Philosopher and mathematician Alfred North Whitehead once remarked, “Science
is not only stranger than we imagine but stranger than we can
imagine.” For this reason, comments about the future
of breast cancer research at the Miller School of Medicine,
or in general, fill me with anxiety that some people may later
compare what I write to what actually happens over the ensuing
years. This anxiety is well founded given the great likelihood
of enormous gains in a variety of technologies that will contribute
to the diagnosis and treatment of this disease.
Before looking ahead, it is certainly legitimate to point out
the dramatic successes in managing this common malignancy.
Over the past half-century the mortality of breast cancer has
dropped from nearly 50 percent 50 years ago to approximately
18 percent today. Some of this decline is clearly attributable
to early detection, mostly via mammography.
The greatest gain, however, has occurred through
the use of adjuvant hormonal and/or chemotherapies. Appropriately
hormone therapies, such as Tamoxifen in premenopausal women
and Aromatase inhibitors in postmenopausal women, reduce
recurrence rates and improve survival 30 to 40 percent.
Chemotherapy has a similar beneficial impact.
For women whose tumors are in part caused by over-expression
of the HER-2 gene,
trastuzumab (Herceptin) has even more dramatically improved
As we look to the future, I believe breast
cancer therapies will become more individualized. New strategies
examination of virtually all of the genes expressed by a
given tumor have permitted the reclassification of breast
into at least six highly distinct subsets. Thus, therapies,
which are relatively more useful in one subset or another,
can be used with greater accuracy and less toxicity. It is
inevitable that this process will be further refined with
increasingly more precise technologies.
Furthermore, as we move into an era of so-called
targeted therapy (therapy aimed at the actual expressed molecules
that are responsible
for the malignant behavior itself) such sub setting will
permit greater individualization of therapy. As a trivially
analogy, we do not use one antibiotic to treat every infection;
we take advantage of sensitivity data from the microbiology
lab to use antibiotics specifically targeting the pathways
for growth employed by the pathogen of interest. In exactly
that same sense, we will increasingly see the deployment
of treatments that get at the root causes of breast cancer
than the more nonspecific cytotoxics currently used.
One prediction is that breast cancer research
will be more intertwined with research in other malignancies,
and vice versa.
As an example, a single drug recently developed to target
a growth factor responsible for tumor vessel formation not
has shown substantial success in breast cancer but has worked
in at least eight other tumor types that make use of the
same molecule to promote vascular growth.
The Braman Family Breast Cancer Institute
at UM/Sylvester has already generously begun to support the
of a cadre of breast cancer investigators. It is through
their zeal and enthusiasm to not only communicate their own
also through their multiple interactions in the clinic and
in the lab—that they will unquestionably provide significant
new ideas for even more successful control and eventual eradication
of breast cancer, something I firmly predict will occur over
the next 20 years.
Marc E. Lippman, M.D., is chairman of the Department of
Medicine and one of the nation’s leading breast cancer