I have been carefully monitoring the Breast Meetings in San Antonio this week so that I can summarize and report to you a summary of the findings and what they mean to you. Friday morning’s plenary session by Lesley Fallowfield from the UK was the best yet. She actually did a whole talk on the collateral damage of treatment both in the newly diagnosed and those with metastatic disease. Much of what she talked about mirrored what you have told us in the Collateral Damage Collaboration we have been conducting with the Komen Foundation, the Young Survival Coalition and many other advocate groups that have been spreading the word. She titled her talk “Psychosocial/Survivorship issues: are we doing better?” She went on to say that while “many more women have prospect of cure and others survive longer, nothing comes without cost, considerable psychosocial and iatrogenic harms often created by diagnosis and treatment both acute and long term.”
This was a talk aimed primarily at clinicians and researchers (I wonder how many were in the hall?) and really made some great points about the collateral damage of treatment. For example, 30% of women expressed symptoms of anxiety or depression and 47% of women more than two years out from treatment expressed fear of recurrence, which Dr. Fallowfield pointed out was not inappropriate. She mentioned a variety of proven but under-utilized approaches to help women deal with their anxiety, including cognitive therapy, yoga, mindfulness, visualization and other techniques. She noted that nausea and vomiting are no longer the most common side effect of treatment probably because of better symptom management. They have been replaced by fatigue as the biggest complaint. Counterintuitively, exercise is actually the best treatment both psychologically and also probably by decreasing the inflammatory cytokines.
Dr. Fallowfield also covered lymphedema, hormonal issues, and sexual problems (reported by 70% of women within the first two years post diagnosis.) Interestingly, she also included financial hardships, which are rarely mentioned. Not only the cost of care and drugs (she is in the UK where they have a government-run health care system,) but loss of income (40% are not back at work at 10 months).
The particular problems of patients with metastatic disease were also highlighted in Dr. Fallowfield’s talk. In one study done in the U.S., 48% of participants reported difficulty talking to others, denying severity of illness to close friends and relatives and most experienced shock, isolation and loss of control. They also found that their physical problems, especially fatigue and pain, led to canceling activities that caused guil. Bone metastases were a particular problem with pain and fractures. She discussed choices of treatment; i.e., IV or oral pills and whether consideration should be given to delivering even IV treatments at home rather than in a clinical setting.
Dr. Fallowfield’s concluding slides said that “the emphasis on change from how long to how well patients live,” pointing out that most of the improvements and research on survivorship have been on early breast cancer and not metastatic breast cancer. She advised support services and survivorship care plans be tailored to individual needs. It is really encouraging that this issue was part of a plenary session at the meeting rather than an afterthought. I certainly hope it is the beginning of a serious conversation about the “cost of the cure”.
Pre Surgery Responses to Predict Whether a Drug will Work
Some news on the triple negative front came from presentations exploring whether adding carboplatin to chemotherapy before surgery would improve the pathological response; i.e., decrease the size of the tumor before surgery. Two studies showed benefit. This is promising and since it has now been shown in three studies, it is likely to be real. Other drugs, such as avastin or a new blocker of vascular endothelial growth factor did not seem to make a difference. Another study looked at whether circulating tumor cells in the blood can be used to predict when a drug being given for metastatic disease should be changed. Although it seemed as if it should, it turned out that it did not.
Two interesting studies confirmed what many have suspected, that the molecular analysis of the primary tumor may not be the same as that of a metastases. As we have learned that initial breast cancers may not be uniform in their molecular type, it now appears that the initial treatment may treat the majority of cells, leaving the minority type to persist and show up as metastasis. This would suggest that whenever possible, metastatic disease should be biopsied and analyzed.
Finally, an Italian group collected all the published data on hormone-induced fertility treatments and found no increase in breast cancer incidence.