This past spring, I spent several days at the University of Maryland Medical Center reporting on a piece about the art of medicine. It detailed how tough it is for doctors and patients to make medical decisions when the science is lacking to guide them. One patient I met was Miriam Smyth, a 51-year-old breast cancer patient from Gambrills, Md. She'd been diagnosed with a small breast tumor back in December and immediately decided to have a lumpectomy and radiation since her cancer had been caught early. But like so many other cancer patients, Smyth soon discovered that other treatment decisions aren't so easy to make.
Her first major dilemma—whether or not to have chemotherapy—was particularly difficult. "I assumed I wouldn't need it, had even decided not to tell my young son or coworkers that I had cancer," Smyth tells me. Smyth, an oncology researcher at the University of Maryland Medical School, thought she'd have her surgery over Christmas break and head back to work without missing a beat. But then she had a test called Oncotype Dx, which revealed that her tumor had certain markers that put her at somewhat higher risk of having a recurrence. Suddenly, chemotherapy was back on the table.
"I read all the research on patients with similar Oncotype scores, but the data didn't help me," she says. "It was inconclusive as to whether I'd really be helped by the chemotherapy." Her husband, also a scientist, advised her to think about skipping the chemo, but she ultimately decided to have it. "I knew I'd never forgive myself if I had a recurrence," she explains. Still, it was tough for her emotionally. "I've studied these very same drugs in a lab, put them on human cells. I've seen the damage they do on a molecular level. But I had to get myself into the mind-set of being a patient and just deal with it."
After finishing the chemotherapy in May, Smyth had yet another decision to make: whether or not to start taking bone-building bisphosphonate drugs as part of a clinical trial being conducted at UMMC. The drugs might lower her risk of recurrence, but by how much? Smyth already had less than a 5 percent chance of having a relapse, thanks to all the treatments. Would slashing her risks an additional percentage point or two—if that—be worth the side effects? Her dentist told her she'd have to delay some planned dental work if she took the bisphosphonates because of the risks of a jawbone disease associated with these drugs.
Again, Smyth read the studies showing a lower risk of recurrence in breast cancer patients who took bisphosphonates. This time, however, she decided to skip the clinical trial. "I just wasn't convinced that the potential benefit, if any, outweighed the risks," she says. Smyth's case illustrated to me how personal these decisions really are for patients. When science can't firmly point the way to the right decision, women have to go with their gut and ask themselves, what's really right for me?
I'll be discussing this again in my next post about a new study finding a significant amount of overdiagnosis of breast cancer caused by mammography.