Cutting down on treatment

A new US clinical trial aims to shorten treatment from more than seven months to seven weeks for women with early stage breast cancer

WHEN RHONDA Bautista Grenier learned she had breast cancer at age 42, she faced not only a terrifying diagnosis but the daunting logistics of treatment. How could she tackle a gruelling schedule of chemotherapy and radiation, full of painful side effects and hours spent away from three teenagers and a full-time job?

Grenier learned of a new clinical trial at Johns Hopkins Kimmel Cancer Center that promised to shorten treatment from more than seven months to as little as seven weeks for women who had been diagnosed with early stage breast cancer.

Instead of treating the cancer first with months of chemotherapy, then weeks more of radiation, patients received chemotherapy and radiation at the same time. The radiation treatments were significantly shortened by delivering higher doses to just a portion of the breast.

Combining chemotherapy and radiation treatments was once unheard of in breast cancer treatment, because it posed a high risk of toxicity, resulting in painful, disfiguring burns.

But with the experimental treatment at Hopkins showing promising results – fewer side effects, less toxicity and increased convenience for patients – Grenier decided to go for it.

“The C-word alone is devastating, then you have to decide how you’re going to attack this thing,” says Grenier, now 46. “The way I looked at it, this new trial was attacking the cancer from both angles at the same time. I was really scared, but it sounded logical to me.”

As new technologies enable specialists to detect breast cancer earlier, researchers are searching for ways to treat the disease faster, in shorter intervals and with greater precision.

A clinical trial in Canada last year found that giving women three weeks of radiation to their entire breast worked just as well as the standard five or more. Another huge national trial is under way, testing whether giving high doses of radiation to just a portion of the breast is as effective as treating the entire breast.

And still other researchers are experimenting with hi-tech tools that administer radiation in specialised ways. One, known as MammoSite, is a small balloon connected to a tube that is placed in the breast for several days. Radiation is given through the tube and the balloon is removed a few days later when treatment is completed.

At University of Maryland Medical Center, researchers have received funding from the National Institutes of Health to develop a device that delivers high doses of radiation to small areas. Their hope is that one day women may never need to go under the knife to have their cancers treated – and cured.

For many women, a cancer diagnosis comes at the most productive part of their lives as they juggle the demands of work and family life. It means getting time off work for treatments, finding a babysitter and adding something scary and exhausting to already chaotic schedules.

“Coming in on a daily basis for radiation is tiresome. Shortening that treatment – that’s something that makes a great deal of difference to them,” says Dr Eric Winer, director of the Breast Oncology Center at the Dana-Farber Cancer Institute in Boston.

Shortening treatment is not just about improving quality of life; it has practical implications, he says. Some women don’t show up for their treatments because it takes too long, they have to travel too far or they can’t get time off work. Shorter courses mean being able to deliver treatment to more people, he says.

Reducing the course of radiation also means limiting radiation exposure to other areas of the body – such as the lungs, ribs and even the heart, says Dr Richard Zellars, assistant professor of radiation oncology at Hopkins who is heading the trial.

Not everyone is convinced such techniques will prove successful – and safe – in the long run.

It can take more than a decade for side effects to appear, says Dr Nicole Simone, assistant clinical investigator for the radiation oncology branch of the National Cancer Institute. This could be especially true of the Hopkins trial, in which chemotherapy and radiation are combined, she says.

“This could be phenomenal for the patients not to spend so much time trying to eradicate their disease,” Dr Simone says, “but I would worry with this particular trial, that there would be more long-term toxicity: increased skin pigmentation, blood vessels more apparent on the skin and lymphedema – swelling of the arm.”

Dr William F. Regine, chief of radiation oncology at University of Maryland Medical Center, says combining chemotherapy with radiation can pose more risks than advantages. Other experiments are treating women with radiation for just one week.

“I think adding chemo would make injury more severe,” he says. “Some people would say, great, let’s do it all at once – but we need to ask, was it really worth exposing them to this, when we can give just a week of radiation?”

Zellars began his trial in 2004, and 30 women have participated. When he pitched the idea to Hopkins’ Institutional Review Board – which must approve and monitor trials – one member was so aghast that she screamed at him, Zellars says.

Prior studies had shown that combining radiation and chemotherapy caused burns as severe as third degree, and researchers abandoned the idea. But those studies had treated the entire breast with radiation. If radiation beams are used to give a very targeted dose, the side effects would decrease, Zellars reasons.

So far, preliminary findings, published this summer in the Journal of Clinical Oncology, have indicated that to be true.

Women showed fewer side effects than with standard treatment – 80 per cent had skin redness from the radiation, but not severe burning as some had feared, and 20 per cent had no visible burns. Other side effects include what is typical of cancer treatments – fatigue from radiation, and nausea and vomiting from chemo. “They’re doing fantastically well,” he says of the study’s participants.

Grenier, who has gone three years since her last chemotherapy treatment, says a recent mammogram showed no signs of cancer. There were some side effects during treatment, she says, “but it wasn’t so bad in the long run. I would hear these horrible stories from other women and I just couldn’t relate. I started to feel a little guilty, actually.”