In a curious paradox, women who experience an improvement from treatment to halt estrogen production or action may later benefit from large doses of estrogen and other hormones. About 60 percent of women with positive estrogen receptor tests will benefit from additive therapy, which usually involves giving diethylstilbestrol (DES). Women who are five or more years postmenopausal seem to have the greatest benefit. Side effects include nausea, vomiting, vaginal bleeding, diarrhea, urinary frequency, fluid retention, bone pain in women with metastases to these sites, and changes in skin pigmentation.
Other hormones that may be administered during additive therapy include androgens, progestins, and corticosteroids. Androgens, which are male hormones, may cause growth of facial and body hair and other signs of masculinization. The type of hormone given depends upon age, site of metastases, and responses to previous antihormone therapies.
Considerations in Breast Cancer Treatment Selection
With so many treatments now available for breast cancer, it is understandable that many women are confused or at a loss to know what is best for them. As emphasized throughout this chapter, there is no single approach to treatment that is best for all women. The matter is further complicated by the fact that even the experts disagree. In some cases it is tempting for a woman to go from doctor to doctor until she finds one who agrees with her preconceived idea of how she would like to be treated. While seeking a second or even a third opinion is justified and even encouraged, there are real hazards to this kind of doctor-shopping. Also, one must be sure that the second opinion comes from a highly qualified physician.
In recent years the National Institutes of Health has sponsored several Consensus Development Conferences, bringing together panels of physicians, researchers, consumers and others to review the data and recommend specific courses of action. The conclusions reached by these panels are summarized in The Breast Cancer Digest, published by the Department of Health and Human Services, as follows:
Consensus Panel of Treatment of Primary Breast Cancer: Management of Local Disease (1979)*
- Total mastectomy with axillary dissection (also known as modified radical mastectomy), a procedure that preserves the pectoral muscle, should be recognized as the current treatment standard for women with Stage I and some women with Stage II breast cancer.
- In most cases, a diagnostic biopsy should be separated from definitive treatment.
- The question of postoperative radiation therapy remains moot pending further results of adjuvant clinical trials.
- Ongoing clinical trials exploring the roles of lesser surgical procedures and primary radiation therapy, because of their exciting preliminary results, warrant support from both patients and physicians.
- Consensus Panel on Steroid Receptors in Breast Cancer (1979) Estrogen receptor assays provide valuable information for making clinical decisions on the type of therapy to be employed, when hormonal therapy is under consideration.
- Every primary tumor should be assayed for estrogen receptor content.
- Estrogen receptor status is a useful prognostic indicator for Stage II (and perhaps other) patients.
- Consensus Panel on Adjuvant Chemotherapy for Breast Cancer (1985)f
- Outside the context of a clinical trial, and based on the research data presented at the 1985 Consensus Development Conference, the following statements can be made:
- For premenopausal women with positive nodes, regardless of hormone receptor status, treatment with established combination chemotherapy should become standard care.
- For premenopausal patients with negative nodes, adjuvant therapy is not generally recommended. For certain high-risk patients in this group, adjuvant chemotherapy should be considered.
- For postmenopausal women with positive nodes and positive hormone receptor levels, tamoxifen (an antiestrogen drug) is the treatment of choice.
- For postmenopausal women with positive nodes and negative hormone receptor levels, chemotherapy may be considered but cannot be recommended as standard practice.
- For postmenopausal women with negative nodes, regardless of hormone receptor levels, there is no indication for routine adjuvant treatment. For certain high-risk patients in this group, adjuvant therapy may be considered.
Treatment options should be discussed fully before a decision is made. The discussions should include the woman and close family members, her primary-care physician, and the specialist(s) who will carry out various aspects of treatment. The physicians should answer all questions in clear, understandable language and make sure the woman knows what is involved at each stage of her treatment.
Although the physicians are obligated to recommend what they consider the best course of treatment for a patient, in the final analysis it is the patient who must decide what is best for her. The more information and understanding that go into the decision, the better for all concerned.