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	Editor’s Note
	Candor with Humility

As Michael Baum began his William McGuire lecture at the San Antonio Breast Cancer Symposium, there was no doubt in my mind that at some point, he would challenge the audience’s belief in a long-held concept. In the last issue of Breast Cancer Update, Gabe Hortobagyi mentioned Baum’s 1982 presentation in Jasper, where with only two years of follow-up for the classic NATO trial, he boldly predicted that tamoxifen would soon become standard of care for adjuvant therapy. Over the years, in journal articles, meeting presentations and interviews for this series, Dr Baum has always pushed us to critically evaluate long-held paradigms and beliefs. In his San Antonio presentation — as he states in this interview — he “dared to challenge the Holy Grail of mammography,” suggesting the possibility that in some patients, unnecessary biopsy can perturb and stimulate otherwise indolent tumors. His comments were grounded in science and clinical experience, but, undoubtedly, many attendees took great exception to his challenge of not only the medical rationale but also the ethics of current breast cancer screening practices in the United States.

One of the privileges of editing this series is the opportunity to develop longstanding relationships with “movers and shakers” in clinical research. It has been surprising to see how often these people are humble at heart, and Mike Baum is no exception. Last year, I met with him shortly after he presented perhaps the most important initial data set in the recent history of breast cancer research — the ATAC adjuvant trial. During our interview, he was totally at ease, and rather than promote his own role in designing and launching this historic study, he emphasized the dedication of the women who chose to enter the trial. Interestingly, Dr Baum also was very conservative in his approach to translating the data to clinical practice. It was not until recently, one year later with further follow-up, that he began to fully support the use of anastrozole as the first option for adjuvant therapy for postmenopausal women with receptor-positive invasive breast cancer.

I queried a number of research leaders about Dr Baum’s comments on breast cancer screening in San Antonio, and most disagreed with the notion that data supports the potentially deleterious effect of mammography on the biology of the disease.

However, there was near universal agreement with Dr Baum’s insistence that clinical research on breast cancer screening be held to the same standard as treatment trials. It is also difficult to argue with Dr Baum’s demand that the primary care community inform women about the risks and benefits of mammography before they undergo the procedure.

It is quite unlikely that further randomized trials of mammography will be conducted, and as is often the case in clinical practice, we will be left with an imperfect data set from which we must base decisions and recommendations. In that regard, it is interesting to consider a very striking graphic that was presented by Aman Buzdar in San Antonio comparing the ATAC trial results to the most recent findings from the tamoxifen versus control disease-free survival curves from the international breast cancer overview.

Dr Buzdar’s point is that the ATAC study’s data on tamoxifen overlaps the overview data (with anastrozole demonstrating an advantage over both), but within this graphic is a key message about current clinical research. There were more postmenopausal women with estrogen receptor-positive breast cancers in the ATAC trial than there were in the entire international overview of randomized trials of tamoxifen given for five years. Through more than 30 years of randomized trials in breast cancer, we have learned that the most effective way to avoid controversies like the one we see with mammography is to conduct very large, well-designed studies that will help lead to clear cut answers and clinical recommendations.

—Neil Love, MD

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