Our Feel Good War on Breast Cancer

[Deleted]

It's a long article from the NY Times but intriguing. It goes into the role that mammography plays in breast cancer detection, whether or not it's actually helping to save lives, whether the treatment is worse than the cause for some types of breast cancer, the increasing number of women choosing to get both breasts removed, whether or not screening is actually detracting from more fruitful avenues of research that could save lives, etc.

Recently, a survey of three decades of screening published in November in The New England Journal of Medicine found that mammography’s impact is decidedly mixed: it does reduce, by a small percentage, the number of women who are told they have late-stage cancer, but it is far more likely to result in overdiagnosis and unnecessary treatment, including surgery, weeks of radiation and potentially toxic drugs. And yet, mammography remains an unquestioned pillar of the pink-ribbon awareness movement.

Breast cancer in your breast doesn’t kill you; the disease becomes deadly when it metastasizes, spreading to other organs or the bones. Early detection is based on the theory, dating back to the late 19th century, that the disease progresses consistently, beginning with a single rogue cell, growing sequentially and at some invariable point making a lethal leap. Curing it, then, was assumed to be a matter of finding and cutting out a tumor before that metastasis happens. The thing is, there was no evidence that the size of a tumor necessarily predicted whether it had spread.

Even as American women embraced mammography, researchers’ understanding of breast cancer — including the role of early detection — was shifting. The disease, it has become clear, does not always behave in a uniform way. It’s not even one disease. There are at least four genetically distinct breast cancers.

Those early mammography trials were conducted before variations in cancer were recognized — before Herceptin, before hormonal therapy, even before the widespread use of chemotherapy. Improved treatment has offset some of the advantage of screening, though how much remains contentious. There has been about a 25 percent drop in breast-cancer death rates since 1990, and some researchers argue that treatment — not mammograms — may be chiefly responsible for that decline.

Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and co-author of last November’s New England Journal of Medicine study of screening-induced overtreatment, estimates that only 3 to 13 percent of women whose cancer was detected by mammograms actually benefited from the test.

If screening’s benefits have been overstated, its potential harms are little discussed. According to a survey of randomized clinical trials involving 600,000 women around the world, for every 2,000 women screened annually over 10 years, one life is prolonged but 10 healthy women are given diagnoses of breast cancer and unnecessarily treated, often with therapies that themselves have life-threatening side effects. (Tamoxifen, for instance, carries small risks of stroke, blood clots and uterine cancer; radiation and chemotherapy weaken the heart; surgery, of course, has its hazards.) Many of those women are told they have something called ductal carcinoma in situ (D.C.I.S.), or “Stage Zero” cancer, in which abnormal cells are found in the lining of the milk-producing ducts.

 Before universal screening, D.C.I.S. was rare. Now D.C.I.S. and the less common lobular carcinoma in situ account for about a quarter of new breast-cancer cases — some 60,000 a year. In situ cancers are more prevalent among women in their 40s. By 2020, according to the National Institutes of Health’s estimate, more than one million American women will be living with a D.C.I.S. diagnosis. D.C.I.S. survivors are celebrated at pink-ribbon events as triumphs of early detection: theirs was an easily treatable disease with a nearly 100 percent 10-year survival rate. The thing is, in most cases (estimates vary widely between 50 and 80 percent) D.C.I.S. will stay right where it is — “in situ” means “in place.”

 Unless it develops into invasive cancer, D.C.I.S. lacks the capacity to spread beyond the breast, so it will not become lethal. Autopsies have shown that as many as 14 percent of women who died of something other than breast cancer unknowingly had D.C.I.S. There is as yet no sure way to tell which D.C.I.S. will turn into invasive cancer, so every instance is treated as if it is potentially life-threatening

It wasn’t so long ago that women fought to keep their breasts after a cancer diagnosis, lobbying surgeons to forgo radical mastectomies for equally effective lumpectomies with radiation. Why had that flipped? I pondered the question as I browsed through the “Stories of Hope” on the American Cancer Society’s Web site. I came across an appealing woman in a pink T-shirt, smiling as she held out a white-frosted cupcake bedecked with a pink candle. In a first-person narrative, she said that she began screening in her mid-30s because she had fibrocystic breast disease. At 41, she was given a diagnosis of D.C.I.S., which was treated with lumpectomy and radiation. “I felt lucky to have caught it early,” she said, though she added that she was emotionally devastated by the experience. She continued screenings and went on to have multiple operations to remove benign cysts.

By the time she learned she had breast cancer again, she was looking at a fifth operation on her breasts. So she opted to have both of them removed, a decision she said she believed to be both logical and proactive. I found myself thinking of an alternative way to describe what happened. Fibrocystic breast disease does not predict cancer, though distinguishing between benign and malignant tumors can be difficult, increasing the potential for unnecessary biopsies. Starting screening in her 30s exposed this woman to years of excess medical radiation — one of the few known causes of breast cancer. Her D.C.I.S., a condition detected almost exclusively through mammography, quite likely never would become life-threatening, yet it transformed her into a cancer survivor, subjecting her to surgery and weeks of even more radiation. By the time of her second diagnosis, she was so distraught that she amputated both of her breasts to restore a sense of control.

 Should this woman be hailed as a survivor or held up as a cautionary tale? Was she empowered by awareness or victimized by it? The fear of cancer is legitimate: how we manage that fear, I realized — our responses to it, our emotions around it — can be manipulated, packaged, marketed and sold, sometimes by the very forces that claim to support us.

www.nytimes.com/2013/04/28/magazine/our-feel-good-war-on-breast-cancer.html?pagewanted=all&_r=0

[Deleted]

I got a baseline. Figure I might want to see possible change some day, but I don't plan on getting routine... Most of what I've read suggests they aren't as beneficial as we are led to believe... Like too many things med? .... 

[Blonde Granny]

My breast cancer was discovered on a mammogram at age 49.  I had them every year from the age of 40 as I had many of the risk factors.  I had 2 types of cancer in the same breast one sitting atop the other.  The agressive one was lobular cancer and had spread into 2 lymph nodes.  Lobular cancer does NOT show on a mammogram as it tends to be the same density as normal breast cancer.  The second type, and the one that showed up was intraductal breast cancer and there was no spread of that one.

I had a modified radical mastectomy of my right breast, followed by what I called the 4 Treatments from Hell.  At the time, back in 1994 is was a clinical trial protocol.  Radiation was not required.  I followed for 5 years taking the estrogen blocker drug called Tamoxifen, then volunteered for a double blind clinical trial of a drug called Femara (letrozole).  That study was to be for 5 years, but the results of the drug were so outstanding the trial was cancelled and the results released.  I later found out I had taken the placebo, so the drug company gave me 5 years of drugs at no cost for my participation.

My cancer was detected in Jan. 1994...therefore I am a 19 year survivor.  The original treatments from hell have now been modified somewhat but are still the gold standard for some advanced types of breast cancer.

Get your mammograms!!!!!!!!!!!!!!!!!!  It just might save your life!!!!!!!!!!!!!!

[Deleted]

If I had risk factors, maybe? 

But from your example, the one that was aggressive was caught mainly by luck. A lot of what I've read says in a a lot of cases early detection does not drastically change outcomes, just length of treatment... 

[midjd]

Very interesting article. 

I know there are other types of cancer that aren't commonly treated with chemo/radiation anymore, and are just monitored (e.g. prostate)... My grandfather has a brain tumor that the doctors say is so slow-growing that it will start to become a problem when he's about 130. I guess it kind of makes sense that the same could be true with types of breast cancer.

And it seems pretty clear that shooting radiation into your chest every year starting in your 30s might cause more problems than it solves...

[Blonde Granny]

My long time best friend, even knowing my situation, screwed around long enough until when she was finally diagnosed 2 years ago, she was stage 4.  She had a double mastectomy, and we've talked for 2 years now about when do you know when enough is enough and you stop all further treatment.

Don't be a stastistic, don't put your head in the sand and think it won't happen to me.  15 minutes of a little discomfort....I can't change my past, but I've been fortunate to be able to "pay it forward" by doing clinical trials, not only of chemo potocols, but of drugs.  Let me pay it forward one more time....get your yearly mammograms, as for now, it's the best chance you have.

Breast cancer is not like prostate cancer or a slow growing brain tumor....it's deadly!!!!

[Deleted]

Blonde Granny - I'm glad you survived and are here with us.

The article was interesting to me because of all the things I learned - I had no idea that radiation could be used on your breasts only once, that DCIS may never turn into something serious, that early intervention may not change the outcome.

My knee jerk reaction is that I will get every test and intervention available.  I want to live as long as possible with my family.  This article made me think about whether every intervention or test is helpful.

[midjd]

My knee jerk reaction is that I will get every test and intervention available.  I want to live as long as possible with my family.  This article made me think about whether every intervention or test is helpful.

[Gardening Grandma]

I think it is smart to get a baseline mamogram - I had one at age 35.  Did not have another for quite some time (5 or 10 years) as I had no risk factors.  After 45 I had one annually - still do.  Hate em.  Hurts like hell.  But I will keep having them.

Until a few days ago I was unaware that you can radiate a part of the body only once....

Very interesting article.

[Blonde Granny]

One of the most interesting things I learned about BC is that there is no one size fits all for treatments.  I was told very early on not ever to compare my treatments to anyone elses.  Estrogen receptors was 2 words I'd nevr heard of, but I sure know about them now.  And those little receptors can be positive or negative.....who knew!

I just wish my friend would have listened.  I'm going to lose her soon, and it's breaking my heart.  She didn't like doctors, didn't believe that what the mammos were showing was true...after all, they are all just after her money......you know, medical people are that way.  She is paying the price now for her stubborness.

[Deleted]

Edited to say: What Sug said...

[Jaguar]

I'm so very sorry Blonde Granny about your friend.

[giramomma]

Apr 26, 2013 18:41:15 GMT -5 Blonde Granny said:

Breast cancer is not like prostate cancer or a slow growing brain tumor....it's deadly!!!!

Actually, I don't think prostate cancer is all that "harmless."

My folks haven't hit 70 yet. Dad has stage IV prostate cancer that went to his bones. He apparently had no physical symptoms of the prostate cancer. Even when he started seeing Drs to figure out what was wrong with him, they didn't really investigate the possibility of prostate cancer because of his lack of physical symptoms.

My folks aren't very clear about things. I'm guessing though, that my dad has less than a year to live, based on what they have been telling me.

So, I'm kinda thinking that prostate cancer can be deadly for some.

[Blonde Granny]

Pc can be advanced without symptoms, I'm so sorry to hear about your dad! Blessings and prayers for you and your family.

[Jaguar]

I currently have what they believe is lung cancer. It seems like it's two types, but I won't know until after the biopsy. I'm having a surgical biopsy on May 7. Mine is all nodule sized or smaller so it's early.

[Blonde Granny]

Sugi....that is terrible news. Prayers for you those doctors treating you.

[Deleted]

Apr 26, 2013 20:57:04 GMT -5 Jaguar said:

I currently have what they believe is lung cancer. It seems like it's two types, but I won't know until after the biopsy. I'm having a surgical biopsy on May 7. Mine is all nodule sized or smaller so it's early.

There's a moment in which the studies, statistics and articles become the faces and names we know.  I wish you a smooth path and safe journey.

[Jaguar]

Apr 26, 2013 21:39:06 GMT -5 @donethat said:

Apr 26, 2013 20:57:04 GMT -5 Jaguar said:

I currently have what they believe is lung cancer. It seems like it's two types, but I won't know until after the biopsy. I'm having a surgical biopsy on May 7. Mine is all nodule sized or smaller so it's early.

There's a moment in which the studies, statistics and articles become the faces and names we know.  I wish you a smooth path and safe journey.

Namaste and Thank You for that.

[Jaguar]

Apr 26, 2013 21:25:13 GMT -5 Blonde Granny said:

Sugi....that is terrible news. Prayers for you those doctors treating you.

Namaste & Thank You.

[Deleted]

Breast cancer in your breast doesn’t kill you; the disease becomes deadly when it metastasizes, spreading to other organs or the bones. Early detection is based on the theory, dating back to the late 19th century, that the disease progresses consistently, beginning with a single rogue cell, growing sequentially and at some invariable point making a lethal leap. Curing it, then, was assumed to be a matter of finding and cutting out a tumor before that metastasis happens. The thing is, there was no evidence that the size of a tumor necessarily predicted whether it had spread.

Right there is the whole problem. There is no way to predict when a tumor will metastasize. The size and age of the tumor are not predictors. I have had three relatives (Mom, Aunt, and Great-Aunt) who had breast cancer. I will be starting mammograms at 35 and if anything is ever found, it will be taken out. I won't be knowingly walking around with a bomb in my chest waiting to go off.

Yes, there are some tumors that are just watched (acoutic neuromas/vestibular schwanomas in my field). But those are tumors that are known to be benign (they don't metastasize), and they are also usually incredibly slow-growing. My aunt's breast cancer went from stage 3 to stage 4 in a month. My grandfather's prostate cancer went into his bones, grew out of his vertebrae, wrapped around his spinal cord and squeezed it shut. He lost use of his legs.

[Deleted]

But what about the potential for mammograms to actually grow cancer? 

What about the lack of consistently real change in outcomes with early detection?

[Gardening Grandma]

Sugi,
Having just gone through (with DH) that awful, anxious  time between tests and waiting for results, I have a clue what your are going through.
Know that you are in my thoughts. <hugs>

[kent]

My wife got regular mammogram checkups and we're glad she did.  The last one is the one that unleashed a furry of activity by Kaiser.  She had it done, they didn't "feel comfortable" with what they saw and scheduled another one, at a different facility, within two days.

They didn't "feel comfortable" with that one either so elected to do an ultrasound right then and there.  They still weren't happy and scheduled an appointment with a surgeon at facility number 3 the next day (may have been the day after that) and he said he would do surgery the very next morning.

He performed the surgery and removed a lump.  Although it was called DCIS (Ductal Carcinoma in Situ), it was anything but a "Stage Zero" cancer.  In fact, the opinion was that her cancer was somewhere between "moderate" and "high" in aggressiveness.  Likewise, her receptors were positive for attracting estrogen and there was a lot of microcalcification per the mammogram and the ultrasound.  This led to the decision to proceed with radiation treatments.

Off point but, yesterday we got the bill for the radiation treatments and it was $37,780.43.  Our co-pay is $15.00 (Whew!).

We will be seeing her oncologist this coming Tuesday for a follow up.  I have no idea what will transpire - maybe another ultrasound?  PET scan? CAT scan? Nothing? 

Now, as far as prostate cancer is concerned.  Do not presume it's "no big deal" because it's "usually" slow growing and treatment is "usually" quite effective.  I have (had) a friend that died from it about a year ago.  This stuff often has no symptoms (I had none) and can sneak up on  guy.

Bottom line.  If I were a woman, I think I'd error on the side of safety and get the mammogram. 

[kent]

Apr 26, 2013 20:57:04 GMT -5 Jaguar said:

I currently have what they believe is lung cancer. It seems like it's two types, but I won't know until after the biopsy. I'm having a surgical biopsy on May 7. Mine is all nodule sized or smaller so it's early.

     From our home to yours but I think you already know that. 

[Jaguar]

Apr 27, 2013 9:21:40 GMT -5 Gardening Grandma said:

Sugi,
Having just gone through (with DH) that awful, anxious  time between tests and waiting for results, I have a clue what your are going through.
Know that you are in my thoughts. <hugs>

You have no clue how happy I am cause I got a Surgical Biopsy date. I done the first Cat Scan on Jan 4, Jan 16 I got the results. It's been a long wait for me.

[Jaguar]

Apr 27, 2013 11:15:44 GMT -5 kent said:

Apr 26, 2013 20:57:04 GMT -5 Jaguar said:

I currently have what they believe is lung cancer. It seems like it's two types, but I won't know until after the biopsy. I'm having a surgical biopsy on May 7. Mine is all nodule sized or smaller so it's early.

     From our home to yours but I think you already know that. 

Yes Friend I know that.

[Jaguar]

Apr 27, 2013 9:12:00 GMT -5 @lonewolf said:

I've told this story before.
I knew a young woman who got a mammogram every year, due to a small spot that the doctors had been watching.
The spot hadn't change in over 10 years. Then, one year she had a very stressful situation happen in her life and it obsessed her. She went from happy to miserable and hate filled in that year. She couldn't let her anger go.
During that year, after a mammogram, that spot took off like a bat out of hell, and for some reason they couldn't stop it.
She fought it like crazy, but it killed her in a little over 2 years.
I believe that her mental attitude, during her angry year, actually had a lot to do with her cancer taking off like it did.
As far as getting mammograms, I don't get them for many reasons. 

You know I'm finding out that my body just doesn't react well when I'm being negative.

[justme]

Apr 26, 2013 20:41:16 GMT -5 giramomma said:

Apr 26, 2013 18:41:15 GMT -5 Blonde Granny said:

Breast cancer is not like prostate cancer or a slow growing brain tumor....it's deadly!!!!

Actually, I don't think prostate cancer is all that "harmless."

My folks haven't hit 70 yet. Dad has stage IV prostate cancer that went to his bones. He apparently had no physical symptoms of the prostate cancer. Even when he started seeing Drs to figure out what was wrong with him, they didn't really investigate the possibility of prostate cancer because of his lack of physical symptoms.

My folks aren't very clear about things. I'm guessing though, that my dad has less than a year to live, based on what they have been telling me.

So, I'm kinda thinking that prostate cancer can be deadly for some.

I think prostate cancer is worse the younger you are. Or maybe there's an aggressive type and a slow type? I know his odds weren't great, maybe because it was found late stage? My uncle got diagnosed in his 40s maybe late 30s and died from it. I think it had already spread by the time he caught it, he was a marathon runner I think they said him being in such great shape unfortunately kept the symptoms at bay and let the cancer progress.

Sorry about your dad.