Choosing an Oncologist

This month I had reason to think about the past two decades of cancer research when I interviewed my own oncologist about treatment for early-stage breast cancer. Bob Mennel, MD, was the oncologist recommended to me by my Dallas surgeon in 1986 after my mastectomy revealed I had 4 centimeters of ugly cancer with one positive lymph node. For those of you who want more detail, here is what I also learned about my tumor back then: grade (poorly differentiated), proliferation (they did what was called an S-phase but I'll be darned if I remember the number), estrogen (slightly positive on a completely different scale than we use now), Her2neu (predated that one), Oncotype DX (predated that one). I was really lucky that Mennel was recommended to me. I would like to say I interviewed many docs and thoughtfully chose him based on his personality and knowledge, but, come on, I was terrified and we patients had not been told we had choices back then. I was just lucky.But now I know I got one of the best, because in the ensuing 24 years since my diagnosis of invasive breast cancer (stage 2b), I have learned a lot about oncologists. Clearly the medical community agrees with my assessment because Bob Mennel is now the director of clinical oncology at Baylor Sammons Cancer Center in Dallas. But it was more than his expert knowledge that was important, it was his ability to explain things in a way that I could hear through my terror. It was also the caring way he dealt with the panic attacks that followed me for the decade after my diagnosis and treatment. After my interview with Mennel for the current story on treating early stage breast cancer, I realized how far we have come and how much changes so fast for these men and women who try to stay on top of what will keep us alive. The story in this issue focuses on the new ways to determine a woman's risk for recurrence if she is estrogen positive, which includes 75 percent of the women diagnosed. In fact, the formula for who gets chemotherapy for this subset has become so complicated that there are Internet tools to help oncologists distill information for the best options. While I was interviewing Bob Mennel about this, he mentioned that he had talked with his oncology fellows (you know, the baby oncs) only that week about how complicated the information has become, going over all the options that have to be considered. He then told them how many tests were there beyond basic staging when he was a fellow more than 30 years ago – none. So since my diagnosis he has had to constantly update his education to stay on top of the newest information about that nasty cancer cell, which can elude even the best drugs. He also has the thousands of women he has treated who gave him his own research study of sorts as he watched how they responded to treatment. I was ruminating on how important my oncologist has been in my life when I happened on the new ASCO patient website where I opened a blog called "On Being Wrong" written by the current president of ASCO, George W. Sledge, Jr. MD, a professor of oncology at Indiana University Simon Cancer Center. He is also a researcher who has studied molecular and tumor biology, growth factors, and anti-angiogenic therapy related to breast cancer. His blog topic was about being wrong, not something we think of oncologists studying much and certainly never admitting to. Sledge really put something in perspective for me, and that is how hard it must be for these physicians to juggle all the facts that come their way from studies, clinical trials, and their patients. How do they assess a treatment that they adopted because of a clinical trial result only to find that it, ultimately, will not impact long-term survival. It's what he calls a "thicket of value judgments." For every therapy, Sledge says, physicians are faced with cost and value, possible side effects, and the biggest question: Does prolonging time to progression improve quality of life or reduce suffering to any significant degree? This final question he follows with a parenthesis ("surprisingly difficult to measure, or to know what the measurements mean"). Don't go looking for his answers to these questions because he doesn't provide any. This is fine with me since I already know there aren't any after watching friends grasp at all the "wrong" choices in treatment during the past 24 years. But with men like Mennel and Sledge on the clinical and research fronts, I know we have the best advocates available.