Dedicated to Bea Henderson, the owner of “San Francisco”, a women’s clothing boutique in Madison, New Jersey
Breast cancer’s new frontier was surveyed more than 100 years ago and was found wanting.
The natural history of untreated breast cancer was well known to doctors of the 19th and early 20th century. At the time, surgery was the only option on the table. Even then, women refused surgery and elected to take their chances. The choice to just do nothing invariably resulted in a protracted and ungodly demise. Interestingly, many of the women who agreed to surgery – always a Halstead radical mastectomy in which the breast, the muscles of the chest wall, and all the lymph nodes under the arm were removed – died in pretty much the same way and in pretty much the same length of time as the women who elected to just do nothing. “What was the point of surgery?”, they asked. Surgeons didn’t have much of an answer. It wasn’t until the 1970’s that less radical forms of surgery were introduced and were found to be as effective as radical surgery: women who had lumpectomy lived just as long as women who had “everything removed.” Indeed, even women who chose to have no lymph nodes removed lived as long as the women who had every lymph node in sight excised. Clearly, surgery wasn’t the key to survival. The truth of this has yet to fully sink in.
The introduction of chemotherapy for the treatment of breast cancer did what surgery failed to do – it increased survival. It increased survival significantly. The early studies looked at what happened to women who just did nothing versus those who received chemotherapy. The women who got the chemo lived longer, a lot longer. Yes, women who received chemo still died of breast cancer, but not to the same degree as those who opted out of chemo. Thereafter, chemo began to be part of the standard of care for the treatment of breast tumors larger then 1.0 cm, which is really pretty small. Again, not everyone benefited; but the women who received chemo lived longer, overall, than those who were candidates but elected to forego treatment.
Once it became clear that chemotherapy saved lives, the next objective was to design better drugs and to devise better protocols – recipes – for how those drugs should be given and to whom. Here we are today with a fairly well-ordered menu of what to give and who to give it to, but women seem to be pretty fed up with the penalties that attend the trials and tribulations of chemotherapy. That’s perfectly understandable. I really don’t blame them. There’s so much we still don’t know. And there are no guarantees, just statistics and mind-numbing numbers that don’t make sense to most patients who are trying to decide whether to let the doctors feed poison into their arms or take their chances by foregoing the tried and true.
The decision to not go the distance with the standard protocols found to be most effective for breast cancer patients of every type (protocols painstakingly carried out in thousands of randomized clinical trials) and do nothing instead is becoming more common of late. The news that one third of breast cancers diagnosed as a result of mammogram screening would likely never have bothered the patients if they had not been treated was a bitter revelation for hundreds of thousands of survivors! Of course, we have no way of telling at this point which of those women did not require treatment; but the fallout from this news led many women to wonder if they had been over-treated. Sadly, no one can say for sure. Not yet.
We’ve come a long way in 100 years, but it’s still very murky territory. Not much comfort there, I admit.
However, if we complete the research on the human mammary tumor virus (HMTV), and make further inquiries into the possibility that other viruses might cause breast cancer too, then we will be in a position to take everything off the table: surgery, radiation, and all forms of chemotherapy. If, as I suspect, HMTV plays a role in a large portion of breast cancer, we can make a vaccine like the one we now have for the human papilloma virus (HPV) that prevents cervical cancer. Today, if you get the HPV vaccine, you won’t get cervical cancer: the problem of how to treat cervical cancer does not exist when the disease does not exist. There is a distinct possibility that we could do the same for a large portion – perhaps, all – of breast cancer. Develop a vaccine that protects against HMTV: no disease, no treatment.
The time has come to broaden the choices we now have with regard to breast cancer. Treat it? Do nothing? Prevent it?