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Dare to dialogue on cancer.

Dr. Samuel Broder, director of the National Cancer Institute, pulls no punches when he updates SatEvePost readers on the good and bad news of cancer prevention, research, and treatment. In this, the second half of our two-part series, Dr. Broder discusses new options for breast cancer victims, explains the patient's role in choosing among possible treatments, and predicts the future management of colon cancer.

With the current push for more AIDS research, this portion of the interview begins on the hot topic of funding. Specifically:

Dr. Ser Vaas: What do you say when you see editorials about how AIDS research might be taking money away from cancer research?

Dr. Broder. The Cancer Institute is not the dominant lead institute or agency on AIDS. That is the National Institute of Allergy & Infectious Diseases, the operation which Dr. Anthony Fauci heads, but we do have a specialized role in vaccine and new drug development. We're very proud of our role in that, and I think we have a lot of expertise and a tradition in this field; I think we have something to offer. We will continue to make a major commitment to AID of the Cancer Institute always has been and always will be cancer.

Dr. S. What is the good news and the bad news about cancer?

Dr. B: I think that in both basic research and prevention, in early diagnosis and treatment, in all of those areas there's been a lot of progress. But there's also bad news, and I think that that's something people have to come to terms with.

The bad news is that we do not have a unifying molecular explanation for cancer. We do not have a cure for all cancers in an advanced state. And, in fact, for some cancers we really do not have effective treatment of any kind. This is the bad news, but my job is to tell you the truth.

If you want to talk on the treatment area, the good news is that in very young people we have astonishing success in testicular cancer, lymphomas, and leukemias. We are also reducing the annual death rate for cancers in people under 65.

Now the advantage of that is that in curing people who have leukemia, certain lymphomas, testicular cancer, and certain gynecological conditions, you do an enormous amount of good because curing somebody who's 22 years old allows [them] a lifetime of productivity. That's very important.

Dr. S. Could you give us an update on therapy progress with other cancers?

Dr. B: We're making progress. If you look under age 65 in general, and if you exclude lung cancer, which is the very special disease that I've talked to you about, because it's being linked to smoking and is avoidable, we are making substantial progress in a number of cancers-how to treat them and how to prevent them. No question about it. So I would say there are many different advances. We are learning how to treat a lot of diseases better.

I could regale you with the

news but I must say that there's also bad news, and this is something that the public has to hear. We do not have a cure for all cancer. We do not have a way of treating all cancers, and even when we have certain knowledge about some things, we sometimes still don't have the ability to take it to heart. Smoking is the best example of that.

Dr. S. Does the NCI have some programs we could tell our readers about-programs in which you don't have enough patients participating where it might do some good to get the word out?

Dr. B. What I think would be good to stress is that we have cooperative groups. These are academic groups of physicians that have gotten together. These groups have important and interesting clinical trials, funded by the Cancer Institute, which try to offer new knowledge, but which also try to always test the best available therapy against something that people expect would be equal or better.

I would urge individuals who develop a cancer to ask their doctors if they are suitable for referral to an appropriate cooperative group. We also have the community clinical oncology program which works very closely with the cooperative groups. Physicians in the community-not academicians but community physicians-enroll patients in their practices and enter them into appropriate clinical trials.

So if you wanted to suggest that to your readers, I think it would be a good thing. There's something else that I would urge you to suggest to your readers. I think we're in an era in which the patient and the doctor need to be in a dialogue about cancer treatment. The patients should view this as part of their responsibility.

Dr. S. I wonder if our typical readers would dare dialogue with their oncologists or question their treatment.

Dr. B. They should listen to me, they should read my lips, and they should understand that asking questions or defining things that affect their own health is not an inappropriate thing to do; that a patient has to be a partner with the doctor. I don't mean in technical matters-in a particular drug dose or something like that-but the patient should have an understanding of what the options are, what the latest information is, and then he or she should participate in that process. Just as you have a role in helping your readers stop smoking, you should have a role in having them be participants.

I think that the patient has to interact with the doctor, and has to play a role; it's a definite role for the patients and their families. They need to know what the options are. All life is a matter of choices.

The patient, in my opinion, should say, "First explain to me what I've got. Then explain to me what the options are." The question could be, "Is there more than one way of treating this?" Then you can ask the doctor, "Well, what are the pros and cons from your point of view? What are the benefits I'm likely to get from each therapy? What are the toxicities I'm likely to get from each therapy? " You could ask the doctor if there's another specialist in the area who could give you a second opinion.

Dr. S.- How does a doctor view such participation?

Dr. B: I think that a doctor should never feel threatened. I'm excluding emergency situations. On serious matters of health, I think that doctors should welcome a collegial relationship with other doctors and should welcome second opinions. Sometimes this can be very important. Many times an article will have just been published and maybe not be widely available or widely known. Sometimes the infor- mation can be presented only in abstract form. That is, it's only presented at a certain meeting and the patient still might benefit from that knowledge.

We have a system with the AMA by which any doctor anywhere in the country can access all of our clinical trials information, including state-of-the-art information, where to go, what protocols and what the preliminary results are, with their own personal computer. We can work it so they could use their personal computer and in a very user-friendly way get significant information related to a tumor that the patient might have and be able to respond to that. We think that with the prevalence of computers there will be thousands and thousands of doctors who have access to this system.

Dr. S. And the fax machines. Dr. B: And there'll be fax machines, but they don't need it because this is an on-screen thing. We have a name for it. It's called PDQ, for Physician Data Query. Basically, I don't think it would be inappropriate in a setting of cancer for the patient to say, "Doctor, what did the PDQ print-out show for me?" PDQ was developed by NCI, but we want to extend its use by cooperating with the AMA and other professional groups.

The doctor might say, "What is PDQ? " But there's a point here that I want to stress for a minute. All of medicine is a continuous learning process, and patients need to understand that too. It is not a sign of weakness for a doctor to say, "Mrs. Jones or Mr. Jones, I want to have a day to review the latest findings on your problem." People need to become accustomed to that. They need to hear that, and they need not to be threatened by that because that's the way that the technology is. I think to me, if the doctor's being sincere, that would be much more encouraging, provided he or she acted on that, than to have a doctor say, "I know everything about everything and I never have to look anything up. " Now, it is not a criticism of doctors-this is just a general thing that patients need to work into a dialogue and to accept responsibility for their own care. This is one theme that I have. In that specific sense, it's a whole new consumerism, but that's our mission here. We do not want to dictate or regulate doctors. That is not our responsibility.

We want to generate knowledge, and the same taxpayers who pay for our research efforts have a right to expect that we will disseminate knowledge in a wide scheme. We are not afraid of knowledge. We feel that's the thing that liberates everybody, and I think that patients slowly and surely, I hope, will come to terms with certain concepts that can help. One of them is that it's O.K. to ask a series of questions. It's O.K. to seek a second opinion. It's O.K. for a doctor not to know everything, and a patient should not draw the wrong inference when a doctor says, "I don't know; I will check into it." It could be they'll check into it by looking into the PDQ system, which I think is a very effective one.

Dr. S. Don't you also have something like PDQ for the patient-it's dial 800-4-CANCER?

Dr. B: We have that, yes. Dr. S. Is it effective? Dr. B: Yes, that's another technology. That's also linked up so that patients can call with specific questions. We at the Cancer Institute provide information; we do not want to practice medicine via the telephone with a patient we haven't seen. Now, we have our own treatment unit here, so in that sense we will practice medicine. But we don't want to substitute a telephone call as a way of practicing medicine. We don't want to put ourselves in the middle of an ongoing doctor-patient relationship.

The other thing that we try to do is we try to make a strong effort to respond to patients' questions when they come up and to try on an individual basis to answer as much as we can. I have a great deal of faith in these computerized systems. I think we, in particular the practice of medicine, will be slowly but surely adapted so that people are used to the fact that medicine is a continuous, evolving discipline, and that's a sign of health. Dr. S. Is there any news for a cancer vaccine? Dr. B. I think it's a research tool, and I think it's something that I wouldn't want to build an expectation for. I think there are many other exciting areas. I really feel, for example, that doctors are going to be managing breast cancer and colon cancer fundamentally different than they have in the past. I think you're going to see very significant changes in how women with breast cancer are handled. I think it should become very common practice for the average woman who gets breast cancer to go to a doctor and for the procedure not to stop with simply an operation and that's it, but for an analysis to be done of what kind of estrogen receptors that woman has in her tumor, and for a decision then to be made that that woman will be offered hormonal therapy or certain types of chemotherapy, whether her nodes are positive or not. Even though there's no discernible tumor at the time you're making that decision, that kind of approach is going to lead to significant delays in the recurrences of cancer. The typical woman who dies of breast cancer does not-there are some exceptions to this-die because the tumor has come back at the same local site, although that is a certain problem. But the real problem that we're trying to address is that the woman may come back with disease at a distant site and then die of that disease, and therefore I see we're going to have fundamental differences in how women are going to be treated.

Dr. S. What about fat and breast cancer?

Dr. B. There are still many things we don't know about breast cancer, but there are some things that we do. Everything we know about breast cancer suggests that in one way or another certain types of estrogen stimulation seem to play some kind of role. We know that's one of the factors for breast cancer, and there is a large database of information on that. Diets high in animal fats are thought to contribute to an increased risk of breast cancer, and it is possible that they affect the amount of interior estrogen stimulation in a woman's body, but we don't know for sure.

Dr. S. How does the estrogen in the birth-control pill compare in amount to the replacement estrogen that is used for postmenopausal women?

Dr. B. It really depends on the dose that the doctor chooses, and there's still some controversy with it. One issue with breast cancer and the pill is that there are some suggestive data-not firm data, suggestive data-that taking the pill might be a risk factor for acquiring breast cancer for some women. There are physicians on both sides on this. Within the Cancer Institute, we have recently launched a special study which will try to specifically address that point, and we will try to find out if there's that risk. We know certain things about breast cancer already in that if you start menstruating early, if you have a late menopause, if you wait until after the age of 30 to have your first full-term delivery-these are all things that have a factor that increases the odds of getting breast cancer. We think they do so by altering the hormonal milieu, but we do not have the precise facts. We're trying seriously to consider an area in which doctors have no consensus. But one of the questions that might be worth asking is would it be worthwhile to give an anti-estrogen drug to women who might be at risk of breast cancer, let's say after the age of 50, as an almost pharmacological nutrient. Tamoxifen is a substance that blocks the activity of estrogen and has relatively low side effects.

Dr. S. How is it used? Dr. B: Tamoxifen is used in people with advanced breast cancer, but the question is would that be something that we should test. I want to be very clear on this, and if you choose to write about this, please make it clear that I'm not saying that tamoxifen be used for the purpose I've just suggested. What I would hope is that doctors and scientists will ask whether the time is right to make this a test and ask for a study in which women over the age of 50 will volunteer if they have some history of breast cancer in their family. Some women who do not have cancer would volunteer to receive tamoxifen while they are well. And some women would volunteer to receive tamoxifen or receive a placebo. Such a study would be followed for a certain number of years, and we would then learn whether giving tamoxifen in that setting would prevent the development of breast cancer.

Dr. S.- If you had a group of women who said, "Yes, we would like to do that, " how soon might it be tried?

Dr. B: You have to understand that what I'm suggesting would still be considered controversial in the scientific community, so you would not necessarily reach a consensus; not all doctors and scientists would say the time is right to do this, or there might be additional factors. In order to do what I'm proposing, by the way, one would need to be able to really work out all the issues about whether there's any toxicity or long-term side effects from the drug.

Dr. S. What about colon cancer? Dr. B: The same thing with colon cancer. My prediction for the future will be that if somebody comes in with colon cancer and has microscopic spread beyond the place where the colon cancer started-even in microscopic amounts and even if all the lymph nodes seem to be taken out of the person's body-such a person has about a 50 percent chance of having the tumor come back, let's say in three to five years. And we will have, I predict confidently, therapies which will make an impact against that. I do not think they will solve the whole problem, but we will lower that high percentage. We are not going to cure people, necessarily, but we will certainly reduce the risk and delay the time that it will take for somebody in that setting to be at risk for cancer again. So I think confidently-take it to the bank-that those therapies will be bart of the common practice.

Now that doesn't mean that we have a cure for cancer around the corner, and that's why I want to balance my entire discussion with you, as always, good news and bad news, and I don't want to end any discussion of cancer on either an excessively upbeat note or an excessively downbeat note. I think we have areas where we've made progress. I think we have areas where we have not made as much progress as we want or we haven't made any progress, but I am continuously optimistic about the future.
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Title Annotation:includes sidebar on the author's secretary's bout with cancer
Author:SerVaas, Cory
Publication:Saturday Evening Post
Date:Jul 1, 1989
Words:3045
Previous Article:Circusmania.
Next Article:Battling the beast within.
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