Who Benefits from Adjuvant Chemotherapy for Breast Cancer?

In the past, the majority of patients with breast cancer with a tumor size larger than a centimeter received chemotherapy after surgery to prevent relapse.

Today, medical oncologists consider each patient’s particular tumor characteristics to decide whether to follow surgery with chemotherapy — a treatment called adjuvant chemotherapy.

“Over the last 10 years, we’ve tried as much as we can to de-escalate treatment protocols based on data and try to better target those patients who can really benefit from chemotherapy,” said Frances Valdes, M.D., a breast oncologist and assistant professor of medical oncology at Sylvester Comprehensive Cancer Center, part of the University of Miami Miller School of Medicine.

How do oncologists determine whether a breast cancer patient would benefit?

Major factors oncologists consider are the cancer subtype and tumor genomics.

The majority of patients with triple-negative or HER2-positive breast cancer are offered adjuvant chemotherapy, Dr. Valdes says.

For patients with hormone receptor-positive and HER2-negative subtypes, oncologists use additional next-generation sequencing studies to help guide their decisions. Genomic tests can show whether a patient’s breast cancer is likely to benefit or not from chemotherapy.

“Occasionally, we have cases where you may not have thought a patient would benefit, and these special tests end up telling us that we should offer chemotherapy or scenarios where we thought chemotherapy was needed and genomic tests indicate we can spare certain patients chemotherapy,” Dr. Valdes says.

Oncologists also consider the size and grade of the tumor, as well as how many nodes are involved.

What are the benefits and risks of adjuvant chemotherapy?

The main benefit of adjuvant chemotherapy is to decrease the risk of relapse and prevent distant spread, so the patient never has to face breast cancer again, says Dr. Valdes.

Adjuvant chemotherapy for breast cancer takes three to five months on average.

“I think patients can function, work, live their lives and do most of their daily activities, but they’ll be a little more fatigued and somewhat impacted in their day-in and day-out routine for that period,” Dr. Valdes says.

Neuropathy and hair loss are common chemo side effects. Dr. Valdes says she advocates for patients to use cold gloves and socks or booties to help prevent neuropathy and cold caps to reduce the chance of hair loss.

Chemo can cause nausea and vomiting, but Dr. Valdes says anti-nausea treatments have also improved in recent years.

Adjuvant chemotherapy for breast cancer also carries a less than 2% chance of causing a secondary bone marrow disorder, but Dr. Valdes emphasizes that this risk is rare.

What else should patients talk to their oncologists about?

Chemotherapy may cause patients who are premenopausal to go into menopause, so patients who are interested in growing their families should ask about fertility preservation.

Dr. Valdes says patients should talk to their oncologists more in-depth about treatment options if they have triple-negative or HER2-positive breast cancer.

Patients with triple-negative breast cancer should ask about considering chemotherapy before surgery — called neoadjuvant chemotherapy — so they can also receive immunotherapy, she says.

What medicines are delivered during adjuvant chemotherapy?

Patients who need adjuvant chemotherapy for breast cancer typically receive a well-established “backbone” of drugs.

“Frankly, it’s nice to know that what we’ve used in the past is still effective,” says Dr. Valdes.

However, oncologists also look for opportunities to de-escalate treatment, for example, by using two drugs instead of three.

Some chemotherapy regimens for breast cancer use doxorubicin, nicknamed “red devil” for its color and side effects, or HER2-targeted agents, which can impact heart function. Dr. Valdes said patients who receive these drugs should talk to their doctors about strategies to help protect their heart.

How is breast cancer treatment continuing to evolve?

Breast cancer researchers at Sylvester and around the world are studying more ways to customize treatment for each patient.

The OFSET clinical trial is a national effort to “answer a very important question about whether lower- or intermediate-risk patients with premenopausal breast cancer really need chemotherapy,” says Dr. Valdes, who is the institutional primary investigator for this study at Sylvester. The trial is specifically for patients with hormone receptor-positive and HER2-negative breast cancer.

Patients at Sylvester will soon be able to enroll in the national I-SPY clinical trial, which studies which drugs are most effective for different types of breast cancer to develop more patient-directed and personalized treatments.

Patients can schedule an appointment with a breast medical oncologist at Sylvester if they want to be considered for clinical trials. Call 1-844-324-HOPE (4673) to schedule an appointment.

“We are trying to personalize treatment approaches, targeting therapies to a particular individual and their particular cancer, which is important to ensure cures and to minimize toxicities,” Dr. Valdes says. “One size doesn’t fit all.”

By Tara Roberts, contributor for Sylvester Comprehensive Cancer Center

Tags: Breast cancer treatment options, Dr. Frances Valdes, Personalized cancer care, Triple-negative breast cancer, Tumor genomics