When is active surveillance of a tumor appropriate?

Question: In a recent column, you addressed breast cancer in an older woman.

She expressed concern about overtreatment of small tumors and if just keeping an eye on the tumor (active surveillance) might be a way to go.

Doyou think active surveillance might be an option at any a geina woman’s life, rather than chemo and radiation for some tumors? — G.C.

Answer: “Active surveillance” refers to not treating a lower-risk condition initially, but actively monitoring it to look for signs that it might be changing to a condition with greater risk. This is a preferred means for many men with very-low-risk or low-risk prostate cancer. A recent trial has been started and is recruiting women with DCIS (ductal carcinoma in situ) to see whether active surveillance might be reasonable for this condition as well. I think thisisani mportant study, with the potential to affect many women who otherwise are recommended for lump ectomy, sometimes with radiation. Many women, in fact, opt for a total mastectomy for this condition, and if we can identify women who might not need such invasive procedures, that would be a major benefit.

Howev er,fora woman with invasive intraductal breast cancer (which is a much more aggressive tumor than DCIS, usually), Ic an’t recommend active surveillance. Olderw omen with this diagnosis, or those with one of many other medical conditions, still can receive medication, like an anti-estrogen, which has far fewer side effects than surgery or traditional chemotherapy.

Women who would not consider treatment of an invasive breast cancer should reconsider getting a mammogram in the first place.

Q: I hav e been taking hormone treatments for 10 years. I’m 60 years old. I have concerns about long-term usage.

I tried getting off them slowly. The results are always th esame:I end up with 10 to 15 hot flashes a day. I can’t sleep, because I get five to six at night. I end up going back on my Divigel and progesterone. Do y ouh ave any thoughts on how I can eventually get off them without going through the hot flashes again? — Anon.

A: P uts impl y,you have three options: go off the hormone and likely be miserable; continue the treatment and have a risk of side effects; or tr y a different treatment.

I don’t recommend being miserable. The other options are both better ,i n my o pinion.

Continuing estrogen treatment has risks. Combined treatment with estrogen and progesterone increases risk of blood clotting, coronary artery disease and breast cancer. It decreases the risk of bone fracture and of colon and lung cancers.

Other options to reduce hot flashes without the risk of hormone treatment include medications like venlafaxine or citalopram. A new treatm ent,ca lled a neurokinin 3 receptor antagonist, shows promise for the future.