Unfriendly Fire in the Cancer War

[Guest guest]

Second Opinion: Unfriendly Fire in the Cancer War

By Abigail Trafford

Washington Post Staff Writer

Tuesday, January 8, 2002; Page HE01

Two Danish researchers have challenged the sacred dogma that mammography

saves lives - and touched off another breast cancer war. As the furor over

their study spreads, I think back to a woman with a fierce spirit who died

of breast cancer more than 25 years ago. She initiated me into the

ideological warfare that has dominated this disease for decades.

The woman was in her eighties. A feminist and a dentist, she had taken a

holistic approach to illness long before the current era of granola chic

made " integrative medicine " a popular trend. Skeptical of conventional

doctors, she preferred to take care of herself.

She was in her sixties when she discovered a lump in her breast, but she did

not have it diagnosed or removed. Instead she monitored it, determining that

it was a slow-growing tumor. Then she went about her life for the next 20

years.

Finally, the cancer got out of hand. She told her son that she knew she was

dying and that she was content and proud of her long, independent life. But

now, she said, she needed to go to a nursing home for support through her

final weeks. To get into a nursing home, she was told, she would have to go

to a hospital first. So she walked into the emergency room of a local

hospital to get a referral.

That's when the furies of the cancer establishment descended on her. Shocked

to see such an advanced case of breast cancer, the doctors questioned her

sanity and berated her for not seeking treatment sooner. In a conversation

relayed to me then by her son, one doctor asked incredulously: " Do you know

what you have? "

" I have breast cancer, " she replied. " I've had it for 20 years. "

" Without treatment, you're going to die, " said another doctor.

" Of course I'm going to die, " she snapped. " I'm dying right now. "

When she refused to undergo immediate surgery, the doctors wouldn't

discharge her. It took several days and the intervention of a well-known

cancer specialist at the National Institutes of Health to get the woman

released from the hospital and transferred to a nursing home. By that time,

she was bedridden, her spirit broken.

Her experience does not mean that women who find a lump should not seek

medical attention. But her story reveals how closed the medical community is

to those who deviate from prescribed norm.

The same kind of professional response is recurring in the current battle

over mammography. The report, in the British journal The Lancet, concluded

that " screening for breast cancer with mammography is unjustified. " In an

analysis of existing studies, researchers found no compelling evidence that

mammography saves lives in women of any age. They suggest that breast cancer

screening may lead to more aggressive and debilitating therapies, not less,

as is generally thought. They challenge the dogma that early detection with

mammography is the key to cure.

An editorial accompanying the report concluded: " At present, there is no

reliable evidence from large randomized trials to support screening

mammography programs. "

To many in the cancer community, this amounts to heresy. For decades women

have been told to get regular mammograms to detect cancers at an early

stage, before they can be felt, when treatment is most likely to be

effective. In a culture of consumer empowerment, women were instructed to

get a mammogram every year as one thing they could do to protect themselves

from the disease. Many breast cancer survivors believe that they are alive

today because a mammogram picked up their disease.

Members of the medical establishment were quick to condemn the report. It is

" riddled with misrepresentation, inconsistency . . . errors of method and

fact, " wrote A. of the American Cancer Society in a letter

co-signed with two leading European cancer experts. To them, the evidence is

persuasive that mammograms have reduced the death rate from breast cancer.

Certainly more studies are needed to settle this question. No one is

suggesting that women not get screened on the basis of one report. But more

people in and out of the doctor's office are raising questions about

mammograms. That's healthy. Subsequent research may well demonstrate the

benefit of early detection. If not, then screening guidelines and treatment

approaches would have to change.

What's disturbing is how difficult it is to get real debate on the basic

issues of breast cancer. There is a kind of pink ribbon fundamentalism that

clamps down on dissent. Anybody who challenges the ruling dogma is branded a

heretic.

This has been true for half a century. In the battle over the radical

mastectomy that began in the 1950s, a few scientists first raised the flag

that perhaps early detection was being oversold. They suggested that

outcomes in breast cancer were due more to the underlying biology of the

tumor rather than the timing of diagnosis.

" There was a huge backlash. These guys were seen as traitors, killers of

women. They were shouted down at meetings, disdained by the cancer

establishment, " said Barron H. Lerner, associate professor of medicine and

public health at Columbia University and author of " The Breast Cancer Wars. "

The battle flared up again in the 1970s, when mammography was first promoted

as a front-line defense in the government's war on cancer. Those who

questioned the program were seen as the enemy. It surfaced again in the

1990s, when Congress essentially overruled a National Cancer Institute

panel's recommendation against mammography for women in their forties.

" People take sides. They are less willing to give ground, " said Lerner. " To

some degree, it's the same in the current debate. "

This us-vs.-them rigidity does no service to women or to medical science.

" The focus has to shift, " said Fran Visco, president of the National Breast

Cancer Coalition. Mammography, she points out, is a small piece of the

breast cancer puzzle. For too long, " breast cancer has been equated with

mammography. 'Early detection saves lives,' so let's give every woman a

mammogram, " she said. " Now there is an acknowledgment that mammography

screening is not the answer to breast cancer. "

The war on breast cancer needs a new strategy. The more important questions

are how to prevent breast cancer in the first place, how better to detect

and treat the many different kinds of breast cancer, how to provide

state-of-the-art health care to those with the disease.

And how to be more tolerant.

© 2002 The Washington Post Company