Less Radical

The largest cancer meeting in North America just wrapped up. Held annually in the spring. the American Society of Clinical Oncology meeting is where many big advances and discoveries are announced. This year, the highlights included a study that showed that moderate exercise improved survival in colon cancer patients as much or greater than many chemotherapy agents. Another study showed that treatment for breast cancer could be modified based on levels of cancer DNA circulating in the blood, increasing the lead time and success rate of new treatment over waiting for imaging tests to show new “spots.”In reflecting on these findings, oncologist Daniel Flora, MD, PharmD pointed out a flaw in how we talk about “success” in clinical trials. The endpoints that researchers typically use are binary and designed to counter ambiguous interpretations. Overall Survival, for example, measures if patients are alive or dead. Progression-Free Survival measures if patients are alive with their cancer controlled or uncontrolled. These yes/no answers condense complicated scientific questions into concrete endpoints that are useful for regulatory bodies like the FDA to make decisions about approving a drug treatment for routine clinical use.Dr. Flora pointed out that most of us would agree that being alive is great. However, patients surviving cancer often have a more nuanced view. Many older patients begin conversations with statements like “I want QUALITY of life” or “I don’t want to suffer.” A rubric to incorporate these wishes does not exist. Would a patient, for example, trade a better quality of life for a 20% less chance of cure? 10? 5?Today, I invite you to listen to a conversation I had with two cancer survivors. Both Mark and Yvonne are alive without active cancer. In our professional parlance, they would be considered success stories. And as you hear them talk about their lives after cancer treatment, they are living.But they are living with life-changing side effects. You will hear about how large chunks of their identities disappeared in the aftermath of cancer treatment. These sacrifices are part of the hidden cost of cancer that is not often discussed (and certainly not used for approval) of new treatments. Years after their last treatments, they have accepted their “new normal” but aren’t satisfied. They want better treatments for those diagnosed now.Afterwards, I talk with a colleague, Dr. Bhishram Chera, about his groundbreaking work in studying less toxic ways to treat patients like Mark and Yvonne.I’m not sure, however, that we should be throwing these trials out. Would I, for example, be willing to sacrifice a 5% increase in the chance my cancer would return if I had a better chance of being able to taste food for the rest of my life? Perhaps. But right now, I wouldn’t have that choice. It would be considered unethical to even discuss it.Enjoy and I look forward to hearing your thoughts in the comments. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit cancerculture.substack.com

I’m thrilled to tell you that Less Radical has received TWO nominations in the 29th annual Webby Awards: We’re up for Best Indie Podcast - Limited Run and Best Podcast - Documentary. We were chosen out of 13,000 entries! We’re up against companies like Audible, Wondery, Mother Jones, and Al-Jazeera, so we need your help. You can vote for Less Radical in both categories until midnight PT on Thursday, April 17th.* Vote for Less Radical for Best Indie Podcast - Limited Run* Vote for Less Radical for Best Podcast - DocumentaryAnd after you’ve voted, tell a friend! We’re so grateful for your support of our tiny but mighty team. Together we can make Dr. Bernie Fisher a household name! This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit cancerculture.substack.com

Mammograms were introduced fifty years ago. Recommendations for women to have annual screening mammograms began thirty years ago. The hope was that by finding breast cancer early, we could drastically reduce the number of women dying from breast cancer. And in some ways, we have been successful. The problem with annual screening mammograms is that it is based on the assumption that every breast cancer follows the pattern - progressing from a pre-cancerous lesion to a more aggressive tumor in a logical, linear way. Today, we know this isn’t true. Yes, some cancers are slow growing. So slow growing that they may not need treatment at all. But others, especially those in young women, grow fast. So fast, in fact, that they develop into masses in between annual mammograms. Or develop in women that are “too young” to be screened. And why aren’t we doing more to prevent breast cancer from forming in the first place? Why aren’t we finding women at high risk and doing more than just pushing them into radical surgeries?TLDR: Our current breast cancer screening paradigm is not working. We are doing too much for some women and not enough for others. Today, I’m talking with two women who think women deserve better than this outdated, one-size-fits-none approach. Martha Kaley is a breast cancer survivor and founder of Earlier.org: Friends for an Earlier Breast Cancer Detection Test. Martha’s breast cancer was not mammographically detected. She is also tired of the same old debates about what age we should start screening women for breast cancer. Martha has dedicated her life to supporting innovation in earlier detection methods - finding a better test than a mammogram. Dr. Laura Esserman is a surgeon and professor at University of California - San Francisco. She’s spent her career trying to find less radical ways to treat breast cancer. Now she’s leading a study trying to find the best way to screen women for breast cancer. (Hint: it’s probably not going to be annual mammograms for everyone.)Screening will never be perfect. It’s not now. But why are we settling? What if we demanded a screening approach that was better than a mammogram? Do something… This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit cancerculture.substack.com

When a colleague’s misconduct is discovered, Fisher is forced to resign from the NSABP and becomes the subject of a Congressional investigation. As the walls close in, Fisher fights back. He spends the rest of his life trying to restore his reputation. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit cancerculture.substack.com

We return to Washington, D.C. In the fall of 1974, the results of Bernie’s clinical trials promise to change the treatment of breast cancer forever... if only it were that easy. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit cancerculture.substack.com

In 1958, Bernie Fisher participated in the first randomized clinical trial in patients with breast cancer. The trial was a disaster, leading most surgeons to abandon the idea of using chemotherapy to cure more patients. Bernie, however, noticed something different. This put him on a path that would change the course of cancer treatment forever. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit cancerculture.substack.com

For most of history, the voices of women with breast cancer have been silent, including the daughter of an American president. Fifty years ago, they began to speak. While Bernie Fisher worked to change doctor’s minds, women demanded input into their care. Those whose lives are impacted by cancer continue to influence how doctors, including me, approach our patients and your treatment. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit cancerculture.substack.com

At the end of the 19th century, a New York surgeon determined that the only way to cure breast cancer was with radical surgery. For the next hundred years, millions of breast cancer survivors bore the mark of his disfiguring approach. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit cancerculture.substack.com

Our story begins exactly fifty years ago. On a fall weekend in late September 1974, a former dancer from Michigan and a young surgeon from Pittsburgh met just outside Washington, DC. The treatment of breast cancer would never be the same. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit cancerculture.substack.com

Introducing Less Radical, the true story of Dr. Bernie Fisher, the surgeon-scientist who revolutionized the way we treat breast cancer. After generations of surgeons subjecting women to brutal, disfiguring surgeries, Bernie found a better way. And the thanks he got? A performative, misguided Congressional hearing that destroyed his reputation and haunted him until his death.Over six episodes, radiation oncologist Dr. Stacy Wentworth will take you into operating rooms, through the halls of Congress, and into the labs where breakthrough cancer treatments were not only developed, but discovered.The first episode of Less Radical debuts September 25. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit cancerculture.substack.com