“My daughter is 14 and I lug her back and forth to the mall and to her friends; I take care of the house, with my two Chihuahuas and husband. My son is 18 and he helps me with my daughter and going to the grocery store. I’m just a mom who does chemo every week.”
— Mrs C, a 37-year-old woman with metastatic breast cancer
“I am struck by the strength and courage of women with metastatic breast cancer. You could imagine them so bogged down carrying the weight of their potential mortality around the corner. And I did have one patient say to me, ‘Dr Robert, you don’t know what it is to have death stalk you every day.’ I can imagine some patients feel that way some of the time. What I’m impressed with is that many of the patients don’t seem to feel that way most of the time. They’re somehow able to carry on with their lives, knowing that the clock is ticking and that their disease may change, but they continue to come to the office with smiles, being upbeat and having meaningful lives. Part of the reason I think we see this is that today we can offer our patients so many better-tolerated treatment options — endocrine agents, chemotherapy agents, biological agents like trastuzumab — that can give people quality of life and a better chance of living longer.”
— Nicholas J Robert, MD
“I’ve always enjoyed my interactions with the nurses, and one good thing that came from this cancer is that I’ve encountered a whole new profession where the driving force is wanting to help people. In my career, people are driven to promote themselves. But in oncology nursing and with some of my oncology doctors, human relations is the critical element. So, I look forward to my appointments, because I experience women (and some men) who are kinder and gentler. The nurses do a good job with the infusions, but what they’ve also done for me is listen to my issues, particularly the physical side effects of chemotherapy. They let me talk about my life under chemo and my life under a metastatic diagnosis. They offer perspective; they provide a lot of information and help me rally my emotional strength. And they’re very sensitive.”
— Ms F, a 42-year-old woman with metastatic breast cancer
Nick Robert is an unusual medical oncologist. While he maintains a busy US Oncology-based clinical practice focusing on breast cancer, he also is very actively involved in clinical research. I asked Nick and two of his oncology nurses — Heather Morgan and Ann Marie Bamford — to see if they could identify patients with breast cancer from their practice who might be interested in being interviewed for this educational program. I didn’t specify anything other than that the patients had been treated with at least one form of molecular targeted therapy and that they would be comfortable sharing their experiences anonymously on this audio program.
To my surprise, the three women I interviewed were all between the age of 37 and 42 and had metastatic disease. I sat immobilized listening to their courageous stories as they verbalized a panoply of feelings about their life circumstances. Like many well-known breast cancer researchers, Nick’s practice tends to have a higher fraction of younger women who perhaps are more active about seeking second opinions than older women.
Judging by the volunteers for our recording session, younger women may also feel more impetus to make their stories known to others. It also seemed that through the recruitment of these women, Nick, Heather and Ann Marie might have been making a point about the compelling nature of breast cancer in the premenopausal years.
Oncology nurse Jean Lynn is also interviewed in this program, and she discusses many of the issues specific to younger breast cancer patients — particularly concerns about treatment-induced menopause and fertility. As you will hear, dating and marriage are extremely important to some of these patients.
Jean started the Breast Care Center and Mobile Mammography Program at George Washington University and is familiar with issues related to cancer screening and diagnosis in younger women, as exemplified by the painful story on this program of Ms Y, a 41-year-old woman who was initially told for months that a mass in her breast was benign. On eventual diagnosis, the tumor was locally advanced with many positive axillary nodes. Sadly, delayed diagnosis of breast cancer is a very common occurrence in younger women and one of the most frequent scenarios for malpractice litigation.
It is easy to say that young women with breast cancer are better off than patients with similar stage disease treated in the past, but it is also clear that we have a long, long way to go. Gershon Locker and Mark Pegram are nationally respected clinical research leaders in molecular targeted therapy for breast cancer, and in this issue they review recent developments in their fields.
Gersh is one of the lead investigators in the ATAC trial, the largest cancer treatment study ever conducted. This landmark study focused on the first form of molecular targeted therapy, endocrine treatment, which attacks tumor cell growth via the estrogen and progesterone receptors. ATAC demonstrated that in postmenopausal women with estrogen receptor-positive tumors, the third-generation aromatase inhibitor, anastrozole, resulted in few recurrences and less toxicity than the other tried and true treatment, tamoxifen. Gersh reviews detailed subprotocol data on important endocrine-related secondary effects of these agents, including endometrial cancer, an increased risk of thromboses and vasomotor symptoms with tamoxifen, and bone loss and arthralgias with aromatase inhibitors.
Dr Locker also discusses new endocrine treatment strategies, including the injectable pure antiestrogen, fulvestrant, which seems to have a unique mechanism of action in that it leads to degradation and loss of the estrogen receptor in breast cancer cells. Fulvestrant is now used solely in postmenopausal women with metastatic disease, but new trials are investigating combinations of this interesting agent with other endocrine therapies and biologic agents. Eventually, these approaches are likely to be utilized in the adjuvant setting.
Mark Pegram reviews the breathtaking pace of clinical research in women with HER2-positive tumors, particularly the evolving use of the monoclonal antibody, trastuzumab, which is now a standard part of first-line therapy for this subset of patients with metastatic disease. A number of major clinical trials are evaluating this fascinating agent in the adjuvant setting, and most researchers expect results from these studies over the next two to three years.
This issue of our series provides an educational window into the most common neoplastic condition in younger women, and the message that comes across is clear — a great deal has been learned about optimal care for these patients, but much more research is needed before optimal management is truly defined.
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