Too much chemo. Too much radiation. And way too many mastectomies
“Why Doctors Are Rethinking Breast Cancer Treatment“ is the cover story of the current issue of Time. The article leads with one of the most important questions a person freshly-diagnosed with cancer can ask:
“What if I do nothing?”
After heart disease, cancer is the second most lethal cause of death in the United States, followed by chronic lower respiratory disease, accidents, stroke, Alzheimer’s and diabetes. A diagnosis of cancer is one of our society’s greatest fears because cancer is often perceived to be as inescapably lethal and cruel.
Fear and the accompanying sense of urgency which follows a diagnosis can result in patients making treatment decisions without ever asking what seems to be a nonsense question in the face of an obvious threat.
In his May 11, 2015 New Yorker article, “Overkill,” surgeon and author, Atul Gawande addresses the problem of over-diagnosis and over-treatment of chronic diseases, particularly cancer. Gawande refers to an analogy used by H. Gilbert Welch, a professor at Dartmouth Medical School and author of Less Medicine, More Health:
…we’ve assumed, he says, that cancers are all like rabbits that you want to catch before they escape the barnyard pen. But some are more like birds—the most aggressive cancers have already taken flight before you can discover them, which is why some people still die from cancer, despite early detection. And lots are more like turtles. They aren’t going anywhere. Removing them won’t make any difference.
We’ve learned these lessons the hard way. Over the past two decades, we’ve tripled the number of thyroid cancers we detect and remove in the United States, but we haven’t reduced the death rate at all. In South Korea, widespread ultrasound screening has led to a fifteen-fold increase in detection of small thyroid cancers. Thyroid cancer is now the No. 1 cancer diagnosed and treated in that country. But, as Welch points out, the death rate hasn’t dropped one iota there, either. (Meanwhile, the number of people with permanent complications from thyroid surgery has skyrocketed.) It’s all over-diagnosis. We’re just catching turtles.
The Time article tells the story of Desiree Basila and her reaction to a diagnosis of breast cancer. She managed to step through the panic that she felt the morning after her diagnosis and began to do some research on her own. She learned a few important facts:
- Doctors are not always tolerant of inquisitive patients
- The doctor’s recommendation for a mastectomy didn’t acknowledge the disagreement in the field on how best to treat ductal carcinoma in situ, her kind of cancer
Basilia met with Dr. Shelley Hwang at the University of California, San Francisco. Hwang recommended a lumpectomy. In response to Basila’s exasperated question of doing nothing, Hwang replied, “Well, some people are electing to do that.”
Basila was ahead of the curve in making her decision to refuse the traditional treatments for breast cancer and opted instead for taking a drug called tamoxifen to block estrogen because of its tendency to cause growth in tumors.
Both men and women would do well to read the Time article. It may surprise you to learn that with all the effort devoted to curbing fatalities related to breast cancer, the annual death rate remains at 40,000 women each year. For the past thirteen years, about 40,000 women have died from breast cancer. For all those mastectomies and lumpectomies, not much has been done to curb the mortality rate of cancer.
This is maps with Gawande’s observation that we have tripled the number of diagnoses of thyroid cancer in the United States but the death rate has not decreased as a result of the increase in detection.
My exhortation is not to say that chemotherapy or radiation is a bad decision. It is to say, however, that it is important to move past the panic and fear of a diagnosis of cancer and take the time to understand the specific kind of cancer and to consider whether one of the possible approaches is to monitor closely and wait to see what happens.
In my book, Dying With My Mom, there is a chapter on the importance of asking “What if I do nothing?” Asking this question places more responsibility on the patient to learn about their disease, to seek multiple opinions and to look for evidence that doesn’t support the diagnosis. Choosing chemotherapy may well be the best course of action. Given the hardship of chemo though, wouldn’t it be to one’s advantage if they were informed and confident that a doctor isn’t just prescribing chemo out of laziness, habit or financial gain?