The Crab in the Breast

In breast cancer, promising approaches of twenty years ago are still…promising.

Today I talked about breast cancer to an audience already energized about Breast Cancer Awareness Month. Among other things, I told them that diseases need lobbies, and that breast cancer has one, having learned from the AIDS awareness movement, which in a momentous few years in the 1980s turned our country toward committed prevention.

But in breast cancer, science has made limited progress during my lifetime. It wasn’t for lack of money; there was plenty to go around for the ideas that were available. The ideas were great; the results were not.

I don’t exonerate myself. I graduated from medical school in 1985, and I could have gone into breast cancer research; I did other things I thought were worthwhile. But in 1988 my wife was diagnosed. With the best care available, her cancer spread. And, with the best care not just in the U.S. but in Germany and Japan too, it took her life in 1996.

My elder daughter had just passed her eighteenth birthday. My son was fourteen, my younger daughter nine. Fortunately, their mother had lived long enough to give them a psychological foundation that even I couldn’t completely screw up. They suffered, they survived, and they eventually thrived.

But the treatments their mother got were almost the same as they were in eighteen-ninety six: as we said in medical school, Slash, Burn, and Poison.

In 1896, Halsted had developed the mutilating but effective radical mastectomy; radiation, unfocused and crude, was just being invented; toxic drugs completed the triad. Surgery was sometimes definitive; cutting the damn thing out is still the best option. But radiation and toxic drugs killed healthy tissues and organs as well as tumors.

Fast forward to 1996. Surgery was much more focused and conservative, but still often mutilating. Radiation was safer and more directed, but still debilitating. The drugs were less poisonous but still ravaged your gut, reproductive organs, blood, even your hair.

Survival was better, yes, and you were less likely to die from what the doctors did to help you. But the overall grade for a hundred years of medical progress? C+.

I went to a big national breast cancer conference in 1993 where many new things were just on the horizon. Not just new toxins that stretched a hard life out for a month or two, but new ideas based on different, revolutionary concepts.

One big line of research was angiogenesis. Tumors over a certain size have to build their own blood supply; if you stop that, you get a tumor you can live with. A professor of surgery in my medical school, Judah Folkman, was already famous for this work in the ‘80s. I recall a front-page article in the New York Times about a breakthrough years ago. Resulting effective treatments now? None.

So many ideas excited us all in the ‘80s and ‘90s: preventing metastasis, the process by which cancer leaves the local area and spreads in the body; stopping seeds from being sown in distant organs after they do enter the bloodstream; attaching the toxic drugs to molecules that seek out tumor cells and target them specifically, sparing healthy cells; making tumor cells especially vulnerable to radiation; and countless therapies that would result from the study of genes—both those of the tumor and the patient.

Beefing up the immune system was another shining idea. Result so far: interferon, a treatment that helps in melanoma, has no use in breast cancer. A Nobel laureate told me in my living room in 1978 or so that monoclonal antibodies would do great things; they actually did produce a result, one of two serious advances that are outside the harsh triad.

First, tamoxifen and other drugs that block estrogen receptors or diminish estrogen have a real impact on survival in women whose breast cancers contain estrogen receptors. Second, a growth-factor receptor called HER-2 can be blocked by Herceptin. This too makes a significant difference in the survival of women whose breast tumors bear that receptor.

Both these treatments are significant for women in certain categories, but their impact on total breast cancer mortality has not been huge. What about prevention?

Unlike lung, cervix, and colon cancers, on which preventive measures have made a tremendous impact, there is little that is known about preventing breast cancer. Reducing alcohol to one drink a day or less will help protect you. So will avoiding postmenopausal hormone treatments.

If you’re ready to change your life around, you can try having children early and often and breastfeeding them for years. It’s how our hunter-gatherer ancestors avoided breast cancer. They had around 150 ovulations and menstruations for our 450, and that seems to have made the difference. But even if you could mimic this, the gains would be limited. As for screening, the American Cancer Society just the other day admitted that screening is of uncertain value.

I have two daughters at increased risk for this disease that killed their mother. And what does medical science have to offer them that we couldn’t offer their mother when she was struck by it? Only a little–and certainly no cure.

One comment

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