[Debbie L.]

Great discussion.

I agree with AA on both her points. We need more evidence to know what to do with very small HER2+ primary cancers, and we need to dial it down so that we give anti-HER2 therapy in the most targeted way possible (knowing who is most likely to benefit and from which anti-HER2 tx). One of the "problems" with figuring out how to manage the very small (say, under 0.5cm) primaries is that the recurrence rate is so low that it requires huge studies that take forever to get results. And then, even if we do get results, by the time we get them there are many more options on the table (for example, Kadcyla, Perjeta, etc).

It's easy, with hindsight, to say that a certain treatment (Herceptin is the best example), should have been approved sooner. But as others have said, it (alas) takes a long time to prove that a treatment is both effective and safe. In addition, the old style of taking a big group of cancers and just seeing if "x" is better than "y" is no longer enough. Most if not all of the newer trials are collecting as much data as they can -- markers, immunoscores, gene assays (of both the cancer and the host) etc., to attempt to tease out how to predict who will benefit. This can eventually spare both the toxicities and cost of treating those who won't benefit -- while also spurring research into finding new treatments for them.

I also agree with Mountain Girl about mammography. It may have a small benefit, but not nearly as much as we've been led to believe. This debate has been going on for a long time. There are many studies showing no benefit (no improvement in survival) for those whose cancers were detected by mammography vs. those whose cancers were detected by other means. Even the positive studies (showing benefit) show only a small benefit (and some harms). There are lots of reasons for this fact, including that it's the slower-growing, less deadly cancers that are most likely to be detected by mammography. Also, it's tricky (perhaps impossible) to figure in the improvements in treatment and know for sure whether improved survival can be attributed to earlier detection or improved tx (or both). Someone asked for the evidence -- here is one fairly-concise summary, with references: National Breast Cancer Coalition Statement on The Canadian National Breast Screening Study

No one person can state that "x" (mammography, Herceptin, whatever) saved her/his life. Although, those with stage IV HER2+ disease and long NED-ness can certainly make a good case for the argument (smile).

I'm putting my hopes on the immunotherapy research -- not just vaccines, but ways to trigger/control/direct immune responses in more global ways. Our knowledge about it is increasing daily. The bad news there is that with each increase in understanding, the incredible complexity of immune function becomes more evident. But still, I believe that it has potential both for primary prevention and for preventing or controlling metastasis.

Debbie Laxague