by M. Ellen Mahoney, M.D., F.A.C.S.
After nearly two decades of attending the world’s largest scientific meeting dedicated to breast cancer, the San Antonio Breast Cancer Symposium (SABCS), breast surgeon Ellen Mahoney reflects on how it has changed since its early days. She also offers suggestions on how it could improve and evolve to best serve the breast cancer community. (SABCS is often rife with breaking news, but the 2006 meeting featured little new “news.”)
I am in mourning for what SABCS used to be. When I started attending, about 18 years ago, it really was an international gathering of those most dedicated to seeing this disease eradicated. We saw old friends and previous mentors and trainees, and had access to the “big guys” in the breast cancer world to ask practical questions that had arisen in the previous year. The group itself was a lot smaller, and more time was available for informal discussion and comment. Perhaps, most importantly, the marketing was confined to a limited number of small tables for nonprofit organizations and conference sponsors in the hallway outside.
The symposium still offered plenty of exciting information on the beginnings of molecular oncology, but there was also more honesty and more of a sense of the big picture, and, it seemed to me, much more of a sense of why we were there. While “advocates” were not always treated as well as they should have been, at least they were present, which was groundbreaking in itself for a scientific meeting of this magnitude. I remember well the first time I saw BCA’s executive director Barbara Brenner stand up and ask a thoroughly sharp and challenging question of a presenter. I knew I had to meet her some day. A malaise seems to have settled over the whole field since those days. It sometimes feels as though clinicians, like me, are expected to be attending the symposium just to be enlightened by the gurus, and we are led to infer that we have nothing to offer them in return. Nowadays, the conference hall is so huge that the speaker is a dot in the distance and a picture on the screen. Except for the exhibitors’ access to those of us—doctors, researchers, and advocates—who can help their bottom line, the whole thing could be virtual. The exhibit area is also very large, and a carnival atmosphere dominates the entrance to the meeting itself. The food is abundant and generally as unhealthy as one can imagine.
It’s not that SABCS is so bad compared to other cancer conferences, but it used to be different and better than others. This symposium could regain its luster by bucking some of the trends in breast cancer research that have afflicted the field, rather than conforming so thoroughly.
Successful organizations regularly revisit their strategic plans and adjust, often in a retreat. For the breast cancer world, San Antonio used to be our annual retreat, and the field was better for it. The following are my recommendations for ways to improve SABCS and bring it back to its roots:
- The scientific community needs to start honoring “negative” results—those that show, for example, the lack of benefit from a given drug. By encouraging and publishing these studies showing “negative results,” clinicians would have a better picture of whether a drug only has a marginal benefit, information that is key for our patients’ informed consent.
Let’s look at a couple of examples. Chemotherapy used to be given for one to two years. It was big news when we found that the marginal benefit of treatment beyond four to six months did not justify it, and we backed off. Another example is that mastectomy was once the only standard breast cancer surgery. Lumpectomy plus radiation became an additional standard because survival was the same, with less trauma to the patient.
There is now such reverence for studies that show positive results that relatively meaningless endpoints are being accepted to justify more treatment—endpoints like “time to progression.” Now it seems that more clinicians are made to feel that the standard of care mandates adding additional and more aggressive treatments to the patient’s schedule, and there is much less consideration of prescribing fewer treatments. If any additional treatment can be justified by a published study—no matter how weak the level of evidence for it or what the effect is on the patient—then it generally is given, unless the patient balks. It should be remembered that, several decades ago, when surgery was the main treatment, there were still long-term survivors. Even in 2007, however, we cannot clearly determine which patients will fall into this group.
This tension is clearest perhaps in the treatment for DCIS, where the large study group leaders tell us that most patients should have radiation and hormone blockers, and fail to consider a group of criteria for women who might need only excision. The closest this year’s San Antonio meeting came to a presentation that questioned additional treatment was a presentation on providing a radiation “boost” to the area of a lumpectomy. It was not news that a boost does not improve survival and is associated with problems in the breast, though perhaps some of the doctors in the audience could stand a reminder.
- Look at reforming the clinical trial process. If patients and their physicians trust this process, and have input in study design, there may well be more participation.
Trials must be slowed down so that adverse reactions have a chance to surface. The rush to get a product to market has led to absurdities like the expansion of “surrogate endpoints,” defined as a series of events that
move the trial closer to completion even if they don’t correlate with the improvement the drug is supposed to provide. If activists and clinicians had more to say about the design and conduct of a trial, one would hope that statistical significance (a study result unlikely to be due to chance) would not continue to be confused with real-world clinical significance (a result meaningful to patients). At least risks and benefits would be defined more clearly, and the time a drug is studied might be closer to the recommended time it is to be taken.
The tendency of the scientific establishment to ignore or minimize the down side of the “prevention” trials and to overemphasize the benefit to healthy women of taking powerful drugs for an undefined period to lower risk of, but not necessarily prevent, a disease that they may never get is also eroding the confidence of women in science, and may be affecting their willingness to participate. The potential subjects appear more savvy and imbued with more common sense than the researchers.
- I would like to see a reversal of the trend in turning what used to be a think tank atmosphere into a pharmaceutical trade show. Presentations need to be more balanced, with all issues and fields better represented. For each of the fields—including epidemiology, surgery, radiation, and others—there should at least be a formal review or assessment of what we know and what we should know to provide that aspect of care better, as well as a good discussion of where each field should be heading, with the researchers and funders listening carefully to clinicians and activists in a real dialogue.
- I wish that the exhibit hall—which often seems like a vendor carnival—would be moved to another building, or that the products exhibited would be restricted to educational materials. The reduced expense to the companies involved could be taken as donations to advance the field further, perhaps. In any case, I would certainly ban noneducational gifts to attendees, from electronic devices to meals to limo rides. Books, papers, and materials for patients, free of big ads, would be fine.
- And finally, I would like to see common sense return. The biggest news out of the 2006 symposium was the presentation about the decline in breast cancer incidence attributed to fewer women taking hormone replacement therapy (HRT) following the Women’s Health Initiative’s (WHI) first report. If the incidence is dropping, is it really because of the WHI report, which showed a nonstatistically significant rise in breast cancer rates in women taking HRT? Breast cancer takes years to develop, so there is likely more to the picture than just HRT. (For more on this report from SABCS see Barbara Brenner’s column and Jane Zones’s Day One Reflections from the symposium.)
The very first year that aromatase inhibitors were introduced at San Antonio, an oncologist made a comment after a presentation suggesting that the drugs might be given in order to completely shut down the hormone-producing mechanisms in tumor cells capable of making hormones no matter how much the patient is deprived of exogenous exposure to them, while a small dose of hormone could be given to the patient for reduction of side effects and symptoms in systems of the body that may benefit from them. This might be a way of more selectively depriving the tumor cells, with less misery. This idea, which was mentioned in passing again this year, was refreshing because it espoused a new and testable hypothesis based on common sense.
There is a tremendous need for us to have discussions and input into the endeavors of those who dedicate their lives to research. We need to encourage the best and brightest to go into the various fields involved and to stay real. A true method of dialogue within those of us in the trenches is sorely needed. The San Antonio Breast Cancer Symposium used to come close to that ideal, but it was never perfect. Now that it is clearly so imperfect, we need to find a better mechanism for an annual or biennial retreat on the state of breast cancer, with cooperation in planning. The California Breast Cancer Research Program has a philosophy that is congruent with this goal, with researchers and activists meeting in virtually equal numbers to discuss a broad spectrum of issues. Perhaps they can serve as a model for a national mechanism to bring these groups together.
Ellen Mahoney is a breast surgeon and activist.
- Read reflections from BCA staff in attendance at the 2006 San Antonio Breast Cancer Symposium.
- News from the 2006 San Antonio Breast Cancer Symposium included results from the trial of lapatinib (trade name Tykerb) for the treatment of advanced breast cancer. Read more about the results from this study…