How long can a patient wait before treatment?
It is no surprise that this question has not been studied at length. Who normally recommends waiting to treat a cancer? As soon as a diagnosis of cancer is available, there is an overwhelming urgency to do something about it in hopes that intervention will stop an unregulated and potentially lethal process that started, in many instances, for reasons that are not clear.
Studies of the natural course of breast cancer are very limited. To obtain data about the natural course of untreated breast cancer, one must look at data from decades ago. According to Hellman and Harris (2000), a study done at the Middlesex Hospital in early 1900’s (data was collected between 1805 and 1933) looked at outcomes for 250 patients who had been admitted with advanced forms of breast cancer. These patients were admitted for terminal care, and very few had a diagnosis of early breast cancer.
Studies of the natural course of breast cancer are very limited. To obtain data about the natural course of untreated breast cancer, one must look at data from decades ago. According to Hellman and Harris (2000), a study done at the Middlesex Hospital in early 1900’s (data was collected between 1805 and 1933) looked at outcomes for 250 patients who had been admitted with advanced forms of breast cancer. These patients were admitted for terminal care, and very few had a diagnosis of early breast cancer.
What is remarkable about this study is how long the patients lived without any treatment. Realizing that the majority of patients (74%) had stage IV disease, it is surprising to learn that the median survival for this group from the onset of symptoms was 2.7 years while as many as 18% of untreated patients lived 5 years, and 4% lived as long as 10 years.
How biased this information is remains uncertain. Individuals who were reported on did have a postmortem examination; however, information was collected over a period of one hundred years, and how many individuals were excluded is unclear. The study does suggest, however, that not every breast cancer is rapidly growing and that many forms of the disease follow a rather slow pattern of growth.
The presence of distant metastases (areas where cancer has spread in the body after originating in the breast) frequently results in an undesirable and fatal outcome. The time that it takes a breast cancer to metastasize appears to be ‘influenced by the size of the primary tumor’. Clearly, the smaller a breast tumor is in size the longer it takes for cancer to appear in a distant part of the body (Hellman and Harris 2000).
The problem at the time of diagnosis is that staging tests are not conclusive, and it is unclear, therefore, how long a patient can wait before seeing an expert. Most studies, however, demonstrate that delaying intervention for weeks and even months is not life threatening.
Some evidence suggests that the interval of time from the discovery of a mammogram abnormality and clinical detectable breast cancer is about one to two years. This implies that early stages of disease are not frequently lethal; therefore, especially with early-stage breast cancer, time is available for discussing surgery and other treatment options without putting a patient at risk (Hellman and Harris 2000).
Another more recent study examined the timing of the administration of chemotherapy in early forms of breast cancer (Cold et al. 2005). Clearly, death from breast cancer is influenced by the presence of macro and micrometastases (large and small areas where cancer has spread in the body after originating in the breast), and chemotherapy is the best method of treatment for metastases. Investigators in the recent study reviewed existing reports and the results of the Danish Breast Cancer Cooperative Group (DBCG). In the trial by the DBCG, investigators examined survival based upon time of initiation of chemotherapy among 7,501 breast cancer patients treated between 1977 and 1999. Four different timings of chemotherapy were studied: the initiation of chemotherapy between 1 and 3 weeks after surgery, at 4 weeks after surgery, at 5 weeks after surgery, and between 6 and 13 weeks after surgery. The evidence suggested that chemotherapy could be delayed for up to 3 months without an adverse outcome. This was true even in high-risk patients with lymph nodes involved and among patients with high-grade or receptor negative breast tumors.
Similar results had been demonstrated in other studies, including one done at M.D. Anderson (Buzdar et al. 1982). This study, however, was not randomized, and the type of chemotherapy provided to patients is not as potent as current chemotherapy treatment. Still, the study, like previous studies, suggests that chemotherapy started within three months of surgery does not lead to an undesirable outcome.
Similar results had been demonstrated in other studies, including one done at M.D. Anderson (Buzdar et al. 1982). This study, however, was not randomized, and the type of chemotherapy provided to patients is not as potent as current chemotherapy treatment. Still, the study, like previous studies, suggests that chemotherapy started within three months of surgery does not lead to an undesirable outcome.
References
1. Hellman, S. and J. R. Harris. 2000. Natural History of Breast Cancer. In Diseases of the Breast. Philadelphia: Lippincott Williams & Wilkins.
2. Cold, et al. 2005. Does Timing of Adjuvant Chemotherapy influence the Prognosis after Early Breast Cancer? Results of the Danish Breast Cancer Cooperative Group (DBCG). British Journal of Cancer 93: 627-632.
3. Buzdar, A., et al. 1982. Effect of Timing of Adjuvant Chemotherapy on Disease-free Survival in Breast Cancer. Breast Cancer Research and Treatment 2: 163-169.