Cancer Without Chemotherapy: 'A Totally Different World'

A growing number of cancer patients, especially those with breast and lung cancers, are being spared the dreaded treatment in favor of other options.

Dr. Seema Doshi, a dermatologist near Boston, thought it was a foregone conclusion that she would have to undergo chemotherapy when a cancerous lump was found in her breast in 2019.Credit...Lauren Justice for The New York Times Dr. Seema Doshi was shocked and terrified when she found a lump in her breast that was eventually confirmed to be cancerous. “That rocked my world,” said Dr. Doshi, a 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 was the 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 Center in Houston. But data from a variety of sources offers 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 ever-expanding array of drugs, including estrogen blockers and drugs that destroy cancers by attacking specific proteins on the surface of tumors. And there is a growing willingness among oncologists to scale back 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 to 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. (Breast cancer is second, killing 43,000.) Still, the opportunity to avoid chemotherapy is not evenly distributed, and is often dependent on where the person is treated and by whom.

But for some patients who are lucky enough to visit certain cancer treatment centers, the course of therapy has changed. Now, even when chemotherapy is indicated, doctors often give fewer drugs for less time. “It’s a totally different world,” said Dr. Lisa Carey, a breast cancer specialist at the University of North Carolina. 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,’” Dr. Vonderheide said. The breast cancer treatment guidelines issued by the National Cancer Institute 30 years ago were harsh: chemotherapy for about 95 percent 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 percent of patients who have a particular protein on their tumor 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, Dr. Hortobagyi said, “started to break the dogma” that chemotherapy was essential.

But changing cancer therapies was not easy.

“It is very scary,” to give fewer drugs, Dr. Hortobagyi said.

“It is so much easier to pile on treatment on top of treatment,” he continued, “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 percent, from 26 percent. For those with evidence of cancer in their lymph nodes, chemotherapy was used in 64 percent of patients, down from 81 percent. More recent data, compiled by Dr. Jeanne Mandelblatt, a professor of medicine and oncology at Georgetown, and her colleagues, but not yet published, included 572 women who were 60 or older and enrolled in a federal study at 13 medical centers. Overall, 35 percent of older women received chemotherapy in 2012. That number fell to 19 percent by the end of 2019. Cheaper and faster genetic sequencing has played an important role in this change. The technology made it easier for doctors to test tumors to see if they would respond to targeted drugs. Genetic tests that looked at arrays of proteins on cancer cells accurately predicted who would benefit from chemotherapy and who would not.

There are now at least 14 new targeted breast cancer drugs on the market — three were approved just last year — 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. For women with tumors that are fed by estrogen, the median survival increased from about 24 months in the 1970s to almost 64 months today.

Now some are in remission 10 or even 15 years after their initial treatment, Dr. Hortobagyi said. “At breast cancer meetings, a light bulb went off. ‘Hey, maybe we are curing these patients,’” Dr. Hortobagyi said.

(Source: New York Times)