“Although Dr. Slamon may feel that the issue is clear, the majority of academic oncologists in the world do not agree,” says Karen Gelmon, co-chair of the Breast Site Committee of the NCIC (formerly National Cancer Institute of Canada) Clinical Trials Group. “There are options for treatment which include anthracyclines and options that do not.”
British Columbia has one of the most forward-looking approaches, allowing for either regimen to be used, depending on the patient's tumour and risk factors.
“Personalized medicine is in its infancy,” says Dr. Gelmon, “but we are trying to do what we can and prescribe according to the individual, what appears to be optimal for that individual.”
Behind the pink ribbon
Herceptin isn't an isolated case. As cancer has transformed in many cases from a killer to a chronic disease, long-term side effects are being noted for many drugs – simply because patients live long enough to describe them.
And even without complications, the extended survival Herceptin makes possible comes with other costs. Cancer does not end when treatment does, yet a public bombarded by inspirational stories has expectations of what a survivor should be.
At age 40, Leslie Cowan was diagnosed with stage-3C cancer – the nearest curable step to the fatal stage 4. The culprit was a tumour roughly the size of an apricot.
Now 46, she sits in her sister's home in Toronto, where she's visiting from Calgary, looking remarkably healthy and fit, a black sweater and pants over her petite frame.
Ms. Cowan has lost a right breast and two ovaries, endured chemotherapy, radiation treatment and a reconstruction. When she, like thousands of others, fell outside the Herceptin treatment gap in the spring of 2005, her daughter Samantha wrote a letter to then-Ontario Health Minister George Smitherman, explaining that her mother needed the drug to live. Ms. Cowan's son, Sean, presented his mother with his piggy-bank money.
At the time, Herceptin was available in the United States for a price. So Ms. Cowan drove to Buffalo and paid out of pocket for two treatments. Later that summer, when Alberta approved the drug for funding, she was invited to the press conference, and became one of the first to receive it.
With her treatment behind her, Ms. Cowan says she no longer looks like a cancer patient – but she still sometimes feels like one. “What I find is when you're bald or you look sick, people are great, they bring you dinner,” she says. “The minute you start to look good, people think, ‘You're fine.' That's when you need the support the most. And there's nowhere to go.”
She became obsessed for a time with making the most of her reprieve from death, perhaps by climbing a mountain or working in an orphanage in a developing country.
“I feel like I failed Cancer 101. I got one shot at it. I didn't climb Kilimanjaro. I haven't written a book,” says Ms. Cowan, who used to work in fundraising and public relations. “There's this pressure to do something spectacular with your life because you have cancer. It didn't result in some greater meaning for me.”
It's hard to escape those expectations. Each October, in Breast Cancer Awareness Month, an avalanche of pink products hits shelves – ribbons, hats, T-shirts and blenders. Inspirational stories fill papers and magazines.
For Ms. Cowan, there was fallout: Her marriage faltered and she sought the help of a psychiatrist.
Last June, lesions were found on the bottom of her lungs and liver. The bumps are too small to biopsy, so a PET scan this spring is expected to provide more information. It could be benign, but as a cancer patient, there is always the worry of the disease returning.
“You hope it's nothing but they don't really know,” she says. “I don't know why I feel I need to give back to something that took so much. I don't care how many people say it made their life better. I don't believe that.”