The Rough Road to Recovery

By Claudia Wallis

Colleen Fallscheer, a cheerful 40-year-old mother of two from Waterford, Mich., is living proof that breast-cancer therapy is not the horror show it used to be. A little over a year ago, a mammogram revealed a bright malignant spot, no more than 1.5 cm (about 0.6 in.) across, imbedded in the translucent tissue of her left breast. A surgeon recommended a mastectomy, to be followed by chemotherapy. Fallscheer was appalled. She sought a second opinion from David August, a surgical oncologist at the University of Michigan Medical Center, who told her that her tiny malignancy made her an ideal candidate for a lumpectomy, a less drastic procedure.

Last November, in a two-hour operation, Dr. August's team removed the cancer plus a margin of surrounding tissue, leaving Fallscheer with a 5-cm (about 2- in.) scar in an otherwise normal-looking breast. To catch any residual cancer cells, she received six weeks of daily radiation therapy, which produced a light suntan but left no permanent trace. "A lumpectomy plus radiation does not cure more women than mastectomy," says radiation oncologist Allen Lichter of the University of Michigan, "but it creates fewer physical and emotional scars." Fallscheer concurs: "It was only after I saw Dr. August that I felt I wasn't going to die after all."

Ten years ago, lumpectomy would not have been an option for Fallscheer. Since then, studies have shown that when a tumor is small, confined to a single area and readily accessible to the surgeon's scalpel, lump removal plus radiation is no less effective than removing the entire breast. But as Fallscheer's experience shows, not every surgeon is convinced. Nor does every eligible patient choose the lesser operation. Though about 50% of breast- cancer patients are candidates for lumpectomy, only about half of those elect it. Many, including Nancy Reagan, feel safer if the entire breast is removed. "For most women, whether or not they lose their pectorals is not the issue," explains University of Chicago surgeon Monica Morrow. "It's whether or not they lose their lives."

Choice of surgery is only the first of many decisions faced by patients and doctors. None are simple, and women sometimes get the impression that there are as many variations in therapy as there are doctors. The key question following surgery, however, is whether the cancer has spread. It is not localized disease in the breast that kills more than 40,000 U.S. women a year, but the dissemination of the cancer to other, more vital organs, usually the brain, the bones, the liver or lungs.

To determine if the deadly process of metastasis has begun, surgeons performing mastectomies and lumpectomies routinely remove 10 to 25 lymph nodes from under the arm near the affected breast and examine these glandular structures for signs of cancer. A woman with "positive" nodes has a 37% to 75% chance of a cancer relapse within five years, depending on the number of affected nodes and the size of the original tumor. In such cases, chemotherapy or hormone therapy will be urged.

The kind of drug treatment depends on many things, including a woman's age and the biology of her tumors. The cancer cells of postmenopausal patients often require the hormone estrogen in order to grow. If lab tests show the presence of estrogen receptors in a tumor (a sign of a good prognosis), therapy with tamoxifen, an estrogen-blocking drug, is usually recommended. It reduces the risk of disease recurrence by approximately 20%, with relatively mild side effects.

Younger women and those who have no estrogen receptors usually receive combinations of two to five chemotherapy agents, such as Cytoxan and methotrexate, over a period of four months to a year. Because these drugs target rapidly dividing cells, they not only destroy cancer cells but also cells in the hair follicles, the lining of the digestive tract and the bone marrow. That produces the dreaded side effects of chemo: hair loss, nausea and a decline in infection-fighting white blood cells. Premature menopause can be another consequence. Even this harsh treatment provides no guarantee of a cure, though in certain groups of patients, it can increase survival rates as much as 40%.

Today, thanks to the widespread use of mammograms, breast tumors are being discovered earlier, before the cancer has spread. Now 60% of patients are "node negative," up from 50% 10 years ago. Increasingly, cancers are being found at a very early, localized stage, known as "in situ carcinoma" (cancer in place).

While early detection vastly improves the chances of a cure, it also raises questions for doctors. No one is certain how much treatment is right for in situ carcinoma. Nor is it easy to determine therapy for patients whose cancer has begun to spread but has not yet affected the lymph nodes. Experience has shown that up to 30% of these node-negative women will develop a recurrence. The question: Which 30%?

Frequently, doctors use a variety of factors to determine which patients are at highest risk. One major consideration: tumor size. "One centimeter ((0.4 in.)) is considered the major turning point," says Dr. Larry Norton at Memorial Sloan-Kettering in New York City. "Over 1 cm, and I lean very strongly toward additional treatment." A close look at the tumor cells will provide other clues, says Dr. William McGuire, chief of medical oncology at the University of Texas Health Science Center at San Antonio. Misshapen cell nuclei, abnormal amounts of DNA or an accelerated rate of cell division are all bad signs, suggesting a need for chemotherapy or tamoxifen. Newer tests include examining tumor cells for extra copies of cancer-causing genes or excess amounts of an enzyme called Capthepsin D, which seems to play a role in metastasis. Says McGuire: "Today we know that if you have a low score on all these markers, your chance of recurrence is less than 10%. If you score high, your chance is greater than 50%."

To have the cancer return even after the trauma of surgery and the misery of chemotherapy is the nightmare of every patient. When this happens, the outlook is grim. But in recent years doctors have been experimenting with a controversial treatment for advanced and recurring breast cancer that involves massive doses of chemotherapy and a bone-marrow transplant. Annette Crossley, 45, of Glendora, Calif., is hoping it will save her life. Crossley suffered a cancer relapse just a few months after completing a course of treatment that included a mastectomy, chemotherapy and radiation. Given slim odds of survival, she chose to try the new treatment at the University of Chicago Medical Center. Over a five-day period, she received intravenous chemotherapy in four to seven times the usual doses. Because such treatment destroys the bone marrow, healthy marrow was extracted from Crossley's pelvic bone before she began the toxic therapy. After the sessions and some rest, the marrow was re-injected into her body.

Such high-dose therapy is perilous. Until the transplanted marrow replenishes the patient's supply of white blood cells, she is highly vulnerable to infection. Jacob Bitran, Crossley's oncologist, believes that the procedure is worth the risk. He and his associates have treated 67 advanced breast-cancer patients in this manner over the past four years. Though 11 have died of complications, mostly infections, 16 are in complete remission, seemingly disease free. "That means 1 in every 4 is a long-term survivor," he says. Others are not persuaded. "I am not convinced that we have the benefits to justify the toxicity," says Harvard oncologist I. Craig Henderson, noting that, regardless of treatment, 10% of women with advanced, metastatic disease will be alive after 10 years. Such doubts have led many insurance companies to refuse to pay for the procedure, which typically costs about $120,000.

For Annette Crossley, cost is not the main concern. Slowly regaining strength, with little hair left on her head, she remains a picture of hope. "This is the caterpillar stage," she says, grinning gamely, "the ugly stage before the butterfly comes out."

With reporting by J. Madeleine Nash/Ann Arbor