Caution is hope's conjoined twin for people with cancer. One is always attached to the other.
The promise carried by reprieves from nausea and other chemotherapy misery is countered by medical prognoses that are at best vague. Five-year survival rates have escalated to about 61 percent, yet are compromised by the fear of what happens to the other 39 percent. Lingering remissions are offset by the way some oncologists still recoil from the word "cure," as if they were in Alcoholics Anonymous.
But in a world where some people evaluate themselves through the level of confidence they'll see the next day, new breeds of medication are inspiring predictions that within a decade most cancer will be viewed as just another condition that can be managed and survived.
"A generation ago, a diagnosis of cancer was a death sentence," said Dr. Judith Gasson, director of UCLA's Jonsson Cancer Center, one of the nation's leading research centers. "Today, we have a 60-40 chance. I think we'll get to a point where you say, 'Oh it's only breast cancer."'
UCLA is researching drugs such as Herceptin and Avastin in clinical trials. The first medication, already approved for some patients, uses a protein's antibody to control a strain of breast cancer. The latter views a malignancy as a vampire, barricading tumors from the blood needed to grow.
An already approved drug, Gleevec, reacts to molecular mutations in leukemia and has generated enough dramatic remissions to become the champion of cancer treatment.
People with aggressive cancers view the revolution with a reserve learned from other glimmers of hope that have been eclipsed. Even those apparently benefiting from new medications have no way to measure the success and no idea if their good health will last.
But they are alive and, at least temporarily, free of the vomiting, diarrhea, baldness and other side effects triggering the joke that cancer treatment is worse than the disease. And though its cautionary guard is still present, hope is at least beginning to metastasize.
Every Monday at her oncologist's office in Thousand Oaks, Calif., Gail Crawford sits in an easy chair and reads a magazine as Herceptin drains intravenously into her body.
The drug contains the antibody to a protein called HER-2/neu that whips some breast cancers into frenzied growth. Already available for Crawford and other patients with Stage 4 cancers - Stage 5 means death - the medication is being tried on less advanced cases in clinical trials.
Crawford, who lives in Moorpark with her husband and their 14-year-old son, assesses the drug's purpose with the bluntness of someone who learned she may have about a 15 percent chance of living three years.
"I hope it is killing the aggressive cancer cells that are killing me," she said. "I'm counting on my Herceptin to change the statistics. It's my brass ring."
Though undetected by a mammogram, the cancer in her right breast was the size of a baseball when diagnosed 16 months ago. It had infected surrounding lymph nodes so that when Crawford stroked her neck, it felt like a string of pearls.
A vice president for a high-powered automotive accessories company, she was so sure of her imminent death she cleaned out her desk. At home, she went through her newest clothes, playing with the idea of returning anything with a price tag.
She went to bed wondering if she would wake the next morning.
Herceptin isn't her only trip to the cutting edge. During a 21-day stay at the UCLA Medical Center, the blood was pumped out of her body, flushed of the bone marrow stem cells that produce immunities, and then returned. She went through a week of especially toxic chemotherapy aimed at destroying the cancer. The stem cells were transfused back in hopes of regenerating her body's defense systems.
The chemotherapy left her bald, looking puffy and gray, her eyes devoid of life.
Herceptin, which she has taken without accompanying chemo for about nine months, has relatively minimal side effects. Today, Crawford looks vibrant. Her hair has grown back curly. She has the energy to take weekly golf lessons and has joined a badminton club.
Whether because of the stem-cell transplant, the Herceptin or both, her cancer is undetectable at the moment. Crawford understands the reason doctors haven't told her she is in remission is that they don't know if her cancer is diminishing or simply dormant - a bear waiting for spring.
She struggles with anemia, a lung capacity nearly half of what it once was and the still daunting pall of uncertainty.
But something has changed and Herceptin has helped, along with the emotional medication provided by a Wellness Community support group.
A year after doing a morbid inventory of her bedroom closet, Crawford is again buying new clothes. She and her husband talk about retirement plans. She worries about three years from now but has gained confidence about her immediate whereabouts.
"I know I'm going to wake up tomorrow and that's really good," she said.
Of the about 400 cancer drugs being researched in clinical trials and other studies, dozens hone in on unique characteristics of specific cancers.
Like Herceptin, they may consist of an antibody to an especially aggressive protein. As with the Avastin drug being used in clinical trials for colorectal and breast cancer, they may be growth inhibitors designed to stop a protein involved with creating blood vessels through which a cancer grows. Such drugs are aimed to keep a tumor the size of a pinhead in hopes accompanying chemotherapy can wipe it out. Larger cancers may be induced into shrinking by being blocked from their food supply.
Other new drugs invade cancerous cells and disrupt proteins that represent biochemical growth messages. Already approved by the Food and Drug Administration, Gleevec has used such a scrambler strategy to bring remissions to people with early stages of a form of leukemia called chronic myeloid.
The medications offer striking contrast to standard chemotherapy and other treatments that use drugs to strafe an infected region with a wide range of success depending on the type cancer, in some cases deteriorating not only the malignancy but healthy tissue nearby.
"It's the difference between throwing a hand grenade and using a smart bomb," said Gasson, of UCLA, noting the new drugs are available only to patients with very specific forms of cancer. "If we can do it for these cases, there's incredible optimism that we can find the molecular targets in the most common forms of cancer."
No one labels the new drugs as cures. Dr. Cary Presant, a researcher and oncologist who is past president of the California branch of the American Cancer Society, envisions the new medications being used with standard treatments and a growing emphasis on medication, nutrients and lifestyle changes focused on prevention. He thinks that within a decade, three of four cancer patients will survive cancer.
"I think that's very big," he said. "Do I think it's the end of improvement? No, not at all. Progress is being made on an hour-to-hour basis."