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Hi all,
I'm feeling worn out by this thread. I do love debate and critical thinking and I would like to continue the discussion but I'm weary of the personal ... searching for a word that isn't emotionally charged ... and not finding it. If you've followed this thread, perhaps you know what I'm weary of.
Some of the defenses of personal views have been - well, defensive. And sometimes also offensive, in the literal meaning of that word, which Websters lists first: 1. "making attack, aggressive".
I'd like to repeat that I did not invent the recommendation of not doing tumor markers for follow up of primary disease.
I do not see any evidence that TM's make more or less sense depending upon the aggressiveness of the cancer. It could be argued that the more aggressive the disease, the shorter the interval between being able to detect it with TM's and it showing up with symptoms - which would make it less likely that the TM's would be run at the point in time where they could make a difference, if they ever DO make a difference.
Part of the reason that the national guidelines on TM's after primary disease do make sense to me is that I'm not a big fan of the whole idea of "small" being synonymous with "early". Whether we're talking primary disease or recurrence, I believe that what happens has more to do with the biology of the cancer and less to do with its bulk (brain excepted - see below). Not that it's entirely one or the other - certainly both have some influence. But I think quality trumps quantity in most cases, at least as long as we're looking to eradicate or slow it using systemic treatment. If the cancer responds to the systemic treatment, it seems to respond equally well whether there is lots of disease or a minimal amount. If its response is sluggish or absent, that again seems less to do with bulk and more to do with biology. It's true that larger tumors can do more damage but it's unusual for them to get to the point of being able to do permanent damage without first announcing their presence with symptoms.
Another point is that the quicker a recurrence or progression is detected and acted upon, the quicker one runs thru the available options. It's a valid argument to say that factor alone could impact length of survival. Some perfectly intelligent and thoughtful women and their providers prefer to move slowly even when there's clear evidence of progression, for this reason.
So brain mets - what a puzzle. If it works to zap relatively small lesions, and sometimes to surgically remove larger ones, why isn't the same true for other organ mets? Maybe it could work but it's considered a better option to treat them with systemic meds (chemo, Herceptin, hormonals), so it's not been offered enough to study? Is that because the mets stay gone better if there's response to systemic treatment? Or because systemic tx is more likely to get more of the too-small-to-see lesions and cells?
I don't know the answers but it's hard not to see the questions. IF we ever were to get to the point of removing or zapping organ mets (besides brain), then the argument for frequent scans and TM's would make more sense to me. But to my knowledge, we are not there (yet?). I'm not saying that it's not being done, but there's scant evidence that it makes a difference. And whether we like it or not, we do need evidence to make changes in practice. Again I reference the bone marrow transplant fiasco, and the book "False Hope" by Richard Rettig (very pricey book, which is why I haven't read it yet).
Regards,
Debbie Laxague
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