TIME: Almanac 1993/TIME Almanac 1993.iso/time/011491/0114351.000

Text File | 1992-08-28 | 8.5 KB | 168 lines

                D                                                              MEDICINE, Page 53

COVER STORIES

The Rough Road to Recovery


Options for therapy have multiplied, but making the right
choices can be daunting for both doctors and patients

By CLAUDIA WALLIS -- Reported by J. Madeleine Nash/Ann Arbor


    Colleen Fallscheer, a cheerful 40-year-old mother of two
from Waterford, Mich., is living proof that breast-cancer
therapy is not the horror show it used to be. A little over a
year ago, a mammogram revealed a bright malignant spot, no more
than 1.5 cm (about 0.6 in.) across, imbedded in the translucent
tissue of her left breast. A surgeon recommended a mastectomy,
to be followed by chemotherapy. Fallscheer was appalled. She
sought a second opinion from David August, a surgical
oncologist at the University of Michigan Medical Center, who
told her that her tiny malignancy made her an ideal candidate
for a lumpectomy, a less drastic procedure.

    Last November, in a two-hour operation, Dr. August's team
removed the cancer plus a margin of surrounding tissue, leaving
Fallscheer with a 5-cm (about 2-in.) scar in an otherwise
normal-looking breast. To catch any residual cancer cells, she
received six weeks of daily radiation therapy, which produced
a light suntan but left no permanent trace. "A lumpectomy plus
radiation does not cure more women than mastectomy," says
radiation oncologist Allen Lichter of the University of
Michigan, "but it creates fewer physical and emotional scars."
Fallscheer concurs: "It was only after I saw Dr. August that
I felt I wasn't going to die after all."

    Ten years ago, lumpectomy would not have been an option for
Fallscheer. Since then, studies have shown that when a tumor
is small, confined to a single area and readily accessible to
the surgeon's scalpel, lump removal plus radiation is no less
effective than removing the entire breast. But as Fallscheer's
experience shows, not every surgeon is convinced. Nor does
every eligible patient choose the lesser operation. Though
about 50% of breast-cancer patients are candidates for
lumpectomy, only about half of those elect it. Many, including
Nancy Reagan, feel safer if the entire breast is removed. "For
most women, whether or not they lose their pectorals is not the
issue," explains University of Chicago surgeon Monica Morrow.
"It's whether or not they lose their lives."

    Choice of surgery is only the first of many decisions faced
by patients and doctors. None are simple, and women sometimes
get the impression that there are as many variations in therapy
as there are doctors. The key question following surgery,
however, is whether the cancer has spread. It is not localized
disease in the breast that kills more than 40,000 U.S. women
a year, but the dissemination of the cancer to other, more
vital organs, usually the brain, the bones, the liver or lungs.

    To determine if the deadly process of metastasis has begun,
surgeons performing mastectomies and lumpectomies routinely
remove 10 to 25 lymph nodes from under the arm near the
affected breast and examine these glandular structures for
signs of cancer. A woman with "positive" nodes has a 37% to 75%
chance of a cancer relapse within five years, depending on the
number of affected nodes and the size of the original tumor.
In such cases, chemotherapy or hormone therapy will be urged.

    The kind of drug treatment depends on many things, including
a woman's age and the biology of her tumors. The cancer cells
of postmenopausal patients often require the hormone estrogen
in order to grow. If lab tests show the presence of estrogen
receptors in a tumor (a sign of a good prognosis), therapy with
tamoxifen, an estrogen-blocking drug, is usually recommended.
It reduces the risk of disease recurrence by approximately 20%,
with relatively mild side effects.

    Younger women and those who have no estrogen receptors
usually receive combinations of two to five chemotherapy
agents, such as Cytoxan and methotrexate, over a period of four
months to a year. Because these drugs target rapidly dividing
cells, they not only destroy cancer cells but also cells in the
hair follicles, the lining of the digestive tract and the bone
marrow. That produces the dreaded side effects of chemo: hair
loss, nausea and a decline in infection-fighting white blood
cells. Premature menopause can be another consequence. Even
this harsh treatment provides no guarantee of a cure, though in
certain groups of patients, it can increase survival rates as
much as 40%.

    Today, thanks to the widespread use of mammograms, breast
tumors are being discovered earlier, before the cancer has
spread. Now 60% of patients are "node negative," up from 50%
10 years ago. Increasingly, cancers are being found at a very
early, localized stage, known as "in situ carcinoma" (cancer
in place).

    While early detection vastly improves the chances of a cure,
it also raises questions for doctors. No one is certain how
much treatment is right for in situ carcinoma. Nor is it easy
to determine therapy for patients whose cancer has begun to
spread but has not yet affected the lymph nodes. Experience has
shown that up to 30% of these node-negative women will develop
a recurrence. The question: Which 30%?

    Frequently, doctors use a variety of factors to determine
which patients are at highest risk. One major consideration:
tumor size. "One centimeter [0.4 in.] is considered the major
turning point," says Dr. Larry Norton at Memorial Sloan-Ketter
ing in New York City. "Over 1 cm, and I lean very strongly
toward additional treatment." A close look at the tumor cells
will provide other clues, says Dr. William McGuire, chief of
medical oncology at the University of Texas Health Science
Center at San Antonio. Misshapen cell nuclei, abnormal amounts
of DNA or an accelerated rate of cell division are all bad
signs, suggesting a need for chemotherapy or tamoxifen. Newer
tests include examining tumor cells for extra copies of
cancer-causing genes or excess amounts of an enzyme called
Capthepsin D, which seems to play a role in metastasis. Says
McGuire: "Today we know that if you have a low score on all
these markers, your chance of recurrence is less than 10%. If
you score high, your chance is greater than 50%."

    To have the cancer return even after the trauma of surgery
and the misery of chemotherapy is the nightmare of every
patient. When this happens, the outlook is grim. But in recent
years doctors have been experimenting with a controversial
treatment for advanced and recurring breast cancer that
involves massive doses of chemotherapy and a bone-marrow
transplant. Annette Crossley, 45, of Glendora, Calif., is hoping
it will save her life. Crossley suffered a cancer relapse just
a few months after completing a course of treatment that
included a mastectomy, chemotherapy and radiation. Given slim
odds of survival, she chose to try the new treatment at the
University of Chicago Medical Center. Over a five-day period,
she received intravenous chemotherapy in four to seven times
the usual doses. Because such treatment destroys the bone
marrow, healthy marrow was extracted from Crossley's pelvic
bone before she began the toxic therapy. After the sessions and
some rest, the marrow was re-injected into her body.

    Such high-dose therapy is perilous. Until the transplanted
marrow replenishes the patient's supply of white blood cells,
she is highly vulnerable to infection. Jacob Bitran, Crossley's
oncologist, believes that the procedure is worth the risk. He
and his associates have treated 67 advanced breast-cancer
patients in this manner over the past four years. Though 11
have died of complications, mostly infections, 16 are in
complete remission, seemingly disease free. "That means 1 in
every 4 is a long-term survivor," he says. Others are not
persuaded. "I am not convinced that we have the benefits to
justify the toxicity," says Harvard oncologist I. Craig
Henderson, noting that, regardless of treatment, 10% of women
with advanced, metastatic disease will be alive after 10 years.
Such doubts have led many insurance companies to refuse to pay
for the procedure, which typically costs about $120,000.

    For Annette Crossley, cost is not the main concern. Slowly
regaining strength, with little hair left on her head, she
remains a picture of hope. "This is the caterpillar stage," she
says, grinning gamely, "the ugly stage before the butterfly
comes out."