Ten remarkable years.

In this issue of Clinical Breast Cancer, we celebrate the first 10 years of the journal’s existence. We also celebrate 10 remarkable years of progress in breast cancer, with reviews by several distinguished authors who have played an important role in the changes we have experienced. This progress has involved changes in both local-regional and systemic therapies, changes that have improved patient safety, reduced the morbidity of both the disease and its treatments, and (most importantly), decreased breast cancer mortality. As impressive as the past 10 years have been, I expect the next 10 to be even more exciting. It is a fun time to be a cancer researcher, and a particularly satisfying time to be a breast cancer researcher. In the past decade, we finally cracked the code of this disease. Genomic studies in particular have vastly enriched our understanding of the disease. They are our Bletchley Park to the enigma of breast cancer and have required a skill set not too dissimilar to that employed by a previous generation of code-breakers: expertise in higher mathematics, understanding of a foreign language, and an impressive degree of persistence in unraveling the meaning of the enemy’s actions and motivations. Breaking the code is not the same as winning the war, but it is an important starting place. Knowledge truly is power, and the knowledge encoded in the tumor genome has the potential to irrevocably alter the future of breast cancer therapy. The first generation of genomic studies established basic population patterns in breast cancer, with its luminal, basal, and HER2 subtypes. The next generation will move from population studies to something equally fascinating and revolutionary. The existence (within the very new future) of the $1000 genome will offer clinicians unparalleled knowledge, not of the disease as a whole, but of the drivers of the individual’s cancer. At present, this is still heavily black-boxish. Breast cancer will no doubt prove far more complex than we can currently even imagine. Most clinicians (I count myself among them) lack the intellectual tool kits necessary to examine the individual genome for mutational events or biologic pathways. Conquest of the disease will ultimately require the understanding of those for whom math problems are first nature, perhaps a generation of physician-scientists raised to the task. It will require awe-inspiring computational skills and enormously large storage capacity. But the history of science is utterly consistent on this point: when a field becomes amenable to mathematical characterization, to algorithms and formulae, progress is rapid. And cancer is quite close to becoming a math problem. Past the science, we next must deal with the realities of clinical research and cancer care. As outlined by three reviews in this issue, the past decade has seen important advances in the treatment of patients with breast cancer. These include (1) significant improvements in local-regional therapy that have improved local control and simultaneously reduced morbidity; (2) improvements in the use of systemic chemotherapy that have focused their use to select populations, and simultaneously improved outcome through the use of novel chemotherapeutic agents (the taxanes) and better means of administration (dose-dense and weekly chemotherapy approaches); and (3) increased and more effective use of targeted therapies (eg, trastuzumab for HER2-positive breast cancer and aromatase inhibitors for estrogen receptor–positive disease). These changes have had an important cumulative effect in reducing breast cancer mortality in the past decade, a trend that is likely to continue for several years as the advances of the past decade are fully deployed. In large part, these advances came about as the result of cooperative group trials. Our nation’s cooperative groups face increasing challenges that threaten the future progress of our field. These challenges are largely self-inflicted wounds: increasing regulatory burden and diminished resources emanating from the federal government, which at its best has practiced only benign neglect of this national treasure. The groups themselves have been slow to respond to changes, particularly changes in technology, and have essentially the same administrative structures as they had a half-century ago: teaching the elephant to dance has not been easy. A recently released Institute of Medicine report may breathe new life into the cooperative group system. It would be tragic indeed if the rapid advances in our understanding of breast cancer biology were not translated into clinical progress because of the lack of a clinical trials infrastructure. We also face important national challenges in the delivery of health care, including care for patients with breast cancer. Here, the issue is one of value, loosely defined as delivering high-quality care at a reasonable cost. Changes in the wider health care environment pose both challenges and opportunities for caregivers. It is too early to know what effect health care reforms will have on our ability to deliver care to all women with breast cancer, but it is clear that the ride will be bumpy for the next few years. At Clinical Breast Cancer, we have enjoyed playing a small part in the progress of this field, and we hope to continue in this role going forward. We will continue to publish clinical trial results that advance treatment options for our patients, and to review the important work of others in what we trust will be a well-reasoned and intelligent manner. The next decade has the potential to largely eliminate breast cancer as a major cause of mortality in the developed world, and we all, by playing our parts, can advance that important goal.