The Art of War: “The weapons of warfare to defeat the terrorist in our midst. If you know the enemy and know yourself, your victory will not stand in doubt; if you know Heaven and know Earth, you may make your victory complete.” ~ Sun Tzu, The Art of War
The Past
Breast cancer was around in ancient Egypt. The word cancer in fact originates from a Greek word. In the middle ages, young girls who survived to adulthood (13 yrs.) were then faced with pregnancy and childbirth (many too did not survive this). If these adult women were unfortunate enough to get breast cancer they were under the treatment initially of barbers… Later they became patients of doctors trained in surgery, without anesthetics – the outcome were dismal.
In the 1890s, breast cancer, its pathology and treatment were thought to be a fixed and static, therefore radical mastectomy was a logical therapeutic option (Halsted 1894). The weapons of warfare up until the Second World War, clumsy and up close and personal, the sword dominated, the surgeon yielded Excalibur with scant regard to blood control and the bigger the operation the better. Up until the1950s, the surgeon mainly treated breast cancers. The surgeons of that era had bold, strong personalities and were giants in the field of medicine (some ogres), ensuring radical procedures were done and named after them. The term, the Halsted mastectomy involved removal of the entire breast and the muscle under the breast (pectoral muscles), as well as all the lymph nodes in the axilla (the armpit), and this was the gold standard of care for breast cancer. The Halstedian theory of breast cancer spread was that breast cancer spread contiguously (from breast to lymph nodes) and then onward to other parts of the body (Halsted 1907).
The bigger the better was the surgical mantra (only male surgeons n’est ce pas) of the day, and as bigger is not always better, the likelihood of cure was thought not to be due to the failure of surgical prowess, but rather the patient or the cancers fault.
A type of cancer called inflammatory cancer revolutionised breast cancer treatment in the 1950s. Even today the term “inflammatory breast cancer” is considered a type of cancer that once the diagnosis is made (core biopsy please, not surgery), the treatment is to start with chemotherapy and not surgery first. Note to all when the breast presents as a red-hot breast, there are other causes too (beware Dr Google).
So, way back then, the surgical giants (ogres) had such poor results operating on inflammatory cancer, the cancer came back in the skin and elsewhere…
Deemed that in these “non operable” breast cancers they should be sent to the oncologist as the last ditch attempt to ensure better quality of death.
The field of oncology then consisted of a few very clever doctors who were “experimenting” with a variety of drugs to try and improve the survival in people with cancer and so the Dawning of the Age of Aquarius in oncology.
Oncology is the term used to treat cancers with medicines or drugs
So, because the oncologist did not know what to use for what cancer, a cocktail of as many agents possible was literally assembled. The cytotoxic “cocktail” presented by Cooper originally contained cyclophosphamide, methotrexate, 5 fluorouracil, vincristine and prednisone (CMFVP). These may be meaningless names to most who are reading this article, but this is a hectic combination. An analogy this equates to a stew of drugs – this would be classified as a paella, something of everything meat, seafood, chicken, veg, sausage, and rice. May taste nice and yum, but at this stage still peasant food for the oncologist that was about to become a Michelin Star chef. The result produced a dramatic response rate in greater than 80% of patients with advanced breast cancer. The good news is the hype from the patient “surviving” the treatment, inspired oncologists to strive for greater – one giant step for mankind.
Unfortunately medicine tends to go from one extreme to another and the word on the street was that cancer would be curable if the right drug combination could be found. Inspiring many self ego driven or other save humankind oncologists to realise that if the patient could be kept alive through the aggressive high dose regimens, or if patients could be treated who had a low tumour burden (small cancers) with chemotherapy, then all cancer cells could be killed and well, the era of little or no surgery and preserving the female breast would be achieved. Considering the hectic and aggressive surgery done till now, it was no surprise that this was considered exciting!
By the 1960s, the use of combination cytotoxic chemotherapy for the treatment of breast cancer had moved to centre stage. The chemotherapy in that era was brutal. The goal was to pretty much kill any cell that looked like cancer, without killing the patient. This was an atomic bomb approach to cancer.
The oncologists were clever, often not very empathetic, as dealing with war and terrorists on a daily level takes its toll on the warrior as well.
Thus the expert in battle moves the enemy, and is not moved by him.” ~ Sun Tzu, The Art of War
So how did the drugs develop?
I know most non-doctor types think some mad scientist sits at a desk with pills potions and lotions, test-driving drugs in all sort of nefarious ways. Not so? I have often mentioned the huge respect I have for oncologists. Oncology drugs undergo rigorous screening and testing. In fact my one complaint about oncologists is that they are so rigorous about the potential problems that often patients are informed at initial consultation about so many complications (information overload) of the various treatments, that the road of oncology is so daunting to a patient that they don’t want to take the treatment.
Failing to understand the basic premise that the cancer actually is the real terrorist capable of killing the person in question.
Let’s understand what the early oncologists had to deal with. They were only sent the poor unfortunate patients that the surgeons deemed inoperable and incurable. Thus, the choice was death or drugs. Each drug combination had to be shown to improve the survival of the patient by however many months and that was weighed against the side-effects of the drugs. In other words it was pointless to gain a month or two if the life on treatment was so miserable patients would prefer not to be on the treatment.
Therefore, oncologists are wired to talk around side-effects; Compare this to the general physician or cardiologist who tells a person to take their blood pressure medicine or cholesterol lowering medicine (statins) because if you don’t, you will have a heart attack and die – deal with the side-effects!
The premise that the cancer is going to kill you anyway meant that the field of cancer treatment had to show improved quality of life/death.
As oncologists got better at killing and shrinking these locally advanced cancers, the surgeons started losing the control. The way cancer spread was questioned
The Fisher hypothesis (by a clever dude called Bernard Fisher) revolutionised cancer treatment in the US whilst a charming and clever Italian (Veronesi), under whom I was fortunate enough to work, did likewise in Europe. This dogma changed when Fisher questioned the high failure of “cured” patients within 10 years and suggested breast cancer to be a systemic disease where the spread of the cancer was due to its biological characteristics, hence the concept of the “personality of the cancer” being the most important determinant of its behavior. Remember breast cancer in the breast does not kill you, it is the cancers ability to spread that will. Whether a breast saving operation or a mastectomy is done, the survival is equal; understanding whether the cancer has an ugly nature is critical! So, the need for radical surgery was questioned, this was the dawning of the age of breast conserving surgery. At this stage most women were treated with surgery first and then assessed for need for chemotherapy.
I am not going to discuss hormone therapies, such as tamoxifen in this article (will definitely later this year).
Since the late 19th century, hormonal or endocrine therapies have been used to manage breast cancer when a surgical oophorectomy (surgically removing the ovaries) was performed to treat metastatic breast cancer. Later in the 20th century various hormonal manipulations became available for the treatment of advanced breast cancer.
Many of the drugs used and studied were actually developed from nature – from mushrooms, sea creatures (periwinkle), and tree bark (pacific Yew tree to be specific) – whilst other oncology drugs were developed from metals and other noxious war like substances. Women who say they want to have only natural treatment often fascinate me. Natural products are medicines too and as you can see from above a large number of drugs have been developed from natural substances! We can’t keep on producing them from natural substances, as that would deplete the planet rapidly of all natural resources. Natural products can also give side-effects. The morale of the story is too much of anything can be bad for you…
There are many types of medicines used to treat breast cancer; some given in tablet form and others in a drip and these are all oncology drugs. Oncology drugs are not unlike antibiotics. If you have a bug (bacteria, parasite, or some virus) a specific antibiotic is used. You can’t treat malaria with penicillin, nor tick bite fever. Specific infections are treated with specific antibiotics. Some bugs such as TB require a combination of antibiotics to treat them. The most important is that if the course is not finished the bugs come back resistant. Oncology drugs are antibiotics to treat cancer and different combinations can be used either alone or in combination.
When discussing oncology drugs it is useful to understand the following terms:
Chemotherapy: The treatment of cancer, using drugs that are destructive to malignant cells by using chemical agents or drugs that are selectively toxic to the cancer.
Endocrine therapy: Drugs used to slow or stop the growth of certain cancers. These may be synthetic hormones or other drugs that block the cancer cell or the body’s natural hormones.
Adjuvant chemotherapy:
Anti-cancer drugs given after surgery.
Neo-adjuvant chemotherapy/ primary chemotherapy: Anti-cancer drugs given before surgery.
Targeted therapy: A treatment that uses drugs or substances to identify and attack specific types of cancer cells whilst inflicting less harm on normal cells. Targeted therapies may work by blocking the action of certain enzymes, proteins, or other molecules involved in the growth and spread of cancer cells.
Oncology treatment is the umbrella that protects from the acid rain of cancer cells. Under the umbrella are the local treatments of surgery and radiation; what enables them to both fit under the umbrella is good aesthetic result (reconstruction), and the umbrella stick – the multi-disciplinary team.
Thus we may know that there are five essentials for victory:
He will win who knows when to fight and when not to fight.
He will win who knows how to handle both superior and inferior forces.
He will win whose army is animated by the same spirit throughout all its ranks.
He will win who, prepared himself, waits to take the enemy unprepared.
He will win who has military capacity and is not interfered with by the sovereign. ~ Sun Tzu, The Art of War
Oncologists today should be saluted for ensuring victory more times than not. Their ranks are the multi-disciplinary team. They know when and how to fight, and when not too, don’t let the “sovereign” be your fear, your gossiping friend, Dr Google or misinformation.
MEET THE EXPERT
