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Clinical trials and research are pointing to a new trend in cancer treatment: individualized care. Chemotherapy is no different. As advances are made, the goal is to allow doctors the ability to know who needs treatment and what treatments will benefit the patient based on their genetic makeup.

“Individual care really is where things are going and where the real challenges are,” according to Samuel Shelanski, M.D., oncologist with Greeley Medical Clinic, based at McKee Medical Center in Loveland. This is due to new technology that has allowed doctors to narrow down mutations in genes that affect the success of many treatments.

“Instead of taking a shotgun approach to treating cancer, we are narrowing down certain patients that won’t respond well to certain drugs,” he says, “we are moving away from disease-specific treatment to patient-specific treatment with a molecular diagnosis of the disease. This will lead to more effective treatment and a better ability to identify people who need to be treated. Today, many are being treated ineffectively.”

In breast cancer specifically, certain types have long been known to be more receptive to hormone treatment than chemotherapy and vice versa. Breast cancers that are estrogen and progesterone receptor-positive often respond well to hormone therapies and typically have a better prognosis. These therapies generally block estrogen from the receptors. But some of these cancers should still be treated with chemotherapy. The trick is figuring out which cancers need chemo, and which can be treated with hormonal therapies.

A genomic test, called Oncotype DX, which follows American Society of Clinical Oncology and National Comprehensive Cancer Network guidelines, can provide this information. “This is one way for us to identify if a tumor is low, moderate, or high risk in a patient,” says Regina Brown, M.D., oncologist with Cancer Center of the Rockies.

Hormone receptor-negative breast cancer can be trickier to treat. Generally, this cancer is treated with a chemotherapy regimen. In addition, 20 to 30 percent of breast cancers make too much of the protein HER2, leading to the increased growth of cancer cells. These cancers used to have a worse prognosis, but medicine that specifically targets the HER2-positive cells has improved outcomes, which has created a standard of accurately measuring all breast cancer’s HER2 status prior to treatment.

Regina Brown, M.D., Cancer Center of the Rockies

“How we think about cancer is changing as we know more about each individual tumor and how it may respond to different therapies based on those characteristics,” says Dr. Brown. “Tailoring therapy based on the individual is where we want to go. There are so many different factors in breast cancer. One size [treatment] does not fit all.”

“I am a big proponent of clinical trials,” she adds, “This is how our field advances.” Dr. Brown calls the job oncologists do as “mop up duty. We make sure the things you can’t see never have the opportunity to be seen. And that is always evolving because of the clinical trials.”

A clinical trial can take years to complete, but can, at times, revolutionize the way oncologist treat their patients. One such ongoing trial is the investigation into the chemotherapy drug Adriamycin. The study, according to Dr. Shelanski, will determine just how effective this mainstay chemotherapy drug is when treating patients with certain gene abnormalities. If the research proves correct, it may determine that there is a segment of breast cancer patients that gain no benefit from Adriamycin.

The result? “Adriamycin is potentially toxic to the heart and contributes to nausea, hair loss, and other side effects of chemotherapy. This knowledge could make a significant difference in people’s ability to tolerate chemotherapy,” he finishes.

“These studies,” adds Dr. Brown, “will be able to tell us who needs Adriamycin based on the biology of that tumor.”

Samuel Shelanski, M.D., Greeley Medical Clinic

“In breast cancer, we have already made great strides in who should be treated,” says Dr. Shelanski. “But this is an always-evolving field.” For instance, previously, patients with a small tumor (less than one centimeter in diameter) that is node-negative (has not spread to lymph nodes) were thought to receive minimal benefit from chemotherapy. With recent developments, “now we can determine that for some patients with the same risk factors, chemotherapy is, in fact, an important tool.”

“What it all comes down to is learning to look at treatment as patient-specific to determine who should be treated and with what treatment,” says Dr. Shelanski. He adds that though in the past five years there has not been dramatic changes in how breast cancer is treated, “five years from now, because of current studies, hopefully there will be significant differences.”

Advancements have also been made in the medications that support a patient as they are going through chemotherapy. Anti-nausea mediations “are getting better and better all the time,” says Brown. “I know for a fact that my patients who remain more active do better and supportive medications allow them to be more active.”

Finally, changes are being made in the way chemotherapy is administered. Typically, chemotherapy is done every three weeks for six months. Now “dose dense” chemotherapy can be given to a patient, if their doctor deems they can handle the effects of the higher dosage, every two weeks and wrap up after about four and a half months. “This enables us to help stop the amount of time good cells are down and speed recovery time.”

An oncologist’s challenge is always to evaluate the latest information and determine when to embrace new changes and where to continue a conservative approach to treating their patients. Regardless, information garnered from breast cancer research has practical benefits for all cancers. “Breast cancer,” concludes Dr. Brown, “is leading the way in research. Findings can be applied in principle to all other cancers.”