Editor’s Note
	Looking for pearls

From my perspective, the most enjoyable part of our Meet The Professors audio series is the individual premeeting teleconferences I hold with the community-based oncologists who will be presenting cases to faculty members during our recording sessions. Sure the daylong events themselves are exciting and thought-provoking, but these one-on-one conversations — during which we sift through a variety of potential patient histories and try to pick out the most controversial and instructive to spring upon the unknowing research leaders — are truly what I look forward to most.

The reason for this is simple: Our CME group has been fortunate to work with many very astute practitioners who seem to share my passion for delving deeply into the critical issues that shape oncology education and practice. Each time we attempt to identify actual cases, I am amazed at how adept these physicians are at selecting interesting patients. Recently, after hearing Dr Jim Wade’s saga of an 83-year-old woman with ER-negative, “HER2-negative” breast cancer, I knew we had another winner.

This woman’s case — like many of those presented by these knowledgeable clinicians — is far more instructive than any journal article or meeting presentation. From the moment this woman was diagnosed with Stage II disease, her situation posed a fortunately uncommon dilemma. During the discussion, faculty members Adam Brufsky and Dan Budman quickly pulled out their Palm Pilots to “run the numbers” using Peter Ravdin’s Adjuvant! program. Based on these assessments, both believed that adjuvant chemotherapy would have minimal impact on long-term mortality because of the woman’s age and competing causes of mortality.

The research leaders then suggested that they would have discouraged this patient from being treated, and Leon Dragon — another community oncologist at the meeting — noted that even if the patient wished to have treatment, chemotherapy had an adverse therapeutic risk-to-benefit ratio and consumed resources that might better be utilized elsewhere. Nonetheless, after discussing the marginal benefits of treatment, Dr Wade and his patient embarked on four courses of AC, which she tolerated without any problems. Like many selfless older people, this patient’s primary concern regarding therapy was that it might cause side effects that would interfere with her ability to provide care for her infirm husband.

I set up the geriatrics education program at the University of Miami School of Medicine in the mid-1980s, and perhaps the most important message from that experience is that you can’t make generalizations about older patients any more than you can about younger ones, and that most people tend to retain their attitudes and personalities with time.

Nonproductive people don’t suddenly get motivated when they become older, and go-getters remain go-getters regardless of age. This woman obviously was a dynamo all her life and was so motivated to avoid mastectomy that she commuted 40 miles each way to receive postlumpectomy radiation therapy.

The story becomes even more complicated three years after initial diagnosis, when the patient developed metastatic disease. Again facing chemotherapy, this woman’s physician (Dr Wade) had a hypothesis that, if confirmed, would greatly impact her quality of life and ability to provide care for her husband.

In spite of an IHC assay that was read as “0”, Dr Wade ordered a FISH test that subsequently revealed HER2 gene amplification. The patient was treated with trastuzumab — both monotherapy and in combination with chemotherapy — and experienced significant tumor response with minimal treatment-related morbidity. Like many patients successfully treated with trastuzumab for metastatic disease, this woman’s ultimate problem was CNS metastases, and Dr Wade comments on her valor in facing this situation:

“She’s a profile in courage. She is strong, stoic and proud. The best example is positioning her furniture around the house so she wouldn’t have to use a cane or a walker. She’s a remarkable woman who has taught us a lot about how brave many of these more senior citizens are. I don’t know if I could have done nearly what she has during the course of her illness.”

All of us learn early on after medical school that optimal continuing education is a combination of studying data, listening to the perspectives of our colleagues and just taking care of patients. This case history typifies the management gems that we hope to uncover during these Meet The Professors programs, and it is gratifying to be able to make such instructive discussions available to so many clinicians in practice.

—Neil Love, MD
NLove@ResearchToPractice.net

Select publications

Herrero A et al. High incidence of brain metastases at the time of death in women with metastatic breast cancer treated with trastuzumab. Proc ASCO 2004;Abstract 765.

Kirsch DG et al. Brain metastases from breast cancer: Survival by HER2 status in the trastuzumab era. Proc ASCO 2004;Abstract 779.

Lindrud S et al. Central nervous system progression during systemic response to trastuzumab, humanized anti-HER-2/neu antibody, plus paclitaxel in a woman with refractory metastatic breast cancer. Breast J 2003;9(2):116-9. Abstract

Osoba D et al. Effects on quality of life of combined trastuzumab and chemotherapy in women with metastatic breast cancer. J Clin Oncol 2002;20(14):3106-13. Abstract

Paik S et al. Real world performance of HER2 testing — National Surgical Adjuvant Breast and Bowel Project experience. J Natl Cancer Inst 2002;94(11):852-4. Abstract

Ravdin PM et al. Computer program to assist in making decisions about adjuvant therapy for women with early breast cancer. J Clin Oncol 2001;19(4):980-91. Abstract

Roche PC et al. Concordance between local and central laboratory HER2 testing in the breast Intergroup trial N9831. J Natl Cancer Inst 2002;94(11):855-7. Abstract

Shmueli E et al. Central nervous system progression among patients with metastatic breast cancer responding to trastuzumab treatment. Eur J Cancer 2004;40(3):379-82. Abstract

Slamon DJ et al. Use of chemotherapy plus a monoclonal antibody against HER2 for metastatic breast cancer that overexpresses HER2. N Engl J Med 2001;344(11):783-92. Abstract

Vogel CL et al. Efficacy and safety of trastuzumab as a single agent in first-line treatment of HER2-overexpressing metastatic breast cancer. J Clin Oncol 2002;20(3):719-26. Abstract