
Our Feel-Good War on Breast Cancer - tokenadult
http://www.nytimes.com/2013/04/28/magazine/our-feel-good-war-on-breast-cancer.html?_r=0&pagewanted=all
======
DanielBMarkham
Read a great book last year on cancer -- The Emperor of All Maladies
<http://amzn.to/10fEm78>

If I remember correctly, most of the breast cancer that develops early is
fast-spreading, while most of the cancer later in life is slow-spreading. So
as you screen younger and younger people, you quickly reach a point where you
cause more harm than good. You're only finding more disease you can do nothing
about, and the false positive cause tremendous hardships on tens of thousands
of women.

I also seem to remember that there's some serious discussion over the idea of
categorizing cancer based on where it's first detected or starts. Cancer is
much more a cell-based disorder than a location-based one. We may have created
this huge categorization and treatment system that describes the problem in an
inefficient way.

Good read.

~~~
chollida1
Agreed, many times over this is a great book. Not many books have over 500
reviews and a 4.6 out of 5 star rating.

Here's the link without the affiliate code:
<http://www.amazon.com/gp/product/1439170916>

~~~
gianbasagre
I don't get why you have to post a link without the affiliate code.

~~~
nness
I agree. If you weren't aware of this book, followed that link, liked what you
saw, and then purchased it, why shouldn't the person who linked you to it in
the first place have some kind of reward? (particularly since Amazon pays it,
not the purchaser)

I think some people get all up in arms about it when larger publications do
it, since it throws into question the validity of what they've written if
they're trying to make money from referral links. However, the above is
clearly someone's personal opinion , and I don't think that it should be
scrutinised as if it were deceitful.

~~~
ekianjo
At least the person who shares the link should have the decency to say it's an
affiliate link.

~~~
derefr
I don't understand what's "decent" about that. What do you expect the benefit
of that information to be, in Consequentialist terms? That people get the
opportunity to be dissuaded from clicking on a link they'd have otherwise
clicked on--and thereby disuaded from purchasing something they'd have
otherwise purchased--because clicking that link _makes someone else money with
no cost to them?_ Even though it was a link to something they already saw
enough objective value in to click without knowing that?

Would you also like Dropbox to add disclaimers to all their referral links
reminding people that the person who sent them the referral is getting extra
space as well?

~~~
ekianjo
What's not decent is when there is an artificial asymetry of information for
no reason. If you tell me it's an affiliate link, at least you are being
honest and transparent that the link will benefit you. Whats wrong with being
transparent ?

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bherms
Slightly related anecdote that I share because I found the perspective so
interesting:

A few years ago I built an event management website for a decently large lung-
cancer awareness program. During some of the meetings, I met with a world-
renowned surgeon who supported the cause and we got to talking about how the
breast cancer movement had grown so large. His perspective on it shocked me.
Basically he said that breast cancer, in the large scale scheme of diseases,
is actually not that dangerous. The mortality rate is incredibly low. Cancers
like pancreatic, however, are incredibly high. When a woman gets bc, the cause
gains her, her sons/daughters, brothers/sisters, significant other, etc and
that support lasts for the duration of treatment, and typically up to a year
and a half to two years. With pancreatic cancer, the person usually dies, the
family experiences a grieving period, and maybe only gets involved for a short
period of time because they spent a large portion of their time focused on the
disease in grieving. It was interesting to think about.

edit: changed prostate to pancreatic

~~~
Domenic_S
> _Basically he said that breast cancer, in the large scale scheme of
> diseases, is actually not that dangerous. The mortality rate is incredibly
> low. Cancers like pancreatic, however, are incredibly high_

You may have taken away the wrong message from the surgeon, or maybe I'm
reading it wrong. One of the major reasons breast cancer prognosis is so good
is because it's often caught early. Pancreatic cancer has no early symptoms,
so by the time it's caught it's often too late.

Indeed one school of thought is that improved detection methods system-wide
are going to be the #1 factor in winning against cancer long-term.

~~~
jquery
But conversely, pancreatic cancer that _won't kill you_ is probably never
caught because it is symptomless. Thus, you "survive" it and you don't even
realize it. Improved pancreatic-cancer detection might well increase the
amount of early pancreatic-cancers caught and the survival rate of pancreatic
cancer _without saving a single life!_

------
dr_
I don't disgree with the viewpoint of this article.

However, having served on a hospital credentials committee, and bearing
witness to what type of lawsuits medical providers have been subject to, I can
assure you that if a physician advises against a screening mammogram to a
woman in her early 40's despite the fact that there are "organizations" that
encourage it, and she ends up with breast cancer and possibly dies, that
physician will get sued and will in all likelihood lose, or have to settle.
Task forces can make all kinds of recommendations, but unless there are
changes to the legal system to back them up , don't expect major changes.
Somewhere in this discussion it was suggested that doctors are ignorant. It
is, in fact, the exact opposite.

~~~
comrade_ogilvy
I am the guilty party, and I think your counterargument is a good one.

It is not the actual screenings that I particularly care about -- that is just
data. The elephant in the room is the implied _massive_ amount of
overtreatment that are justified on the basis of the screenings --
overtreatment that inflicts a tremendous physical, emotional, financial, and
health toll on the patient.

What are the long term health costs of unnecessary chemotherapy? Is it
ethically okay for a doctor to inflict torturous poisoning (chemotherapy) on a
patient for fear of potential lawsuits, when it could easily be true that 75%
of those patients gain zero medical benefit?

~~~
sliverstorm
_Is it ethically okay_

I'd think in the general case, yes. The patient is going to want it, even if
it is only 25% effective. I'm not an expert on medical ethics, but in my mind
if the patient has complete information and still wants the treatment, the
doctor is not morally bankrupt in providing it. The doctor can certainly
advise otherwise if they choose, of course.

~~~
comrade_ogilvy
You are assuming the patient has complete information. If actually true, I
would agree. What is "complete information"? Do the doctors offer the
statistics that the treatment is _not_ 25% effective, that by American medical
treatment norms chemo is 75% worse than useless and of the remaining 25% many
will still die?

The patients are scared. Doctors are playing on those fears, acting on the
assumption that fast and aggressive treatment is the wisest course all the
time. The patients are reacting out of fear, not getting second opinions, and
are hurried into the operating table to be cut open.

That is the norm. I have seen it happen.

It is my personal opinion that, no, most doctors are not offering complete
information. So your argument, while reasonable, simply does not apply.

------
comrade_ogilvy
Most people lives happily for decades with many cancers. The difficult
question is finding those cancers that are likely to actually cause harm.
Mammograms are not very useful here, and may be a net negative for health
outcomes because...

The "Feel-Good War" is causing a lot of harm: tens of thousands of women
tortured by medically unnecessarily poisoning and radiation, inflicted by
well-meaning but ignorant doctors.

~~~
hashmymustache
It's not just because doctors are ignorant. It's largely in part to a health
issue that has become an overwhelmingly political issue that ignorantly
preserves the status quo of "more screening = better." For doctors not to
abide by such screening procedures then if their patient gets breast cancer
and were encouraged not to screen given the low yield and high risk they can
be sued for negligence.

~~~
jacquesm
> It's not just because doctors are ignorant.

So, doctors are ignorant? That's news to me, I know a few doctors and they
don't strike me as ignorant at all.

~~~
comrade_ogilvy
Your superficial impressions are very persuasive.

Many of the best con artists are sincere. So if they do not recognize their
own ignorance, why should you? If there was an important gap in their
knowledge they were aware of, would they be confessing that to you, a non-
doctor?

As for my evidence, our HMO is run by doctors. My wife's clearly reasoned
decision to not get a mammogram before 50, _based on her own reading of the
medical literature_ , has proven unpersuasive to her gynecologist or the
people who set the policies that "provide" the harassing phone calls.

~~~
jacquesm
Do you second guess your mechanic in an auto workshop? (I do, but then again,
I've restored a couple of cars from the ground up). How about a contractor, an
engineer or someone working on a high voltage line? Maybe the pilot of the
airplane that you're taking to your holiday destination or the cook in the
restaurant where you ate yesterday? Based on a reading of the literature you
could easily become an armchair expert in just about anything. But that does
not give you the years of practical experience that typically go with the
territory and that should count for something.

Doctors are emphatically not con artists.

I applaud you wife's reasoned decision, clearly she is in control of her own
destiny and her decision (if by unfortunate chance it is the wrong one) will
mostly affect her and her immediate family.

But if we spend a good sized fortune and several years educating someone I
really wonder why we'd bother with that if all that it would take to
counteract all that effort and knowledge would be a lay persons reading of the
medical literature. Most of which is not exactly written for easy consumption
by the general public.

Whether you're in a risk group for certain cancers depends on a lot of factors
and you'd need to know all of those to make a weighted decision. This is not
always as easy as applying the general case to yourself calling it a day.

Age and sex are obviously the big ones but there are many (not sure how many)
contributing factors that may cause doctors to be more concerned about one
individual than another. We call those people specialists because we recognize
that the amount of knowledge required is typically larger than what one person
can acquire in a lifetime.

The time when I'm going to trust my own interpretation of a pile of google'd
medical papers over a qualified specialist is still a while away.

In the meantime I'm terribly happy I'm not a medical doctor, I'd hate to have
to continuously defend each and every minor decision to a general public that
I'd be trying to help in an already time-constrained practice. It's hard
enough when non-technical (read: totally clueless) customers question
evaluations of technical issues based on some popular text they've been
reading, at least there are usually no lives on the line.

~~~
DanBC
You make a bunch of really good points. However, there is a need for patients
to learn the right questions to ask of doctors.

"How do you know this is the right treatment?" and "What happens if we do
nothing?" are two good questions.

Doctors are overwhelmingly not con artists or stupid, but they do make
mistakes and they do have to keep up with changing science.

This is especially important with doctors. They're science based, they're
educated, the stuff they do has plausible mechanism of action. But this is
exactly the time we need better science; double blinded studies etc. See, for
example, knee arthroscopy which was found after controlled studies with sham
operations to be no more effective than the sham for many people.

~~~
jacquesm
I'm all for doctors informing their patients and for a proper dialogue.
Obviously it is a lot simpler to be treated for a broken arm or a gallbladder
infection than for something as invasive as cancer or something that is hard
to diagnose.

Screening (especially um-necessary screening) is doing more harm than good.
But who to screen and who not to screen is _still_ a specialist decision and
depending on your locality more or less care will go into the making of that
decision. Categorically rejecting screening before you're 50 if you're in a
risk group is not smart (not saying the OP's better half is, but these things
tend to be complex).

The doctor-patient dialogue is a tricky affair and I think that somewhere
along the line doctors lost the ability to clearly communicate with patients
about their treatments and the necessity thereof. On top of that doctors now
see so many patients that there simply isn't time enough to have a proper
conversation with every patient.

Those things are the crux of the problem here, not that doctors are out to
make money of unsuspecting citizens or that they would perform procedures or
generate referrals because there is money in it. Though I'm sure that occurs
the Hippocratic oath is still very much a part of medical education.

<http://en.wikipedia.org/wiki/Hippocratic_Oath>

> See, for example, knee arthroscopy which was found after controlled studies
> with sham operations to be no more effective than the sham for many people.

I noticed a 'many' in that sentence, that's a bit of wiggle room there, if it
were a really ineffective treatment there would be an 'all' in there. So now
the question becomes one of degree and how to tell the people for whom that
treatment is effective from the ones for whom it isn't.

On another note, the communications problem in part stems from the vast body
of knowledge in modern medicine, two specialists already have a hard time
communicating their ideas to one another, a doctor explaining the intricacies
of some treatment to a patient would have to be at least as good an educator
as a doctor, however education is typically not their specialism.

------
pkulak
I recently went in for a checkup and, as a part of that, got a blood test. My
liver panel had an elevated ALT, so I was referred to a gastroenterologist. He
sent me for an MRI, where he saw what he thought was cancer. So, then it's off
for a liver scope, which gave me pancreatitis and put me in the hospital for a
solid week of really intense pain and tens of thousands in medical bills.

Turns out the scope found nothing and I'm perfectly healthy (I have a
suspicion that the elevated ALT was from riding my bike to the doctor's
office). The lesson I learned was that every time you step into a medical
facility you're increasing your risk for disease. You shouldn't be afraid of
tests, but they are absolutely not without risk. But everyone thinks that more
tests and procedures make you healthier and that anything less than the most
is "rationing". It's insane.

~~~
seanmcdirmid
> The lesson I learned was that every time you step into a medical facility
> you're increasing your risk for disease.

Sort of the antithesis to "primum non nocere."

On the other hand, people like me are afraid to go to the doctor for anything
at all; even yearly checkups are taboo. I'm completely insured, but still hate
trips to the doctors.

------
alexholehouse
One of the most damaging impressions the public has relating to cancer is that
"cancer" is a single disease. This article touches on this idea ("... at least
four genetically distinct breast cancers....") but even this is a _gross_
underestimation of the complexity of cancers.

Essentially, the only thing that unites cancers together is that they
represent a class of diseases in which your own cells multiply in an
uncontrolled manner. Beyond this idea of "out of control growth", there are a
number of common ways which these distinct phenotypes occurs (such as too much
of pro-growth molecules, not enough "slow down" molecules etc) but
genetically/molecularly there are many, _many_ different routes which these
phenotypes can be achieved.

This, again, is still only touching on the surface. After you have the
molecular underpinnings of the "out of controlness", you have genetic and non-
genetic factors relating to things like where the tumour is, how do the cells
change once the cancer begins to progress, how your body reacts to the cancer,
how your body reacts to drugs etc.

In 100 years time, I'm confident we'll look back on our present day way of
thinking about cancer in the same way people now look back at our previous
ideas relating to mental illness 200 years ago, or general diseases 500 years
ago.

------
lucisferre
There have been similar issues around prostate cancer and things like
"Movember". The jury is still out I suppose, but a number of doctors believe
prostate exams are doing more harm than good.[1]

[1]: <http://www.nytimes.com/2011/10/07/health/07prostate.html>

~~~
hashmymustache
Well the PSA test specifically, not prostate exams in general (i.e. rectal
exam palpation). And like mammograms it depends on the population of interest
and repeated tests.

What bothers me is the lack of equal awareness and emphasis of prostate cancer
with breast cancer even though it has a greater incidence and more profound
negative effects from treatment. When a guy gets prostate cancer and has a
prostectomy, he will more often than not experience severe erectile
dysfunction. I hear a lot about how women feel disempowered when they get a
mastectomy even though it can be replaced without any loss in sexual function,
but much less on the scarring effects of prostate cancer on men with permanent
sexual dysfunction.

~~~
rgejman
Just as an FYI: Women can also have some loss of sexual function, either
physically (due to ligation of the 4th intercostal nerve that supplies the
nipple), psychologically or both.

~~~
jacquesm
It is also possible that due to a mastectomy menopause onset is accelerated.

~~~
rgejman
I wasn't familiar with that. Is that stress-related? Mastectomy without chemo
should not induce menopause, as far as I understand the physiological
processes at work. If the patients are also being treated with tamoxifen or
other estrogen receptor antagonists then the menopause is, I believe,
reversible.

------
wcgortel
Just a quick NB here: I installed the 'churnalism" add-in that was talked
about here a few days ago, and it popped up with a note that some of the text
had appeared in a press release from the British Medical Journal.

In this case, it is no big deal, but what a cool use of technology to inform
and extend our knowledge.

------
tokenadult
An edited group blog post by a medical doctor who researches breast cancer
treatments has a good discussion of the science behind mass screening trade-
offs:

[http://www.sciencebasedmedicine.org/index.php/once-more-
into...](http://www.sciencebasedmedicine.org/index.php/once-more-into-the-
screening-breach-the-new-york-times-did-not-kill-your-patient/)

~~~
danielweber
That opening anecdote fills me with rage. I've seen lotteries do loss-aversion
advertising: wouldn't you feel bad if your numbers came up but you didn't play
that week? Now we have doctors doing it, too: wouldn't you feel bad if you
were one of the cases where screening would have helped but you didn't do it?

------
Scramblejams
Single page link: [http://www.nytimes.com/2013/04/28/magazine/our-feel-good-
war...](http://www.nytimes.com/2013/04/28/magazine/our-feel-good-war-on-
breast-cancer.html?_r=0&pagewanted=all)

------
sliverstorm
_you can’t irradiate the same body part twice_

Can anyone provide more details?

~~~
ars
Yah, I wondered about this as well.

The only thing I can think of is that perhaps the radiation will cause cancer.

------
jghrng
Wow, I never heard of doing annual mammograms, or even "base-line screening"
(!). Wouldn't that actually count as personal injury?

EDIT: Continued to read the actual article -- I didn't know about the
mammography madness in the US. AFAIK doing X-Rays or CTs without reasonable
suspicion is considered personal injury here (in Germany).

------
ttrreeww
Research pink ribbon, it's a very large scam.

