Excerpts from the Professionals:
DR PRITCHARD: The most interesting piece of data I saw was a curve showing that disease in untreated patients with ER-negative disease recurs quickly in the first few years, but then their curves level out much more than patients with ER-positive disease. On the other hand, untreated patients with ER-positive disease do much better in the first five years, and they’re still ahead in the next five years. However, at approximately 10 years, the disease-free survival curves for ER-positive and ER-negative disease cross over each other, and at 15 years, the survival curves are crossing.
DR LOVE: So the untreated patients with ER-positive disease have a higher delayed relapse rate than those with ER-negative disease?
DR PRITCHARD: Yes. It’s slower and steadier, but they keep recurring. It makes sense that we’re now seeing that treatment after five years can be very helpful, because these patients have an ongoing risk. We haven’t all appreciated this very well until the last few years. I believe that the Saphner paper showed this ongoing risk, and the Oxford Overview data have shown this before as well (Saphner 1996).
We all think of ER-positive disease as having a better natural history, but the fact is that by 10 years, more of the patients with ER-positive disease have recurred than the ER-negative group, both untreated. It’s shocking because we thought we could treat these patients with tamoxifen and after that they would do well and we would not have to worry about them, but they continue on having recurrences.
So I think adding additional treatment with an aromatase inhibitor or certainly evaluating these patients in clinical trials is important.
And more interesting comments on TX. for small tumors; excerpts from the Professionals:
DR LOVE: How do you manage a HER2-positive tumor smaller than one centimeter in the adjuvant setting?
DR BURSTEIN: The honest answer is that we don’t know whether these women need trastuzumab. We do need to be respectful of the fact that these women have a better prognosis because their tumors are so small. Certainly for women whose tumors are ER-positive and less than one centimeter, I’ve not offered trastuzumab.
For patients with ER-negative disease, I suppose one could consider trastuzumab, though the quantifiable gains from adding this agent are not known. It would be interesting to conduct a study evaluating trastuzumab with or without chemotherapy in patients with very small tumors. Maybe we can begin to eliminate chemotherapy for the lower-risk patient population if we can alter the natural history of their disease.