Efficacy of Adriamycin

I was dianosed with Breast Cancer almost 2 years ago and  one of my meds was the adyamicin which left me with congestive heart failure. I am not saying that it was not good for me, but now I can not work and Social security refuses to give me help. What a bomber hey?

Nico,

This thread was started last summer (May 2007).  It's unfortunate that the original post included the statement, "Did you know that Adriamycin should no longer be used to treat breast cancer?".

There are highly qualified, board-certified oncologists at NCI Comprehensive Cancer Centers that would disagree with that statement, or would at least say that it is premature.  A more accurate statement would have been, "Did you know that oncologists are questioning whether Adriamycin is appropriate for treating all the various subtypes of breast cancer?" 

The main arguments for phasing out Adriamycin in the treatment of BC are 1) its long-term side effects (mostly the possibility of cardiac damage), and 2) evidence that its effectiveness may be greater in HER2+ tumors than in HER2-negative ones.

The benefit of Adriamycin in HER2+ tumors is probably not because of HER2 itself.  It turns out that HER2 is very near another gene, Topo II, which encodes an enzyme called "topoisomerase II alpha."  When HER2 is "over-expressed" or amplified in a tumor (HER2+), Topo II is sometimes amplifed as well.  Over-expression of Topo II occurs in about 1/3 of all HER2+ tumors.  Based on retrospective testing of tissue blocks, it appears that the best response to Adriamycin and other anthracyclines may be in that small percentage of tumors that over-express Topo II.  Since only about 25% of BC are HER2+, it follows that only about 8% of BC will be highly responsive to Adriamycin.  At least, that's the mathematical argument.  It's also possible that some HER2-negative tumors over-express Topo II, but I haven't seen those numbers.

There appear to be two main research groups advocating a phase-out of Adriamycin (doxorubicin) in treatment of early-stage BC, particularly in the case of HER2-negative tumors.

In the U.S., the most vocal opposition to Adriamycin comes from a group led by Dennis Slamon at UCLA Medical Center.  Slamon is pretty blunt in his criticism of Adriamycin--he thinks there is such a small group of women who would benefit from it, that it shouldn't be used at all.  In fact, I read in an editorial in the Journal of the National Cancer Institute that the UCLA group has decided to "avoid" using Adriamycin-based chemo regimens in the treatment of BC.

The other group of critics is led by Stephen Jones at Baylor/U.S. Oncology Group in Houston.  They conducted a prospective study which showed that disease-free survival and overall survival were greater in women treated with Taxotere/Cytoxan than with Adriamycin/Cytoxan.  Jones is not quite as outspoken as Slamon about moving away from Adriamycin, although he thinks that will eventually happen.  In the meantime, he wants to see more evidence. So his group is conducting another study that will compare Taxotere/Cytoxan with Taxotere/Adriamycin/Cytoxan in women with HER2-negative tumors.  He expects there will be no difference in effectiveness; but the results won't be in for several years.

Plenty of oncologists outside those two centers think it's too early to give up on Adriamycin.  They say there's just not enough evidence yet:  the studies so far have been on small numbers of women; or they involved retrospective testing of archived tissue blocks; or they were statistical "meta-analyses" of previously published reports.

I hate being on the "cutting edge" of anything, but that's definitely where we are with BC treatment.  It's true for so many aspects--SNB vs. ALND; 6 weeks of daily radiation therapy vs. the "Canadian" method; aromatase inhibitors vs. tamoxifen.  There's always something new coming along, that will benefit women in the future but may not help those of us going through this right now.

otter 

Nico, it will be very interesting to see what your onco says.  I was originally supposed to get Adriamycin/Cytoxan.  It's sort of a standard therapy for early-stage BC that has not spread to the nodes but needs to be hit with chemo.  Fifteen years ago, I most likely would have been given CMF; but my oncos don't use that much anymore.

My first onco (the one I fired) simply told me I would be getting AC.  No discussion, no debate, no alternatives.  My second onco (the one I like) also said she thought I should get AC.  I asked her about the cardiac risks, and she said I would need a MUGA or echocardiogram before my chemo started.  I showed her a previous echo report, and she said my LVEF was OK.  I pointed out that the echo had been done 7 years ago, and she started to waffle a little.  (I never could have had a discussion like that with onco #1.)  Then she said, well, if I was in my 60's instead of 56, and if I had a long history of hypertension, she would be more concerned about the AC.  Well, I do have a history of HTN, and once I told her about it, she backed off completely and said Taxotere/Cytoxan (TC) would be a better choice.  Then she warned me that the immediate SE's of TC were probably worse than those of AC.

It was clear, though, that the medical oncos at my "NCI-designated Comprehensive Cancer Center" have not been won over by the Adriamycin opponents, at least not yet.

otter