The choice: When is chemotherapy the right treatment for breast cancer?

Treatments are meant to stop disease and help people feel better, but chemotherapy, a common treatment for breast cancer, may make you feel worse before you feel better. Chemotherapy is known for causing side effects, from hair loss to nausea to heart damage to neuropathy, a numbing sensation in the hands and feet. Not everyone experiences all or most of these side effects, but the possibility is enough to worry people diagnosed with cancer.

How doctors recommend who gets chemotherapy has changed in recent years. Treatments like hormonal therapy can allow some to go without chemotherapy. New tests can now estimate certain people’s risk of recurrence and how much chemotherapy could lower that risk. But for many people with breast cancer, chemotherapy is still standard treatment.

Every person with breast cancer faces a choice when the doctor recommends treatment, says Pallav K. Mehta, MD, director of integrative oncology at MD Anderson Cancer Center at Cooper, in Camden, New Jersey. Dr. Mehta is also a member of Living Beyond Breast Cancer’s board of directors. For some people the choice is clear: Chemotherapy is the best chance to stop the recurrence of early-stage breast cancer or the spread of metastatic breast cancer. But others may need to talk about the benefits and side effects of chemotherapy to choose treatment.

The Talk

“Right now, today, I know it was the right thing to do,” Alison Mead of Chilmark, Massachusetts, says about getting chemotherapy. But it is only recently that she has been able to say that with any confidence. Alison was 43 when she was diagnosed with stage I estrogen receptor-positive breast cancer in 2015. Her doctors at Massachusetts General Hospital, in Boston, recommended chemotherapy because the tumor was large and fast-growing, but Alison worried about the side effects.

Alison pushed back. She told her doctors she was uncomfortable getting chemotherapy and she got a second opinion at the Dana-Farber Cancer Institute, also in Boston. In addition, she asked to get the Oncotype DX test, which can estimate how much certain women will benefit from chemotherapy.

“I think from the very beginning I just felt like information was the only thing I could control,” Alison says. “[Breast cancer is] a huge deal and to be comfortable with all of these horrendous decisions you’re making, you want to be really sure.”

‘A sea change’

Doctors look at the features of each breast cancer diagnosis when recommending a course of treatment, says Dr. Mehta. Though there are many factors, some of the first features that doctors consider are your age, your overall health, the cancer’s receptor status and whether lymph nodes — the first places breast cancer is likely to travel — are affected. He says certain types of early-stage breast cancer, such as HER2-positive and triple-negative, will probably need treatment with chemotherapy, as will a cancer that has spread to the lymph nodes. Doctors may also recommend more aggressive treatments like chemotherapy for women who are diagnosed before menopause. But these are not fixed rules, he says, and even if none of these conditions are present in a diagnosis, chemotherapy may be recommended.

In looking at these initial factors, not much has changed over the years. Finding breast cancer in the lymph nodes was one of the first ways doctors decided whether to recommend chemotherapy, Dr. Mehta says. But there are many differences today in the way doctors decide whether to recommend chemotherapy, compared to even a few years ago.

“I would say, without exaggeration, there has been a sea change in how we approach chemotherapy,” Dr. Mehta says.

The Oncotype DX test is one of those major changes. The test looks at the genes of a tumor to estimate the risk of recurrence for a woman with early-stage, hormone receptor-positive breast cancer who takes the hormonal therapy tamoxifen for 5 years, without chemotherapy. The test also tells how likely the woman is to benefit from chemotherapy.

“What was happening before [Oncotype DX] was we were treating a lot of women to benefit a small percentage of them,” Dr. Mehta says.

Doctors wanted to get chemotherapy to everyone who could benefit from the treatment, but there was no way to tell women with cancers that would respond to chemotherapy apart from women with cancers that wouldn’t, he says.

Alison’s Oncotype DX test reinforced what she heard from her doctors at Massachusetts General and the second opinion from Dana-Farber that her best chance to prevent recurrence was to get chemotherapy.

Alison had an Oncotype DX score of 28, an intermediate risk by the existing standard, but combined with what the doctors had already observed, chemotherapy was seen as the best option. Alison was told the pathologist asked why her oncologist would even order the test, saying “She’s young, she’s got an aggressive cancer. Of course she is going to have chemo.”

‘That stuff is pretty serious’

Christine Cave, 50, was diagnosed with hormone receptor-positive breast cancer in August 2014. Though the cancer was stage I, her doctor initially recommended chemotherapy.

The doctor spoke with Christine, who lives in Phoenix, Arizona, about the benefits and the side effects of chemotherapy. Her pathology report and Oncotype DX test results showed how much having chemotherapy would lower her risk for cancer recurrence. The doctor encouraged Christine to take the information home and read it over.

“I didn’t feel like the damage to my body would be worth the lower [risk] of recurrence,” Christine says.

She brought her concerns to her doctor and they talked, eventually deciding treatment without chemotherapy would be best for Christine. She got a lumpectomy, then 7 weeks of radiation therapy. She was on tamoxifen but she had uncomfortable side effects, so she was switched to letrozole (Femara), which she will take for at least 5 years.

“I’m watching my mom have chemo right now and that stuff is pretty serious,” Christine says.

Christine might make other treatment decisions differently if she could choose again, she says, but she is happy she decided against chemotherapy.

 

Treatment by subtype

Being able to target treatment based on a number of factors, including the type of breast cancer a person has, is the other part of the big change in treatment, Dr. Mehta says.

Early-stage breast cancer

If the breast cancer is hormone receptor-positive, hormonal therapy may be used to limit estrogen in the body or change the way the body reacts to it. Some people who get hormonal therapy are also treated with chemotherapy, but not all are. Trastuzumab (Herceptin) is the most widely used targeted therapy in breast cancer. It significantly lowers the otherwise-high recurrence rate of HER2-positive breast cancer. But the medicine is usually given with chemotherapy, not instead of it.

Metastatic breast cancer

People with metastatic, or stage IV, breast cancer will be in active treatment for the rest of their lives. Because of this, managing symptoms and side effects so the person can maintain a good quality of life is very important. Chemotherapy can cause a number of unpleasant side effects, so doctors may look for other treatments that can be less harsh before they recommend it.

If the disease is hormone receptor-positive, Dr. Mehta says doctors try to use hormonal therapy without chemotherapy as long as they can. If the disease is HER2-positive, doctors will likely recommend a HER2-targeted therapy, which may be given with other medicines, including chemotherapy, or on its own.

Triple-negative breast cancer

People with triple-negative breast cancer are more limited in their options for treatment. Chemotherapy is still standard treatment for them, whether they have early-stage or metastatic disease. But researchers are looking for new subtypes, and new medicines that could benefit people with triple-negative breast cancer. Dr. Mehta says it’s especially important for people with metastatic triple-negative breast cancer to consider clinical trials at any point in their treatment to possibly benefit from new medicines not available to the public yet.

Sara Sibley, of Stamford, Connecticut, was diagnosed with stage I breast cancer in October 2013. While testing and treatments have changed the experience for many with breast cancer, Sara had triple-negative breast cancer, the type for which there are no targeted therapies yet.

Like Alison, Sara did not want to get chemotherapy. Her doctors were patient and spoke with her about the reasons they recommended chemotherapy, but her breast surgeon laid it out bluntly: “When you spin the unfortunate breast cancer wheel and land on triple-negative, you receive chemo,” she said. Sara had trouble understanding the different messages from different doctors before her surgeon put it in those direct terms.

Sara struggled with her choice. She got the chemotherapy, but she had such a bad reaction to one of the chemotherapy medicines, paclitaxel (Taxol), that she asked to stop treatment. Her doctors again explained why that would be a bad idea and convinced her to see the treatment through.

Your voice

People should know chemotherapy comes with side effects, Alison says, and it may be unpleasant. Still, it’s important to tell your doctor how the treatment makes you feel. The doctor can tell you which side effects are normal, which can be treated or managed, and why they recommend certain medicines for you.

“I learned that every breast cancer is different,” Alison says. “Every single person has a different situation. My advice would be just focus on your situation and not what your neighbor’s sister had.”

Doctors will provide a recommendation based on the information available in that situation, Dr. Mehta says, but it is not the doctor who makes the decision.

“Patients have a say in this. I think patients sometimes feel [doctors] make the recommendations and that’s that,” says Dr. Mehta. “I think it’s important for them to understand that we give them the pros and cons and make a recommendation, but ultimately the decision is theirs. We just want to make sure it’s an informed decision.”