Terra Infirma

Can bone-marrow transplants save breast-cancer patients? There's little middle ground in the debateand lots of uncharted territory.

McLaughlin found her three-day high-dose drug bombardment less traumatic than she'd feared. It was perhaps a little less difficult than regular chemo, she says, because of the careful support and monitoring she received at the hospital. But the days that followed were far worse. "Here I am," she says. "They've killed off all my white cells, which are the ones who do repair, who fight off infection. I've got a sore throat from the mucus running down the back of my throat. I've got a really dry mouth. I've gotten mouth sores, because my body can't heal itself. Vaginal bleeding. Vomiting. I got to where I couldn't swallow."

Pagano takes her sister's hand. "She's a very brave one, I'll tell you," she says. McLaughlin is shaking her head; once again the tears are leaking. "You are," Pagano says. "Brave."

"Everybody comes up and says, 'You're doing such a good job handling this,'" McLaughlin says finally. "I said, I've got two choices. I've got this disease. I can either curl up in a ball and let it get me, or I can laugh and joke and I can fight. That's all you can do. There's no other choice."

"On Saturday her vehicle was falling apart," adds Pagano. "She needed two pints of blood and she needed platelets. She really had to be picked back up. But they gave her a tuneup, and then she felt a lot better." The women have their heads together--Pagano's dark curls close to McLaughlin's bald skull--and they're giggling. Clearly this is a sister joke. "You know," Pagano continues, "a change of oil..."

"Go over the chassis..." her sister chimes in.
"New transmission fluid..."
They sputter into amused silence.

Last week, 20,000 cancer experts from all over the world converged on Atlanta for the annual meeting of the American Society of Clinical Oncology (ASCO). Bone-marrow transplant was the hottest topic on the agenda.

The first well-constructed, randomized studies--five of them--were scheduled for discussion. But even before the convention, the findings had leaked out--and they did not bring good news. Four indicated that women who had bone-marrow transplants, whether for aggressive or metastasized cancer, did no better than those who had conventional chemotherapy. Only one small study, from South Africa, showed positive results. (The results of all five studies have been published at www.asco.org.)

A cancer diagnosis topples the world into chaos. If there's one thing a patient needs from her doctor, it's calmness and authority. And here were the best cancer doctors in the world, arguing passionately about the one treatment for advanced breast cancer that had offered the possibility of cure.

Activist organizations were quick to join the discussion. "We have not seen the study results," the National Breast Cancer Coalition announced blandly before the conference, but "it has become clear that the results will not show that this treatment benefits women with breast cancer." Barbara Brenner of the San Francisco-based Breast Cancer Action says she found the results "pretty unambiguous." But while she supports further, highly controlled clinical studies, Brenner also believes that resources should be redirected toward "less toxic, more targeted" therapies.

The ramifications are enormous--and they hit close to home. Across the country, researchers like Jones and Shpall have staked their reputations and careers on bone-marrow transplant. Thousands of women have undergone the procedure; many are convinced it saved their lives. Thousands more are trying to decide whether to enter a transplant program.

"People who do what I do for a living have justifiably been criticized for too much high-dose therapy in breast cancer," says Dr. Jeffrey Matous, who works for Rocky Mountain Cancer Centers. "We need to be skeptical of our data; we need to be very truthful with our patients. There's a lot that we do not know yet."

But, he adds, "when you look at these studies, in no study is high-dose therapy inferior to standard therapy. The question you have to ask is, [has the transplant method] adversely impacted quality of life?"

Quality of life is the primary issue for Shonda Cortez. The Carbondale woman was diagnosed with inflammatory breast cancer, which is almost always fatal, and underwent a bone-marrow transplant of a particularly focused kind in January. "It was nightmarish," she says. "I really don't like to hear my family tell me much about the first week. They give you drugs that help you forget, but my mother said I would just roll back and forth in bed and say, 'I'm so miserable.'"

She also had psychotic episodes. One night she unhooked her catheter, got her walker and tried to leave. When the nurse came in, Cortez was terrified and made her empty her pockets. On another occasion, she kept begging her parents to get rid of the flies in her room. One of the drugs she was given causes nerve damage in the hands and feet. For a while she could hardly stand up, and the mere touch of the bedcovers on her feet caused excruciating pain.

Cortez's thinking was affected. Sometimes she meets other women who have been through the treatment and is relieved, she says, to find "their brains aren't too bad. Maybe mine will come back."

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