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The first question that most breast cancer patients ask is whether they will need chemotherapy. Their eyes are filled with fear, anxiety, and uncertainty. Patients willingly accept surgery, medication and radiotherapy. Still, once chemotherapy comes into the management of the disease, the stigma of losing femininity, especially hair loss, becomes the most difficult step to take. However, chemotherapy is not required for all breast cancer patients.
A selective group of patients can avoid chemotherapy.
Patients with early-stage breast cancers, such as:
Patients with hormone receptor–positive cancers, including:
One factor in deciding whether a patient requires chemotherapy is the use of risk assessment tools to evaluate the likelihood of cancer recurrence. If the risk of recurrence is low, chemotherapy can usually be avoided. Certain types of breast cancer, such as mucinous, tubular and colloid cancers, tend to have a better prognosis and may not need chemotherapy. In very elderly and frail patients, where quality of life would be far more affected by the side effects of chemotherapy than by the disease itself, chemotherapy can be avoided.
A 65-year-old postmenopausal woman presented with early-stage breast cancer. Early breast cancers are usually T1(<2 cm) and T2(2 -5 cm) with a few nodes, and one to two nodes are positive. She underwent a biopsy, and the biopsy came out to be hormone positive and HER2-neu negative, following which she underwent surgery. The surgery can be either in the form of a mastectomy, that is, complete removal, or breast conservation surgery. The axillary nodes can be negative or, in some cases, one to two nodes may be positive.
The patient was strongly hormone positive, and a recurrence risk test was done on her. Her risk of recurrence was low. Her breast conservation surgery was done, followed by radiation and endocrine therapy. If a mastectomy is done, patients are placed only on endocrine therapy. The patient has done very well, especially once the risk-recurrence score came out as negative or low risk, with low risk being the more favourable outcome. She was able to avoid chemotherapy safely.
Once diagnosed, patients immediately ask, “Will I have to take chemo?” They are worried about the physical, mental, social, emotional, psychological and financial impact that chemotherapy can cause. The drugs used in chemotherapy also cause multiple side effects. But the main concern for patients is hair loss. Although many options are available, including cooling caps, natural hair wigs, artificial hair wigs, and scarves, people remain anxious about chemotherapy and its side effects. Chemotherapy also has a significant financial impact. The drugs are expensive, and the cost of treatment can range from ₹25,000 to ₹4.5 lakhs per cycle, depending on the type of cancer and the drugs used.
In early breast cancer patients, the survival rates have nearly reached 90–95%. Patients are almost cured if detected and treated early. One of the key advances has been the use of prognostic tests that predict the risk of cancer recurrence. We have calculable risk-recurrence scores that identify a group of patients who can selectively avoid chemotherapy regimens. This is very scientifically based, using large databases, so all the tests are validated. We have many tests, both international and Asian.
The international tests include Oncotype DX, EndoPredict, and MammaPrint. These tests show that, if applied to a selected group of patients who fall into the low-risk category, chemotherapy can be avoided scientifically, as the patient will not gain any additional benefit from chemotherapy over endocrine therapy. So, this approach has a strong scientific basis. With effective endocrine therapies, patients usually benefit without having to experience the side effects of chemotherapy.
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