Editor:
    Each year I grow a little older and realize one advantage is that I can look back along the road traveled and speculate on where I am in relation to where I’ve been. I have practiced oncology for quite some time and am appreciative that we have entered a new era of breast cancer care.
     Not so long ago, a diagnosis of metastatic breast cancer (breast cancer that had spread to other areas of the body e.g.: the bones or the liver) was something of a death sentence. It was the rare patient who experienced long term survival. Every oncologist had at least one such patient in their practice; but that was not the norm. Today, even with metastatic disease, it is not unusual that patients with breast cancer may live for many years. Breast cancer has come to be considered a chronic disease a little bit like Diabetes.
     I recall when all breast cancer was lumped together as primarily one disease. Now most oncologists consider breast cancer as a multiplicity of diseases requiring (if not necessitating) multiple approaches to treatment. Indeed, we are moving toward an age of truly individualized treatment. The tissue from a tumor is dissected in the laboratory to identify not only unique changes in its DNA but also specific proteins that may make that tumor amenable to a specific therapy.     A few years ago we entered the age of “Targeted Therapy.” We now treat patients by directing antibodies to specific proteins produced by the tumor cell. We are now killing tumor cells in a unique way. More importantly we are blending the older drugs (conventional chemotherapeutic agents) with the new targeted therapies to yield astonishing results. In the near future we will be designing specific treatments for individual patients using the protein characteristics of that patient’s tumor tissue.
     Yet, coming soon to an oncologist near you is one test that I find particularly interesting. This tests measures concentration of tumor cells circulating in the blood. It is a simple blood test. The blood is then checked to determine if there are any tumor cells circulating in the blood. You have to have a diagnosis of breast cancer, of course, to have the test and have active disease. I see this as a useful tool in the armamentarium of the oncologist. This test can be used to monitor patients and study correlation with subsequent appearance of metastatic disease. This may in the future be used to determine when and if therapies might be changed or modified.
     However, here is something already in use. If your have a small tumor and no involvement of the lymph nodes, we can now test tissue and determine whether intravenous therapy would be beneficial. We could do this in the past by using the pathology report to assess a patient’s risk of recurrent disease and to approximate benefit of chemotherapy. Now, we have a scientific test that backs up our assessment. One prototype is called Oncotype Dx. Many more similar tests are on their way. The science came out of the laboratory years ago and is now standing at the bedside.
     It is an undisputed fact that death rates from breast cancer has decreased over the past twenty years. The statistics show that deaths from breast cancer have decreased 2.3 percent per year each year since1990. The larger decreases have occurred in younger women (less than 50). We are also more vigilant with screening and many more cancers are being diagnosed earlier. This is wonderful and is in part due to the breast cancer activists. We owe an incredible debt of gratitude to those patients, families, researchers and medical professionals who worked (and are still working) tirelessly for a cure. It is by their efforts that we can now speak of survivorship.     
     Last but not least, the relationship between the oncologist and the patient has changed. At one time the patient sat and listened and, for the most part, accepted the advice of the oncologist without question. Now, with the internet, patients have access to as much information as the oncologist. They come armed with questions and often know the most recent data on the latest clinical trails. We, the oncologist, have come to expect and anticipated this. Oncologists are partnering with their patients as we take care of them. Patients do not only want to survive breast cancer. They also wish to live well with it. We know that quality counts as well as quantity. We have all entered the age of “Mandated Autonomy.” It is the year 2007.
     I cannot but applauded all these changes and look ahead with anticipation. I live and work in Southern Maine and know that I can offer my patients all these opportunities right here at home. I am excited to be a part of the changing landscape that is breast cancer treatment. I see a vista with terrain that may be full of challenges but wonderfully exciting and hopeful to explore. I wait expectantly for a cure. —  Patricia C. Deisler, MD