The Cancer Journal - Volume 9, Number 6 (November-December 1996)
Breast cancer - Audacity and yet more audacity.... !
The Journal has recently published articles on the breast cancer controversy. In this issue, we return to the topic, and probably not for the last time. Why such obstinacy?
There is only one reason : the inability to increase the proportion of true cures in any significant manner and its correlate, mortality by age group. The last real advance dates back to the beginning of the 1970's. It was the modest but undisputed improvement afforded by systemic treatments such as premenopausal chemotherapy and postmenopausal tamoxifen therapy for cancers with moderate lymph node involvement. Since then it has been - if you will forgive me - a case of "variations on a theme" and "much ado about (nearly) nothing".
It is not yet clear whether routine mammography of women over 50 can reduce mortality. I already hear the protestations and indignation of those who think otherwise and who proclaim their opinions so loud that, at a time of economic restriction, those in charge would be ready to launch 'prevention' campaigns based on early diagnosis. There is even talk of bringing down the age limit to 45 years. The description of familial forms of breast cancer and the identification of at least two 'causal' genes (1) has inflamed spirits and also the value of certain shares on Wall Street.
The arguments of both Zajicek (2), who fears overuse of radiation and unnecessary tumorectomies and who advises women to curb their demand for mammographies, and van Zetten & Cann (3), who describe the mechanical factors of mammography that might activate dormant intraductal lesions, are not to be taken lightly. On the other hand, a paper by Bay & Chan (4) in this issue disputes the benign nature of in situ intraductal cancers. Our readers thus benefit from two - if not opposing at least different and well-argued points - of view.
At this stage, it might be appropriate to resurrect a rarely cited article by Nielsen et al. (5). Nearly 10 years ago, they performed a series of 110 medicolegal autopsies on women between 20 and 54 years of age and showed that 20% of these women, apparently free of any kind of mammary lesion, in fact had in situ mammary cancer. This percentage is well above the number of expected cancer progressions. Half the tumours were multicentric.
Last but not least, Ojasoo (6) points out, also in this issue of the Journal, that the crucial and long-expected study comparing ovariectomy, adjuvant chemotherapy, and adjuvant hormone therapy is still eagerly awaited in the field of clinical research (7) have not brought about any changes as regards prscription habits (reduced prescription of chemotherapy), have not incited further studies comparing tamoxifen and ovariectomy, nor have they led to a large-scale comparative study as is wont when highly important issues are at stake. And yet! All hope that breast cancer research will no longer be bogged down, and that more relevant studies will replace the many insignificant, costly and often painful studies undertaken now, is not lost. We must shake off overcautiousness and unavowed self-interests.
Audacity and yet more audacity ....
1. Gogas H, Sacks N.P.M. Familial breast cancer. Cancer J 9, 115-117, 1996.
2. Zajicek G. Lady, think twice before having a mammography. Cancer J 9, 172-173, 1996.
3. Van Netten J.P., Cann S.A. Compression mammography and breast cancer: should pain be ignored? Cancer J 9, 278-279 , 1996.
4. Bay B.H., Chan S.T.F. Ductal carcinoma in situ of the breast - the other story. Cancer J 9, 334, 1996.
5. Nielsen M., Thomsen J.L., Primdahl U. et al. Breast cancer and atypia among young and middle-aged women: a study of 110 medicolegal autopsies. Br J Cancer. 56, 814-819, 1996
6. Ojasoo T. Castration of the body or mind? Cancer J 9, 280-281, 1996.
7. Adjuvant ovarian ablation versus CMF chemotherapy in premenopausal women with pathological stage II breast carcinoma: the Scottish trial. Lancet 341, 1293-1298, 1993.