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New Breast Cancer Treatment Pathways Remove High-Dose Chemotherapy Trial Option: Presented at DG DISPATCH - NCCN

By Ed Susman

Special to DG News

FORT LAUDERDALE, FL -- March 2, 2001 -- Doctors who put together breast cancer treatment guidelines for the 18-member hospitals of the National Comprehensive Cancer Network (NCCN) have removed mention of high-dose chemotherapy with bone marrow transplantation as a clinical trial option for women with metastatic disease.

Speaking at the 6th annual meeting to outline the new NCCN guidelines, Dr. Richard Theriault, DO, professor of medicine at the University of Texas MD Anderson Cancer Center, in Houston, Texas, said that various studies over the past two years had failed to show any survival benefit for people undertaking the grueling procedure.

Dr. Richard Theriault, DO, professor of medicine at the University of Texas MD Anderson Cancer Center, in Houston, Texas, said that high-dose chemotherapy does not produce worse survival results than other treatments. However, the expense of the treatment -- well over $100,000 -- and its toxicity profile mean that its use should be curtailed and probably not used outside a clinical trial.

Although never a recommendation, the NCCN had given emphasis on having women participate in clinical trials of the controversial and expensive "last resort" treatment.

"We have taken a step back from that position," said Robert Carlson, MD, professor of medicine at Stanford Medical Center, in Palo Alto, California, and chairman of the committee writing the treatment algorithm for the consortium of prestigious cancer centers.

"While we still believe that high-dose chemotherapy and bone marrow transplantation should be evaluated in clinical trials," Dr. Carlson said, "we no longer give these clinical trials more weight than any other clinical study."

Dr. Carlson said that there still might be some particular cases in which a patient might be offered the treatment.

The breast cancer guidelines have been updated in each of the six years that NCCN committees have been writing them, and Dr. Carlson said that in past recommendations, doctors were urged to place their patients in clinical trials to evaluate high-dose chemotherapy.

In the latest iteration of the guidelines, the doctors from various institutions recommended for the first time that the HER2/neu expression status of all breast tumors be evaluated in an initial assessment of the patient in order to better guide treatment. Dr. Carlson dubbed this new recommendation "evolution rather than change".

He said the recommendation puts HER2/neu expression status at the same level as estrogen and progesterone receptor status. Knowing the status of HER2/neu expression could help doctors to decide if treatment with trastuzumab (Herceptin) was warranted in the event of recurrence.

The committee also declared that use of magnetic resonance imaging (MRI) to assess cancer in the breast was a viable option -- only if the MRI scan was performed with machinery developed for the breast and was performed by experts in the field of breast cancer diagnosis.

"If an MRI can be used for your knee, it shouldn't be used for you breast," said Dr. Carlson.

Stephen Edge, MD, chief of the breast division at Roswell Park Cancer Institute, Buffalo, New York, said non-specialized machines cannot give doctors the information they need, and worse, sometimes insurance companies will refuse to pay for a second MRI.

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