The Role and Rationale for Oral Options in the Treatment of Metastatic Breast Cancer - Episode 2
Adam M. Brufsky, MD, PhD: Lee, the next question related to that is this: We have all these things, so what are the goals when we treat someone with metastatic breast cancer? What are we trying to do right now? What is realistic? Is it to cure? Probably not. Is it more survival or progression-free survival and the avoidance of symptoms? What are the goals when we try to treat somebody, either through a clinical trial or in practice?
Lee S. Schwartzberg, MD, FACP: I am a few years behind George, and I agree: The change over the last 3½ decades has been incredible, and it is so exciting. I come to work believing that there has never been a better time to be a medical oncologist and take care of patients with cancer. We are optimistic about the future. But with that said, Adam, we still do not talk in terms of cure for metastatic breast cancer. There is a small percentage of patients, a growing percentage in some of the subgroups, who live a decade or more with metastatic disease.
It is fair to call metastatic breast cancer a chronic disease today, which we could not do in the 1980s or 1990s when some subgroups of people lived just a few months, and some lived a couple of years. Now we can anticipate most of our patients will live at least a few years. Quality of life is important too, so that is the other thing: extending life and maintaining quality of life when you are dealing with hopefully a chronic disease.
Adam M. Brufsky, MD, PhD: I want to push that a bit more because I am interested in trying to figure it out. We always say that there is going to be a cure. I am not as old as you guys—maybe 15 or 20 years, younger. I am older than I look, though. My hair never turned gray. I am trying to determine what the parameters are when we sit down and say “We have cured this.” Are we ever going to say that, or are we going to say that we have turned it into something chronic?
Something like coronary artery disease is a perfect example. Think about it: 50 years ago, everybody dropped dead at their desk, and we now have all these things. People are living, but they are living with it. We do not get rid of every plaque in somebody. My thought is this: You guys have been around a long time. I am curious what you think of this formulation. It is more like we are trying to turn this into something you can live with.
You are probably going to die, just like with coronary artery disease. Eventually as part of a whole panoply of things, you will eventually die of something. To me, the cure to this—not the cure but the control of it—will look like this: You get this, and we give you a bunch of things just like in coronary artery disease. We treat you systemically and medically, and we keep you going for as long as we can. What do you guys think of that? Is that where you think we are going with this?
George W. Sledge Jr., MD: The model I think of is what we have seen in CML [chronic myeloid leukemia] with BCR-ABL targeting agents, which is to say that we have a life span that, in essence, approximates that of the general population, if one looks at age of the patient. The overall survival curves are basically parallel to that of the general population. We have not reached that for any subtype of breast cancer. We have gotten better at all the subtypes of breast cancer, but we are nowhere close to what you would say about a Gleevec [imatinib mesylate]–type definition.
It is a good analogy in another way, which is to say this: If you stop your imatinib, your cancer will come back. A true chronic disease, I would argue, would be 1 in which you do not stop your imatinib, and the disease does not come back. We are not there yet.
Adam M. Brufsky, MD, PhD: Yeah.
Lee S. Schwartzberg, MD, FACP: I agree. I usually use the analogy of diabetes, which all our patients are familiar with 1 way or another. We think of diabetes as a disease that you are not going to cure, but you probably know at least 1 or maybe many people living with diabetes. They can often live a perfectly normal life. It depends on how they get controlled and what medications we need to use for that.
Of course, it would be great to talk about a normal life span, but we do not do that. We are moving the conversation from cure, which is what patients are thinking about—“Am I cured or not?”—and moving it from a dichotomous variable to say, “No. It is a chronic disease. We can keep you alive and well for a long time.”
Transcript Edited for Clarity