The Cancer Journal - Volume 9, Number 4 (July-August 1996)
Lady, think twice before having a mammography
Medicine in the grip of technology - Although health is the main concern of medicine, its exact meaning is not at all clear. Medicine is more concerned with non-health, known as disease. Yet not every disease may be regarded as non-health. Many young adults carry in their arteries arteriosclerotic plaques without any apparent health deterioration. Are these plaques non-health and should they be treated? Obviously health and disease are not complementary. How then to handle diseases that do not impinge upon health? Sophisticated technology reveals slight aberrations that in the past were unknown, e.g., mild hypertension, a slightly elevated blood sugar or, breast cancer precursor lesions. Are these aberrations real diseases? Modern technology has confronted medicine with a new problem: how to deal with aberrations in a patient who feels healthy?
Technology has also revealed that diseases evolve. They start as small aberrations without clinical manifestations, while the patient feels healthy. Advancing technology reveals more and more pre-clinical aberrations, and medicine lacks clear guidelines for dealing with them. To wait until they become more pronounced is generally regarded as malpractice. Medicine presumes that the traditional guideline "primum non nocere" results from ignorance and helplessness, and is not advised. Yet technological innovations endow this concept with a new meaning, e.g., "Do not harm, and don't interfere until the aberration ripens for treatment".
Breast cancer - Medical confusion is most pronounced in the treatment of breast cancer. Apparently cancer starts as a lump that gradually spreads from the breast into remote sites. For years breast cancer was treated by radical mastectomy with axillary lymph node dissection and irradiation. Yet this treatment failed since patients continued to die at the same rate. For fifty years, age-adjusted mortality of breast cancer remained virtually constant (1). Treatment failed since, at the time of diagnosis, the disease was already systemic, involving the breast and remote sites. Chemotherapy entered the limelight, yet it did not affect the age-adjusted mortality either. Two technological innovations, mammography and genetic markers, promise to improve the prospect of cancer patients, yet medicine is at a loss as to how to interpret their findings, and the controversy mounts.
Apparently mammography helps mainly women aged 50 or more, while younger women do not benefit (2). Should they be advised to be screened? Mammography is not harmless, particularly since X-rays are carcinogenic, why then irradiate the breast if the procedure is useless? Yet the real threat to young women results from the thoughtlessness that accompanies mammography. Medicine shies away from the real issue; how to interpret mammographic findings. Should the detected aberrations be regarded as cancer?
Ductal carcinoma in situ (DCIS) of the breast - DCIS is a benign lesion that may or may not evolve into clinical cancer. Despite its name, it is not a cancer. Similar lesions appear in other organs, e.g., colon, and urinary bladder. 30-40% of mammographically detected aberrations are DCIS, and in women aged 30-39 years, 92% of aberrations are DCIS (3). Since DCIS is detectable only with mammography its incidence is continually rising. Between 1983 and 1989, DCIS incidence rates among white women, increased 213% (4), and in 1992 its incidence rate rose by 12.1%. Before mammography was known, DCIS was hardly ever treated. Today, all women with DCIS are treated. In 1983, 71% of the patients were treated by mastectomy. In 1992, 42% were treated by mastectomy. Only about 3% had no surgery (3). Many healthy women may carry DCIS, which was documented in several autopsy series of women without breast cancer, who died of causes other than breast cancer. 6%-18% of the women had a latent DCIS.
Mammography initiated an epidemic of DCIS. A iatrogenic disease with appalling consequences. Survival with DCIS up to 9 years is 100% (3). Who can assure the young DCIS carriers that they will benefit from mastectomy? A similar benefit might be achieved by waiting until the age of 50. However, more of them are treated by mastectomy than women with localized cancer, who usually undergo lumpectomy. This is an epidemic of thoughtlessness and helplessness that could be resolved by a simple measure, watchful waiting. Primum non nocere! Wait until the aberration ripens for treatment.
BRCA1 - Technology has conjured up a breast cancer gene, BRCA1, that was found in families with breast cancer. Instead of giving it a innocuous name, e.g., factor-x or gene-13462, arrogant scientists named it "the breast cancer gene". Soon it was followed by other genes, e.g., BRCA2, BRCA3. Finally it was discovered that many patients with breast cancer lack this gene, which raises the possibility that BRCA1 may not be a cancer gene after all. At best it might indicate which families have a higher risk of getting breast cancer. Yet this could also be determined by asking the patient about her family history. If some of her relatives had had cancer, she would be advised to check her breasts now and again. On the other hand, would anyone advise her to remove her breasts? Absurd? Not at all, since this advice is given by some genetic counsellors, to patients carrying the BRCA1 gene.
An innocuous gene, which has received a demonic name, has initiated another epidemic of futile mastectomies, and more. It has raised ethical debates, e.g., should women be tested? Accordingly, a woman with a BRCA1 gene suffers from a genetic disease and ought therefore to consult a genetic counsellor, whose only concern would be whether to remove her breast or not. This absurd situation has raised the concern of several advisory committees. None was concerned with the scientific and medical relevance of these genes. After all, they do not meet the necessary requirements of genes that cause other genetic diseases, e.g., specificity. Since many patients do not have BRCA genes, they are unreliable cancer markers. All this did not concern the advisors. Instead, they tried to obviate the difficulty by political means, and in vain. The Advisory Committee on Research on Women's Health could not even agree to ban these tests. A top level advisory panel on women's health issue to the US National Institutes advised that such genetic testing should be carried out only within cautious guidelines (5).
What's in a name? An innocuous gene endangers the lives of young women since some arrogant scientists called it a breast cancer gene. Exactly as was done previously with oncogenes. These household genes, that operate in every cell, were first discovered in cancer cells, and named by arrogant scientists cancer genes. Many still regard oncogenes as cancer genes. Even then, they are less dangerous than BRCA1 because they do not drive the patient to remove her breast.
H.H.Humphrey Center for Experimental Medicine and Cancer Research, P.O.Box 12272, Jerusalem 91120, Israel
Internet home page: http://www1.huji.ac.il/md/home.html
1. McKay FW, Hanson MR, Miller RW. Cancer mortality in the U.S.: 1950-1977, NIH Publ. No. 82-2435, 1982.
2. Margolese R. Screening mammography in young women: a different perspective. Lancet 347, 881-882, 1996.
3. Ernster VL Barclay J, Kerlikowska K et al. Incidence and treatment for ductal carcinoma in situ of the breast. JAMA 275, 913-949, 1996.
4. Swanson GM, Ragheb NE, Lin C-S et al. Breast cancer among black and white women in the 1980s. Cancer 72, 788-798, 1993.
5. Wadman M. Panel softens gene test warning. Nature 380, 573, 1996.