug. It was developed as a so-called "targeted" therapy. It's actually an anti-body that's directed towards a particular target that some breast cancers express. Referred to as "HER-2," "H-E-R-2." And if a breast cancer expresses that so-called "target," then Herceptin could be considered.
Where Herceptin has been established as an appropriate treatment is in patients with advanced disease. In other words, metastatic disease. And in a small fraction of those patients, you can actually cause tumor regression when Herceptin is administered.
In the adjuvant setting -- which is sort of the theme today -- Herceptin is not yet an established component of our treatment approach. It's being studied, though.
VAREN BLACK: Will all patients with breast cancer need adjuvant therapy?
WILLIAM GRADISHAR, MD: What we do when we evaluate a new patient with breast cancer is we try and judge what her risk of recurrence is. And that judgment is based on the size of tumor, the number of lymph nodes that are present, the age of the patient, whether the patient has a tumor that expresses hormone receptors. And all of those pieces of information go into our sort of mental equation, trying to define what the risk in the future is that this patient might develop a recurrence of her disease. And if we feel that -- based on those factors -- she is at a high-enough risk for recurrence, then we would typically recommend that she receive adjuvant therapy.
And as an example, a woman who has a tumor less than a centimeter in size and the nodes are negative, we would typically say that that woman -- as a routine or standard -- would not receive adjuvant therapy, because the side effects would outweigh any potential benefit. Whereas a woman that has multiple positive lymph nodes containing cancer, her risk of recurrence is so high that we know from clinical trials that she would derive benefit from getting chemotherapy. One of the regimens that I -- or recipes that I described.
One other thing that is worthy of mention is although adjuvant therapy can take the form of chemotherapy, if a woman has a hormone receptor-positive tumor -- this estrogen-progesterone-positive tumor -- then in addition, or in lieu of chemotherapy, tamoxifen -- an endocrine therapy -- could be considered as well.
VAREN BLACK: And how long should a patient undergo adjuvant therapy?
WILLIAM GRADISHAR, MD: The standard duration of adjuvant chemotherapy is between three and six months, and that's generally based on the recipe that's selected. So therapy, for instance, with ACH or mycin and Cytoxan can be as short as four treatments administered over a twelve-week period, compared to other recipes that require six-months' duration. In the past, durations longer than six months have not shown to be providing additional benefit, so we've really arrived at a standard between three and six months.
If we were talking about adjuvant endocrine therapy -- in other words, a drug like tamoxifen. If a woman is appropriate for that therapy, the standard duration is a daily pill for five years.
VAREN BLACK: Now, is this therapy ever given before surgery?
WILLIAM GRADISHAR, MD: Therapy can be administered prior to surgery in a couple of different circumstances. One is if the disease still appears to restricted to the breast but the tumor is large enough where a lumpectomy wouldn't result in a good cosmetic outcome, we will sometimes give either chemotherapy or -- in some situations -- endocrine therapy, in an effort to shrink the tumor so that a lumpectomy could be performed and the woman can preserve her breast.
The other situation is where the tumor within the breast is either inflamed or it's really a very large tumor. And even though the woman is ultimately going to have a mastectomy, giving the therapy prior to surgery makes the surgery technically more feasible.
VAREN BLACK: Now, doctor, do you have any final thoughts on this therapy?
WILLIAM GRADISHAR, MD: I would encourage women to consider all of their options when they speak to their physician about options for adjuvant therapy. And the options include standard therapies -- which we discussed today -- but it also may include clinical trials. And some of the clinical trials that are ongoing are looking at new treatment strategies that could include drugs like Herceptin as well as newer therapies. And these may ultimately be the kinds of therapies that truly do reduce the risk of breast cancer ever coming back again. So I think that is always an options for patients with early-stage disease, and one that we strongly encourage patients to consider.
VAREN BLACK: Well, it sounds very promising.
WILLIAM GRADISHAR, MD: It is. There are many new therapies. There are more new therapies today compared to ten years ago, that we're evaluating. So we're really in an incredible period when the biology and the molecular biology is caught up to the clinic. And they're merging now so that we have all of these new treatment options available to patients.
VAREN BLACK: Well, thank you Dr. Gradishar, for this important information. And thank you for joining us on our webcast. I'm Varen Black.
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