A growing number of cancer patients, especially those with breast and lung cancers, are being spared the dreaded treatment in favor of other options.
Dr. Seema Doshi, a dermatologist near Boston, thought it was a foregone conclusion that she would have to undergo chemotherapy when a cancerous lump was found in her breast in 2019
Dr. Seema Doshi was shocked and terrified when she found a lump in her breast that was eventually confirmed to be cancerous.
“That rocked my world,” said Dr. Doshi, a dermatologist in private practice in the Boston suburb of Franklin who was 46 at the time of her diagnosis. “I thought, ‘That’s it. I will have to do chemotherapy.’”
She was wrong.
Dr. Doshi was the beneficiary of a quiet revolution in breast cancer treatment, a slow chipping away at the number of people for whom chemotherapy is recommended. Chemotherapy for decades was considered “the rule, the dogma,” for treating breast cancer and other cancers, said Dr. Gabriel Hortobagyi, a breast cancer specialist at MD Anderson Cancer Center in Houston. But data from a variety of sources offers some confirmation of what many oncologists say anecdotally — the method is on the wane for many cancer patients.
Genetic tests can now reveal whether chemotherapy would be beneficial. For many, there are better options with an ever-expanding array of drugs, including estrogen blockers and drugs that destroy cancers by attacking specific proteins on the surface of tumors. And there is a growing willingness among oncologists to scale back unhelpful treatments.
The result spares thousands each year from the dreaded chemotherapy treatment, with its accompanying hair loss, nausea, fatigue, and potential to cause permanent damage to the heart and to nerves in the hands and feet.
Breaking down the dogma.
The breast cancer treatment guidelines issued by the National Cancer Institute 30 years ago were harsh: chemotherapy for about 95 percent of patients with breast cancer.
The change began 15 years ago, when the first targeted drug for breast cancer, Herceptin, was approved as an initial treatment for about 30 percent of patients who have a particular protein on their tumor surface. It was given with chemotherapy and reduced the chance of a recurrence by half and the risk of dying from breast cancer by a third, “almost regardless of how much and what type of chemotherapy was used,” Dr. Hortobagyi said.
There are now at least 14 new targeted breast cancer drugs on the market — three were approved just last year — with dozens more in clinical trials and hundreds in initial development. Some patients have reaped benefits beyond avoiding chemotherapy. Now some are in remission 10 or even 15 years after their initial treatment, Dr. Hortobagyi said.
‘Some cases keep me up at night.'
Dr. Doshi’s oncologist, Dr. Eric Winer of the Dana-Farber Cancer Institute, gave her good news: A genetic test of her tumor indicated she would not get any significant benefit from chemotherapy. Hormonal therapy to deprive her cancer of the estrogen that fed it would suffice.
But as much as Dr. Doshi dreaded chemotherapy, she worried about forgoing it. What if her cancer recurred? Would chemotherapy, awful as it is, improve her outcome?
She got a second opinion.
The doctor she consulted advised a “very aggressive” treatment, Dr. Doshi said — a full lymph node dissection followed by chemotherapy.
She had multiple conversations with Dr. Winer, who ended up discussing her case with four other specialists, all of whom recommended against chemotherapy.
Finally, Dr. Doshi said, “my husband said I should just pick a horse and run with it.”
She trusted Dr. Winer.
Survival rates are tripling for lung patients.
Another type of lung cancer treatment was developed about five years ago — immunotherapy, which uses drugs to help the immune system attack cancer. Two-thirds of patients from an unpublished study at Dana-Farber were not eligible for targeted therapies but half of them were eligible for immunotherapy alone, and others get it along with chemotherapy.
Immunotherapy is given for two years. With it, life expectancy has almost doubled, said Dr. Charu Aggarwal, a lung cancer specialist at the University of Pennsylvania.
Now, said Dr. David Jackman of Dana-Farber, chemotherapy as the sole initial treatment for lung cancer, is shrinking, at least at that cancer treatment center, which is at the forefront of research. When he examined data from his medical center he found that, since 2019, only about 12 percent of patients at Dana-Farber got chemotherapy alone, Dr. Jackman said. Another 21 percent had a targeted therapy as their initial treatment, and among the remaining patients, 85 percent received immunotherapy alone or with chemotherapy.
In contrast, in 2015, only 39 out of 239 patients received a targeted therapy as their initial treatment. The rest got chemotherapy.
Dr. Aggarwal said she was starting to witness something surprising — some who had received immunotherapy are still alive, doing well, and have no sign of cancer five years or more after their initial treatment.
‘It’s almost surreal.’
Dr. Burns is amazed by how lung cancer treatment has changed.
“It’s been remarkable,” he said. “We still quote the one-year survival but now we are talking about survival for two, three, four or even five years. I even have patients on the first targeted drugs that are on them for six or even seven years.”
Mark Catlin, who is being treated at Dana-Farber, is one of those patients.
On March 8, 2014, Mr. Catlin, who has never smoked, noticed a baseball-size lump under his arm. “The doctors told me to hope for anything but lung,” he said.
But lung it was. It had already spread under his arm and elsewhere.
Oncologists in Appleton, Wis., where he lives, wanted to start chemotherapy.
“I was not a fan,” Mr. Catlin said. His son, who lives in the Boston area, suggested he go to Dana-Farber.
There, he was told he could take a targeted therapy but that it would most likely stop working after a couple of years. He is 70 now, and still taking the therapy seven years later — two pills a day, with no side effects.
He rides a bike 15 to 25 miles every day or runs four to five miles.
His drug, crizotinib, made by Pfizer, has a list price of $20,000 a month. Mr. Catlin’s co-payment is $1,000 a month.
But, he says, “it’s keeping me alive.”
“It’s almost surreal,” Mr. Catlin said.
