adjuvant therapy for young women

[loub]

I'm writing on behalf of my wife, she is 32 yrs. old, premenopausal, and being treated (lumpectomy and radiation to come) for invasive ductal carcinoma, she is node negative, 1.5 mm tumour, low/moderate grade tumour, er+, pr+, no family history of breast/ovarian cancer but a personal history of thyroid cancer.  Although our oncologist generally treats young women more aggressively my wife's tumour is so small he has recommended no further systemic treatment and believes her risk for recurrence to be about 5%.  We understand that in the context of risk vs benefit chemotherapy in my wife's case doesn't make sense, but he doesn't really recommend tamoxifen either.  Most of the benefit she would derive would be from a reduction of risk of contralateral disease, and tamoxifen as prevention seems a little more complicated.  How long do you take it, more than 5 years?  When do you stop receiving a benefit?  If you only take it for 5 years, which 5 years do you choose, the riskiest ones (later on in life)?  Do you add medication to suppress ovarian function?  Is it possible to spawn a tamoxifen "resistance", so that if a recurrence or new primary came up it would be er-?   If tamoxifen is not recommended for my wife, and she is at a high risk for contralateral disease, whom would it be recommended for?  What are your thoughts on tamoxifen for reducing risk in someone like my wife?  Any insight would be of great help to us at this anxious time.

[CCF-RN,MSN-JS]

Dear Lou, Stage 1 disease is a tumor that is 2cm or less in size, without any evidence of spread to nearby lymph nodes or distant sites.  For many years it was not customary to treat Stage I breast cancer with chemotherapy or hormone therapy.  Recent trials suggest that Stage I patients will benefit from adjuvant therapy.  (Adjuvant treatment is treatment given after surgery to try to prevent or minimize the growth of microscopic deposits of tumor cells that might grow into a recurrent tumor).

Two large trials by the National Surgical Adjuvant Breast Project (NSABP) showed significant reduction in recurrences in the opposite breast at four-year follow-up for estrogen-receptor-negative patients given chemotherapy and for estrogen-receptor-positive patients treated with tamoxifen.  Although there is early benefit for adjuvant treatment in patients with negative nodes, studies are continuing to see if there will be an improvement in survival.  Adjuvant therapy usually begins four to six weeks after surgery. In terms of duration of tamoxifen therapy, 5 years of therapy is the standard of care.  At present the available data support stopping tamoxifen at 5 years.

At this time the recommendation is that women with invasive breast cancer who have positive lymph nodes or tumors greater that 1cm with positive hormone receptors should receive adjuvant tamoxifen for a period of 5years.  For women with small tumors < 2 cm and negative lymph nodes, the risk of systemic recurrence is relatively low, and decisions about tamoxifen need to be considered carefully.  For the majority of such women, the benefits of tamoxifen probably outweigh the risks.  The decision whether or not to take tamoxifen needs to be made after careful discussion of the risks and benefits with your wife’s oncologist, specific to your wife’s situation.