Breast Cancer | Cancer.Net

Thursday, October 24, 2002, 4:00 - 5:00 PM ET

About Dr. Norton

Dr. Norton is head of the Division of Solid Tumor Oncology and holds the Norna S. Sarofim Chair in Clinical Oncology at Memorial Sloan-Kettering Cancer Center. He is renowned as a leader in the development of drug treatments for breast cancer. His research includes the use of monoclonal antibodies to target growth factor receptors as a way of slowing or shrinking tumors, and the study and identification of breast cancer genes. Dr. Norton is the immediate Past President of the American Society of Clinical Oncology.

Moderator 1: On behalf of the American Society of Clinical Oncology (ASCO), welcome to the Cancer.Net chat on breast cancer, a live question-and-answer session hosted by Larry Norton, MD. During this hour, Dr. Norton will answer as many questions as time permits. Some questions may be adapted so Dr. Norton's answers can help as many people as possible.

Dr. Norton will take questions from 4:00 PM to 5:00 PM ET. As you phrase your questions, please keep in mind that Dr. Norton is unable to give individual medical advice in this setting. In answering questions about specific drugs, Dr. Norton's comments will be focused on the state of current research and clinical trials on drugs and drug regimens.

This chat is governed by all terms and conditions of the Cancer.Net website.

Dale: Is anastrozole the drug of choice when tamoxifen is discontinued due to side effects?

Dr. Norton: Anastrozole is one example of a class of drugs called aromatase inhibitors. There are three of these that are now in common use, and all are very good treatments. Yes, these drugs are often used in patients who need hormonal therapy if tamoxifen cannot be used. However, you should remember that the aromatase inhibitors are only active in postmenopausal patients.

Lou: My 32 yr. old wife was treated with lumpectomy and radiation only for a 1.5mm moderate grade tumor, she is node negative and er+and pr+ with no family history of cancer. She was tested for BRCA, and was given a result of "variant of unknown clinical significance." Does this affect the management of such patients with respect to prophylactic surgery or tamoxifen?

Dr. Norton: This is a very difficult question because there are a lot of details I would need (including a physical examination) to render a really authoritative opinion here. So please do not regard what I am about to say as a medical opinion, just as some issues that should be discussed with your health professional.

A laboratory result such as the one she received means that she might have an abnormality in BRCA1 or BRCA2 (whichever was tested), or she might not. With time it is possible that we will see other cases with her specific gene structure, and this information--eventually--could be used to tell if her gene is normal or not. For this reason, I think that BRCA1/2 status is not really relevant to her decisions now. (Some women with BRCA abnormalities choose mastectomy rather than breast conservation. However, if her BRCA1/2 status is indeterminate--as it seems to be--that is not a consideration here.) For this reason, she should be treated the same way as any other patient with her tumor size and nodal status.

Krazymoi: When should people with stage I breast cancer receive chemotherapy?

Dr. Norton: This question requires an expert opinion in the individual case. In general, however, patients with tumors greater than 1 centimeter in diameter are usually considered for chemotherapy regardless of the status of the axillary lymph nodes. In many cases, however, even those with smaller tumors are well advised to receive chemotherapy. An individual decision is critical here.

Gerri: After five years of tamoxifen, are there any other treatment options?

Dr. Norton: There is a clinical trial that has just completed enrolling patients that will tell us if such patients should receive five years of an aromatase inhibitor or not. We will probably know the results of that study in five years or so. At present, however, there are no data to suggest that any additional treatment after five years of tamoxifen is advisable. However, patients should be followed carefully by their health care professionals including annual mammography.

Dale_ : Will endometrial hyperplasia build up again after tamoxifen is discontinued?

Dr. Norton: No. But the endometrial effects of tamoxifen do last longer than the 5 years of (usual) tamoxifen use. For that reason, patients need to be followed after tamoxifen is discontinued. But we all need to remember that the impact of tamoxifen in increasing the diagnosis of endometrial cancer is very very slight, especially in younger women.

Annie: Dr. Norton, what is your advice to women on hormone therapy? I have read recently that HRT may cause breast cancer.

Dr. Norton: I am not a fan of HRT. Most postmenopausal women do not need any specific treatment, and for the ones who do there are safer and quite effective medications for most postmenopausal problems. The available evidence is that HRT does indeed increase the risk of breast cancer.

Violin: I've just recently been diagnosed with ductal carcinoma, after a fine needle biopsy. Tomorrow is my first appointment with a surgeon. Any advice on what I should ask, what I might expect...?

Dr. Norton: There is so much to say here that I think that your best first move is to read about two things on ASCO's People Living With Cancer (www.cancer.net) website. Check out "ductal carcinoma in situ" and "invasive ductal carcinoma." From your FNA report, both diagnoses might be possible. Decide before you see the surgeon how you feel about breast conservation (lumpectomy) versus mastectomy, just in case the issue comes up. You will find information about this as well on www.cancer.net.

Kelly: Does having a period while on tamoxifen mean you are still producing estrogen? Are there tests to determine your estrogen levels?

Dr. Norton: Having a period does mean that you are still premenopausal. However, tamoxifen is just as effective in premenopausal patients as in postmenopausal patients. Tamoxifen doesn't stop estrogen production, it just blocks the effect of estrogen at the cancer cell.

Lou: Is young age alone enough of a poor prognostic indicator to warrant systemic therapy, irrespective of other considerations?

Dr. Norton: There is controversy on the issue of age being a prognostic factor all by itself in breast cancer. If it is, it is a weak one. In general, younger patients tend to have more aggressive cancers, but this is clear by looking at the tumor size, number of involved nodes, and other measurements. A person should be treated based on these other factors (size, nodes, estrogen receptor status, etc.), not just age.

Sowha: With all of the most recent research about lumpectomy versus mastectomy, would you still recommend prophylactic mastectomy for someone with BRCA1 who already had breast cancer?

Dr. Norton: This is a very personal decision. At our recent (May 2002) meeting of ASCO there were data presented suggesting that if the ovaries are removed the breast cancer incidence is reduced enough that mastectomy as a prophylactic procedure may not be necessary. Please discuss the specifics here with a genetics professional. ASCO has helped train many such people throughout the country.

Taylor: Given the recent study in China, what is your opinion about breast self exams?

Dr. Norton: I still think that they are a good idea. It is always helpful for a woman or a man to know their own body. The situation in China may be quite different than the situation here in a variety of ways (which were discussed in the recent paper). More information can only help if it is used properly.

Sowha: In follow up to your previous answer on prophylactic mastectomy, is this true in the case of estrogen negative breast cancer?

Dr. Norton: The real question here is: If a person has an ER-negative breast cancer, is it likely that if they get another cancer that it will be ER-negative? Some investigators have found that ER-negative predicts ER-negative, but others--including my institution--have not had this experience. Since a person with an ER-negative breast cancer could get an ER-positive breast cancer later, oophorectomy would still be expected to help. (The same goes for tamoxifen chemoprevention).

Gupta: What do you think of partial breast radiotherapy and the mammosite device?

Dr. Norton: These data are very interesting, but I think that we will need more experience to see how their results compare with more conventional radiotherapy. This is a very exciting area of current research.

Jewel: How soon will molecularly-targeted therapies be available for early-stage breast cancer (not Herceptin-positive)?

Dr. Norton: Can't say. But this is such an active area of research that I expect major advances within the decade.

Tammy: What is good to take to alleviate hand foot syndrome while taking capecitabine?

Dr. Norton: The only thing that really works well is to reduce the dose of the drug in the next cycle.

MKW: What is your opinion of ductal lavage/ductoscopy/nipple aspiration fluid for detecting cancer in high risk women?

Dr. Norton: Still a research technique.

Sowha: Do you feel that MRI of the breast is a good tool for early detection?

Dr. Norton: I am getting more and more excited about MRI as we gain more experience. The key question is: Who are the best candidates for MRI? Right now we are studying high-risk women, such as women with BRCA1/2 problems. But please remember: MRI might augment mammography, but it does not replace mammography.

Ee1: What other drugs in addition to trastuzumab are available for adjuvant treatment specifically for HER2 /new 3+ patients?

Dr. Norton: Herceptin is still an experimental drug for the adjuvant setting. There are some investigators who feel that patients with HER2-overexpressing disease (best measured by FISH) respond best to adjuvant therapies that use doxorubicin, and perhaps a taxane (paclitaxel or docetaxel). This latter question is still being investigated.

Kelly: How soon can you have a mammogram after a lumpectomy, chemotherapy, and/or radiation therapy?

Dr. Norton: 6 months.

Kelly: If someone is premenopausal and more than 10 positive nodes, would ovary removal be more effective than tamoxifen?

Dr. Norton: There is some evidence that both together might be best. However, chemotherapy usually suppresses ovarian function enough that surgical oophorectomy is not necessary. Tamoxifen works as well in premenopausal patients as in postmenopausal patients. That is, one doesn't need an oophorectomy to allow tamoxifen to work.

Lou: In your opinion, how long before we will actually be able to effectively treat metastatic cancer that we can consider a cure?

Dr. Norton: I can't predict the future, but I have seen other cancers (childhood leukemia, Hodgkin's Disease, testicular cancer and others) cured in my career, and I don't see why breast cancer cannot join them. And I have had some patients with breast cancer live so long that they have died of other diseases.

Kaye51: There is new research suggesting that COX-2 inhibitors have anti-tumor activity. Would you comment?

Dr. Norton: They decrease colon polyps, and in that way they might decrease the incidence of colon cancer. There are many trials now looking at the effects of these drugs on established cancers, especially when given jointly with other drugs like chemotherapy and hormonal therapy.

Dr. David: For Stage I invasive breast cancer with no malignancy in the lymph nodes, post- lumpectomy and radiation, hormone receptor test negative, and not a candidate for tamoxifen. Best approach?

Dr. Norton: As I answered in a previous response, this is the kind of issue that requires an individual consultation. You can learn the questions that you should ask your doctor at www.plwc.org.

Gupta: What is the utility of the PET scan in managing breast cancer?

Dr. Norton: PET scans have proven very useful for discriminating between benign shadows on CAT and other imaging tests and true malignancies. Their ability to screen for metastatic sites is still under investigation. A particularly interesting area of research is the assessment of response to therapy. That is, PET scans may change in tumors that are going to respond to a treatment much sooner than waiting for the cancer itself to shrink after treatment.

Ee1: Please comment on any treatments being developed for node positive ER negative patients.

Dr. Norton: In general, chemotherapy is more effective against ER negative disease than against ER positive disease.

Jewel: I am currently on tamoxifen. I stopped a serotonin-uptake inhibitor antidepressant due to it being a possible inhibitor of the CYP2D6, which is required for breakdown of tamoxifen to hydroxy-tamoxifen. Please comment on this.

Dr. Norton: There is no evidence at present to suggest that patients on antidepressants have any different response to hormonal therapy than patients not on such treatment. If the antidepressants are helping you, I would continue them while being treated with tamoxifen.

Sowha: Is tamoxifen still recommended for a woman who has already had her ovaries removed?

Dr. Norton: Having one's ovaries removed makes you postmenopausal. Tamoxifen works very well in postmenopausal women. As I said earlier in this chat, tamoxifen does not affect the secretion of estrogen from the ovary. Tamoxifen blocks the action of estrogen at the surface of the cancer cell.

Kelly: What type of follow-up tests are important and at what intervals with node positive/ node negative breast cancer survivors?

Dr. Norton: Your doctor can find ASCO's guidelines for follow-up on our website at asco.org.

Kaye51: I have had continual lower back pain. I had a PET scan which suggested arthritic activity. How can arthritic activity be differentiated from bone metastases?

Dr. Norton: PET scans are actually quite useful in discriminating between benign conditions like arthritis and cancer. However, they are not infallible. Good clinical judgement is necessary here.

Lelani: What clinical trials are available, or is there a good website for metastatic breast cancer that is PR, ER- HER2?

Dr. Norton: Your best source of information is www.cancer.net. The National Cancer Institute has a very comprehensive list of clinical trials, which you can obtain from their website. You may also want to look at www.nabco.org.

Sowha: My last question related to Dr. Norton stating that data suggests that if the ovaries are removed mastectomy as a prophylactic procedure may not be necessary. I was asking if this is still the case with estrogen negative cancers, or only estrogen positive?

Dr. Norton: There probably would be benefit, but the degree of benefit would require more research. Please read over previous answers to similar questions in this chat.

Moderator 1: The chat is now ending. Thank you for your thoughtful questions. We hope this discussion has been valuable, and we regret not being able to answer every question.

You may also visit Cancer.Net (www.cancer.net) for more information on breast cancer.

SAVE THE DATES: The next Cancer.Net online chat will feature Paul A. Bunn, Jr., MD, addressing lung cancer on Wednesday, November 20, 2002, from 4:00 to 5:00 PM ET. Dr. Bunn is the current President of ASCO and serves as the Grohne/Stappe Chair in Cancer Research and Director of the University of Colorado Cancer Center in Denver.

Cancer.Net's December chat, "Coping with Cancer During the Holidays," is scheduled for December 3, 2002, at 4:00 PM ET. The chat will be co-hosted by Diane Blum, MSW, Executive Director of Cancer Care, Inc., in New York and PLWC's Editor-in-Chief, and Deane L. Wolcott, MD, President of The American Society of Psychosocial and Behavioral Oncology/AIDS.

The chat room is now closed. Thanks again for joining us.

For more information, see our breast cancer section.