Women are more alarmed than they need to be about the chances that they will develop breast cancer, and they are also more confident than they should be in “modern” medicine.
Few things frighten a woman more than discovering a lump in one of her breasts. With good reason: breast cancer may transform a woman’s breast into the vehicle of her death. It is twice as likely to be diagnosed in an American woman today as it was sixty years ago. And the treatment—surgery, usually followed by radiation and chemotherapy—is disfiguring, painful, and all too often unsuccessful.
I have been researching and treating this disease for more than fifteen years, a period in which the public’s awareness of breast cancer has risen enormously. The disease has brought into being an entire industry of research organizations, charitable agencies, commercial ventures, and advocacy groups. Every new statistic is trumpeted in the media, and every encouraging research finding, no matter how flimsy, is held up reported as a potential breakthrough.
One result of this visibility has been a rise in public sympathy for victims of breast cancer and a accompanying rise in funding for breast-cancer research. But the growth in awareness has had another, less desirable result: a flood of often contradictory information that has led to public confusion. Paradoxically, women are both too anxious about their chances of developing breast cancer and too hopeful about the current approaches to diagnosing and treating the disease. They believe that breast cancer is an epidemic and that it is being cured. Unfortunately, both these beliefs arise from flawed reasoning—not by women but by the medical profession.
Two groups in the health-care profession are involved in the fight against cancer—indeed, against any kind of disease. The first works principally on the front lines, helping patients understand the therapies available and offering insight, treatment, and reassurance whenever possible. The second works mostly at scientific institutions, performing the methodical, frustratingly slow tasks associated with epidemiology, clinical trials, and laboratory analysis. As researchers, the members of the second group are necessarily less concerned with the fate of specific patients than with understanding specific diseases and whether medicine is successfully combating them. To move forward, they must coldly distinguish between genuine advances and wishful thinking. I have spent my career as a member of the first group, although I have also spent years helping to conduct and analyze clinical trials. In what follows I have adopted the researcher’s view of the big picture, while also summarizing the risks and benefits of the treatments now available to women with breast cancer—treatments the clinician in me recommends and performs. Only by stepping back from the perspective of caring for individual patients can one hope to make clear what doctors mean (or should mean)when they use such broad words as “epidemic”and “cure.”
IS BREAST CANCER AN EPIDEMIC?
Many of my patients have conflicting images of their breasts. On the one hand, breasts are symbols of beauty, sexuality, and nurturing; on the other, they are troublesome organs that are increasingly likely to threaten women’s lives. In the United States the likelihood that a woman will be found to have breast cancer has slowly and inexorably mounted since the 1930s, when some systematic data collection began. The increase in diagnoses, already a cause for concern, accelerated in the 1980s, growing by a rate of four percent a year. This year, according to the American Cancer Society, some 246,660 women will discover that they have the disease; another 41,000 will die of it. Of the women in whom cancer is diagnosed, 12,200 will not yet be forty—nearly three times the number of women under forty who were found to have breast cancer in 1970. The disease is now the leading cause of death for American women aged forty to fifty-five, and causes women to lose more years of productive life than any other disease. Numbers like these are why breast cancer is often called an epidemic.
To our grandparents, this picture would have seemed amazing. At the turn of the century cancer of the breast was a relatively unusual disease. What happened? Why does the incidence of breast cancer seem so much higher today?
A big reason for the increase in diagnoses of breast cancer is the growing use of mammography, a technique that uses x-rays to examine the breast. With mammography doctors catch many cancer cases earlier than they otherwise would have—and many cases that would never have been caught at all, or caused any issues. The technique surged in popularity in the 1980s, and accounts for much of the recent spurt in diagnoses.
At the same time, most experts in medical statistics believe that these factors do not explain all of the rise. Even when all other factors are taken into account, a real, underlying increase remains. The chance that a woman will be found to have breast cancer has been growing steadily for decades, at roughly one percent a year. Now estimates put lifetime breast cancer risk at 12%!
What lies behind this rise? Although there is not enough evidence to say with certainty, an increasing number of observers have come to believe that the emergence of breast cancer as a widespread health problem is tied to the extraordinary transformations in women’s lives. Coupled with horrible processed nutrition, the expansion of opportunities for women, especially in the industrialized West, altered not only women’s lives but also their bodies, and especially their cycles of reproductive hormones—apparently making them more susceptible to certain cancers.
For most of human history, the age of first menstruation, usually occurred in the late teens. (This is one reason that previous generations saw less early-teenage pregnancy—fewer adolescents were physiologically capable of having babies.) Once fertile, women of past millennia quickly became pregnant with the first of perhaps half a dozen children, each of whom they breast-fed for an extended period—a practice that regularly stops the menstrual cycle. If they survived to their mid-thirties, they were aged in appearance and probably post-menopausal; their brutal living conditions usually did not permit them to live much longer. Late first menstruation, multiple pregnancies, long nursing times, early menopause—all these combined to make women of the past menstruate much less often than their modern counterparts. Many women in the past may have ovulated only twenty times in their entire lives.
Not until modern times has a large percentage of humankind been able to obtain a continuous supply of chemically laden, processed food and potable water. The average age of first menstruation has fallen to twelve in Western industrialized nations due in large part to high xenoestrogens in foods. Meanwhile, the age of first marriage has risen. According to the U.S. Census Bureau, it now averages twenty-seven for women in the U.S.; many educated and affluent women do not marry until their thirties, partly because of the increased opportunities to have careers outside the home. Pregnancy, too, has become much less common, as lost working time drives up the cost of having babies. Marriages produce an average of two children, which women nurse briefly if at all. And menopause does not occur until age fifty or later. Women today are thus exposed to reproductive hormones over a much longer span than in the past. They may have 300 to 400 periods—fifteen to twenty times as many as their ancestors had, exposing their breasts to historically unprecedented numbers of estrogen-progesterone cycles.
Estrogen and progesterone, like aspirin, have such familiar-sounding names that people often don’t realize how powerful their effects are. Among these effects is the multiplication of cells within the breast. With repeated menstrual cycles that are rarely interrupted by full-term pregnancy, the number of cells in some parts of the breast can increase by a factor of a hundred or even more. If only because of the simple increase in number, this constantly repeated cellular multiplication is believed to increase the likelihood of genetic accidents. Most cancers are believed to arise from such accidents, and so the strong suspicion is that repeated menstruation is a precursor to cancer of the breast. An additional significant implication is the high density of xenoestrogens in the genesis of cancer. Xenoestrogens are foreign estrogens. They are estrogen mimickers that effect the estrogen in our bodiesand can alter hormone activity.
If the improvements in women’s lives have indirectly promoted breast cancer, then it is unhelpful to call the growth in its incidence an epidemic. In medical terms an epidemic is the sudden outbreak of a generally rare condition, such as the deadly spread of cholera in a city with contaminated water, and should be stopped by striking at its source—in this example the contaminated water. The “epidemic” of breast cancer, in contrast, may be an unwanted accompaniment to what most people view as social and material progress. If this suspicion is true, it is obviously unacceptable to eliminate the epidemic’s cause.
Equally important, the increase in breast cancer does not resemble other epidemics. Although the likelihood that a woman will be found to have the disease has climbed, the likelihood that it will end her life has not. After adjustments for today’s slightly onger life-span and the population bulge associated with the Baby Boom, the proportion of women who are killed every year by breast cancer—has remained little changed since the 1930s. Women face an ever-increasing risk of being discovered to have breast cancer, then—but not of dying from it. It is highly unusual, to say the least, for a nationwide epidemic of a fatal disease not to affect the death rate.
This odd and even paradoxical situation has sown much confusion and fear. Breast cancer is a major public-health concern; it kills 0.04 percent of all American women yearly. But it is important for women to recognize that other conditions, especially the various forms of cardiovascular disease and, for smokers, lung cancer, are much more likely to claim their lives. Unfortunately, the enormous publicity accorded the rise in breast-cancer incidence has obscured the fact that the disease is not the leading killer of women. In a survey conducted by three researchers at the Dartmouth Center for the Evaluative Clinical Sciences and published in the Journal of the National Cancer Institute, the median estimate female Baby Boomers gave of their chance of dying of breast cancer within a decade was 10 percent. A substantial minority thought the risk was 30 percent or more. In fact, the likelihood that a woman in her forties will die of breast cancer in the next ten years of her life is on the order of 0.4 percent.
In my view, the medical profession, too, has lost perspective. If a woman’s chances of dying of breast cancer are little changed despite a huge rise in the incidence of the disease, there are two possible explanations. First, the medical establishment could be making progress. To go on from the current hypothesis: as women’s changing hormonal environment slowly drove up the number of breast-cancer cases, our mastery of the disease could have grown at such a rate that, year after year, the increase in cures precisely canceled out the increase in incidence, leaving the overall death rate unaffected. When my colleagues claim that we are curing breast cancer, they are implicitly endorsing this view. And why not? When physicians treat more cases of a disease while observing the same number of deaths, that means a smaller percentage of their patients are dying.
The second possible explanation is that the change in women’s hormonal environment is creating a surge in slow-growing, less-aggressive forms of breast cancer. Because this “new” breast cancer, if it is indeed responsible for the rise in diagnosed cases, is a much less dangerous disease than the breast cancer that was found before, in many cases it would not need treatment. The rise in incidence would not be matched by a rise in breast-cancer mortality, because women would die first of other causes. The apparent good news about the decline in the proportion of fatal cases would in fact be masking the unchanged prevalence of the “old” breast cancer: a persistent public-health problem that is just as likely to kill women now as it was eighty years ago. I believe this is just what we are seeing.
Female breasts are one of the most variable parts of the human anatomy. Evolved from sweat glands, they are designed to provide milk for infants through a system of ducts and lobules. The ducts are small tubes that run several inches back from the nipple to the milk-producing lobules, which stick out from the ducts like clusters of tiny grapes. Both are enveloped by fat and connective tissue, which are contained within a sac of skin shaped roughly like a teardrop. The whole assembly changes dramatically in size, shape, and constitution during the menstrual cycle, pregnancy, breast-feeding, and menopause. Not only do breasts vary from woman to woman but each woman’s breasts continue to change throughout her life.
At any given time a third to a half of all Western women have some kind of breast problem, although most are not particularly concerned about the symptoms—nor need they be. The symptoms frequently include swelling and aching before menstrual flow; women may feel their breasts engorge and grow tender. If their breasts become lumpier, however, this may be owing to cysts—fluid-filled balloon-like sacs within the breast. Or the lumps may be solid, nodular clumps of overgrown breast-duct cells, known generically to doctors as mammary dysplasia or , the most widely used term, fibrocystic disease. These conditions are benign—a term doctors use to mean “not cancerous.” (“Benign” does not mean “not painful” or “not harmful.” Many benign conditions require no treatment.)
If much of the breast is palpably lumpy, as is often the case, the diagnosis is usually “benign.” Matters are less clear when the problem is in a small area: “dominant mass” is the term used by most doctors for a swelling that stands out sharply. In such a case a biopsy is almost routinely done nowadays. It is a procedure that we discourage due to the significant invasive risks.
Breast cancer is as diverse as the breast itself, appearing in many different guises. Some cancers seem to erupt out of ordinary breast tissue with an awesome virulence, spreading rapidly throughout the body. When viewed under a microscope, the cells in these cancers almost always bear no resemblance to ordinary duct or lobule cells—they have lost all the specialized characteristics that differentiate cells in the breast from cells in other parts of the body. “Poorly differentiated” malignancies, as pathologists refer to them.
Much more often—perhaps in half of all breast-cancer cases—pathologists see malignancies that still bear some of the characteristics of normal breast tissue. These “moderately differentiated” tumors have a wide range of outcomes, though the prognosis for the patient is generally more favorable. A substantial number of women with moderately differentiated tumors will survive for years after treatment—even decades. In most cases these tumors evolve more slowly than their poorly differentiated cousins, probably taking years to become detectable. “Well-differentiated” tumors, a less common form, are more lethargic still. Indeed, pathologists sometimes have trouble ascertaining whether they are truly malignant.
In recent years doctors have increasingly encountered a fourth, somewhat different type of breast tumor: in situ cancer. Thirty years ago in situ tumors made up no more than one or two percent of all breast-cancer cases. The term in situ means “in its original place.” DCIS is called “non-invasive” because it hasn’t spread beyond the milk duct into any normal surrounding breast tissue. Today the diagnosis figure is 25 percent or more of diagnosed breast cancers, a twelve- to twenty five-fold increase. In situ tumors are usually small—half an inch or less across—and confined to the ducts and lobules of the breast. When diagnosed, these tumors usually appear not to have invaded the connective tissue or spread elsewhere in the body; like well-differentiated tumors, in situ tumors are not life threatening, even though they are commony addressed her in the Philippines with mastectomies.
I must caution that breast-cancer characterization remains an inexact science. The categories themselves are fuzzy. Well-differentiated and in situ tumors can occasionally grow fast and develop into serious, even fatal, disease; some poorly differentiated tumors respond amazingly well to immunotherapy treatment, while many cases can disappear entirely with no interventions at all. The uncertainty is partly due to a lack of absolute procedures for distinguishing among the classifications. Often a tumor is classified as poorly differentiated by one pathologist and moderately differentiated by another. This is just the nature of differing human opinions.
Notwithstanding the myriad forms in which breast cancer presents itself, researchers believe that at a fundamental level all breast cancers are similar. In their view, breast cancer, like other cancers, is the result of accidental changes in the genetic makeup of a cell—mutations. When the cell reproduces, it passes on its altered DNA. It begins to reproduce independently, regardless of the body’s needs—the defining characteristic of cancer. Cells depend on nutrients and oxygen from the bloodstream. Under ordinary circumstances aberrant, independently growing cells would outpace the available blood supply by the time they had formed a blob of tissue one or two millimeters in diameter; they would then die from a lack of oxygen and food. Instead cancer cells create their own network of blood vessels to secure necessary nutrients in a process known as angiogenesis. Once this circulatory system is established, the nascent tumor can continue to grow at its own pace. Eventually a discrete mass of aberrant cells becomes identifiable as a lump detectable by touch.
As the cancer progresses, it can invade the surrounding tissue and spread throughout the body in the familiar and frightening process known as metastasis. Left untreated, as it generally was in previous centuries, the original, or primary, tumor usually grows very large, sometimes to the size of a grapefruit. Eventually it begins to outstrip its self-generated blood supply; portions of the tumor die, leading to ulceration of the breast surface and eventual death from infection, hemorrhage, or both. As it grows, the primary tumor sheds cancer cells into its self-generated network of blood vessels. Spreading through the body, these cells can lodge in almost any vital organ, creating a second tumor—or a third, or a fourth. Like the primary tumor, the new tumors create their own blood supply, each one siphoning off nutrients from the body to feed its expansion. When the metastases reach an appreciable aggregate size—a total tumor load of two pounds or so, scattered throughout the body—the struggle for life is usually over.
From an intellectual point of view, metastasis is an amazing phenomenon. If a surgeon inserted a microscopic clump of normal cells from a woman’s breast into another organ, the body’s defense systems would wipe out the misplaced normal cells almost instantly. Yet cancer cells that split off from the main tumor and lodge elsewhere in the body not only survive but can grow exuberantly. For this reason most doctors believe that the best method for stopping breast cancer is to detect it before it has spread. Find the problem while it is still small and isolated—that is their hope, due to the current oncologic limitations for treatment.
Many physicians been trying to treat breast cancer aggressively for decades, and now believe that the long effort to detect and control this disease is meeting with success. I shall argue otherwise. Despite the hopes pinned on mammography, it has had little impact on women’s health—indeed, it has been shown to have none in the larhest studies of it. And although medicine has taken some important steps forward in treatment of breast cancer once it has been diagnosed—steps that can add years to a woman’s life—they have remained stubbornly attached to ineffective treatments such as chemo, radiation and surgery.
DOES MAMMOGRAPHY HELP?
Finding breast cancer as early as possible seems to be a great idea, like trying to diagnose high blood pressure before it damages the heart or the kidneys. And mammograms can occasionally detect tumors as small as an eighth of an inch across, whereas the lower limit for tumors diagnosable by palpation (examining the breast manually) is about half an inch across. Yet one would like to be sure that this difference actually translates into a higher likelihood that treatment will be successful. An official nationwide mammography program would be a huge commitment: over 70 million American women are aged forty or above. And one must bear in mind the cost of needless medical procedures generated by the huge number of false-positive mammograms—two to four false positives for every true positive, according to some measures. (A false positive shows a mass or lump that proves after further testing not to be cancerous.)There is a continued and widespread consideration in creating a national screening program, in spite of the lack of demonstrateable benefits.
To prove the value of mammography scientifically is difficult. In some studies investigators ask women to volunteer for screening, and then report the number of breast-cancer cases and the percentage of women who survive five years after diagnosis. This figure is compared with the percentage in the population at large. In these studies researchers often go to considerable trouble to eliminate potential sources of confusion. For example, they may try to match by age the women undergoing regular mammography with other women. Or they may match by race or socioeconomic class. No matter how hard researchers try, though, such studies remain susceptible to three of the most common sources of bias in medical research.
Mammography may find a tumor as early as two years before it could have been detected by palpation. Let us, however, consider a hypothetical case in which the cancer has already spread to other parts of the body by the time it is discovered, and the woman goes to her grave on exactly the same day she would have if the tumor had been discovered later. In that case the sole effect of early detection has been to stretch out the time in which the woman bears the knowledge of her condition. But that is not how the woman would appear statistically if she had happened to become part of a research study. Pushing back the date of first diagnosis would increase the interval between diagnosis and death, apparently lengthening her survival. Statisticians call this effect “lead-time bias.” Although nothing has actually changed, a woman who would have died, say, three years after treatment now dies five to six years after treatment—manufacturing an apparent victory for medicine.
A second problem with measuring the benefits of mammography is known as “length bias.” Women typically have mammograms every year or every other year. Any cancers that are found between mammograms will be detected by palpation—very possibly by the woman herself. Such tumors are likely to be fast-growing; indeed, their rapid onset often explains why they were not picked up by the previous mammogram. The more aggressive tumors tend not to be diagnosed mammographically, and thus the tumors that are discovered by mammograms are often less dangerous. Mammography will be made to look good in a study comparing the survival rate of women whose tumors were diagnosed by mammography with that of women whose tumors were diagnosed by palpation, because the tumors discovered by mammography tend to be those that grow relatively slowly and thus take longer to kill patients.
The third and most important problem is “selection bias.” This occurs when researchers measure the effect of a treatment on a group of people without realizing that those people are different from the general population. The risks that selection bias will occur are high, because women who participate in medical experiments are often not like the general population. Researchers typically work in teaching hospitals and thus draw their subjects from the patients who frequent them. These people may be more affluent than most Americans, and thus more prone to diseases of affluence. Or they may be more worried about their health, and thus more likely to seek expert medical care. In either case, the results of a test on such a select group can be misleading.
Many researchers agree that lead-time, length, and selection biases have flawed the unfounded optimistic accounts of the efficacy of mammography that have appeared in the scientific press and the popular media. The principal reason people support the idea of routinely screening women is that benefits from mammography have been observed in a special kind of study known as a prospective randomized clinical trial. In such a trial researchers randomly divide large numbers of volunteers into two groups at the outset (prospectively): a control group, which receives ordinary medical care; and a test group, which receives the medication or procedure under scrutiny. After a given period of time the two groups are compared. Properly conducted, such trials avoid all three kinds of bias. Even prospective randomized clinical trials have their pitfalls, though, because doctors can’t control the actions of their patients. Members of the test group may fail to take their medicine or to show up for their medical procedures, and members of the control group may seek out a drug or procedure they are not supposed to have. As hard as researchers may try to ascertain levels of compliance, misclassification of a certain number of participants is inevitable. In addition, the medical care provided at research centers, which often conduct clinical trials, may not be representative of the care received by most people.
Nonetheless, by ensuring from the beginning that the test group and the control group are statistically similar and by tracking everyone in both groups, these trials can produce data that are as solid as medical research gets. And several big prospective randomized clinical trials have reported that women who regularly undergo mammography have, roughly speaking, 25 to 30 percent less chance of dying from breast cancer in the decade after initial screening than women who are not screened. Many breast-cancer specialists thus endorse mammography.
Many women are completely unaware that the science backing the use of mammograms is sketchy at best. As was revealed in a 2011 meta-analysis by the Cochrane Database of Systemic Reviews, mammography breast cancer screening led to 30 percent overdiagnosis and overtreatment, which equates to an absolute risk increase of 0.5 percent.
There’s also the risk of getting a false negative, meaning that a life-threatening cancer is missed.
Unfortunately, even though some high-profile people agree that mammography has limitations as well as dangers, others prefer to ignore the science and continue to campaign for annual screenings without so much as a hint at the risks involved.
Now, they’ve unrolled “new and improved” 3D TOMOSYNTHESIS mammogram, which still requires mechanical compression, and delivers 30 percent more radiation!
Nearly every woman age 40 and older continues to be told by their primary care physician, their gynecologist, the media, self-proclaimed advocacy groups, and even their medical insurance carrier, “get your annual mammogram!” despite the fact that nearly every recent authoritative study concludes that women should know all of the facts before agreeing to a mammogram screening. Yet nearly all health care professionals insist on mammograms. If a woman dare refuse, she may be chastised or worse, threatened. These efforts have gone beyond persuasion to guilt and even coercion, “I can’t be your doctor if you don’t get a mammogram.” Women need to stop this runaway train, not only for their sake, but for the sake of their daughters.
In November 2012, the New England Journal of Medicine published a study by Dr. Archie Bleyer, M.D., from The Oregon Health Sciences Center, and his co-author, Dr. H. Gilbert Welch, M.D., M.P.H., from Dartmouth, challenging the validity of mammogram screenings and concluded that mammograms have little to no influence in the reduction of the number of women who ultimately die of breast cancer.
Thirty years of US government data studied found that as many as 1/3 of cancers detected by mammography may not have been life threatening, and that over 1 million women have been over-diagnosed; leading to unnecessary treatments involving disfiguring surgeries; radiation and chemotherapy. They also showed that mammogram screenings have increased from about 30 percent of women 40 and older in 1985, to about 70 percent of women screened, proving how effective we have been at convincing women they need to get a mammogram.
I have witnessed this strategy for decades and I have seen the profound psychological effect it has had on many of my patients. This paradigm has seriously misled women regarding the actual effectiveness, and the benefits vs. potential dangers of mammograms. They also have women confused about the erroneous belief that mammography is their only tool. Some women actually believe mammograms can prevent cancer, or do not realize they have the right to say, no!
Most women comply with the current “gold standard” in fear of the ravages of breast cancer, convinced their annual mammogram will save their life through early detection. It is nearly impossible for them to negate decades of slick marketing, annual reminders from radiology imaging centers and the exploitation of October’s Breast Cancer Awareness month blitz. All of these efforts beautifully packaged, tied up with a pretty pink ribbon.
I take my oath to do no harm very seriously. After many years of research, clinical practice, I cannot in good conscience recommend mammograms. I inform my patients that mammograms are considered the current “gold standard”, but I also make certain they know the facts about the screening and that there are other screen tools available.
Facts and Persisting Concerns: Mammograms
More women are refusing mammograms. This is reflected in the dramatic decline of 4.3 percent in 2010. Previously, mammography use had increased annually by 1 percent between 2005 and 2009. Mammograms:
- Are incorrect 80 percent of the time (providing a false negative or false positive)
- Require repeated ionized radiation that can cause cancer
- Use compression, which can damage breast tissue or potentially spread cancer
- Are not effective for up to 50 percent of women (women with dense breasts or implants)
- Can lead to over-diagnosis and over-treatment of non-invasive cancers
- Can lead to the disturbing practice of “preventative” double mastectomies
What is Mammography Industries Solution?
The “new and improved” 3D TOMOSYNTHESIS mammogram, still requiring mechanical compression, and 30 percent more radiation! We know all levels of ionizing radiation can cause cancer but, astonishingly, radiologists still want you to have your traditional mammogram screening first, followed by tomosynthesis mammogram for those with dense breasts or an area of suspicion. When my local Radiology Community approached me in an effort to disprove my concerns, I posed one simple question: Can you show me, one well-designed study that proves screening mammography has improved ultimate survival rates? I am still waiting for their answer.
We cannot prove that screening mammography improves the ultimate survival rate. A quick look at the SEER data would suggest treatment has improved, by a decline in the death rate since 1998 of 1.9 percent. For every 1,000 women in this country, today 125 will ultimately be diagnosed with breast cancer. Of those 125, over 40 will be over-diagnosed, and receive treatment they never needed, and suffer the potential psychological consequences of a cancer diagnosis. That leaves about 80, of which 28 will die of breast cancer. The decline since 1998 in the death rate means that for our 28 women who would have otherwise died from breast cancer, 2 more out of 1000 women diagnosed with breast cancer survived due to over a decade of treatment advances.
But, we really don’t know what actually saved those 2 women, of the 125 diagnosed with breast cancer for every 1,000 women in our group. If we attribute anything to lifestyle changes we have emphasized recently (which has been shown repeatedly to work), then either we wipe out any improved survival rate from decades of treatment advances, or worse, we cause death to some of those 40 women who were over-diagnosed!
If You Have Dense Breasts it is Even Worse
Breast density laws have now been passed in California,9 Connecticut, New York, Virginia and Texas making it mandatory for radiologists to inform their patients, who have dense breast tissue (40 to 50 percent of women) that mammograms are basically useless for them. Dense breast tissue and cancer both appear white on an X-ray, making it nearly impossible for a radiologist to detect cancer in these women. It’s like trying to find a snowflake in a blizzard. A law is now being considered at a Federal level as well.
Some radiologists already provide density information to their patients, and encourage them to utilize other options like thermography, ultrasound and/or MRI. I believe it reasonable for a woman to trust that her radiologist is not withholding vital density information. Unfortunately, many have kept this potentially lifesaving data from women for decades, and our government agencies have failed to protect them from this unethical practice.
I know it is extremely difficult to navigate through all of the contradicting information and study findings. It would better serve women if efforts, money and resources were utilized on educating women on cancer prevention, being that 95 percent of disease is lifestyle related. Yet 40,000 women continue to die of breast cancer each year. The only way to reduce this number is through utilizing preventative therapies.
Basic Cancer Prevention Strategies
As mentioned above, many women are completely unaware that the science backing the use of mammograms is sorely lacking, and that more women are being harmed by regular mammograms than are saved by them. Many also do not realize that the “new and improved” 3D tomosynthesis mammogram actually delivers even MORE ionizing radiation than the older version. This is not a step forward…
Please understand that there are other screening options, each with their own strengths and weaknesses, and you have a right to utilize those options. Also remember that in order to truly avoid breast cancer, you need to focus your attention on prevention.
A few simple, yet great options to assist in your efforts to avoid breast cancer are: making sure you are getting enough vitamin D, K2 and iodine; that you utilize lymphatic massage; use stress management techniques, exercise often, and balance your hormones naturally. It is also wise to eat a whole food diet consisting of organic foods. Avoid processed and GMO foods; and toxic environments.
In my practice, I recommend breast thermography, even for young women to get a baseline, but also combine the imaging not only with a review of the findings, but more importantly, as a venue to educate women on breast health. It is far more effective to prevent breast cancer, than it is to wait until it is there and then treat it. We are all different so make sure you consult with your doctor and do your own research before utilizing any of these suggestions.
A similar radical stance was adopted by Michael Baum, the research director of the British Institute of Cancer Research, who quit England’s national breast-cancer-screening advisory board because he felt that nationwide mammography is “not worth doing.” Having helped to set up the country’s screening program, he was disturbed by claims about the effectiveness of mammography. The London Sunday Times quoted Baum as saying, “There is a political correctness about screening. I took pride in setting up the service, which is as efficient as it can be, but just because you are doing something efficiently, it doesn’t mean it is worth doing.”
ARE WE CURING BREAST CANCER?
Once a tumor has been found, whether by mammography or palpation, many Doctors feel that it must be treated. The basis for the contemporary approach dates back to the 1890s, when William Halsted, a professor of surgery at Johns Hopkins University, developed radical mastectomy—the technique for removing a breast, the underlying chest muscles, and the lymph nodes in the armpit. A giant in medical history, Halsted was held in such respect that surgeons after him took an uncommonly long time to admit that his ideas about cancer were way off base. He believed that breast cancer oozed slowly through the lymphatic system of the body the way foul water from a brackish pond travels through ditches to other parts of the landscape. (The lymphatic system is the collection of ducts, lymph nodes, and other organs that drain the tissue fluid called lymph into the bloodstream.) To Halsted’s way of thinking, breast cancer could be cured by carving a wide swath around the initial tumor and its draining sites, leaving clear margins of healthy tissue—a scorched-earth approach.
Seventy-five years later a number of North American researchers began questioning Halsted’s ideas. Instead of seeping slowly throughout the body from its initial site, breast cancer seemed to hop from place to place as cells sloughed off by the main tumor mass floated through the bloodstream. If this was true, removing a woman’s entire breast would often be pointless, because most of the tissue surrounding the tumor would be healthy. After this heretical notion provoked much controversy among cancer specialists, Bernard Fisher, of the University of Pittsburgh, put together a series of large clinical trials that were intended to resolve the dispute. These trials demonstrated that a much less drastic operation called a lumpectomy provided a chance of survival indistinguishable from that provided by Halsted-style mastectomy. After the results were published, in the mid-1980s, surgical practices changed. Remarkably, though, they didn’t change very fast. Even today, the vast majority of breast cancer patients here in the Philippines who undergo surgery, are mutilated even for in situ cases with modified radical mastectomies, a somewhat less severe version of Halsted’s operation.
In the same period researchers questioned another tacit assumption about breast cancer: that lumps in the breast appear suddenly and must be treated quickly. Instead we have come to think that most breast tumors take years to develop to detectable size; some need decades. In its initial stages the tumor would be visible under a microscope—if one could somehow scan the entire breast with such precision. Only after months or years, however, can the malignancy be detected on a mammogram or by palpation. Yet standard practice still involves a rush to operate after diagnosis. The patient wants to know the details of her condition right away, and are told that surgical exploration is the only conclusive means of providing this information. Many surgeons also operate partly in the name of “getting this thing out before it spreads.” I cannot count the number of times I have seen a surgeon solemnly tell anxious family members in the hospital waiting room, “Well, we got it all.” Although surgeons today target their work more carefully and humanely than they did in the past, they still ignore a crucial fact: we know that due to circulating tumor cells, when someone says we “got it all”, they are either lying or inept. Although typical treatments can eliminate the primary tumor, there is little evidence that they actually eradicate breast cancer in any more patients than they did decades ago.
Any improvement in our treatment of breast cancer must therefore come from radiation or chemotherapy, both of which are by now unfortunately standard practice. Radiation has no known effect on distant metastases from breast cancer (nonlocal recurrence), which are the chief sources of danger. As a result, post-surgical radiation has no demonstrable effect on survival—a point seldom made clear to patients. Reducing local recurrence is a reasonable goal, because any tumor in the breast could be lethal. But it will not diminish the danger from metastases.
Nor should we think that the modest benefit from radiation has no price. Radiation therapy is rough on the body. It kills cells, inducing inflammation in the breast. Responding to the inflammation, cells called fibroblasts proliferate and lay down scar tissue. Fifteen to twenty-five years after radiation therapy tissues in the irradiated area often feel thick, hard, even wooden—a strange, unpleasant sensation. Meanwhile, the blast of radiation may have created genetic damage that will lead to other types of cancer. For instance, worrisome evidence shows that radiation promotes lung cancer in the irradiated side of the body.
Chemotherapeutic compounds kill cancer cells; the hope is that they will destroy any metastases lurking in the body. Yet studies have demonstrated conclusively that the benefit of chemotherapy for breast cancer is in the order of 2% Along with that paltry benefit comes a truckload of side effects and significant risk of metastasis.
Before chemotherapy, doctors sought to create a similar effect by directly removing patients’ ovaries. If the cancer recurred, they tried to amplify the effect by removing women’s adrenal glands—a procedure involving major abdominal surgery—wasn’t the final step. In their zeal to combat estrogen, doctors also injected women with testosterone or prescribed synthetic male hormones.
Although these treatments sometimes slowed the progress of breast cancer, their cumulative impact was horrific and even barbarous. After having the breast and underlying tissue on one side of her chest cut away and covered with a thin skin graft, a woman could be subjected to intense radiation tharapy, primitive forms of chemotherapy, the removal of her ovaries, and, eventually, the removal of her adrenal glands. If this failed, she might be injected with male hormones that made her skin oily, pimply, and hairy.
Things are much better today with the introduction of immunotherapy which releases the brakes on the immune system to potentially cure breast cancer.
ANOTHER VIEW OF BREAST CANCER
In 1935, 26.2 out of every 100,000 women died of breast cancer. That was a long time ago, of course, when life expectancy for women was sixty-four years. Americans now live longer, which means that diseases of the elderly are more common. Although breast cancer affects many young women, it is still principally a disease of middle and old age—the median age at diagnosis is sixty-one. Statisticians must adjust raw data about incidence and mortality to compensate for underlying demographic shifts. In 1992, the adjusted rate of mortality was 26.2 women per 100,000—the same as in 1935. (The death rate rose a bit from 1986 to 1989 and declined by about the same amount from 1989 to 1992.) Since 1935 medicine has seen improvements in surgical technique and anesthesia, and the introduction of mammography, radiation therapy, and chemotherapy, along with an enormous jump in general medical knowledge. But all this progress has had no effect on the chances that an individual woman will die of breast cancer. To my way of thinking, the constancy of the death rate in the face of rising incidence and aggressive treatment is a strong hint that medicine needs to embrace immunotherapy because they keep doing the same thing over and over with no significant change in resuts.
When I discussed the evidence relating to mammography, radiation, and chemotherapy, I was in the realm of fact—although some colleagues may disagree with my interpretation. In what follows I am moving into unsteadier terrain. Of course, I believe that my view of breast cancer is correct, and much of it is shared by other specialists. But I will be satisfied if I can persuade readers that the mere existence of a coherent alternative explanation raises questions about the mainstream view.
As I have said, almost all cancer researchers think that the disease is triggered by an accidental change in the DNA of at least one cell. That cell divides, producing two cells, then four, then eight, and so on, with the volume of the tumor doubling in each successive generation. By the time the tumor has doubled twenty-three times, the original cancer cell has multiplied to more than eight million. At that point the tumor is about an eighth of an inch in diameter, just big enough to be detected (sometimes) by a mammogram.
Such a tumor is not very dangerous by itself; the danger lies in the metastases. The question is how soon the tumor metastasizes.
For over thirty years the late Dr. John S. Spratt, a cancer surgeon at the University of Louisville Department of Surgery, measured the growth rates of breast tumors. In one of his most renowned studies, performed in collaboration with researchers from Heidelberg, Germany, Spratt examined the progressive mammograms of 448 women who had tumors that turned out to have been visible in mammograms made before the tumors were diagnosed. Comparing first, second, and even third mammograms provided evidence of how fast the tumors grew in the intervals. The median doubling time was 260 days, but the range was considerable: the fastest tumor doubled in ten days, the slowest in 7,051 days—that is, almost twenty years. These striking implications demonstrate how truly unique each and every patient is.
Consider a woman who is unlucky enough to develop a single cancerous cell on her forty-third birthday. If the woman is especially unlucky, the cell has a fast doubling time of, say, thirty days. Twenty-three cell generations later the tumor might be visible on a mammogram; in another six or seven doublings it will be just big enough to feel. By then the woman will be forty-five. She will probably die before her fiftieth birthday. If, though, the woman develops a cancer with a slow doubling time of, say, 360 days, twenty-three doublings will take about twenty-three years, at which point the tumor might be seen with mammography. The tumor will be palpable in another six or seven years, meaning that without mammography it probably would not be detected until the woman was in her mid-seventies. By that age some people have already died of other causes.
I have simplified these calculations considerably. Spratt and his German colleagues found that breast cancers do not grow at a constant rate but instead slow down as time passes. Yet the principle holds that tumors that begin with fast doubling rates grow faster than tumors that begin with slow doubling rates at comparable stages of formation.
Close scrutiny of tumor doubling times could explain why the earlier diagnoses provided by mammography seem to provide so little prolonging of individual lives, despite the statistical appearance of benefit caused by earlier diagnosis. Although mammography is able to spot tumors as small as an eighth of an inch, which contain eight million cells, the average size at diagnosis with mammography is about 600 million cells. Such a tumor is only a bit more than a quarter of an inch across, but it has already doubled almost twenty-seven times and may have been in the body for decades. The average size of tumors detected by palpation is about 45 billion cells and about an inch and a quarter in diameter; these tumors have doubled an additional eight or nine times. To argue that earlier diagnosis provides an important benefit, one must believe that the tumor is considerably likelier to spread in those eight or nine later doublings than it was in the preceding twenty-seven.
There is no evidence that this is the case; indeed, the small amount of available data suggests that this view is wrong. With mammography we can see breast tumors earlier than we could before. But it is illogical to assume that our newfound ability to observe breast tumors between the twenty-seventh and thirty-fifth doublings means that they are especially likely to spread during this time or afterward and not before. If tumors are more likely to metastasize after rather than before mammography can detect them, the burden is on mammography advocates to demonstrate it. Meanwhile, I believe that the reasonable course is to assume that breast cancer can spread at any time in its development, and that metastasis has probably already occurred by the time we are able to detect the primary tumor. If this view is correct—and I should stress that studies to prove it have not yet been conducted—then it would explain why research has had such difficulty proving that mammography can save women’s lives.
Similarly, examination of tumor doubling times could explain why chemotherapy has little impact on the annual percentage of women who die of breast cancer—that is, why it leaves them just as likely to die of metastatic breast cancer in the end. My best guess is that adjuvant chemotherapy wipes out a significant percent of the residual cancer cells in a patient’s body. (It doesn’t get them all because the remaining tumor cells are innately resistant to chemotherapy.) Suppose that a woman’s tumor has metastasized and that the new tumor has grown to a million cells—a lot of cells, but not enough to be seen by the naked eye, or palpated, or spotted by any current imaging method (CAT scan, ultrasound, magnetic resonance imaging, and so on). If chemotherapy kills 99 percent of the cancer cells in a woman’s body, this prophylactic treatment will reduce the metastasis from a million cells to 10,000. The remaining cells, which are resistant to chemotherapy, will keep on proliferating, more than likely at the same rate. In six and two thirds cell generations the tumor will have grown back to a million cells and the woman will be right back where she was before treatment began.
Cruelly, chemotherapy helps least those who need it most. If a woman’s cancer has the short doubling time of thirty days, the six and two thirds doublings the tumor needs to recover from chemotherapy translate into about 200 days. Since chemotherapy has little impact on a woman’s chance of surviving either aggressive or indolent tumors, is it any wonder that it makes few inroads on mortality?
Consider the breast-cancer patients most doctors most dread seeing—women in their thirties or forties. Such cases are increasingly common; breast cancer owes its status as the leading killer of women in this age group mostly to the even lower likelihood that they will be killed by anything else. Nonetheless, the individual tragedy of a disease that strikes down young, vibrant people makes it disproportionately urgent to treat them. Sadly, younger women in whom cancer is diagnosed are more likely than older women to have fast-growing tumors, because slow-growing tumors are usually still too small to detect. Given the probable doubling rates, these women will be lucky if typical chemotherapists can give them an extra five years.
CANCER OLD AND NEW
In effect, mammography today provides our definition of breast cancer. Any tumor spotted on a mammogram is treated, almost reflexively, with surgery, radiation, and often chemotherapy and antihormonal drugs. Thinking about doubling times suggests the inadequacy of this approach. When doctors diagnosed breast cancer by palpation in annual exams, they found principally fast-growing tumors—ones whose average doubling time, according to the work of Spratt and other researchers, was about ninety days. Despite decades of work, typical medicine still is unable to treat this kind of cancer effectively. Today the spectrum of breast cancer is different. Perhaps because of the hormonal changes created by the changes in women’s lives, physicians are increasingly likely to observe the “new” cancer described above, which is slower-growing and much less dangerous. These cancers, because they progress so much more slowly, have a radically different impact on women’s lives. For that reason we sare more discriminating in how we treat them.
“New” may be a misnomer for this slow-growing breast cancer. Although its incidence has risen, I suspect that it has been with us for at least sixty years; we just weren’t able to see it. In fact, I would not be surprised if someday we are all found to harbor somewhere in our bodies several small, slow-growing tumors that will never cause us any problems. (They are beaten to the punch by cardiovascular disease or faster-growing cancers.)
Among the most important varieties of the new breast cancer is the in situ tumor—the small, localized, almost nongrowing tumor that at the time of diagnosis has seemingly neither become invasive nor developed the capacity to metastasize. Prior to mammography, as noted earlier, in situ tumors accounted for only one to two percent of all breast-cancer diagnoses, whereas today in communities where people see doctors often and have lots of tests, in situ tumors account for at least 25 percent of all breast-cancer diagnoses. After lumpectomy and radiation, thirty percent of in situ malignancies recur in the next five to eight years.
Most of my colleagues celebrate this as a triumph, because it appears that we are catching cancers earlier than ever and “curing” more of them. They may be right. But consider this—if rhree out of ten in situ cancers recurs after treatment, six out of ten do not. If my view is correct, even without treatment many or most in situ cancers would never have grown big enough to be detected by palpation, let alone to pose a threat to life. They might even have become invasive and metastasized, but the metastases would also be too small to be detectable and would never be lethal—rendering the recurrence rate and thus the question of treatment ultimately unimportant to survival. As a result, mammography is only leading physicians to diagnose an ever-larger number of harmless tumors. Patients who otherwise would never have known they have cancer may needlessly suffer through the unique pain, anxiety, disfigurement, and expense associated with modern medicine and cancer. For all we know, the chief effect of mammography has been to disguise our inability to cure the old cancer, by burying it in cases of new cancer.
WHEN THE DIAGNOSIS IS POSITIVE
Because of the prevalence of in situ and other slow-growing breast cancers, women who receive a positive mammogram should not despair. Two thirds to four fifths of positive mammograms lead to biopsies that do not reveal cancer. Even if the biopsy indicates cancer, the patient should keep in mind that not all tumors are truly dangerous, and she should strive to learn what kind of tumor she has.
Although scientists are divided in their opinion of its accuracy, I believe that one of the most promising gauges of risk is the “S-phase fraction,” which is a rough measure of a tumor’s doubling time, derived from a technique known as flow cytometry. Technicians calculate this measure by chopping up a small amount of tumor tissue in a kind of specialized blender, staining the cell nuclei with a dye, and squirting the result one cell at a time through a very fine nozzle. The cells shoot through a thin laser beam, each nucleus casting a shadow as it crosses the light. Computers record the shadows with enough detail to discern the approximate percentage of cells in the sample that are dividing. From these data physicians can infer whether the cancer is aggressive (a doubling time kf sixty days or less), moderate (sixty-one to 150 days), indolent (151 to 300 days), or very indolent (more than 300 days). Because tumor growth rates may change over time, and metastases do not necessarily march in lockstep with the tumors that spawned them, the actual situation faced by patients is more complex than indicated by this summary. Nevertheless, I believe that the broad principle holds:armed with information about a tumor’s growth rate and the patient’s age at diagnosis, doctors could often be more informative than they are now about what lies ahead for their patients.
If doctors could accurately gauge tumor growth rates, using any agreed-upon test, my strong hunch is that most of the tumors now detected would be found not to need treatment beyond a few weeks of immunotherapy. Perhaps another quarter of women in whom breast cancer is diagnosed could gain considerable time—enough to take them safely into old age—with immunotherapy alone. The remainder could be helped by the combination of immunotherapy and orthomolecular therapy. What most women need to realize about typical oncology, I am very sorry to say, is that it has less to offer than newspaper headlines suggest. The outcome was dictated well before diagnosis—by the date the first cancer cells developed and by the rate at which they grew.
The ultimate opportunity is preventing this awful disease. Meanwhile, my colleagues should carefully consider whether they are misleading some women with messages of unwarranted hope at the same time that they are needlessly terrifying and hurting other women by diagnosing and treating a condition that will never pose a threat to their lives.
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