Cancer cells don’t all grow and spread at the same speed. Some, as with prostate cancer, can be slow-growing, so oncologists have taken the approach at times that it’s safe to do so-called watchful waiting, or active surveillance, to see if the cancer starts to cause problems before they undertake invasive treatments. Active surveillance is most often used as a strategy for keeping an eye on some cases of prostate cancer, but it’s a term that’s sometimes used in reference to breast cancer as well.
Currently, when we talk about active surveillance for breast cancer, we’re talking about monitoring patients for signs of the cancer returning after aggressive therapies, such as surgery, chemotherapy or radiation have ended. “During active surveillance for breast cancer, the typical things that are being done are seeing patients every three to six months, reviewing their symptoms and eliciting a history of any suspicious symptoms such as weight loss, cough and new lumps or bumps and doing a thorough physical exam,” says Dr. Robert Wesolowski, assistant professor of medicine at The Ohio State University Comprehensive Cancer Center — Arthur G. James Cancer Hospital and Richard J. Solove Research Institute in Columbus. “Women on active surveillance for breast cancer also undergo an annual screening mammogram if they didn’t have bilateral mastectomy or if they had a lumpectomy.” Depending on the type of breast cancer, patients may stay in this active surveillance mode for five to 10 years after the conclusion of active treatment.
[See: A Tour of Mammographic Screenings During Your Life.]
Guidelines issued by the American Society of Clinical Oncology currently do not recommend the use of regular blood tests or scans to monitor breast cancer patients during this active surveillance period, Wesolowski says. “There are guidelines from ASCO that clearly discourage use of blood tests such as tumor markers, circulating tumor cells and any other routine blood work simply because these tests sometimes have problems and can be misleading or difficult to interpret. A ‘normal’ tumor marker test doesn’t always mean the cancer is not back because about 30 percent of breast cancers don’t have elevated tumor markers,” he says.
But he notes this reliance on a physical exam, patient history and annual mammogram without the use of more advanced scans or blood test can cause anxiety for some patients. “I think one of the misconceptions that patients sometimes have is that if we say, ‘No scans and we’re going to do active surveillance,’ patients have this feeling that basically the ball gets dropped.” After having just been through a very aggressive treatment protocol that likely included surgery, chemotherapy and radiation treatments, “to hear, ‘That’s it — no more scans, no more blood work,’ that can be very anxiety-forming.”
But while routine blood work and scans may not be part of the plan, Wesolowski says they do come into play when a symptom arises or the patient reports a change in health. “Active surveillance means that we as physicians have to be good at what physicians should do, meaning listening to our patients carefully, examining their symptoms and doing physical exams. If something is concerning based on that work-up, yes, by all means order blood work. Order scans to further evaluate the problem.” But using them without cause has not been proven to elevate survival rates.
Active surveillance is also something that’s currently done for people who have a BRCA1 or BRCA2 genetic mutation. Mutations on these genes raise the risk of breast, prostate and ovarian cancer significantly, and many patients opt to have prophylactic mastectomies to drastically reduce their risk. Others opt for regular screening to watch for changes and then only undergo treatment when a cancer is detected.
However, another application for an active surveillance strategy could be coming in the not-too-distant future. For some patients with very early-stage cancers, the definition of active surveillance could eventually expand to mirror what some prostate cancer patients hear — a period of watchful waiting before treatment is administered to see whether the cancer progresses and only intervening with therapy when the tumor grows or symptoms develop.
This is in part because the widespread use of screening mammography has improved doctors’ ability to spot the earliest breast malignancies before they’re actually considered cancer. Currently, patients who are diagnosed with ductal carcinoma in situ, called stage 0 breast cancer, are advised to undergo surgery and possibly other treatments. This approach has elevated survival rates for this condition to nearly 100 percent. But some researchers are questioning whether that aggressive immediate response is the right one in all cases or whether it results in over-treatment.
“At the present time, for stage 0 breast cancer we still recommend surgery,” Wesolowski says, “but it is a very active area of research because there might be some stage 0 breast cancers that might not progress fast enough to cause problems in the patient’s lifetime.” He says there “are studies now evaluating that, but until those studies show favorable results, we will continue doing what we do today, which is if we discover stage 0 breast cancer, the patient will undergo surgical removal of the tumor.”
[See: What Not to Say to a Breast Cancer Patient.]
Leading one of these studies is Dr. Shelley Hwang, chief of breast surgery at Duke University Health System in Durham, North Carolina. Her clinical trial, called Comparison of Operative to Monitoring and Endocrine Therapy Trial for Low-Risk DCIS, or COMET for short, got underway about a year ago and currently has about 100 participants at 70 sites across the country. She says the trial will continue for another four or five years and will enroll about 900 patients in total. (If you’re interested in taking part, you can learn more about the study at ClinicalTrials.gov and the DCISoptions.org website.)
Unlike with prostate cancer, which is an invasive cancer, “where the majority of men, actually more than 50 percent of them with early stage prostate cancer, start off with active surveillance, for [ductal carcinoma in situ], which isn’t even invasive, we start in with treatment right away. More than 95 percent of women in the U.S. get some sort of surgery for DCIS,” Hwang says. However, because DCIS is not invasive “and we still don’t understand the relationship between stage 0 cancer and stage 1 [breast] cancer, not only myself but many other people are starting to think this might be a good opportunity to do active surveillance on these patients instead of radiation and surgery or bilateral mastectomy that these women are getting.”
The trial will compare how participants fare with a period of active surveillance for DCIS versus the current standard of care and hopefully help determine whether there are ways of predicting which patient is likely to need more aggressive treatment and which may have a DCIS that won’t move fast enough to cause any problems at all. “Our study is really very simple. It takes people with the lowest risk DCIS and we randomize them to what they would usually get, which is surgery and radiation, or active surveillance, and only treating them if they develop a cancer.”
Although it’s too early to know what the results will be, Hwang says “our hypothesis is that if we do active surveillance on these patients, we can save many patients from having any sort of surgery or radiation.” Surgery and radiation will be recommended for patients in the active surveillance arm if they show signs of the cancer progressing.
“What we understand is that there’s some women who are always going to just want surgery,” Hwang says, and that should be an option for them. However, “there’s a large group of women who aren’t given any alternative other than surgery, but who, if given the choice, might just want surveillance.” And if her trial can prove that active surveillance does not reduce survival rates, that could become a more widely available option in the future.
“I think this represents a complete brain shift in how we’re thinking about the disease now,” Hwang says. “We are picking up [breast cancers] so early that it starts being a little bit of a dilemma to know how early is too early. And when we start diagnosing and picking up things too early, I think then we end up ‘treating’ a lot of patients who may have never needed treatment.”
The trial will also collect genetic data from participants, which will hopefully further our understanding of the genetic basis of breast cancer and whether we can find clues for individual patient prognosis from genomic profiling. Hwang says the team will be looking at “all those things that can help us personalize whether patients should get surgery up front or whether they might be better off being monitored with active surveillance,” including examinations of tissue samples, blood and the biological information. This should help better define what it means to be “low-risk” and may better distinguish the patients who won’t need treatment from those who are more likely to develop full-blown cancer.
[See: 10 Innovations in Cancer Therapy.]
“Culturally, it’s so much easier to throw more at patients,” Hwang says. “But if you’re on the receiving end of all that treatment, there are long-term toxicities and side effects associated with many of the things that we do. So being a lot more informed about which patients really do need the most aggressive treatment versus those who need a lot less treatment, that’s really the holy grail of personalized medicine.”
Hwang says that as we learn more, we can be more discerning in administering treatment that’s proportional to the patient’s need. “Active surveillance would not be the right thing for all patients with breast cancer and it’s probably not the right thing for all patients with stage 0 breast cancer. But I think it really is high time for a national discussion around identifying those very early cancer situations that really don’t require the aggressive treatments we’re giving them now.”
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What Is Active Surveillance for Breast Cancer? originally appeared on usnews.com
