BOX 3-3
Advances in Breast Cancer Treatment: Implications for Late Effects

Research that demonstrated that breast-conserving therapy followed by radiation is an efficacious alternative to mastectomy in most women has contributed to less disfigurement and reduced morbidity among women (Fisher et al., 2002). In research conducted over the past three decades, clinical trials have demonstrated that chemotherapy given to women shortly after their primary surgery and/or radiation treatment (called adjuvant therapy) reduces the risk of recurrence by 20 to 40 percent and reduces mortality by 10 to 30 percent at 10 years following treatment (NIH, 2000; Shapiro and Recht, 2001; Early Breast Cancer Trialists’ Collaborative Group, 2004a). For women whose tumors are hormone receptor positive (with either estrogen or progesterone receptor expression), which includes about 70 percent of breast cancer patients, endocrine therapies (e.g., aromatase inhibitors, tamoxifen, surgical removal of the ovaries) have been found to reduce recurrence rates by nearly 50 percent and death rates by more than 25 percent (Early Breast Cancer Trialists’ Collaborative Group, 2004b; Mrozek and Shapiro, 2005). Adjuvant chemotherapy, endocrine therapy, or both are widely recommended for women with invasive breast tumors greater than 1 cm in diameter, irrespective of whether axillary lymph nodes are involved (NIH, 2000; NCCN, 2004b). Although these interventions are beneficial, they can lead to late effects, and decision making about the approach to adjuvant therapy can be complex (Langer, 2001; Ganz, 2001a). During the 1990s, many women with metastatic breast cancer underwent high-dose chemotherapy and bone marrow transplantation, which was later shown not to be more effective than standard-dose chemotherapy alone for advanced disease. Women who survived this treatment experienced not only the late effects, but also the financial costs of this expensive procedure. Most women alive today

ciation of lower quality of life among women treated with systemic chemotherapy as compared to local therapy has been observed in more recent studies (Ahles et al., 2005).

Information on the long-term consequences of breast cancer are also available from the longitudinal Nurses’ Health Study, a study that began in 1976 and has prospectively followed 121,700 female nurses ages 30 to 55 (Michael et al., 2000). The unique contribution of this study is that information on functional health status is available about women both before and after their diagnosis of cancer. In addition, the study was able to control for age-related changes in functional status by comparing women with a history of breast cancer to the large cohort of women in the Nurses’ Health Study without breast cancer. In this study, there were greater than expected declines in physical function and role function due to physical and emotional problems, vitality, social function, and increased bodily pain among the breast cancer survivors relative to the control population. Risk

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