Editor ’s Note

LESSONS FROM CLINICAL TRIALS ON LONG - TERM ADJUVANT ENDOCRINE THERAPY

Nothing fascinates me more than presenting breast cancer treatment scenarios to a group of oncologists and observing the variation in response. For many years, we have used an electronic keypad response system to poll physicians attending the Miami Breast Cancer Conference (see enclosed announcement), and chuckling can be heard in the audience when — as happens not infrequently — the responses are evenly divided among four or more choices.

For all the available consensus conferences and practice guidelines, cancer specialists and their patients often must confront decisions with no clear-cut optimal choice. This challenge is made more complex by the very rapid evolution of new clinical research data and publications that practitioners must consider. While physicians generally strive to make evidence-based decisions, many difficult-to-define intangible factors enter treatment recommendations in oncology.

To move closer to the heart of this important issue, the last issue of Breast Cancer Update included a discussion of an actual patient being treated by one of the research leaders interviewed. Debu Tripathy — asked to pick an instructive case from his practice — chose a woman who presented at first diagnosis with metastatic breast cancer. Interestingly, for this issue Kevin Fox also selected a patient in this situation, and one of the four cases discussed at the interactive clinical case session at the recent Lynn Sage Breast Cancer Symposium was again a woman presenting with metastatic disease.

In addition to the usual complexities of choosing therapy for metastatic breast cancer, this scenario — particularly in a young women, as presented by Dr Fox — offers the psychosocial challenge of not only coping with the first diagnosis of breast cancer but of the grave long-term prognosis of widespread disease.

As is often the case in patients with ER-positive tumors, the first major crossroad encountered in Kevin’s patient was choosing between endocrine treatment and chemotherapy. I was not surprised that the patient received goserelin, and then goserelin/anastrozole, as most breast cancer research leaders generally support using endocrine therapy in these patients, unless there is rapidly progressing visceral disease.

I was also not surprised when Kevin speculated that many community-based oncologists would have used chemotherapy in this situation — a trend with which he vehemently disagreed. Debu Tripathy made similar comments about what he perceives to be an underutilization of endocrine therapy by many oncologists.

To learn more about what seems to be a community/tertiary care dichotomy in practice patterns, we presented Kevin’s case in a survey to 20 practicing oncologists and queried them on a variety of related management issues. Also interviewed for the audio program were Dr Patricia Madej, an oncologist with a very busy community-based practice, and Columbia University’s Dr Linda Vahdat, whose group — under the direction of Dr Karen Antman — has been a major driving force in research on high-dose chemotherapy with stem cell support. Drs Madej and Vahdat provided additional perspectives on the dilemmas of treating Dr Fox’s patient. Selected comments on the case, along with the oncologist survey results, are included in this web guide.

Clinical trial participation is also an important management option, and at one point, Kevin’s patient chose to enter a study of liposome encapsulated doxorubicin and paclitaxel. For our last issue, we introduced what will be a continuously evolving guide to breast cancer clinical trials, which is now posted in its entirety on BreastCancerUpdate.com. This extensive resource contains summaries of more than 200 studies currently accruing patients, with links to the actual protocols and supporting journal articles.

The focal point of Breast Cancer Update has always been the interface of clinical research and patient care — an arena where a physician’s knowledge, judgment and compassion come together — and often, sincere, very well-informed and dedicated oncologists may recommend different approaches. The lack of clarity in many issues such as the decision between endocrine treatment and chemotherapy in metastatic breast cancer, is no reason to avoid this discussion. On the contrary, we hope that these opinions and perspectives will be helpful in arriving at the very best decision for each individual woman in this daunting situation.

—Neil Love, M D

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