Editor's Note Team in need of a coach

Every medical oncology fellow quickly learns about interdisciplinary cancer care, but thank God for the American College of Surgeons’ mandate for tumor boards, because without them, we might be strangers. Personally, I don’t like to think about any surgeon, radiation oncologist or medical oncologist not regularly attending one of these valuable meetings. However, the truth is that we really don’t report to anyone, and our collaboration is pretty much voluntary.

This issue of our audio series attempts to demonstrate how critical it is that interdisciplinary team members talk to each other. We begin with the local control guys, and Pat Borgen and Frank Vicini comment on a plethora of surgical and radiation therapy research issues that profoundly affect systemic management decisions.

For example, Dr Vicini is the principal investigator of a critical NSABP-RTOG randomized clinical trial evaluating partial breast irradiation (PBI). This historic collaboration between two premier collaborative clinical trial groups will provide much-needed answers about PBI, albeit many years from now. In the interim, the pace at which this accelerated and patient-friendly treatment strategy permeates into the nonprotocol management algorithm utilized in the community treatment setting is anyone’s guess.

While we wait for definitive research results, patients should seek input from every team member regarding the advisability of PBI and which technique is preferable. Pat Borgen cautions us that local control may have much more of an impact on long-term survival than previously recognized, and one might imagine that PBI could either have a deleterious effect (if it results in suboptimal local tumor control) or could be a more effective modality (because treatment can be implemented prior to chemotherapy).

With an increasing number of patients receiving taxane-based adjuvant regimens that can take up to six months to complete, earlier radiation therapy could have a potential antitumor advantage.

From a quality of life perspective, avoiding six weeks of daily treks for radiation therapy is appealing, particularly after the physical and emotional trauma of adjuvant chemotherapy. However, patients will surely want to know what their medical oncologist has to say on this issue before they opt for an unproven treatment modality.

Input from Craig Allred, the pathologist for the interdisciplinary team collaborating on this issue of Breast Cancer Update, is unfortunately very disheartening. I have nothing personal against pathologists or Craig, who is a really nice man, but if Adam Brufsky’s interview provides ample documentation that contemporary systemic therapy of breast cancer is essentially target-driven, then Craig’s comments leave us wondering if we have the ability to measure the most critical targets every oncologist must consider — ER, PR and HER2 status. (My apologies to Phillip Roth for that very long sentence.)

I keep expecting some rebel breast cancer patient advocacy group to stage a massive protest at the NCI to demand that pathologists provide impeccable ER, PR and HER2 assays. At the present time, however, women are going to continue to relapse unnecessarily or receive suboptimal palliative care because we can’t get their pathology right. Even if recent history tells us that our usually capable nation is not totally effective in military intelligence gathering, we should be able to at least gather accurate information for the war on cancer.

Maybe we need more than ACOS-mandated tumor boards. Maybe we need someone to rally and guide the entire team — including nurses, pharmacists, radiologists, psychologists, social workers and others — and take a deep breath, and really figure out how to work together better so patients can receive the very best care we have.

— Neil Love, MD
NLove@ResearchToPractice.net

Select publications

Cell Markers and Cytogenetics Committees College of American Pathologists. Clinical laboratory assays for HER-2/neu amplification and overexpresion: Quality assurance, standardization, and proficiency testing. Arch Pathol Lab Med 2002;126(7):803-8. Abstract

Harvey JM et al. Estrogen receptor status by immunohistochemistry is superior to the ligandbinding assay for predicting response to adjuvant endocrine therapy in breast cancer. J Clin Oncol 1999;17(5):1474-81. Abstract

Kurosumi M. Significance of immunohistochemical assessment of steroid hormone receptor status for breast cancer patients. Breast Cancer 2003;10(2):97-104. Abstract

Layfield LJ et al. Assessment of tissue estrogen and progesterone receptor levels: A survey of current practice, techniques, and quantitation methods. Breast J 2000;6(3):189-96. Abstract

Paik S et al. Real-world performance of HER2 testing--National Surgical Adjuvant Breast and Bowel Project experience. J Natl Cancer Inst 2002;94(11):852-4. Abstract

Press MF et al. Comparison of HER-2/Neu status determined by fluorescence in situ hybridization (FISH) in the BCIRG central laboratories with HER-2/neu status determined by immunohistochemistry or FISH in outside laboratories. Breast Cancer Res Treat 2002;76(Suppl 1);Abstract 238.

Roche PC et al. Concordance between local and central laboratory HER2 testing in the breast intergroup trial N9831. J Natl Cancer Inst 2002;94(11):855-7. Abstract

Zarbo RJ, Hammond ME. Conference summary, Strategic Science symposium. Her-2/neu testing of breast cancer patients in clinical practice. Arch Pathol Lab Med 2003;127(5):549-53. Abstract

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