It’s been more than a decade since Malcolm Gladwell published his bestselling book “Outliers: The Story of Success.” The book debuted at No. 1 on The New York Times Bestseller List in November 2008, just a couple months after I started working at the National Breast Cancer Foundation.
At the time, “Outliers” was regularly (and almost religiously) referenced in business meetings, strategy sessions, and conferences. In fact, if you walked into any Starbucks in 2008 or ‘09, you might even think the book powered laptops.
In “Outliers,” Gladwell introduced the masses (and me) to “The 10,000 Hour Rule” — the idea that it takes a person 10,000 hours of practice, dedication, or attention to a thing in order to master it.
According to Gladwell, “To become a chess grandmaster also seems to take about ten years. (Only the legendary Bobby Fisher got to that elite level in less than that amount of time: it took him nine years.) And what’s ten years? Well, it’s roughly how long it takes to put in ten thousand hours of hard practice. Ten thousand hours is the magic number of greatness.”
So here I am, a decade later. I’ve done this thing, put in my hard practice for well over 10,000 hours. I’ve given the topic of breast cancer this magic number of greatness and yet the idea of mastery over breast cancer seems as foreign to me as the day I stared. In fact, as I’ve looked over the mysteries of breast cancer, one thing I’ve learned is that when one layer of insight or knowledge is peeled back, another thousand layers unfold.
I don’t know that I’ll ever master breast cancer but I am not alone in my uncertainty. After all, there is still no cure for this disease and breakthroughs are often not as impactful as the myriad headlines suggest. However, to say I have not gained some level of expertise would be untrue.
I am now an expert in many of the things that matter most — things like uncertainty. I am an expert in what it’s like to lose control, to not be able to fix a problem right in front of you. An expert in feeling helpless.
I am an expert in the pain of loss. I know and understand that little ripple of fear and dread that seems to clamber from an unknown, secreted space within our consciousness. I know it so well that I know it doesn’t take 10,000 hours of practice, but just a single moment. Perhaps the moment a mother, my own even, depleted of platelets, slips on the bathroom floor. It only takes a second, really. And it’s important that I’m an expert in these things because I can’t help what I don’t know.
I am also an expert in hope. The kind of hope that doesn’t make sense. The kind that seems almost miraculous in its ability to strengthen and repair the most heartbroken. I am an expert in finding the silver lining in the darkest cloud — a dying patient that found a mother to adopt her child after her death; an early stage breast cancer patient afraid of bankrupting her family, then finding financial support, undergoing treatment and surviving; a husband who simply wanted to know the safest way to cuddle with his dying wife.
The future of breast cancer
The future of breast cancer is uncertain, mysterious, and will require mastery that exceeds all the rules, but I do have an expert-level amount of hope.
According to the American Cancer Society, “Breast cancer death rates declined 40% from 1989 to 2016 among women. The progress is attributed to improvements in early detection.”
Mortality rates of breast cancer continue to decrease and I think the progress made will continue to compound in the years to come.
In the future, medicine and our understanding of how to treat and diagnose breast cancer will probably flow through a pool of artificial intelligence (AI). Cancer is one of the most complex problems of mankind, and what makes it so complex is its ability to trick and deceive our own cells to turn on us and disrupt the very blueprint of our existence. With AI, I think cancer’s algorithm may have met its match.
You have to admit it’s undeniably clever that humankind created Watson, a supercomputer, to beat Ken Jennings on Jeopardy, then quickly spring vaulted to precision medicine and cancer research. It was if the TV show was a short test drive. Watson can win Jeopardy, now let’s see if it can help us find cancers earlier or treat them more precisely. And now, can we find a cure? One can hope, and I do.
I’m cautiously optimistic about the future of immunotherapy – a cancer treatment that boosts the immune system to help fight tumors. I’m optimistic because of stories like former President Jimmy Carter’s, whose metastatic melanoma went into remission after he received a breakthrough immunotherapy treatment.
However, immunotherapy breakthroughs for breast cancer patients have progressed more slowly.
Last March, a new immunotherapy drug was approved for patients with late-stage, triple-negative breast cancer. The drug blocks the PD-L1 protein on some tumor cells, which triggers the immune system to attack and shrink the tumor. Triple-negative breast cancer patients desperately need more targeted therapies, as they have historically had few options outside of the traditional array of surgery, radiation, and chemotherapy.
Breast density, and improved screening and communication
Breast density has been a hotbed issue for many years. Women with dense breasts are slightly more likely to develop breast cancer and it’s harder to spot tumors because the tissue is the same color (white) on traditional mammograms. New and improved 3D mammography is helping find tumors earlier, and breast MRIs and ultrasounds have helped find cancers masked by dense breast tissue.
New technology, however, requires improved awareness and regulation. Some states enacted laws, such as Henda’s Law in my state of Texas, that require mammography providers to notify all women with dense breast tissue that their mammograms may be less accurate than those of women with lower breast density, and that they may benefit from “supplemental screening” in addition to their annual mammogram. However, these kinds of regulations are not standardized across the United States.
Last March, the FDA proposed an amendment to the Mammography Quality Standards Act of 1992, a law that ensures mammography facilities across the United States are providing quality services. One of the proposals will help improve communications between doctors and patients regarding breast density, and increase access to higher quality screening options for these patients.
According to the FDA Principal Deputy Commissioner Amy Abernethy, M.D., Ph.D., “Given that more than half of women over the age of 40 in the U.S. have dense breasts, helping to ensure patient access to information about the impact that breast density and other factors can have on the risk for developing breast cancer is an important part of a comprehensive breast health strategy.”
The future will be improved screening results for patients with dense breast tissues and more cancers found in the earliest, most treatable stages. I believe future lives will be saved by these measures.
The future is research. We need more well-funded research and more targeted therapies for breast cancer. We especially need breakthroughs in metastatic disease.
I was especially excited to hear about the end-of-study analysis of the CLEOPATRA trial presented by Sandra M. Swain, M.D., FACP, FASCO (the associate dean for research development at Georgetown University Medical Center and the Lombardi Comprehensive Cancer Center, Washington, DC) at the June 2019 American Society of Clinical Oncology Conference.
The trial showed that well over a third of HER2-positive metastatic breast cancer patients who received first-line treatment with pertuzumab combined with trastuzumab/docetaxel were alive after eight years.
Though this study only impacts the HER2-positive subset of breast cancer patients, it could be a game changer for thousands diagnosed with this aggressive form.
An end to health disparities
We live in a don’t-look-back world but, with breast cancer, we have to look at it all — the past, present, and future. And we are surrounded by disparity in healthcare.
Women across America are dying of often treatable breast cancers because they lack access to early detection services, and quality and timely care. These patients are often uninsured or underinsured. The future of breast cancer will be dim if we improve technology, research, and regulation, but do nothing to increase access.
We have to find a solution to rising healthcare costs and the need for quality care. We have to ensure all women in America have access to quality screening regardless of their ability to pay.
Also, this must extend to treatment. We have many examples of patients that present a suspicious finding on a mammogram, but choose not to follow up because of work-up costs, which often exceed thousands of dollars. We can’t offer free screenings and expect patients to be able to afford follow-up biopsies or treatment.
We must increase patient navigation services. Every facility that screens, diagnoses, or treats patients for breast cancer should have a patient navigator or have access to one. Patient navigators work to decrease the wait times between screening, diagnostic, and treatment, and eliminate barriers to timely care — language, cost, fear, and transportation. Without patient navigators working within the complex cancer care systems across America, patients that face these barriers are less likely to overcome and survive a breast cancer diagnosis.
Whatever the future holds, I know it is going to get better for women facing breast cancer. Improvements in research and technology, greater access to better screening methods, and an overall decrease in the mortality rate are the building blocks of what I see as a horizon of hope.
Douglas Feil, Director of Programs, National Breast Cancer Foundation, [email protected]