When Tracie Hoyt found a lump in her breast last summer, doctors confirmed that it was cancer. After surgery to remove the lump, she expected radiation treatments and months of chemotherapy. A self-described workaholic, Hoyt worried that she would be too ill to deliver mail along her Cockeysville postal route. "You hear how terrible chemo can be on your body and that people are really sick," she said.
To her surprise, Hoyt, 46, was spared chemotherapy.
A genetic test known as Oncotype DX provided a look at the inner workings of the tumor, helping her doctor predict that chances were low that her particular type of cancer would return. The test's manufacturer says Oncotype DX has been performed on about 17,000 women.
It is among the tools making their way into doctors' hands and patients' lives as new technology emerges from genetics research. The tools, which include screening tests and targeted drugs, help doctors tailor treatments for breast and other cancers.
"This is just the tip of the iceberg," said Jonathan Weiner, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. "There are only a dozen or so examples now, but one day there are going to be thousands."
Even now, patients, doctors and insurance companies are struggling to keep pace.
Much of the genetics research is focused on treating breast cancer, a disease expected to strike more than 210,000 American women this year and kill more than 41,000.
Breast cancer, like other types of cancer, begins when abnormalities in the genetic machinery of a cell cause it to spin out of control.
"Cancers start as one cell - one little nasty cell that goes awry," said Dr. Michael J. Schultz, who is Hoyt's physician and the medical director of a new Breast Center at St. Joseph Medical Center. As that cell divides, it produces an army of similarly rebellious cells - a tumor.
In the past, doctors were limited to such factors as a patient's age, family history and tumor size in assessing the danger and deciding how to combat it. That has changed as researchers identify genes that, when mutated, alter the normal behavior of cells.
Oncotype DX, a test that was approved in a peer-reviewed process, profiles the DNA of a woman's tumor cells by looking for mutations in 16 genes linked to breast cancer. If the analysis shows the genes are not flawed, chemotherapy is not expected to improve the woman's chances for survival.
Women who scored favorably on an Oncotype DX test gained "minimal, if any, benefit from chemotherapy treatment," according to a study published in August. The test is valid only for women with early-stage breast cancers that respond to estrogen and have not spread to the lymph nodes.
Although chemotherapy is recommended for most women with breast cancer, those who benefit substantially make up a "fairly small" proportion of cases, according to the National Cancer Institute.
In Hoyt's case, the test showed that she had a good prognosis. She avoided chemotherapy and has returned to work.
She credits Schultz for recognizing her eligibility for the test. "He pushed for that," she said, "and that's what saved me from chemo." Her insurance covered most of the $3,600 cost of the test.
For another of Schultz's patients, Doreen M. Lecheler of Harrisburg, Pa., getting the test wasn't so easy, even though the doctor had recommended it.
Lecheler, 45, found out she had breast cancer after her annual mammogram in July. "The thing that everyone said to me was, `If you're going to be diagnosed with breast cancer, you couldn't have picked a better time in history'," she recalls. "I was so excited about the things that they're offering now."
Her insurance company, however, refused to pay for the Oncotype DX test or for a new, minimally invasive form of radiation therapy.
Lecheler paid out of pocket for the test and, based on the results, decided to skip chemotherapy.
She is now undergoing radiation - the more invasive method - and taking the estrogen-blocking drug, tamoxifen.
"I am really doing great," she said of her morale. "The hard part has been dealing with this anger and frustration with the insurance company."
Stories like Lecheler's are likely to become more common as new gene-based tests and drugs flow onto the market.
"This industry is at the beginning stages of a disruptive innovation," said Randy Scott, the CEO of Genomic Health Inc., the California company that developed Oncotype DX.
Scott said that about 60 percent of patients pay for the test. He expects most insurers to cover it by the end of next year - four years after its introduction in early 2004.
"If you want to make a dramatic change in medical practice, it doesn't happen overnight," he said.
Government health agencies and insurance companies - "payers" in medical industry lingo - generally take a cautious approach to adopting new technologies, he said.