Herceptin Treatment
Finding the truth about herceptin treatment
This page contains a transcript of a "conversation" between Gordon Cameron (family doctor and partner of breast cancer sufferer, Marjory) - and Gregory Pawelski (frequent blogger on the subject of cancer treatment, chemotherapy and the role of new drugs for cancer).
The origninal posts can be found on The Cancer Blog
What follows below is slightly complicated but, in the end, profoundly important for those weighing up the complexities of breast cancer treatment options. Stick with it as you read it - the story becomes clearer.
How does herceptin treatment fit into the plan for breast cancer?
What are the benefits of herceptin?
What about the risks of herceptin side effects - either at the time or years later?
Read on below and think ....
The discussion started with a post from Cancer Blog contributor, Jacki Donaldson
Echocardiogram monitors heart for Herceptin damage Jacki Donaldson
Herceptin -- a targeted breast cancer drug used to treat women who are Her2 positive -- has received rave reviews and has shown great promise in cutting down on recurrence of this aggressive form of breast cancer. Given over the course of 52 weeks, Herceptin is wondrous for its lack of short-term side effects. There is no hair loss, no compromise of blood counts, no significant sickness. For me, fatigue may have resulted from this treatment -- but it's unclear to me really whether it was the Herceptin or the two small boys I have living in my house that most contributed to my occasional exhaustion. Regardless, I functioned well while receiving Herceptin for the past year -- and I did not suffer anything more than a twinge of pain when my port was accessed for each treatment. In the short term, I have fared well. In the long term, the jury is still out.
Heceptin is known for it's long-term toxicity on the heart, especially when used with Adriamycin -- a typical breast cancer chemotherapy agent -- which is also toxic to the heart. Heart damage as a result of Herceptin is not common but the heart's ability to effectively pump blood can be compromised. Rarely -- about five percent of the time -- women can experience stroke or life-threatening congestive heart failure. And seven percent of the time, Herceptin causes mild heart failure. The only way to determine if the heart is suffering before symptoms or problems arise is through heart monitoring before, during, and after Herceptin therapy.
So this afternoon, I will report to the hospital for an echocardiogram -- a test that uses sound waves to take pictures of my heart as it pumps blood. I will lie still -- on my side mostly -- while a technician moves around a device on my ribs, over my heart. The whole procedure takes just a few minutes and then a determination will be made about the health of my heart -- now that it's weathered both Adriamycin and Herceptin.
This will be my third echocardiogram. I was tested before my first dose of Herceptin and then again in the midst of treatment. Both tests revealed a healthy heart and no damage. I hope -- and I am confident -- that this third peek into my heart will reveal more of the same. And if not -- if my heart has suffered some damage -- function can be restored by drugs that strengthen the heart.
It's a trade-off -- this cancer treatment thing. In order to survive breast cancer, I must survive the treatment that may lengthen my life but may also limit my body's ability to function in other areas. Someone once told me that I should be so lucky to have a problem with my heart years and years from now -- because it means I would have lived long enough with breast cancer to encounter such a problem. It's amazing how perspective changes with cancer. Never before would I have been content with the knowledge that my heart might one day fail me. Compared to a possible death sentence from breast cancer, though, it seems like a not-so-bad option. And what an odd comfort that is.
Gordon wrote the following in response to the above post:
I've been encouraged by data from the recent HERA study - a large study of herceptin in women with early breast cancer. It seems to show (so far) that heart damage is much less common that was previously thought. As you say - its all still very early days - but here's hoping that there are no long term effects waiting to be unveiled.
Like all things in life however - there's a trade off isn't there. We all simply need to decide if the price is worth paying - and I couldn't agree more with your comments on that front.
Gregory said
It's a cautionary tale. Herceptin combined with standard chemotherapy will have as many as 4% of women who take the regimen develop symptoms of congestive heart failure, compared with less than 1% of women given chemotherapy alone. It's one of those things that benefits a very few patients a whole lot, is neutral in most, and is bad in a few.
Overt congestive heart failure is a very late and serious manifestation of heart muscle damage. For every patient with frank congestive heart failure, there is probably another two, three, four or five patients with heart muscle damage short of congestive heart failure. The sort of heart muscle damage which can cause fatigue and/or shortness of breath with moderate or mild exertion, which otherwise wouldn't occur.
Herceptin has been in use only a few years. We don't know what will happen 10 or 20 years from now in women who didn't need any adjuvant therapy at all, who would have been cured by surgery alone. Only a minority of patients who receive adjuvant therapy benefit from it. Adjuvant therapy is worth it if the women have to suffer only short term, temporary toxicity, and if it even slightly reduces the probability that their cancers will come back. But if it produces permanent toxicity, whether "chemo brain" or "heart muscle damage," that is a whole different order of magnitude in terms of risk.
Monoclonal antibodies like Herceptin are enormous. Very large molecules don't have a convenient way of getting access to the large majority of cells. Plus, there is multicellular resistance, the drug affecting only the cells on the outside may not kill these cells if they are in contact with cells on the inside, which are protected from the drug. The cells may pass small molecules back and forth. This needs further evaluation. I just hope that a prospective, randomized clinical trial is not the way to go about it.
Gordon replied: Gregory's comments above are interesting.
Indeed he posted virtually identical remarks on our blog site at http://www.twinkletwinkles.com/2006/06/herceptin-look-out-theyre-at-it-again.html
If you search for Gregory's name on Google you'll see that he has been a forceful, articulate and intelligent advocate for his views for some time now.
His stance and viewpoint certainly gives food for thought - but there's no doubt that he stands fairly firmly in the camp of those who would seriously question whether chemotherapy / herceptin and the likes should be used at all in the adjuvant setting.
I'm not saying that his views are not well thought out - they very obviously are. Nor am I saying that they may not have some validity - they might and research is now turning towards those very questions.
But I would caution those who read the above comments to keep in mind that Gregory has his own agenda to promote.
Gregory Returned with I was a spouse/caregiver to an ovarian cancer patient. I became intensely interested in cancer medicine by virtue of working through, enduring and surviving my wife's illness. I've gotten a street education by virtue of voluminous reading and hundreds of hours of past and ongoing personal communication with noted authorities in the field.
There is seldom a "standard" therapy which has been proven to be superior to any other therapy. When all studies are compared by meta-analysis, there is no difference.
There are so many new drugs coming down the pike that there is simply no way to evaluate them in prospective, randomized clinical trials. Some trials are positive, some are negative, and it's only after ten years or so that have gone by and 10,000 patients or so, have been enrolled in the trials that anyone can draw conclusions. And by then, what had been the "standard" treatment has now changed, because of all the new drugs which have been introduced. And I wouldn't suggest they hold these new drugs hostage to the really unachievable standard of prospective, randomized clinical trials.
The best chance for discovering the right formula is having "all" the drugs available to oncologists, and allow creativity and insight and the "Art of Medicine" enter into the process. A "standard" therapy would not be for everyone, but having a lot of tools (drugs) available and making use of various tests (molecular and cellular) to match treatment to the patient.
I'm not so sure I would describe it as having my own agenda, but being an advocate for a number of cancer subjects. To paraphrase Martin Luther King Jr: "A scientific communication should be judged on the quality of its content and only secondarily, or not at all, on the qualifications of its author."
Gordon said Thanks again Gregory
I respect your stand point and completely agree that your contribution can and should be judged on its quality. I'm quite certain that you are as well versed in the literature as many oncologists - and better versed than some. Certainly better versed than me!
As you correctly say "some trials are positive, some are negative, and it's only after ten years or so that have gone by and 10,000 patients or so, have been enrolled in the trials that anyone can draw conclusions"
Those of us long in the tooth in medicine know thats always been the case - and not only for cancer drugs or treatments.
But of course - we have to live in the day to day world too. As a doctor I can only do the best I can with the knowledge I have. As the partner of a breast cancer sufferer, Marjory and I can only work as a team to tackle this thing head on - using our intelligence and our instincts (and our reading) to find the path that suits us best.
The last bit is the most important. All of those dealing with cancer should remain involved enough in their care to figure out what "suits them best" and to then stick with that decision and live with its consequences.
No one has the right answers except the cancer sufferer themselves. Doctors and guys like us posting on blogs can provide input - but in the end the individual and their family have to figure it out for themselves.
Marjory and I weighed up all our options - came to a decision and will now run with it. We'll either do well or we won't - but at least we've been involved and in control throughout.
Marjory is drawn more to the views that Jacki expressed in her original post. If heart problems come down the line then let them come. Yeah - we will have to deal with it if and when it happens but at least she will be here to deal with it.
I agree with you - there is a tendency to jump for any new breakthrough and to grab the good news without properly considering the down sides.
Not all women will benefit from herceptin. Some will be harmed. Maybe time will show more harm than benefit. But for now the balancing act has to be achieved and the decisions taken by the individual.
Staying positive is vital. Hope is crucial - even in the bleakest of circumstances. Losing hope is a disaster.
Being as informed as you can be is very important - and your postings are a vital part in helping build the big picture.
Many of those with cancer will find what you write deeply disturbing and painful to read. Some will misinterpret your intent but balance in life is everything. The light seems all the brighter when you've properly looked at the darkness.
I do not intend any criticism of your writing or your views - your input is a vital part of the jigsaw. Keep at it. Keep questioning. Keep shaking the foundations. But bear in mind the pain that your questions cause for those who are already committed to their own path.
Gregory rounded off with:
I understand Gordon, sometimes my comments are termed controversial, which they shouldn't have to be. They are meant to be thought-provoking, to better understand some of the frustrations that are experienced with cancer medicine and its treatment.
I agree, as the average treatment for the average patient cannot possibly work all the time because there are no average cancer patients (each patient's cancer is unique), all of those dealing with cancer should remain involved enough in their care to figure out what suits "them" best, and not for the "average" patient.
Whatever clinical response that has resulted to the average number of patients in a randomized trial, is no indication of what will happen to an individual at any particular time. They are trying to identify the "best guess" treatment for the average patient. You cannot mate notoriously heterogeneous diseases into "one-size-fits-all" treatments.
My wife had an inspiring attitude along the lines of your "staying positive is vital" comment. To her, fighting her disease was "90% Faith and the Will to Live, and 10% the Art (not science) of Medicine."
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