DELAYED TREATMENT OF BREAST CANCER

I’m always amazed when a woman who knows she has breast cancer asks if she can wait to start treatment.   There isn’t a perfect answer to this question, but we know some things about delayed treatment of breast cancer. 

Some delay between biopsy and treatment is acceptable.

Fifty years ago, when a biopsy identified cancer, surgeons removed the rest of the breast as soon as possible, usually within hours. 

When we started doing breast biopsies as independent, separate procedures, the surgery would be at least a day or two later.

The so called “two-step procedure” was initially adopted because it allowed women the time to find a surgeon who would treat them without a mastectomy.   But in the process we learned that doing the biopsy and the mastectomy at different times did not harm women. 

Separation of a week or two between biopsy and surgery does not risk a woman’s healthBut we still don’t have a good answer on how much delay is too much.

There is limited information on the effects of delayed treatment.

For ethical reasons, there will probably never be a planned trial of delayed surgery, so our information comes from observing women who had delay for a variety of unplanned reasons.  

Researchers have looked at delayed treatment three ways:  1.  Delay of surgery when surgery is the only treatment.  2.  The effect of delayed surgery when the patient receives chemotherapy in a timely manner.  3. Reduced benefits if chemotherapy or hormone therapy is delayed for women with higher risk of spread of disease, for example stage II breast cancer.

1.  A long delay may reduce survival of women who have surgery alone.

A study of 2,384 California women all under 40 years of age found that delay of over six weeks adversely affect survival if the women received no anti-cancer drugs [click for abstract]. Younger women tend to have more aggressive cancers so it seems that earlier surgery is important for more aggressive cancers.  However, this is not a major problem today because chemotherapy is offered to most younger women with breast cancer.

In contrast, a study of 1,065 North Carolina women average age 61 years old with early stage breast cancer found that a delay of up to 60 days did not reduce survival [click for abstract].  This agrees with a study of 648 Malaysian women almost all over age 40 (only a few received anti-cancer drugs ) for whom up to two months delay did not reduce survival [click for abstract]

A separate study of 2,045 Korean women extended the delay with no effect to 120 days [click for abstract].  However, a delay of over 120 days to surgery did reduce survival if the woman depended on surgery alone for her treatment. 

Thus, for aggressive cancers in younger women, a delay over six weeks seems to reduce survival.  For less aggressive cancers, reduced survival is seen after a 120-day delay. 

It must be remembered that almost none of these women had any anti-cancer drugs.

2.  Delay of surgery has no effect if the patient receives timely drug therapy.

The same California study that looked at delayed surgery without chemotherapy found that if patients had chemotherapy before surgery – neoadjuvant therapy – or chemotherapy after surgery, delaying the surgery itself did not adversely affect survival [click for abstract]

3.  Delay of drug therapy reduces survival.

Drugs are often given after surgery before there is any evidence of cancer growing anywhere else in the body.   The idea is that cancers that are too small to find will be less established and thus more sensitive, to the drugs.  Giving drugs before detecting any spread of cancer is called adjuvant therapy.

The North Carolina study mentioned above included 721 separate women diagnosed with locally advanced breast cancer.  For these women, a delay of over 60 days to the beginning of treatment – usually chemotherapy – significantly reduced survival [click for abstract].

This agrees with a study of chemotherapy given to 2,549 British Columbia women.  A delay of 12 to 24 weeks to the start of chemotherapy significantly reduced five-year survival from a range of 83 to 88 percent (for various time intervals up to 12 weeks) down to 78 percent for a delay of 12 to 24 weeks [click for abstract]

Can adjuvant therapy be delayed and only given if the cancer comes back?

A possible planned delay of treatment is to withhold therapy intentionally and not give it unless the cancer returns some time later.

In underdeveloped countries, money is scarce, even for drugs such as tamoxifen.  This has led to studies of whether it is necessary to treat everyone at the time of diagnosis – thus spending money treating everyone – or whether it works to treat only the women whose cancer comes back.

A study randomized 709 Vietnamese and Chinese women with Stage II breast cancer to answer just this question. Half the women received intense hormonal treatment with removal of their ovaries and tamoxifen pills beginning right after their surgery.  The other randomly selected young women were closely followed but did not receive any treatment after surgery unless the cancer came back [click for abstract]. 

If a woman in the second, close observation group had a recurrence, she was offered the same ovary removal and tomoxifen that the other group had received right after surgery (three-quarters of women with recurrent cancer actually received the treatment offered). 

In essence, women had the same treatment.  The difference was the timing.  Some women had adjuvant treatment before metastases grew, and some women only had treatment after their metastases grew enough to be detected.  Importantly, most women in the second, closely observed group never needed any further treatment, so money was not spent giving them hormone treatment.

Earlier therapy before metastases grew improved survival.

There were 24 percent fewer deaths among the women who received early, adjuvant therapy compared to those whose treatment was intentionally delayed. When women who did not receive adjuvant treatment had a recurrence, they responded less well to treatment. This caused an absolute increase of 6 more women alive for every 100 women who had adjuvant therapy compared to delayed therapy. 

This is the only study I can find comparing the same treatments given early or later.   The available information, however, suggests that if treatment is delayed until the cancer grows back – or if a cancer is left in place and allowed to grow – the woman never has the opportunity for optimal response to treatment again. 

Don’t panic, but make decisions and start getting care.

There is almost always treatment to help women with recurrence of cancer, but the best thing is to reduce the risk of recurrence by treating within a reasonable time.

A woman can use some time to decide what is the right treatment for her.  However, she will have her best chance for disease-free survival if she gathers her information and starts treatment as soon as she is comfortable with her decisions. 

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