Editor’s Note
	When in doubt, fire the coach

The hapless Miami Dolphins sacrificed their head coach recently, in acknowledgement that this football team is lost at sea. The talent pool had become dry, and every game plan ended in disaster. After years of excuses and pathetic claims that even though they couldn’t win games, the margins of loss were decreasing, the team ran up the white flag and decided to start over.

In my pessimistic moments, cancer research seems to have similarly run aground, and while we have made modest improvements over the years, each new “season” seems to end up as another losing one. I have wondered what would happen if, in our search for new ideas and better answers, we approached cancer research like football, looking for promising talent? This issue of our series brings to you three bright minds with novel approaches who would certainly be first round draft choices.

Monica Morrow is the “shut-down cornerback” of breast cancer who, season after season, receives all-pro honors. In this issue, Monica tells us of her latest research endeavor, endocrine assays on the saliva of patients, and the preliminary data are quite interesting. In an ongoing series of premenopausal women on tamoxifen, marked variations were observed in estrogen and progestin levels, and these correlated with breast density. This suggests the possibility that salivary assays might also correlate with treatment effects or prognosis. The assay is also one of the least invasive approaches available. “All the patient has to do is spit in a cup!” Monica chirps. We need more players like her on our reengineered cancer squad.

Mike Dixon is another oncologic freethinker, and like Monica, one of a small band of breast cancer surgeons who regularly contributes to the rapidly evolving research database on systemic treatment strategies. I always love listening to Mike — a UK researcher — talk about his fascinating experience with neoadjuvant endocrine therapy, a treatment approach that until recently was largely ignored by clinical researchers in the United States. We are not about to make the same mistake, and despite Mike’s European soccer connection, we welcome him as our punter, field goal kicker or both.

As we try to stack our team with hungry talent, a Marvin Harrison-like wide receiver is all but essential. One great candidate is Harold Burstein, a bright young Harvard oncologist who wrote the lead editorial last year to the Goss MA17 paper in the New England Journal of Medicine. Harold is part of a rapidly growing group of investigators who believes in and is committed to molecularly targeted treatment of cancer. In this program, he states, for example, that HER2- negative breast cancer is as different from HER2-positive disease as pneumococcal pneumonia is from staphylococcal pneumonia. We need all the Harolds we can get, and will gladly use a first round draft choice for him.

What about the existing, longstanding therapies for breast cancer? Richard Margolese has been telling me for 15 years that someday, surgery will not be used to treat breast cancer and will be relegated to a leech-like role in the history of medicine. Notwithstanding the hundreds of thousands of women with local tumors who have been cured, surgery in this situation conceptually seems a bit like doing a pneumonectomy in someone with pneumonia. The problem is that no penicillin has yet arrived on the scene, although the molecularists will point to trastuzumab on good days as the beginning of the end.

Should we fire the coach (whomever that might be) or just keep plugging away? Who knows? I just hope there is a strong-armed quarterback out there, or maybe a couple of humongous defensive ends, who will help us win a few more games… soon.

— Neil Love, MD
NLove@ResearchToPractice.net

Recent Faculty Publications

Monica Morrow

Hollingsworth AB, Singletary SE, Morrow M et al. Current comprehensive assessment and management of women at increased risk for breast cancer. Am J Surg 2004;187(3):349-62. Abstract

Hynes DM, Weaver F, Morrow M et al. Breast cancer surgery trends and outcomes: Results from a National Department of Veterans Affairs study. J Am Coll Surg 2004;198(5):707-16. Abstract

White J, Moughan J, Pierce LJ, Morrow M et al. Status of postmastectomy radiotherapy in the United States: A patterns of care study. Int J Radiat Oncol Biol Phys 2004;60(1):77-85. Abstract

J Michael Dixon

Barber MD, Jack W, Dixon JM. Diagnostic delay in breast cancer. Br J Surg 2004;91(1):49-53. Abstract

Cameron DA, Kerr G, Jack W, Bowman A, Kunkler I, Dixon M, Chetty U. Does everyone need letrozole after 5 years tamoxifen and breast conservation? Breast Cancer Res Treat 2004;Abstract 108.

Dixon JM. Role of endocrine therapy in the neoadjuvant surgical setting. Ann Surg Oncol 2004;11(1 Suppl):18-23. Abstract

Harold J Burstein

Burstein HJ et al. Preoperative therapy with trastuzumab and paclitaxel followed by sequential adjuvant doxorubicin/cyclophosphamide for HER2 overexpressing stage II or III breast cancer: A pilot study. J Clin Oncol 2003;21(1):46-53. Abstract

Burstein HJ et al. Trastuzumab and vinorelbine as first-line therapy for HER2-overexpressing metastatic breast cancer: Multicenter phase II trial with clinical outcomes, analysis of serum tumor markers as predictive factors, and cardiac surveillance algorithm. J Clin Oncol 2003;21(15):2889-95. Abstract