Fifty years ago, breast cancer treatment often meant a grim prognosis, with over 60 percent of women succumbing to the disease. Today, that figure has dramatically reversed, with most women now cured and fewer than 30 percent dying, according to Professor Ian E. Smith, a professor of cancer medicine and former head of the breast unit at The Royal Marsden Hospital. Smith, reflecting on his five-decade career, highlights significant shifts in medical practice, treatment approaches, and the overall outlook for patients.
Shifting Treatment Paradigms
In the 1970s, invasive patient examinations and a high mortality rate characterized breast cancer care. Smith recounts a personal turning point around 1980 with a patient named Mrs. Baker, whose severe reaction to chemotherapy for secondary liver cancer prompted a reevaluation of treatment priorities. He realized that hormone-blocking drugs, which offer a longer duration of remission with fewer side effects, could have been a more appropriate initial option for her. This experience led him to adopt a more conservative approach to chemotherapy, a strategy later supported by trials confirming that hormone-blocking tablets are generally the best first-line treatment for estrogen-receptor-positive advanced breast cancer.
Despite this evidence, Smith notes that some practitioners still favor chemotherapy first, particularly for younger patients or those with liver metastases, based on the belief that it works faster or more effectively. He argues that this dogma lacks strong data and that chemotherapy, while life-saving in the right context, is too often used prematurely or at excessive doses when other options, including a "watch and wait" approach, might be more suitable. Smith advocates for considering reduced doses and durations of chemotherapy when evidence does not strongly suggest a detriment to outcomes, prioritizing patient quality of life.
The Role of Hope and Prognosis
Smith also questions the practice of assigning specific life expectancies to patients, particularly those who are otherwise well. He shares the story of Fran, a 26-year-old diagnosed with breast cancer and a subsequent brain tumor. After being given a two-year prognosis and told only palliative treatment was an option, Fran sought a second opinion and found her way to Smith. He opted for an aggressive treatment involving chemotherapy and radiotherapy, aiming for a cure. Over five years later, Fran, now 30, remains cancer-free and works with cancer patients. Smith emphasizes that while honesty is crucial, it is possible to convey an accurate picture without stripping patients of hope, which he considers a vital component of their resilience during treatment.
Advancements and Future Directions
Significant progress has been made in understanding breast cancer as a complex disease with distinct subtypes, each requiring tailored treatment. Preoperative chemotherapy, administered before surgery, has shown remarkable success, particularly for HER2-positive cancers. In some cases, the cancer shrinks completely, raising the question of whether surgery is always necessary. Smith notes that in select cases at The Royal Marsden and other centers, foregoing surgery is becoming an option, with encouraging early results. He recounts the case of Jean, a patient in her early 90s, whose HER2-positive breast cancer significantly shrank with Herceptin and a gentle chemotherapy regimen. Jean declined further chemotherapy and surgery, opting to continue Herceptin. Eight years later, she remains cancer-free, a potential indicator of the growing possibility of curing certain breast cancers with drugs alone.
Research into liquid biopsies, spearheaded by Professor Nick Turner at The Royal Marsden, offers another promising avenue. These tests detect cancer cell DNA in the blood, potentially identifying and eradicating residual cancer cells before they form new tumors. This technology could also help identify specific mutations to guide personalized treatments and monitor therapy effectiveness. The TRAK-ER trial is currently investigating the use of liquid biopsies to detect early signs of relapse in patients with ER-positive breast cancer.
Reassessing Risk Factors
Smith also addresses common patient concerns about risk factors, such as hormone replacement therapy (HRT) and alcohol consumption. He clarifies that the increased breast cancer risk associated with HRT, as reported by the Women's Health Initiative trial, was relatively small—an additional 0.4 percent over five years for users. He also contextualizes the risk from alcohol, explaining that while it does increase risk, the figures are often presented in relative terms that can sound more alarming than they are. For instance, one drink per day might increase a woman's baseline risk of 14 percent by a further 1.4 percent. Smith suggests that for many women, the pleasure derived from a glass of wine may outweigh this modest statistical increase in risk.