December 2006: Updates from San Antonio 2006

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HRT decrease leads to ER+ decrease?

Question from Peachpie: In USA Today there was an article about the decrease in breast cancer after women between the ages of 50-69 stopped taking hormones. At first I thought it referred to tamoxifen, Arimidex, etc. Was this in reference to hormones like Premarin, etc. and not the post-cancer treatment hormones that we take that are supposed to keep cancer at bay, particularly estrogen-positive ones?

Answers —Jennifer Griggs, M.D., M.P.H.: That's a great question! It's a common misunderstanding when we make the distinction between hormonal therapies and hormone replacement therapies. Oncologists don't use hormone replacement therapy (HRT), so we forget to clarify that for our patients. But you are exactly right—the guess on why we are seeing a decrease in estrogen-receptor-positive cancers is that women decrease the use of hormone replacement therapy. Hormone replacement therapy is the use of estrogen and progesterone to treat menopausal symptoms and other changes that happen after the menopause. Hormonal treatment for breast cancer, on the other hand, is used to decrease the risk of recurrent breast cancer or to prevent breast cancer altogether in hormone-receptor-positive cases.

Marisa Weiss, M.D., president and founder: It's great that there was a drop in the number of women affected by breast cancer during the year of 2003. We're not sure exactly how to explain this drop. Researchers think that a decline in the use of HRT that occurred around the same time may explain part of the drop. Of course, we want to see this drop continue over many years—and drop down to zero! To get the risk of breast cancer down to zero, we have to figure out all the different causes that may contribute to breast cancer. HRT is only one of a list of causes.

Jennifer Griggs, M.D., M.P.H.: HRT probably does not cause breast cancer, but facilitates breast cancer's growth.

Tykerb available? Only given with Xeloda?

Question from SarahL: When will lapatinib (Tykerb) be available, and will it only be in conjunction with capecitabine (Xeloda) for patients who have already had an anthracycline?

Answers —Jennifer Griggs, M.D., M.P.H.: Lapatinib is a so-called targeted therapy that appears to have some activity in patients with a particular form of breast cancer. It appears to be effective in some women whose tumors are no longer responding to Herceptin (chemical name: trastuzumab), in combination with Xeloda. The addition of lapatinib led to longer responses to treatment. There are many trials and studies going on to figure out who will benefit the most from lapatinib. The approval date is expected to be soon, but the regulatory process can sometimes be very slow because of concerns about safety. I would expect that the drug will be used in women who are not on Xeloda, but the best use of this drug is still under study. You can ask your doctor if you might be able to get this medication through a program called an expanded access program. You may also be eligible for one of these clinical studies that are ongoing.

Marisa Weiss, M.D., president and founder: breastcancer.org will be one of the first to know when lapatinib obtains FDA approval. Always stay tuned!

Serum test good diagnostic tool?

Question from WSB: A presentation at SABCS showed that lapatinib may be effective whether or not serum levels of HER2 marker are low or high. Does this make this serum test useless as a diagnostic or monitoring tool for lapatinib treatment? Any comments about this test regarding Herceptin treatment?

Answers —Jennifer Griggs, M.D., M.P.H.: It is always helpful to find a way to predict who will benefit the most from treatment, and we certainly are encouraged when such a test exists with a treatment such as lapatinib. The fact that the circulating blood test that you refer to in this one trial did not predict response does not mean that this test isn't helpful. It appears that this test is helpful in predicting who might respond to Herceptin.

Marisa Weiss, M.D., president and founder: As we move along, we also want to learn how the different tests for the HER2 gene compare in their reliability and accuracy and ability to predict response to treatment. We have a lot of work to do in that arena (correlating tests of the HER2 gene and protein in blood as well as in the cancer tissue itself).

Jennifer Griggs, M.D., M.P.H.: Different groups of scientists and physician experts are working very hard to make these methods uniform across different laboratories, so that your test results, whether the test is on you or your tumor, won't be dependent on where you have your care.

Marisa Weiss, M.D., president and founder: When tests become more uniform from hospital to hospital, state to state, country to country, then women will be better able to understand what the results of a clinical trial mean for her—if that trial is coming from her own back yard or from a place around the world. It's important for clinical trials to have reliable measures of different cancer characteristics, as well as unique personal characteristics in each patient. We will make a lot more progress when there is such standardization of important test results.

Exercise and diet affect chance of recurrence?

Question from Pierini: I have hormone-negative breast cancer. The latest research suggests a low-fat diet lowers recurrence rates as much as 66% for hormone-negative cancers. I try to exercise at least one to two hours most days of the week—but I remain about 20 lbs. overweight. I take vitamins. I now feel like every time I eat a fat gram, I'm killing myself. Does cancer "feed" on fat, so less fat means I'm "starving" the cancer cell?

Answers —Jennifer Griggs, M.D., M.P.H.: It's an unfortunate side effect of this type of research that we shift the burden sometimes to the woman who has had or does have breast cancer. Although one wants to feel strong and powerful and in control, in many ways we're limited by the disease itself or the available treatments. Your question brings up two points. The first is that how delightful it is to know that for women with hormone-receptor-negative cancers there is something that can be done in addition to chemotherapy. Certainly, the results of this study which were presented at another meeting and appear to be consistent, offer encouragement for just that reason. The second point is that an individual woman's prognosis and risk of recurrence is sometimes a mystery to us. My concern with this kind of research is that it shifts the blame to the person, should she have a recurrence.

All that being said, you are certainly a motivated, dedicated person and are working incredibly hard to take the best care of yourself. In your particular case, your excess weight is of concern to you. There are several possibilities for women who can't seem to lose that extra weight. The first would be to talk to your doctor about the possibility of another medical problem, such as thyroid disease, which is very common among women. It is also possible that you are not exercising as effectively as you could. You might want to talk to somebody at a gym, or to your doctor, especially your primary care doctor, about ways you could improve the effectiveness of your exercise regimen. Finally, consulting with a registered dietitian might give you some clues into other ways that you can reduce your fat intake while still enjoying the lovely foods in life.

Marisa Weiss, M.D., president and founder: This study provided women on the low-fat treatment arm or intervention arm with a lot of support and education on what a low-fat diet means, how to implement it and stick to it over time. So Dr. Griggs' advice to get counseling from a registered dietitian or nutritionist is very important. The women who followed the low-fat diet also lost weight relative to the other treatment arm where the women stuck to their usual moderate-fat diet level. So we're not sure exactly what may have helped reduce the rate of recurrence: the low-fat diet, the weight loss, or both. In addition, the women who lost weight on the low-fat diet didn't necessarily get to their ideal body weight. Our ideal body weight represents a goal that we all have to work to get to on a daily basis.

In addition to a regular exercise program, I have found a lot of success with Weight Watchers. Also tune into Breastcancer.org's discussion board called The Pound. There are a lot of people there waiting to help you with encouragement and practical tips. Finally, you have to fire the "itty bitty critty-cal committee" that lives in your mind, that intermittently criticizes you for eating this or that, or not doing this or that. You've got to give yourself a lot of support and encouragement to get there, and reach out to experts and to each other to get the support you need. With more follow-up over time, there may also be a significant benefit to a low-fat diet and weight management in women who had a hormone-receptor-positive breast cancer. The study is not completely mature yet. I think they're also having some difficulty with funding to get some of the longer term follow-up results.

Jennifer Griggs, M.D., M.P.H.: Exercise is good for your brain, your heart, your bones, your sex life, your concentration, sleep, etc.

Benefits of taking AIs more than five years?

Question from Nance: Has there been any research on whether there will be benefits for taking aromatase inhibitors more than 5 years for early breast cancer, or by following an aromatase inhibitor with tamoxifen? Also, I have been taking Arimidex for 2 years, but I have heard that studies show Femara is more effective. Is this true? Should those of us on Arimidex ask to be switched?

Answers —Jennifer Griggs, M.D., M.P.H.: You ask two very good questions. The first is still being answered in very large, well-designed clinical trials for which we do not yet have results. The aromatase inhibitor studies that we have so far had, if you've read the previous online chats, raised as many questions as they have answered. As far as the question about whether or not one of the aromatase inhibitors is better than another, we do not have any clear clinical studies that tell us which is the best or if there is a best. My guess is that they are all fairly equivalent. The one thing to keep in mind is if you have side effects with one drug, that switching to another drug may help you tolerate the medications better, but other studies have shown that many side effects just get better with time, even if you stay on the same medication.

Marisa Weiss, M.D., president and founder: Most of what we learn about the efficacy of each medication and how they might compare comes from clinical trials of large groups of women. But in any individual doctor's practice taking care of a particular patient who is special and unique, one medication may be more easily tolerated than another. This may involve a little bit of experimentation or trial and error. Each time you try a new medicine you have to give it a chance to work, approximately three months to see how the side effect profile affects you.

Abraxane okay to substitute for Taxol?

Question from JustNancy: I will be starting chemotherapy next week. The doctors have recommended 4 cycles of dose-dense AC followed by 4 cycles of dose-dense Taxol. My question is, can I substitute Abraxane for the Taxol? I have read (on this website) that it is easier to tolerate, quicker to administer and gives the same results.

Answers —Jennifer Griggs, M.D., M.P.H.: Abraxane (chemical name: albumen-bound paclitaxel) is a very good drug for the rare patient who has a very severe reaction to Taxol (chemical name: paclitaxel). On the other hand, serious problems with nerves are more common with Abraxane, and we are not recommending that we substitute Abraxane for Taxol at this time. This would be something to talk over with your own doctor, however. The drug, moreover, is not approved except in people who have advanced, metastatic breast cancer. More practically, the drug is usually not covered by insurance except in rare circumstances in people without metastatic disease. Most people tolerate Taxol very well, and the severe reactions that you've been told might happen are very rare. We wish you the best in the next few weeks, months, and years.

Marisa Weiss, M.D., president and founder: All along the way, your doctor will make sure that you get the greatest benefit and reduce any side effects.

Combining Arimidex and Faslodex okay?

Question from HKlaus: Is it advisable to combine Arimidex and Faslodex, i.e., are any preliminary results available from the two ongoing international trials?

Answer —Jennifer Griggs, M.D., M.P.H.: The ongoing study that you refer to is a test of Arimidex (chemical name: anastrozole) compared to Arimidex plus Faslodex (chemical name: fulvestrant). This is a great study, and we await the results eagerly. At this point, no preliminary results are available, and I have not recommended the combination of these two drugs unless people are part of this clinical study. Although it seems like it would make sense that the two drugs together would be better than either alone, common sense is not always borne out when we have the actual data.

Raloxifene for early stage breast cancer?

Question from Beth: Is it okay to take raloxifene for the treatment of early stage breast cancer? I understand that the FDA will be approving the use of the drug in the near future. Do you know when?

Answer —Jennifer Griggs, M.D., M.P.H.: This is an excellent question, and one that I hear a lot in my practice. Raloxifene (brand name: Evista) is a drug very similar to tamoxifen that is used in postmenopausal women to prevent worsening osteoporosis (loss of bone mineral density). Recently, raloxifene was compared to tamoxifen in preventing breast cancer in women who did not have breast cancer but were at high risk of getting breast cancer. It appears that raloxifene may be slightly less effective than tamoxifen in preventing breast cancer, but that it "wins" because some of the rare but serious side effects of tamoxifen are less common in people on raloxifene. In contrast, tamoxifen is considered a gold standard SERM (selective estrogen receptor modulator). I would not recommend substitution of raloxifene for tamoxifen in a woman taking a SERM.

Any other medications for metastases?

Question from Yaffa: I'm now being treated with Avastin and Xeloda for a fourth recurrence of metastatic breast cancer. What other drugs for metastatic breast cancer are coming down the pipeline?

Answers —Jennifer Griggs, M.D., M.P.H.: There's more research being done on other targeted therapies that, combined with drugs like Avastin (chemical name: bevacizumab), may provide additional benefit even after drugs like Avastin stop working. There was a long session at the San Antonio Breast Cancer Symposium about this class of drugs, and this was probably the most exciting part of the symposium. These drugs work by shutting off the blood supply to the cancer cells. We are learning more about how the cancer cells learn to grow and become resistant in people on Avastin. Cancer cells are sneaky, but we're getting smarter! In your case, you and your doctor will choose your next medications based on your previous medications that have worked, so it's hard to say exactly what's next.

Marisa Weiss, M.D., president and founder: Researchers are studying medications that work in many different ways simultaneously. We expect to learn more about these new directions sooner than later. At the next big meeting of ASCO (American Society of Clinical Oncology), we expect some of those new results to be presented. Stay tuned.

New research for triple-negative survivors?

Question from SandyC: I was fortunate to be in attendance at the Symposium on Friday and Saturday and was inspired to find so many experts involved in seeking prevention and treatment options for breast cancer. However, I found no information about research or targeted treatment options and recurrence prevention for triple-negative survivors. Please give us some encouragement and information.

Answer —Jennifer Griggs, M.D., M.P.H.: Triple-negative cancers are breast cancers that are negative for the estrogen receptor, the progesterone receptor, and HER2. Sometimes, you might see these cancers referred to as "basal" breast cancer. With all the attention given to hormonal therapy and HER2+ tumors, it can be extremely frustrating to have a triple-negative cancer. Just the name itself is off-putting. It's important to remember that the benefits of chemotherapy are greater in patients with hormone-receptor-negative tumors, compared to hormone-receptor-positive tumors. In addition, there is a great deal of attention being given to the genes (the genetic makeup) of these cancers. I would say that the medical literature regarding breast cancer in biomedical journals is actually focused quite heavily on this type of cancer. As we learn more about the things that go wrong to make these cancers develop, we're going to get even more focused and smarter about ways to interrupt and kill these cancers. Most of the advantages that we see with chemotherapy are, again, effective in the so-called "triple-negative" cancer.

Herceptin more effective after two years?

Question from SFiet: I have been taking Herceptin for one year and want to know if the new clinical trial results now suggest that 2 years of treatment is better. I had early-detected breast cancer with no lymph node involvement. Any news on whether I will be taking the drug for another year?

Answer —Jennifer Griggs, M.D., M.P.H.: At this point, we don't know the optimal duration for treatment with Herceptin in people who do not have metastatic breast cancer. There is an ongoing study comparing one year of Herceptin to 2 years of Herceptin in people following surgery who have no evidence of disease elsewhere in their bodies. Treatment in this setting is called adjuvant treatment. Given that you had no lymph node involvement, my recommendation in this setting in general would be to give the year-long course, but talk this over with your doctor.

Reason for decline in DCIS recurrence?

Question from RoseB: In the study about declining recurrence rates of DCIS over about a 10-year period, it seemed that a lot of the decline was hard to attribute to a specific cause (tamoxifen or radiation). Was there any discussion of whether pathologists have improved their process for declaring that margins on DCIS are clean? Or perhaps have increased their margin requirements?

Answers —Jennifer Griggs, M.D., M.P.H.: It is definitely the case that the reporting standards for pathology reports are improving. We now get much more information from our pathologists, which helps us give much more accurate treatment advice to our patients. It does appear that not all women with DCIS (ductal carcinoma in situ) benefit from tamoxifen, and most of the studies that were presented at the conference in San Antonio did not break down the findings by whether or not the patient was more or less likely to benefit from tamoxifen. Although we still await large published studies on this, it appears that DCIS that does not have the estrogen receptor is not as likely to benefit from tamoxifen. As I just said, the studies that looked at the benefit of radiation therapy did not all account for the differences in DCIS types. In fact, testing DCIS for the estrogen receptor only recently became something we ask our pathologists to do. Even more important in interpreting these studies, very few women with DCIS choose to take tamoxifen. So the mixed effects of tamoxifen and/or radiation therapy are not as complicated as one might think, because so few women actually take tamoxifen after surgery for DCIS.

Marisa Weiss, M.D., president and founder: In addition, over the years, we've made big strides in the quality of mammography. This is the test that is best able to detect DCIS. For example, through the new technology that provides digital mammography we are able to better catch even DCIS at its earliest point. This earlier diagnosis of a non-invasive breast cancer could also positively influence the outcome of women who have such a condition.

News on bio-identical hormone replacement?

Question from Tharps: Is there any new research on the use of bio-identical hormone replacement to treat vaginal dryness after hormone-dependent breast cancer?

Answers —Jennifer Griggs, M.D., M.P.H.: This is a controversial area.

Marisa Weiss, M.D., president and founder: It's highly unregulated. The FDA does not regulate any plant-derived "hormonally active" substances, whereas they are extremely rigorous in their regulation of pharmaceutical grade/manufactured hormonal medicine. As a result, there are an unlimited number of such products on the shelf that are marketed and packaged in a very appealing way. Some may be helpful, but it's also possible that some could be harmful. We agree that these substances deserve and need to be studied more rigorously so that people like you can get more solid answers to such an excellent question.

Jennifer Griggs, M.D., M.P.H.: Vaginal health is a very important part of your life and finding a health care provider you can talk to about your symptoms and your sexuality is critically important.

Marisa Weiss, M.D., president and founder: Amen sister! We will provide you with a number of links to information at breastcancer.org about a happy, healthy, functional vagina.

Editor's Note: Read more about vaginal dryness.

Targeted treatments for ILC?

Question from Yself: Are there targeted treatments on the horizon for invasive lobular carcinoma?

Answer —Jennifer Griggs, M.D., M.P.H.: Lobular carcinoma is less common than ductal carcinoma. It does appear that the prognosis of lobular carcinoma is as good as ductal carcinoma, and some studies suggest a more favorable prognosis with lobular cancers. Most lobular cancer is hormone-receptor-positive and HER negative—both factors associated with an improved prognosis. There are some uncommon forms of lobular cancer that appear to be more "active" (more rapidly dividing). Our pathologist partners are becoming more aware of the importance of telling us about those cancers. In general, the treatments that work for ductal cancers work for lobular cancers. In fact, lobular cancers, being more often hormone-receptor-positive, respond to the most proven targeted therapy of all, anti-estrogen therapy.

How does chemo score affect treatment?

Question from JeanMc: I know Genomics is conducting a clinical trial investigating lowering the lower end of the score for chemo to 11. I had a score of 15 July/05. If it becomes apparent that the lower range should be below the current score of 17, how (or if) will that affect the treatment for those of us with scores between 11 and 17 in the past?

Answers —Jennifer Griggs, M.D., M.P.H.: The genomic profile test that you refer to generates a score between 0 and 100 that appears to correspond to the risk of recurrence and, possibly, the benefit of chemotherapy. The patients for whom we use this test, sometimes called OncotypeDx, are people who have negative lymph nodes (no cancer in the lymph nodes) and estrogen-receptor-positive breast cancer. These are the same patients in whom we recommend hormonal therapy. The test can help us decide who would benefit from chemotherapy as well. The study that you are referring to is being run by several clinical trial groups throughout the country. Our goal is to figure out whether or not chemotherapy helps women who have the in-between (intermediate) score. In other words, some women have a "high" score, and in those women we recommend chemotherapy. Some women have a "low" score, and in those women we often recommend hormonal therapy only. The in-between group, again called the intermediate scores, are less clear in terms of what to do. So the study is enrolling women who have an intermediate score and then randomly assigning them (like the flip of a coin) to either receive chemotherapy or hormonal therapy only.

For women to be able to go on this clinical study, they need to have a score that the study group has called intermediate and you are right that what is called the intermediate group for the study is different from the published clinical trials. It's understandable that this leads to some uncertainty on the part of a woman who has what we previously called a low score and still call a low score, but who could be considered eligible for this study in women with an intermediate risk score. We will not know the answer to your question until the results of this study are available. In the meantime, your score was interpreted according to the published clinical studies.

Marisa Weiss, M.D., president and founder: This ongoing study will require several years before meaningful results are available.

Recurrence rates for lumpectomy, no radiation?

Question from Mags: Could you speak to the press release that came out today regarding lumpectomy with no radiation recurrence rates? Is there some additional information that you can provide regarding this study? Thank you.

Answers —Jennifer Griggs, M.D., M.P.H.: There were a couple of studies looking at omission of radiation therapy. One of these studies was in women over the age of 70. This study had over 600 patients who were followed for over 8 years. It appears that there is a real, albeit small benefit of radiation therapy in this group of women over 70. The risk of disease coming back in the breast was very small at the 8-year mark, so the use of radiation therapy can help make that small number even smaller.

Marisa Weiss, M.D., president and founder: Radiation therapy can reduce the risk of recurrence in the breast by about two-thirds for women with invasive disease, and 50% in women with ductal carcinoma in situ (non-invasive breast cancer). The value that radiation might bring to you depends on your own risk of recurrence. If your risk starts out small, radiation can make it smaller. You have to work with your doctor to decide if going from a small to a tiny risk is worth getting the treatment. If your risk is medium, radiation can help make the medium risk small. Most women who are facing any significant risk of recurrence will want to do any reasonable treatment that can reduce the risk of them ever having cancer again. This is something to talk to your doctor about.

Jennifer Griggs, M.D., M.P.H.: The second study that was very interesting to me was of over 5,000 patients with early stage breast cancer. Patients were randomly assigned to receive an extra dose of radiation therapy, called a "boost," compared to no boost. It appears from this study as though patients younger than 40 years benefited from this extra boost more than older patients (not that 42 years old, for example, is old). We're getting smarter at fine-tuning our treatments, which may help us avoid unnecessary treatment in some people. Your particular treatment will be determined by your particular situation.

Bone marrow transplants for Stage IV?

Question from Rick84: My wife has Stage IV breast cancer and has completed three months of chemo, Taxol, and Avastin. Her doctor has suggested a bone marrow transplant from her brother, who is a match. How successful could this bone marrow transplant be?

Answer —Jennifer Griggs, M.D., M.P.H.: The use of bone marrow transplants for patients with Stage IV breast cancer has been studied, and has, up to this point, not been shown to be better than standard chemotherapy such as your wife is receiving. (Taxol and Avastin is an example of a novel combination of treatments that we've studied in rigorously controlled clinical trials with proven benefits.) There are no studies supporting the use of a bone marrow transplant with bone marrow from another person, such as a sibling, in breast cancer. Given that this is such an unconventional and untested form of treatment, you should consider a second opinion, maybe at a major medical center.

Results of exemestane vs. anastrozole?

Question from Kathy: Are there any results yet from the clinical trial comparing exemestane with anastrozole?

Answer —Jennifer Griggs, M.D., M.P.H.: Not yet. Both drugs are very good at treating both metastatic and early stage breast cancer. From other similar studies, it appears that these drugs are very similar to one another but that side effects may differ between drugs and between patients. Keep watching the research news on breastcancer.org.

Breath test to detect breast cancer?

Question from MGS: Was there an update on the trials for the new exhalation test that detects breast cancer? Details? Thanks.

Answer —Jennifer Griggs, M.D., M.P.H.: There is some work being done on early detection of breast cancer using molecules that might be excreted in the breath of a woman with asymptomatic breast cancer. These studies are extremely preliminary, but obviously exciting if they turn out to be positive studies. There were no studies that I am aware of that were presented at the San Antonio conference.

Ovary removal necessary for ER+?

Question from Ms R: We know that Arimidex has been a wonderful drug to combat recurrence in ER-positive breast cancers in postmenopausal women. Since this population is 4 times more likely to develop ovarian cancer in their lifetimes, does removal of the ovaries seem to be a prudent and sensible move?

Answer —Jennifer Griggs, M.D., M.P.H.: In premenopausal women, removing the ovaries will induce a surgical menopause. Such a procedure may reduce the risk of developing breast cancer in the first place and may reduce the risk of a breast cancer recurrence after treatment for breast cancer. Chemotherapy may provide some of the same benefits as removal of the ovaries. Studies are mixed on whether or not removing the ovaries or, alternatively, suppressing or shutting down the ovaries, gives additional benefit following chemotherapy. In postmenopausal women, removing the ovaries, which no longer function, does not reduce the risk of breast cancer recurrence. Your question about ovarian cancer is a separate issue. Although ovarian cancer is slightly more common among women who have had breast cancer, it is still a relatively uncommon cancer. The decision about removal of the ovaries to reduce the risk of developing ovarian cancer is highly individual. Your family history of breast, ovarian, male breast cancer, or early prostate cancer will play a role in whether or not removal of the ovaries is recommended. In addition, if you have a known gene abnormality in the BRCA I and/or BRCA II gene, removal of the ovaries and possibly the Fallopian tubes should be discussed with your doctors.

Study with AI plus Herceptin, no chemo?

Question from Rooster: I'm post-menopausal, hormone-receptor-positive, HER2-positive breast cancer. I want the benefits of hormonal therapy and Herceptin—but I'd really like to avoid chemo. I heard about a study using an aromatase inhibitor along with Herceptin, without the chemo. Tell me more about this?

Answer —Jennifer Griggs, M.D., M.P.H.: It sounds as if the tumor that you've been treated for is responsive both to hormonal therapies and to Herceptin. Most U.S. oncologists have favored chemotherapy in patients whose tumors are HER2-positive. The use of hormonal therapy and Herceptin without chemotherapy is particularly appealing in somebody with an otherwise "lower risk" tumor, for example, small tumor, negative nodes. The benefits of chemotherapy may be small in somebody with a small tumor and negative lymph nodes. Nonetheless, as I said above, most oncologists will recommend chemotherapy in this setting. This is something you'll want to talk about with your doctor in your particular case. At the San Antonio conference, the combination of an aromatase inhibitor and Herceptin was shown to be highly effective in women with advanced, metastatic breast cancer. Most of us who take care of patients have used this combination for quite some time, often with long-lasting results. Studying this combination without chemotherapy in women with early stage disease will be important before it becomes standard practice.