Our Feel-Good War on Breast Cancer

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

by tokenadult • 13 years ago

135 77 13 years ago

lucisferre4• 13 years ago

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

hashmymustache6• 13 years ago

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.

lucisferre4• 13 years ago

That may be partly because breast cancer survival rates are shorter and lower. In short breast cancern is far more deadly (I also believe it is more likely to affect younger women but I have no source for that).

http://www.cancer.org/cancer/breastcancer/overviewguide/brea...

http://www.cancer.org/cancer/prostatecancer/detailedguide/pr...

You should also read the article I linked. The point is not simply that the PSA test is ineffective and treatment can be harmful, but that prostate cancer itself is not a big enough threat to justify treatment in most cases.

> not prostate exams in general (i.e. rectal exam palpation). And like mammograms it depends on the population of interest and repeated tests.

BTW do you have a source that shows this is true.

rgejman2• 13 years ago

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.

gehar2• 13 years ago

Movember isn't a billion dollar pinkwashing scam like Komen, though. It's grassroots awareness.

illuminate2• 13 years ago

Yeah, at least Movember funds don't go directly towards lobbying against using public funds for low-income mens' health.

No, I'm not talking about Planned Parenthood. Komen's lobbying wing literally believes public funds should not go to any forms of womens' health, they believe it should be handled entirely by private "charities" like themselves.

http://www.southernstudies.org/2012/02/flashback-how-the-kom...

http://www.dailykos.com/story/2012/02/01/1060885/-Behind-the...

comrade_ogilvy10• 13 years ago

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.

hashmymustache6• 13 years ago

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.

comrade_ogilvy10• 13 years ago

Feigning ignorance due to intimidation is not better than simple ignorance. Doctor are morally responsible for doing no harm. I do recognize such is not always easy, for reasons you have mentioned.

My 40something wife would love it if our HMO would stop calling and emailing her 6 times a year to get a mammogram. She has explained clearly to her gynecologist her reasoning, that she is absolutely not going to get a mammogram before age 50, but the annoying calls do not stop. (We shut off our ringer, and use a Google voice number for people we want to her from.)

Much as I sympathize, breast cancer survivor groups have many characteristics of a religious cult. They have paid a high emotional and physical price for entry, and as a result they are so bought in to the idea that the treatment-torture saved their lives that they have only a limited ability to think rationally about health issues anymore.

jacquesm5• 13 years ago

> 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.

makomk2• 13 years ago

No kidding it's politicised. I was following some of the really big feminist group blogs back in 2009 when the US Preventative Services Task Force announced their new guidelines, and they were pretty damn unhappy. Apparently it's "patronizing" to care about the anxiety and unnecessary procedures caused by false positives: http://feministing.com/2009/11/17/what-we-missed-161/

diogenescynic• 13 years ago

Don't forget how much money is involved. Hospitals need to pay for that expensive equipment somehow. This is a stable source of income.

tokenadult2• 13 years ago

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...

danielweber2• 13 years ago

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• 13 years ago

Single page link: http://www.nytimes.com/2013/04/28/magazine/our-feel-good-war...

ttrreeww• 13 years ago

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

DanielBMarkham• 13 years ago

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.

chollida12• 13 years ago

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• 13 years ago

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

incision• 13 years ago

I second that, great book, discovered it via HN Store[1].

I was first introduced to cancer and the methods used to combat it about 10 years ago via unfortunate circumstances.

It's fascinating stuff with surprising parallels to my work in IT.

1: http://www.hnstore.co/

bherms2• 13 years ago

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

frankc• 13 years ago

Did you mean pancreatic cancer or something else and not prostate cancer? I believe prostate cancer has close to a 100% cure rate.

bherms2• 13 years ago

Ahh yes, good catch... Early-morning-brain symptom

danielweber2• 13 years ago

Even cheaper, prostate cancer can usually be left alone and never kill or impact the patient at all.

Domenic_S• 13 years ago

> 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• 13 years ago

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!

stevoski• 13 years ago

> One of the major reasons breast cancer prognosis is so good is because it's often caught early.

Actually, the OP ("Our Feel-Good War on Breast Cancer") argued the very opposite.

tsotha5• 13 years ago

>One of the major reasons breast cancer prognosis is so good is because it's often caught early.

I don't believe the statistics bear this out. In fact, there isn't a lot of evidence early detection of breast tumors does much to prolong life. If your metric is the number of years you live after the cancer is detected, then certainly early detection seems like a huge win. But that would be true even if you didn't do anything at all upon having detected the tumor.

dr_• 13 years ago

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.

thisone• 13 years ago

There was a similar story in a This American Life episode about the PSA test for prostate cancer. There's a short interview in Act One with a doctor who was sued for malpractice for allowing a patient to choose to not have the test.

http://www.thisamericanlife.org/radio-archives/episode/391/m...

comrade_ogilvy10• 13 years ago

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?

sliverstorm3• 13 years ago

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.

tsotha5• 13 years ago

>What are the long term health costs of unnecessary chemotherapy?

How could you possibly know it whether or not it's necessary?

sliverstorm3• 13 years ago

you can’t irradiate the same body part twice

Can anyone provide more details?

ars• 13 years ago

Yah, I wondered about this as well.

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

wcgortel• 13 years ago

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.

alexholehouse• 13 years ago

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.

jghrng• 13 years ago

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).

pkulak• 13 years ago

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• 13 years ago

> 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.

Our Feel-Good War on Breast Cancer

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