Editor’s Note
	Vulcan Oncology

When an oncologist talks to a patient with metastatic breast cancer, one of the first questions should be, "What are your goals?" Not what are my goals as the physician, but what are your goals as the patient? And women will tell you very different things. Some will say, "My daughter is graduating from college next spring, and I don't care how ill I am, I want to be at her graduation." Others will say, "Quality of life is all I care about. I don't want to live longer if I'm not going to live well." And there is, of course, a whole spectrum of patients in between.

In Star Trek, Mr Spock gives the Vulcan hand salute and says, "Live long and prosper." Perhaps we should be thinking more in terms of "Vulcan oncology." In the long run, our job as doctors is to both lengthen our patients' lives and improve their quality of life. Everything else is of secondary importance. This almost borders on the philosophic, but my bias, and I will admit it's my bias and it doesn't have to be anyone else's, is that the major interest of patients is how long they live and how well they live.

George W Sledge, MD

George Sledge and his colleague Kathy Miller have spent so much time pondering challenging decisions in breast cancer management that I sometimes think of them as the "Indiana University School of Oncologic Philosophy." However, unlike ivory tower thinkers, these two remarkable physicians regularly bring their well-thought-out viewpoints into practice, and it is no wonder that the theme of focusing on interventions that either improve survival or offer quality-of-life benefits permeates their management strategies as it does this series.

For this issue, that theme has particular relevance as Dr Sledge cites his own data from the classic ECOG-1193 trial to argue against combination chemotherapy for most patients with metastatic disease. This study demonstrated that long-term survival was equivalent when sequential single agents were utilized, and like most breast cancer research leaders, George uses the most effective, least toxic single agent available except in very symptomatic patients or those with visceral disease, in whom he employs combinations.

Capecitabine is among the first single agents he regularly uses, capitalizing on the oral administration, lack of alopecia and favorable toxicity profile of this drug. He also frequently utilizes vinorelbine and gemcitabine early on, particularly because so many relapsing patients have had prior anthracyclines and taxanes.

When I interviewed Sandra Swain, my primary goal was to learn of her perspective on current clinical trials of adjuvant systemic chemotherapy, including the NSABP-B-30 trial that she is chairing. However, our discussion drifted into metastatic disease, and a case she presented reinforced the "Vulcan" philosophy described by Dr Sledge. Faced with the daunting task of managing treatment in a woman in her thirties with a supraclavicular, HER2-positive recurrence, Dr Swain recommended single-agent trastuzumab, hoping to avoid the toxicity but retain the survival benefit this agent has demonstrated when combined with chemotherapy.

Trusting Dr Swain's judgment, the woman embarked on treatment and had a complete response that now exceeds one year. One might argue that unlike the combination of trastuzumab and chemotherapy, trastuzumab monotherapy has not demonstrated a survival advantage; however, no randomized clinical trial has directly compared these two options. Dr Swain's presumption of efficacy certainly seems justified in this woman's case, and the patient was spared the toxicity of chemotherapy.

Stephen Jones discusses another facet of the "Vulcan" approach to metastatic disease as he delves into the emerging role of fulvestrant, a unique endocrine agent he believes offers a significant prolongation of response in a subset of patients. With the plethora of treatment options available in metastatic disease, it is becoming difficult to detect survival advantages in clinical trials because effective treatments may be given after the patient is treated in a study protocol.

While the randomized trial of fulvestrant versus anastrozole did not demonstrate a survival difference, there was a time to progression benefit for fulvestrant. As Dr Jones explains, this is completely in sync with his clinical impression. Most oncologists dread the moment when they inform a woman with metastatic disease that progression has occurred and therapy must be switched. Treatments that delay this event present an important potential benefit.

Mr Spock's purely scientific perspective often left him perplexed about human behavior, and oncologists face a similar challenge in providing care for patients with end-stage cancer who realistically cannot benefit from additional therapy, but cling to further interventions.

This is the art of oncology where science, empathy and experience intersect. Our series attempts to provide a window into the thoughts and feelings of experienced practitioners like Drs Sledge, Swain and Jones, and I often visualize a first-year oncology fellow - perhaps overwhelmed as many of us were with the burden of counseling patients with no effective options - listening to these and other experienced clinicians and realizing that there are no perfect answers, only our dedication to walk with our patients down this difficult path.

-Neil Love, MD

Select publications

Mauriac L et al. Fulvestrant (Faslodex) versus anastrozole for the second-line treatment of advanced breast cancer in subgroups of postmenopausal women with visceral and non-visceral metastases: Combined results from two multicentre trials. Eur J Cancer 2003;39(9):1228-33. Abstract

Robertson JFR et al. Fulvestrant versus anastrozole for the treatment of advanced breast carcinoma in postmenopausal women. A prospective combined analysis of two multicenter trials. Cancer 2003;98(2):229-38. Abstract

Sledge GW et al. Phase III trial of doxorubicin, paclitaxel, and the combination of doxorubicin and paclitaxel as front-line chemotherapy for metastatic breast cancer: An intergroup trial (E1193). J Clin Oncol 2003;21(4):588-92. Abstract

Vogel CL et al. Efficacy and safety of trastuzumab as a single agent in first-line treatment of HER2-overexpressing metastatic breast cancer. J Clin Oncol 2002;20(3):719-26. Abstract

Home · Search