Breast cancer, the most common life-threatening malignancy in the West, is more curable than ever but remains one of the most common causes of cancer death. The cost of this disease is high; so, too, are the costs of treatment because no “magic bullet” cure exists. Yet, the death rate from breast cancer is falling in most Western countries even though the number of cases remains relatively unchanged. This likely reflects increased attention to the details of care.
Because progress against breast cancer is incremental - ie, no single treatment is instantly recognized as dramatically superior – big disparities exist in how various treatments are applied in different countries. Even though science may clearly point to the best way to fight breast cancer, uneven application of new treatments may cause many women to suffer, or even die, unnecessarily.
Although the causes of breast cancer remain unknown, early detection, before cancer cells spread, is crucial. Large randomized trials from several decades ago showed that mammography added to regular physical examination improves early detection, reducing the risk of death. Recent studies focus on the ideal age to begin screening and the ideal frequency of testing. Soon debates about the ideal technology – conventional mammography, digital mammography, ultrasound, magnetic resonance imaging, or a combination of technologies – are likely.
Screening with mammography is clearly superior to no screening and our first priority should be to assure that women are screened. Arguments about effectiveness here frequently focus on cost-effectiveness. But if this is the barrier to widespread use, efforts to lower costs should be pursued, for this is no excuse to deny women the benefits of screening.
Surgery, although not always curative, is the mainstay of treatment because most tumors left in place will spread. The classic surgical option was the mastectomy, where the entire breast and surrounding tissue was removed. Appreciating the fact that breast cancer could spread even before it was treated led to clinical trials testing breast-sparing surgery (“lumpectomy”). Studies show that the majority of women can be safely treated in this way.
Within the US, variations in the use of breast conservation are linked to surgical bias, as well as to availability of radiation therapy. Individual patients should not be encouraged to have mastectomies because of their surgeons’ bias, although there are specific circumstances where this is appropriate. To treat cancer cells that might remain in the breast even after an optimal surgical procedure, radiation to the preserved breast is routinely used. Even if the breast is removed, radiation is sometimes needed to prevent recurrence of the breast cancer on the skin of the chest.
In the case of breast conservation, radiation therapy is needed from the beginning, except in unusual circumstances. Efforts to assure access to high quality radiation therapy should be made so that breast cancer does not require the loss of a breast. Surgeons and pathology laboratories performing breast conservation need to be skilled in determining the adequacy of the procedure to assure patients of the best result.
Because breast cancer is so invasive and spreads so unpredictably, surgery is not always sufficient. But treatment of cancer cells that may have spread beyond the breast is possible with systemic therapy, meaning drugs. Unfortunately, we cannot know in advance if surgery will succeed because we cannot detect if cancerous cells have spread. This is why treatment of breast cancer is ideally multi-disciplinary and multi-faceted, including not only local treatment of the breast but also systemic treatment for the entire body.
The only way to approach cells that might have spread throughout the body is to give medicines because only drugs circulate throughout the body. Systemic treatment given after surgery is called “adjuvant therapy”. Here, however, are found the widest variations in treatment, both among and within countries. This reflects honest intellectual differences as well as monetary concerns and limits.
The basic adjuvant options are hormone treatments and chemotherapy. Hormone therapy takes advantage of the fact that many (but not all) breast cancers have receptors for the female hormones estrogen and progesterone. Interaction with these receptors can kill cancer cells. Chemotherapy comprises a large variety of drugs that directly kill cancer cells.
Investigators at Oxford University conduct an overview every five years of the many adjuvant treatments now available, and this report points to some clear conclusions. At least 50,000 women have been treated in clinical trials that demonstrate conclusively the impact of tamoxifen, the most widely used anti-estrogen treatment.
Before the Oxford overview, American oncologists typically did not recommend tamoxifen for young patients while Europeans often recommended it for all patients including those whose tumors lacked the requisite receptors. As an outgrowth of the Oxford findings, there is a more consistent approach now and evidence of improving outcomes. Several hundred thousand women are now alive because of effective anti-estrogen therapies.
In contrast to hormone treatments, given only to patients likely to respond by virtue of an analysis of their hormone receptors, chemotherapy is given to all or any eligible patients. Hence, the impact of chemotherapy appears to be smaller than that of hormone treatments in some patient groups. A predictive test for responsiveness to chemotherapy would be a major step forward in treating breast cancer as it might allow more selective use of these agents.
Chemotherapy, usually comprising several drugs, is effective at killing cancer cells, increasingly safe, and adds to the effectiveness of hormone therapy. Building on this success, current research is exploring new drugs, particularly those that rely on our growing biological insights. For example, some aggressive breast cancers were found to have an excess of a protein called HER2. An antibody targeting HER2 appears to be effective both when given alone or in combination with conventional chemotherapy, but such therapy in the adjuvant setting will raise the cost and complexity of care.
Newer targeted treatments entering clinical trials are likely to be even more contentious because of their cost. For some new agents, it is fair to ask whether they truly represent an advance over previously available (less expensive) alternatives. For novel agents, such as the anti-HER2 antibody Herceptin™, where there is no precedent, this cost must be considered against its novel action, activity, and limited toxicity.
These challenges and questions are becoming more frequent and societies must ask how much they can afford. This requires more than discussion about how health care money is spent because this can force doctors and patients to fight over crumbs when what is needed is bigger loaves (budgets)! Discussions over expenditures should not pit pediatricians against oncologists but instead, patients and physicians should discuss with governments overall expenditures for health and non-health needs.
Because the outlook for women can be improved if everyone conforms to best practice, the best available care must be provided to breast cancer’s victims even as we search for incremental steps forward. This requires hard decisions at the societal level as well as dedicated advocates for patients. We should resist sacrificing lives simply because of expense.