Breast Cancer – More is not necessarily better

It used to be that patients with breast cancer requiring surgery had Radical Mastectomy until the 1970’s. It subsequently became clear that Modified Radical Mastectomy, a less aggressive surgical procedure was just as effective as Radical Mastectomy. The next major surgical advance in Breast Cancer was breast preservation with Lumpectomy, Axillary Lymph Node Dissection (ALND) and Radiation. This has been proven to be as good as Modified Radical Mastectomy. Because of the morbidity associated with complete ALND, the technique of Sentinel Lymph Node Dissection (SLND) was developed and it became clear that SLND by itself is as effective as ALND,  in early breast cancer, without the complications associated with ALND.

A randomized clinical trial results published in JAMA this month demonstrated that in women with invasive breast cancer and limited sentinel lymph node metastases, SLND was as effective as ALND. With this data, women diagnosed with breast cancer hopefully will not have to endure the morbidity associated with ALND which include swelling, pain, paresthesias and restriction of movement of the arm.

This philosophy of  ” more is not better” with regards to chemotherapy, held ground, after myeloablative therapy and transplantation for metastatic breast cancer patients showed no benefit. Hopefully newer “kinder and gentler” systemic agents will follow suit, just as the surgical techniques have evolved over the past 40 years.

Maintenance Rituximab

The FDA on Jan 31, 2011 approved Rituximab as a maintenance treatment for patients with advanced follicular lymphoma, who responded to initial treatment with Rituximab plus chemotherapy. Follicular lymphomas are a subset of Non Hodgkins Lymphomas and are very responsive to chemotherapy or chemotherapy with Rituximab. They are usually incurable however, despite treatment with Rituximab plus chemotherapy. So think of this condition as a chronic disease. For this reason, prolonging remission duration is important, as the length of remission tends to be shorter with each recurrence.

In the PRIMA trial, which was a phase III study, maintenance Rituximab for 2 years given to those who responded to induction treatment with chemotherapy and Rituximab, delayed the risk of recurrence and improved progression free survival. These findings are relevant for patients who essentially have a chronic disease and are willing to pursue interventions that would delay recurrence of their lymphoma and therefore improve their quality of lives.