Study Suggests Cancers May Go Away on Their Own

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New York Times

Study Suggests Cancers May Go Away on Their Own

Full text of article

By GINA KOLATA

Published: November 24, 2008

Cancer researchers have known for years that it was possible in rare cases for

some cancers to go away on their own. There were occasional instances of

melanomas and kidney cancers that just vanished. And neuroblastoma, a very rare

childhood tumor, can go away without treatment.

But these were mostly seen as oddities — an unusual pediatric cancer that

might not bear on common cancers of adults and a smattering of case reports of

spontaneous cures. And since almost every cancer that is detected is treated, it

seemed impossible to even ask what would happen if cancers were left alone.

Now, though, researchers say they have found a situation, in Norway, that has

let them ask that question about breast cancer. And their new study, published

Tuesday in the Archives of Internal Medicine, suggests that even invasive

cancers may sometimes go away without treatment and in larger numbers than

anyone ever believed.

At the moment, the finding has no practical applications since no one knows

whether a cancer that is detected might disappear or continue to spread or kill.

And some remain unconvinced.

“Their simplification of a complicated issue is both overreaching and

alarming,†said A. , director of breast cancer screening at the

American Cancer Society.

But others, including M. Kaplan, chairman of the department of health

services at the Schoo

l of Public Health at the University of California, Los Angeles, are persuaded

by the analysis. And, Dr. Kaplan said, the implications are potentially

enormous.

If the results are replicated, Dr. Kaplan said, it might eventually be possible

for some women to opt for so-called watchful waiting, monitoring a tumor in

their breast to see if it grows. “People have never thought that way about

breast cancer,†he added.

Dr. Kaplan and his colleague, Dr. Franz Porzsolt, an oncologist at the

University of Ulm, writing in an editorial that accompanied the study, said:

“If the spontaneous remission hypothesis is credible, it should cause a major

reevaluation in the approach to breast cancer research and treatment.â€

The study, by Dr. H. Gilbert Welch, a researcher at the VA Outcomes Group in

White River Junction, Vt., and Dartmouth Medical School; Dr. Per-Henrik Zahl of

the Norwegian Institute of Public Health; and Dr. Jan Maehlen of Ulleval

University Hospital in Oslo compared two groups of women, all aged 50 to 64, in

two consecutive six-year periods.

One group of 109,784 women was followed from 1992 until 1997. Mammography

screening in Norway was initiated in 1996. In 1996 and 1997, all were offered

mammograms and nearly every woman accepted.

The second group, of 119,472 women, was followed from 1996 until 2001. All were

offered regular mammograms and nearly all accepted.

It might be expected that the two groups would have roughly the same number of

breast cancers, either detected at the20end or found along the way. Instead, the

researchers report, the women who had regular routine screens had 22 percent

more cancers. For every 100,000 women who were screened regularly, 1,909 were

diagnosed with invasive breast cancer over six years as compared with 1,564

women who did not have regular routine screening.

There are other explanations, but researchers say that they are less likely than

the conclusion that the tumors disappeared.

The most likely explanation, Dr. Welch said, is that “there are some women who

had cancer at one point and who later don’t have that cancer.â€

The finding does not mean mammograms caused breast cancer. Nor does it bear on

the question of whether women should continue to have mammograms — since so

little is known about the progress of most cancers.

Mammograms save lives, Dr. said, adding that even though they can have a

downside, most notably, he said, the risk that a woman might have a biopsy to

check on an abnormality that turns out not to be cancer, “the balance of

benefits and harms is still considerably in favor of screening for breast

cancer.â€

But Dr. Suzanne W. Fletcher, a professor emerita of ambulatory care and

prevention at Harvard Medical School, said it was also important for women and

doctors to understand the entire picture of cancer screening and the new

finding, she said, “is part of the picture.â€

“The issue is the unintended consequences that can come with our screening,â€

Dr. Fletcher said, meaning downsides, including biopsies for lumps that were not

cancers or, it now appears, sometimes treating a cancer that might not have

needed treatment. “In general we tend to underplay them,†she added.

Dr. Welch said the cancers in question had broken through the milk ducts, where

most breast cancers begin, and invaded the breast. Such cancers are not

microscopic, often are palpable, and are bigger and look more ominous than those

confined to milk ducts, so-called ductal carcinoma in situ, or DCIS, Dr. Welch

said. Doctors surgically remove invasive cancers and, depending on the

circumstances, may also treat women with radiation and, sometimes, chemotherapy.

The study’s design was not perfect, but researchers say the ideal study is

infeasible. It would entail screening women, randomly assigning them to have

their screen-detectedcancers treated, or not, and following them to see how many

untreated cancers went away on their own.

But, they said, they were astonished by the results.

“I think everybody is surprised by this finding,†Dr. Kaplan said. He and

Dr. Porzsolt spent a weekend reading and re-reading the paper.

“Our initial reaction was, ‘This is pretty weird,’ †Dr. Kaplan said.

“But the more we looked at it the more we were persuaded.â€

Dr. Barnett Kramer, director of the Office of Disease Prevention at the National

Institutes of Health, had a similar reaction. “People who are familiar with

the broad range of b

ehaviors of a variety of cancers, know spontaneous regression is possible,†he

said. “But what is shocking is that it can occur so frequently.â€

Although the researchers cannot completely rule out other explanations, Dr.

Kramer says, “they do a good job of showing they are not highly likely.â€

A leading alternative explanation for the results is that the women having

regular scans used hormone therapy for menopause and the other women did not.

But the researchers calculated that hormone use could account for no more than 3

percent of the effect.

Maybe mammography was more sensitive in the second six year period, able to pick

up more tumors. But, the authors report, mammography’s sensitivity did not

appear to have changed.

Or perhaps the screened women had a higher cancer risk to begin with. But, the

investigators say, the groups were remarkably similar in their cancer risk

factors.

Dr. , however, said the study was flawed and the interpretation incorrect.

Among other things, he said, one round of screening in the first group of women

would never find all the cancers that regular screening had found in the second

group. The reason, he said, is that mammography is not perfect and cancers that

are missed on one round of screening will be detected on another.

But Dr. Welch said he and his colleagues considered that possibility, too. And,

he said, their analysis found subsequent mammograms could not make up the

difference.

Dr. Kaplan is already thinking of how t

o replicate the result. One possibility, he says, is to do the same sort of

study in Mexico, where mammography screening is now being introduced.

A. Berry, chairman of the department of biostatistics at M. D.

Cancer Center in Houston, said the study increased his worries about screening

tests that find cancers earlier and earlier. Unless there is some understanding

of the natural history of the cancers that are found — which ones are

dangerous and which are not — the result can easily be more and more treatment

of cancers that would not cause harm if left untreated, he said.

“There may be some benefit to very early detection, but the costs will be huge

— and I don’t mean monetary costs,†Dr. Berry said. “It’s possible

that we all have cells that are cancerous and that grow a bit before being

dumped by the body. Hell-bent-for-leather early detection research will lead to

finding some of them. What will be the consequence? Prophylactic removal of

organs in the masses? It’s really scary.â€

But Dr. Esserman, professor of surgery and radiology at the University of

California in San Francisco, sees a real opportunity to figure out why some

cancers go away.

“I am a breast cancer surgeon, I run a breast cancer program,†she says.

“I treat women every day and I promise you it’s a problem. Every time you

tell a person they have cancer, their whole life runs before their eyes.

“What if

I could say, ‘It’s not a real cancer, it will go away, don’t worry about

it,’ †Dr. Esserman said. “That’s such a different message. Imagine how

you would feel.â€

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