SURGERY FOR BREAST CANCER.
There is no doubt that the incidence of breast cancer is appallingly high. But the true number of cases of dangerous breast cancer may be vastly inflated by the ‘tools’ of modern medicine.
Perhaps the greatest scandal of breast cancer surgery is that up to half of all cases of so-called breast cancer are not cancer at all, but a harmless ‘something’ that has gone slightly awry but which, in the long term, is likely to sort itself out. Doctors believe that ductal carcinoma in situ (DCIS) is an early herald of breast cancer, much as they imagine that abnormal smear tests are an early warning sign of cervical cancer. But DCIS may well turn out to be a harmless aberration which, like abnormal smear tests, in the majority of cases does not progress to cancer. Indeed, women with DCIS might never become aware of it if medicine didn’t insist on a blunderbuss means of screening for cancer. Insisting on surgery for DCIS is as barbaric as performing a hysterectomy on a woman with a dodgy Pap smear, a common practice a generation ago.
Ductal carcinoma in situ is a condition whereby the milk ducts are filled with little specks of calcium (referred to in medicalese as ‘microcal-cification‘). Any abnormality is contained in the milk ducts of the breast and does not spread out to the fatty breast tissue or any other part of the body, such as the lymph nodes (hence the name ‘in situ’ or ‘in place’). These microcalcifications are not large enough to be palpable, but are picked up only on mammograms. They are believed to be the precursors of cancer, but they are not in themselves cancerous — so even the name itself (‘ductal carcinoma’) is misleading. Nevertheless, DCIS is treated like any other invasive cancer and classified as a stage 0 cancer – that is, a cancer that hasn’t spread anywhere.
DCIS is usually confirmed by either a fine-needle aspiration biopsy, which removes fluid and fragments of breast tissue, or a core-needle biopsy, which removes a larger chunk of breast tissue for examination under the microscope.
The American Cancer Society estimates that 41,000 new cases of DCIS are diagnosed every year, making up some 25 per cent of all diagnoses of breast cancer. The usual treatment is a lumpectomy or full mastectomy, followed by radiation.
Recently, a batch of Australian pathologists writing in to The Lancet noted that, in performing core biopsies for abnormalities picked up on mammograms, they routinely uncover cases of ‘burnt-out’ – that is, healed — ductal carcinoma in situ. These are cases of a calcified mass which was DCIS and which seems to have run its course.
The letter also indicated that this phenomenon – of a DCIS healing — was first described in the medical literature some 70 years ago. The Australian pathologists repeatedly found a ‘foci’ of an abnormality at the centre of these microcalcifications, which had basically petered out. All that was left was a remnant of the old problem, which the body has effectively contained — an abnormal milk duct or a calcified mass surrounded by fibroid tissue.
The Australians were very wary of saying that this finding cannot always be counted on to be benign, and suggested continued follow-up. Nevertheless, UK breast cancer specialist Professor Michael Baum says that, in his experience, more than 80 per cent of all DCIS cases never progress to cancer. Even when they do, mortality is extremely low and conventional treatment offers no survival advantage. According to a review of all breast cancer statistics by cancer expert Maryann Napoli of the Center for Medical Consumers in New York, 1 per cent of women with DCIS die of breast cancer — whether or not they are treated.
Indeed, in many cases the surgery for cancer, including breast cancer or DCIS, may actually precipitate its spread. Dr Judah Folkman of Harvard University has carried out research showing that the creation of new blood vessels, a process known as angiogenesis, is responsible for the spread of cancer. Injury to skin and muscle, as occurs through surgery, and the consequent rush of blood and oxygen to the site, turns on this angiogenic ‘switch’. Extra blood and blood vessels also offer the tumour cells a ‘superhighway’ to distant organs. Even biopsy can trigger angiogenesis.
‘You take a latent cancer that would never hurt a woman,’ says Baum, ‘biopsy it, turn on the angiogenic switch, and it ceases to be latent — it becomes an aggressive disease.’
The implications of these findings are enormous. For many years doctors have admitted that they don’t know whether DCIS spreads, and yet they perform mastectomies as a just-in-case measure. Now we have evidence that, in many instances, these could be little fires that the body is well equipped to stamp out by itself, without having to enlist the full support of the cut-and-burn fire brigade of modern medicine. These findings also suggest that many cases of so-called breast cancer are being misla-belled as such.
Finally, they also highlight how blunt an instrument mammography is as a form of detection. By indiscriminately detecting all abnormalities, including benign ones, mammograms are contributing to the problem of breast cancer, not the solution. Most cases of DCIS might resolve themselves with no one the wiser if they’d not shown up on a mammogram.
For the women with genuine breast cancer, doctors insist on surgery as the first port of call. Although many in medicine believe that cutting out the tumour reduces the cancer burden on the body, a number, including Dr Baum, a breast-cancer specialist for more than 30 years, believe that surgery is responsible for the vast spread of cancer, particularly as surgery appears to increase the risk of relapse or death within three years of the procedure. Even a tiny piercing of the flesh, as occurs through biopsies, is thought to bring on cancer in one in 15 women and to spread cancer in a third of cases.
Besides being unnecessary, a large number of surgical procedures still widely used are clearly obsolete. Despite a variety of surgical techniques, a host of back-up therapies and many confident headlines about breast-cancer breakthroughs, the truth is that surgical treatment of breast cancer hasn’t advanced one single step in the past century. ‘Over a period of 100 years,’ says Dr Edward F. Scanlon of the Northwestern University Medical School in Illinois, who has studied breast-cancer incidence in depth, ‘breast-cancer treatment has evolved from no treatment to radical treatment and back again to more conservative management, without having affected mortality.’
Although governmental and most other official agencies recommend breast-conserving measures for breast cancer caught early, some surgeons persist in a full mastectomy, a mutilating operation developed in the 19th century and never really reviewed to see if it is still applicable to patients today — or indeed if it ever worked at all.
The standard procedure for breast cancer was developed by Dr William Halsted a century ago. (Dr Halsted is better known for advocating what was then a revolutionary notion: that surgeons should wear sterile gloves.) The operation he championed involves removing the breast, much of the skin, the chest wall and the lymph nodes.
Shortly after the Second World War, a study at three hospitals in Illinois showed little difference in five- and 10-year survival rates between radical mastectomies, simple mastectomies, or simple removal of the tumour. Then, some 25 years later, The Lancet reviewed 8,000 cases and again found no difference in survival rates among the patients who had received any of these procedures. Nevertheless, the Halsted procedure maintained a tight grip on the mind of the average surgeon over the next two decades. In some areas it was then replaced by ‘modified’ radical surgery, which removed tissue and breast, but left the chest wall intact, or a simple mastectomy, which only removed the breast itself. But like its predecessor, the modified radical mastectomy was also put into place without any scientific studies proving its worth.
Like the earlier studies, evidence in the 1980s showed that mastectomy provided no benefit in terms of cancer recurrence or survival over breast-conserving surgery (BCS) such as simple lumpectomy (removal of the tumour itself) or quadrantectomy (removal of a portion of the breast). In the most famous study, headed by Dr Bernard Fisher and undertaken by the National Surgical Adjuvant Breast and Bowel Project in Pennsylvania, of nearly 2,000 women over nine years there was no difference in survival rates among those who had undergone lumpectomy, those who had had lumpectomy plus irradiation, and those who had had a total mastectomy.
Several years later, the Chicago Institute discovered that the Pennsylvania trial — which had been the largest in the U.S. on breast cancer — had been falsified. About 100 ineligible patients were included in the trial, which involved 5,000 patients in 485 academic and community hospitals. Once the fraud had been uncovered, two of the Pennsylvania teams pored over the research data again, excluding the ineligible patients, and nevertheless reached the same findings. After a second major U.S. cancer study also headed by Dr Bernard Fisher was discredited, he resigned as research project chairman. In this second study, which tested the efficacy of tamoxifen to prevent breast cancer, Dr Fisher was accused of withholding data about the association of tamoxifen and the development of endometrial cancer. Informed consent forms, which women have to read and sign before agreeing to join the trials, apparently did not include the latest data showing that four women had died after taking tamoxifen.
Luckily, more recent research from the National Cancer Institute (NCI) in Bethesda, Maryland, confirmed that lumpectomy and radiation are just as effective as radical mastectomy in controlling early-stage cancer. The NCI found that about three-quarters of patients given lumpectomy and radiation survived, which was comparable to the number of patients surviving after a radical mastectomy. And in Italy, researchers found that a similar number of patients survived or had local recurrence of cancer, whether they were given radical mastectomy or a breast-conserving operation called a quadrantectomy (removal of only a quarter of the breast), plus radiation.
Since 1990, the American National Institutes of Health has recommended that surgeons opt for breast conservation surgery over mastectomy for the majority of women with stage I or stage II breast cancer. By this they mean for tumours of less than 4 cm in diameter limited to the primary site (the single breast) without involvement of the chest muscle or overlying skin. In the past, doctors felt that cancer found in the axillary lymph nodes was evidence of spread, and grounds for radical mastectomy. With the NIH’s announcement, whether or not lymph nodes are involved (so long as they are on the same side as the tumour) is now considered immaterial.
Despite all the publicity about the safety of lumpectomies, many doctors still think the more they cut out the better off a woman is, and refuse to offer breast-conserving surgery to many women with early breast cancer. A Seattle study examined cancer-registry information over five years. Fewer than a third of women were offered BCS, even though three-quarters of them clearly had early cancer. After 1985 (when publicity about BCS had died down somewhat) the practice of keeping breasts intact declined even further, and doctors returned to modified radical mastectomies even though there was no evidence to support their choice.
Doctors also failed to offer radiation therapy to women with cancer who had already been through the menopause, and were more likely to sacrifice the breasts of older patients than younger ones, even for the same stage of breast cancer. In fact, the more affluent and well-educated the woman, the greater the chances of her breast being saved. In many medical centres, the masectomy is still the operation of choice.
