NEW YORK • Dr Seema Doshi was terrified when she found a lump in her breast that was eventually confirmed to be cancerous.
"That rocked my world," said the 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 is a 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 Centre in Houston. But data from a variety of sources offer 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 expanding array of drugs, including oestrogen blockers and drugs that destroy cancers by attacking specific proteins on the surface of tumours. And there is a growing willingness among oncologists to scale back on 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 nerves in the hands and feet.
The diminution of chemotherapy treatment is happening for some other cancers too, including lung cancer, the most common cause of cancer deaths in the United States, killing more than 69,000 Americans each year.
Dr Robert Vonderheide, a lung cancer specialist at the University of Pennsylvania, remembers his early days on the job, about 20 years ago. "The big discussion was, 'Do you give patients two different types of chemotherapy or three?'" he said. There was even a clinical trial to see whether four types of chemotherapy would be better.
"Now, we are walking in to see even patients with advanced lung cancer and telling them, 'No chemo'," he said.
The breast cancer treatment guidelines issued by the National Cancer Institute 30 years ago were harsh - chemotherapy for about 95 per cent 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 per cent of patients who have a particular protein on their tumour 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.
In a few studies, Herceptin and another targeted drug were even given without chemotherapy and provided substantial benefit, he added.
That, he said, "started to break the dogma" that chemotherapy is essential.
But changing cancer therapies was not easy.
"It is very scary" to give fewer drugs, Dr Hortobagyi said.
He added: "It is so much easier to pile on treatment on top of treatment, with the promise that 'if we add this, it might improve your outcome'."
But as years went by, more and more oncologists came around, encouraged by new research and new drugs.
The change in chemotherapy use is reflected in a variety of data collected over the years.
A study of nearly 3,000 women treated from 2013 to 2015 found that in those years, chemotherapy use in early-stage breast cancer declined to 14 per cent, from 26 per cent. For those with evidence of cancer in their lymph nodes, chemotherapy was used in 64 per cent of patients, down from 81 per cent.
There are now at least 14 new targeted breast cancer drugs on the market, with dozens more in clinical trials and hundreds in initial development.
Some patients have reaped benefits beyond avoiding chemotherapy. The median survival for women with metastatic breast cancer who are eligible for Herceptin went from 20 months in the early 1990s to about 57 months now, with further improvements expected as new drugs become available.
Dr Doshi's oncologist, Dr Eric Winer of the Dana-Farber Cancer Institute in Boston, gave her good news. A genetic test of her tumour indicated she would not get significant benefit from chemotherapy. Hormonal therapy to deprive her cancer of the oestrogen 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. Finally, she said: "My husband said I should just pick a horse and run with it." She trusted Dr Winer.
When Dr Roy Herbst of Yale started in oncology about 25 years ago, nearly every lung cancer patient with advanced disease got chemotherapy. Yet, despite treatment, most tumours continued to grow and spread. Less than half his patients would be alive a year later. The five-year survival rate was just 5 to 10 per cent.
Those dismal statistics barely budged until 2010, when targeted therapies began to emerge.
There are now nine such drugs for lung cancer patients, three of which were approved since May. About a quarter of lung cancer patients can be treated with these drugs alone, and more than half who began treatment with a targeted drug five years ago are still alive. The five-year survival rate for patients with advanced lung cancer is now approaching 30 per cent.
But the drugs eventually stop working for most, said Dr Bruce Johnson, a lung cancer specialist at Dana-Farber. At that point, many start on chemotherapy, the only option left.
NYTIMES
