Even in this digital age the front cover of Time Magazine is a significant place for a news story. An edition earlier this month featured breast cancer on the cover with the headline “What if I decide to just do nothing? Breast Cancers new frontier”.
Sounds crazy. How can one do nothing about any type of cancer? If we accept the traditional notion of cancer as something, which starts small and continues to grow relentlessly, eventually spreading through the body and ultimately resulting in death then we can’t just do nothing.
But what if our understanding of cancer is incomplete.
Our thoughts on cancer, come from the 1970’s and is based on a one size fits all model described above. This led to the notion of early detection and aggressive treatment being the best approach.
In the 21st century what we have found is that there is more than one model of cancer. Not all cancers follow the path of relentless growth. Some never grow at all. Some reach a level and do not change after that.
An analogy might be seeds planted in the soil. Not all “take” and grow to reach the surface.
US experts have suggested that we need a new way of describing the growths that do not grow. When we call them cancer it carries all the connotations of the “standard” type of cancer. The term IDLE (indolent lesion of epithelial origin) has been considered.
People will react very differently to being told they have an IDLE lesion against cancer.
So where does breast cancer fit into this? Many breast “cancers” are actually “IDLE”.
The notion of “doing nothing” with these (IDLE) breast lesions is a bit of a misnomer. Women are doing something. They are monitoring a growth, which is causing them no harm with a view to acting if (and only if) it changes. This is different to having immediate surgery and perhaps radiation or chemotherapy.
Over the last 30 years there has been a near doubling in the number of early breast cancers detected. However there has been a minimal decrease in the number of late stage breast cancers. The number of deaths has been largely unchanged even though the percentage survival has increased. This percentage survival has gone up because the total number of cancers has increased.
But, a cancer is only found once. If there has not been much decrease in late stage cancers but a doubling in early stage (which are treated) this means that the cancers we are finding are not the type that are fatal. Naturally survival rates increase because it is very simple to cure someone of a condition that never would have troubled (let alone killed) them.
Why are we finding so many cancers that are not a problem? Screening mammography. Up to 40% of growths found on screening are ductal carcinomas in situ (also called stage 0 cancer). These are the type that can be watched rather than treated.
The problem is that when found they are all treated. The Time article makes the point that this approach is being reconsidered. This draws on the more watchful approach adopted in prostate cancer, where again, not all need treatment if they do not grow or cause symptoms.
Previous work has shown that improvements in breast cancer survival cannot be attributed to screening mammography. In addition, women are not warned of the risks of over diagnosis and over treatment of growths, which are not a problem. To cap it off women are virtually badgered into having a “life saving” test which may cause them considerable harm.
The real tragedy in all this is that there will be thousands of women who believe that their life has been “saved” when it was never at risk. And that the treatments they have had were not necessary.
The politics of breast screening will seek to stymie any debate on this topic. However in the USA, UK and Australia more questions are being asked and women are starting to vote with their feet. Latest Australian figures show a reduction in screening mammograms with no change in breast cancer incidence and a slight decline in mortality (due to improved treatment).
Our knowledge evolves in medicine. Unfortunately there is much vested interest and dollars dependent on the current approach.
So what is one to do?
Be guided by your own specific circumstances rather than statistics. Be questioning. Get the facts (and not just propaganda).
Ultimately it is about you deciding what is right for you.
This article first appeared on www.drjoetoday.com