Editor’s Note
	Frank's mom

Few things are more enjoyable than a good old-fashioned tumor panel brawl, so it was with great pleasure that I was able to ruffle a few feathers during a Meet the Professor session I moderated at the recent Lynn Sage Breast Cancer Symposium.

A community-based oncologist presented a case referred for a second opinion. The patient had relapsed after prior therapy with neoadjuvant trastuzumab in a nonprotocol setting. I asked Dr Stephen Jones to comment on the neoadjuvant trastuzumab, and Steve launched into an extended polemic intended to crush any notion that this treatment strategy was acceptable.

I then called on another panel member, Dr Charles Vogel, my mentor when I was part of the University of Miami Breast Cancer Research Division and the one person in the room I knew would be unfazed by Dr Jones' rather strong opinion.

Sensitive to Steve's visible discomfort and umbrage, Chuck noted very quietly and calmly that, while he generally agreed that nonprotocol neoadjuvant trastuzumab is not appropriate, he had treated two carefully selected patients in his practice with this approach and both women had done extremely well.

What Chuck did not mention, and Steve definitely did not know, was that one of those patients happened to be the mother of our chief audio engineer, Frank Cesarano, who was recording the proceedings of that event.

I first met Frank in 1990 shortly after he graduated from the prestigious University of Miami School of Music. Prior to that time, our group had utilized a host of different freelance audio production engineers. I sought out Frank because a taping in Atlanta had gone terribly awry. Specifically, a fascinating interview with Bernie Fisher had been recorded incorrectly, and the audio was garbled and unintelligible.

Frank informed me that he personally could not fix this priceless educational resource, but he had heard that Gloria Estefan's producer had developed new software that might solve the problem. The next day, we trooped over to the Miami diva's recording studio and, amazingly, the problem was palliated, albeit at a exorbitant price. Frank and I have been working together ever since, and over the years he has played a central role in developing the Breast Cancer Update audio series - recording hundreds of my interviews with cancer research leaders.

This endeavor has now branched out into tandem audio series on prostate, colorectal and lung cancer, and in tracking down the very elite investigators in these fields, our partnership has, on occasion, resulted in some rather amusing situations.

For example, in 1999 I secured an interview with an internationally known researcher from the United Kingdom who was presenting an important paper at the San Antonio Breast Cancer Symposium. Like many of my interviewees from "across the pond," this investigator wished to be recorded very early in the morning due to difficulties coping with jet lag.

When recording at large meetings, we often convert a hotel suite into a mini-studio, and when I opened the door at 5:30 AM to meet this professor, I encountered a profoundly disheveled, bleary-eyed persona whose night out in one of San Antonio's Mexican cantinas left him - as Saturday Night Live's Mike Myers would say - without voice.

Having spent two years trying to arrange this recording, and knowing that this research leader might not be back in the United States for some time, I was determined to resuscitate my guest's voice. Frank had a suggestion, and before long he and I were pushing this doc into the bathroom of the suite, turning on the hot water in the shower to create some ambient steam in the room, and applying impromptu chest physiotherapy. The result was a fascinating but somewhat gravelly interview.

Around that time, Frank's 72-year-old mother, Mary Cesarano, was diagnosed with extensive but localized, HER2-positive, inflammatory breast cancer. For a number of specific reasons, her treating oncologist, Dr Vogel, decided to forgo his usual approach and utilized six weeks of neoadjuvant trastuzumab and paclitaxel followed by mastectomy, radiation therapy and one year of trastuzumab monotherapy. Today - more than four years later - Mary has no aftereffects of this treatment and remains cancer-free.

Frank and Mary Cesarano

Because Frank has been on our team for so long, many of the research leaders interviewed for our series get to know him, and some have learned about his mom's story. Melody Cobleigh, a pioneer in trastuzumab clinical research, always asks Frank how his mother is doing and smiles broadly when she receives the good news.

Sometimes, when I see Frank huddled over his recording equipment during a research leader's interview, I wonder what he is thinking, particularly when the topic turns to the management of HER2-positive disease in breast cancer patients.

I especially remember our interview with Dr Dennis Slamon, who humbly and eloquently spoke about how deeply he was moved by the human impact of his work on the lives of women treated with trastuzumab. Dr Slamon could not have known that a few feet away was one more family member whose life will never be the same because of this research.

In this issue of Breast Cancer Update, Dr Harold Burstein discusses a recent study he published on neoadjuvant trastuzumab, and like many other preoperative approaches, this work is providing very important clues about the mechanisms of action and predictors of response. Until further studies are reported - including findings from the major ongoing adjuvant trials - controversy will continue to exist regarding the role of trastuzumab in locally advanced disease.

Every CME program we produce includes discussion of clinical questions for which suboptimal databases confound the practice of evidence-based decision-making. This edition is no different as Denise Yardley discusses the role of TAC versus dose-dense AC Õ T adjuvant chemotherapy; Aron Goldhirsch comments on hormone therapy in premenopausal women utilizing ovarian ablation alone or with aromatase inhibitors; and Saul Rivkin presents a controversial perspective on sequential single-agent versus combination chemotherapy for metastatic disease.

Every oncologist has encountered cases with both positive and negative outcomes when interventions utilized stretch the boundary of existing evidence. Mary Cesarano's case typifies a carefully thought-out strategy that worked.

-Neil Love, MD

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