Editor ’s Note

ONE OF THE TOUGHER JOBS ON THE PLANET

With all of the technologic advances in oncology, taking care of women with metastatic breast cancer continues to be a challenge that demands a great deal of skill, knowledge and compassion. Although many more options are now available, all of these patients and their physicians eventually encounter a point when the morbidity of treatment greatly increases relative to the potential benefit.Dr Kathy Miller told me a fascinating anecdote that underscores this dilemma:

“Several patients in our trials of anti-angiogenic agents were absolutely positive that the treatment was working, because they were feeling so much better. Their fatigue, nausea and anorexia dramatically improved,and we were also positive they were having great responses. These were typically patients with liver metastases, so we attributed a lot of their chronic nausea and anorexia to liver disease, and we were shocked when we got their CT scans, and they were clearly progressing. What we learned was that a lot of the symptoms we ’d attributed to their disease were actually symptoms of chemotherapy. And the reason they were better was that we weren ’t giving them chemotherapy anymore,and these new biologic agents were not causing any side effects. It was very humbling.

“The other experience that we never expected in these anti-angiogenic trials was that our patients struggled with not having side effects from these agents.We thought, ‘This is great — we shouldn’t see chemotherapy-like side effects.’ But we ’ve actually had a couple of patients complain about that, which just completely shocked us. And these women struggled with, ‘How do I know I’m in the game — doing something for my disease?’ These were ladies with refractory metastatic breast cancer — multiple previous chemotherapies — many had prior bone marrow transplants. They had spent a long time telling themselves, ‘This is what you have to do to get better — you have to have these side effects. ’So, when they received a therapy that didn’t cause any of that, on the one hand it was nice to be freed from those side effects, but some of them really struggled with, ‘How do I know I’m doing something here? How do I know I’m really in the fight?’”

All four of the researchers interviewed for this program touch on some aspect of the dilemma of chemotherapy-induced toxicity in the palliative setting. Joyce O’ Shaughnessy reviews the benefits of the orally administered fluoropyrimidine, capecitabine, which, if dosed appropriately, offers a highly effective treatment with much less of the classic toxicity Kathy Miller describes. But Dr O’ Shaughnessy also reviews new data on the combination of capecitabine and docetaxel, and Dr Miller and Dr Hyman Muss discuss the clinical implications of the encouraging survival improvement for this combination and the trade-off of increasing toxicity with combination therapies.

Dr Barrie Cassileth — who just prior to our interview delivered a presentation on alternative medicine in breast cancer — also commented on the psychosocial oncology crucible of metatastic disease.Dr Cassileth, a psychologist, believes that the primary reason patients seek alternative modalities is that they wish to exert some control over their illness — like Dr Miller’s comments about “staying in the fight.”

Dr Cassileth believes that oncologists can help patients participate in their care by making available safe and useful complementary modalities like massage therapy, reflexology (foot massage) and dietary recommendations. She also discusses the intense stress and frequent burn-out seen in oncologists, and notes that many of the complementary modalities that help patients — yoga, meditation and taking vacations — are equally useful to physicians.

On our last Breast Cancer Update program, Dr Gabriel Hortobagyi speculated on the possibility that current and future systemic therapies might eventually cure metastatic breast cancer — a dream that we all have. But at the moment, oncologists and patients must struggle every day with unanswerable questions, unfair choices, and decisions that hopefully will not have to be made by future generations.

—Neil Love, MD

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