Chemo Secrets From a Breast Cancer Survivor

Breast Cancer Survivors

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Despite more than three decades of experience with chemotherapy, no undisputed role for its use has been established. In metastatic disease, the role is purely palliative, but chemotherapy benefits a small minority, and only for a brief duration. Whether the use of multiple agents is more beneficial than the use of single agents alone remains controversial, and until higher and more lasting response rates can be achieved, its widespread use is hard to justify outside the context of clinical trials.

Some cures are possible, however, with the use of concomitant chemotherapy and radiation for advanced, unre-sectable locoregional disease at initial presentation or when recurrent. In this setting, superiority over either palliative chemotherapy or radiation alone has recently been demonstrated in randomized trials, but ideal protocols have yet to be established. In primary resectable disease, there is a definite indication for the use of chemotherapy as a neoadjuvant therapy in organ preservation protocols.

Although not yet standard therapy, induction chemotherapy for organ preservation should at least be considered a standard treatment option. This use is still not widespread, and an answer to the debate over whether the benefits seen can be attributed to radiotherapy alone is still pending. Induction chemotherapy has not achieved the important goal of improved survival. With the current therapies available, the best hope for improved survival is by improving rates of locoregional disease. The greatest promise has been achieved using concomitant chemo- and radiotherapy, with benefits repeatedly demonstrated in both primary and recurrent disease. Whether this approach is superior to neoadjuvant chemotherapy is the subject of ongoing multicenter studies.

The use ofintra-arterial drug delivery also shows promise in the improvement of locoregional control, but whether long-term survival is improved by this approach remains to be established.

A need to control systemic disease and the development of second primary tumors also exists. Success depends not so much on the development of new agents, but on the development of new methods of delivering effective drugs selectively to systemic tumor in such a way that normal tissues are minimally affected. Such targeted systemic therapy will depend on advances in tumor genetics and immunology, which are currently the subject of intensive research.

A final controversy that remains, when success with chemotherapy is achieved, is whether complicated protocols from specialized cancer centers can be made available in settings outside such centers, to benefit larger numbers of patients.


Shannon and Robbins—CHAPTER 9

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