The Top of My Christmas List

I will never forget the moment when I first found out about my wife's breast cancer. She had noticed an abnormal thickening in her breast and even though we were spending most of our attention focused on an adenoma on the opposite side, the surgeon felt that a biopsy would be prudent. It was a Monday morning, and I was at my desk. Because of my position within our institution, I happened to be on the distribution list of my wife's pathology report. However, before I got to that point in the mail, my close colleague came to my office to notify me of her diagnosis of invasive breast cancer.

Not knowing how to react, I immediately picked up the phone and called my wife. I told her the news. It was clear after a very short time that I was not the best person to be delivering this message and handed the phone to my colleague who continued the discussion with my wife.

Since then, we have done all the standard things. She underwent staging scans and with every negative test, a brief period of relief returned. She underwent adjuvant chemotherapy on a clinical trial. The trial she enrolled in involved an intensification of chemotherapy extending the number of cycles of dose-dense treatment.

After her sixth cycle of AC, planning for now six cycles of docetaxel, we began to receive emails from concerned members of the oncology community suggesting that with her particular type of breast cancer that she should consider adding platinum to her regimen. After much hand wringing, she decided to come off of the clinical trial and add platinum to finish off her adjuvant chemotherapy. She then completed radiation therapy, and we are pleased to report that at this point has negative CT scans. She finds herself on yet another clinical trial looking at the role of bisphosphonates to prevent bone metastases and recurrence.

Our experience with adjuvant chemotherapy and radiation for breast cancer is probably not unlike many thousands of families who endure this on an annual basis, with the obvious exception that my being part of the oncology community afforded us not only outstanding care, but premium international advice on her day to day management.

But did she really need adjuvant therapy and did it really help? If there is one thing that I would wish to receive for Christmas this year, it is that we should all have a better understanding of who should receive adjuvant chemotherapy for breast cancer, colon cancer, lung cancer, and other cancers and who should not. It is clearly the area in oncology where we dramatically overtreat a population knowing that we are only going to help a small portion of that total population. We need to be refocusing our efforts away from large randomized phase III clinical trials where we are, in essence, wasting a great number of patients due to our poor understanding of the subpopulation who will benefit from the therapy.

Instead we should be making a greater effort to identify those patients who are at the highest risk for recurrence and focusing our attention on them. It would also be important to know those patients who will not benefit from adjuvant chemotherapy even though they are at high risk. While this would be a sad story to tell and hard news to hear, it would allow patients and families to begin to prepare for the road of metastatic cancer that is ahead.

We do enjoy taking care of patients in the adjuvant setting because as oncologists, we perceive that this is our moment when we are contributing to the curative therapy of cancer. However, we must balance the significant life-changing side effects and relatively small benefit. If we drew a parallel to surgeons removing gallbladders or appendices, we would not tolerate such a high rate of toxicity. Yet our treatments are more toxic than those surgical procedures, and we accept these adverse effects every day.

So, in quick summary, we must shift our way of thinking in the world of adjuvant therapy. We must use all of our tools of molecular analysis to identify patients who are at risk for recurrence, treat only those patients, and leave more patients alone, either because they do not need the chemotherapy or because the chemotherapy that we have to offer today will not be of benefit.

—John Marshall, MD