Teaching Kids V. Treating Cancer: What Have We Learned Since 2003?

Pru started her oncology training in 2003. I asked her: What has your field learned about breast cancer since 2003? To keep it simple, just tell me about chemo -- ignore radiation treatment and surgery advances. (Cautionary note: this is undoubtedly my highly inaccurate translation of what she said. Do not use this blog for medical advice. Or financial advice. Though I do think Groupon is overvalued).

Pru replied something along the lines of:

I can think of three big advances that help oncologists treat breast cancer patients.

In 2003, if a woman received chemo for breast cancer, she'd probably get "AC." Adriamycin and cytoxan.

In 2012...

1. About 70% still get AC as their chemo.

But if AC fails, we have much better 2nd, 3rd, 4th, and 5th line options. Taxotere, for example. That's a big deal. Xeloda. Even a bigger deal. Chemo in a pill.

2. There's an amazing test called OncotypeDx. It costs about $4,000 a pop. Became available in 2004 or so.

We learn more about the breast tumor than we ever knew before. By understanding the genetics, we know how likely the tumor is to come back. And if it's likely, we can do something.

For example, we might treat tiny tumors that we'd otherwise ignore. Or the patient might take Tamoxifen, a hormonal treatment.

3. My breast cancer work over the last couple years is in cancer genetic counseling and prevention. This type of work isn't widespread yet. It's new.

Most oncologists are busy just treating cancers, not meeting with women who have no cancer. And insurance companies are just getting up to speed on counseling. Obviously if it'll save them money through prevention and early-stage detection, they'll start to fund and even promote it. Or so we hope.

The process starts with a conversation. If a woman has a family history of breast cancer, we talk about the risks, which depend on how close the relatives were, how old they were when they got breast cancer, is she of Ashkenazi Jewish descent, and so forth.

Then we can do a test. It's for the BRCA mutation. We send the sample to Utah. There's one company in the world that can analyze the genome, called Myriad. $3,000 or so per test.

In the population I'm testing, there's a 10% chance of BRCA mutation. And if my patient has that mutation, she's very likely to get breast cancer. But it's much better for us to learn that early.

a. She can get surgery before any cancer appears; have her breasts removed. This is more popular in Europe than in USA. And when it happens in USA, women more often want to combine a liposuction procedure and plastic surgery so they still have breasts.

b. Even without surgery, a BRCA+ woman can take Tamoxifen before any cancer arrives. This could cut the risk by 50%.

There are risks of side effects. But often patients have a somewhat irrational fear, based on reading random stuff on the internet and following news stories that don't put things in perspective.

For example, it's true that Tamoxifen increases your risk of uterine cancer as a side effect. So you'd think - "Well that is scary. I don't want to protect against breast cancer and cause a different cancer." However, the risk is roughly 0.2%, or 1 in 500. Would you trade a 50% reduction in the chance of getting breast cancer for a 0.2% chance increase of getting uterine cancer?

c. In any case, Tamoxifen still scares people. That's why I'm excited about a new drug, being developed right down the road at Mass General. Paul Goss is leading the work. Exemestane. Cuts breast cancer risk by 65% in older women who are higher risk without (so far) side effects beyond hot flashes.


What has our field learned about teaching since 2003? I can't think of much. Can you?

Let's see. We do have some new buzzwords.

"Data-driven" teaching. It does happen well in a few schools. Thanks to folks like these guys and Paul B. In most schools, though, it's just a buzzword that annoys teachers. Same is true of "differentiated instruction."

"Inverted classroom" is a new way of teaching. That's the idea that kids watch videos at home to learn the basics, and then the teacher leads problem-solving the next morning. I haven't yet heard of it in high-poverty schools, but who knows.

What am I missing here?

I'm not talking ed policy, I'm talking the day to day job of teaching: choices made, methods used. Do we have any concrete advances in teaching?