Peggy Orenstein’s “Our Feel-Good War on Breast Cancer” – a stage we are going through

In a must-read article about the state of breast cancer awareness, medicine and research Peggy Orenstein exposes some of the harsh realities that are often left out of the pink conversation (http://www.nytimes.com/2013/04/28/magazine/our-feel-good-war-on-breast-cancer.html)

Primarily focusing on the recent evidence that more aggressive screening for breast cancer has failed to lead to the significant saving of lives expected, she makes excellent points. Often early detection finds states, notably DCIS, that may never form cancer and so lead to overtreatment and unnecessary hardship for people that feel they have cancer when that is not necessarily the case.

Then, even with more advanced forms of cancer, there is no strong evidence that finding it a year or two earlier makes much difference to the end result, survival. Therefore in many instances it is perhaps OK to wait until the lump is found by the person in whose breast it is, rather than by a mammogram. In a striking quote from Dartmouth’s Dr. Woloshin we consider 100 women who find lumps at age 67 and die at age 70 and so have a 5 year survival of 0. If they had found the lumps at 64 with a mammogram, and still died at 70 it would look like their 5 year survival was 100%. This is very thought provoking.

Finally Orenstein makes the important point that metastatic breast cancer (and metastatic cancer in general) is neglected in research funding, awareness campaigns and in the general national conversation. It is not a hopeful stage, doesn’t look good in ads and is what all cancer patients fear the most. And it is hard not to agree with a condemnation of the excesses of pink washing and the pinkification of everything (believe me, as a guy with breast cancer pink doesn’t speak to me either).

But, as a cancer biologist I take a somewhat different perspective.

While I agree that early detection has not yet borne the fruit it was meant to, we still need it. It is one of the pre-requisites for dealing with cancer. Time is still linear, and the biology of the cancer, for example in terms of mutations in its genome, becomes more abnormal over time. We know metastatic cancer is deadly, and we know DCIS is perhaps entirely benign. There is more than one step between these, and we now think it may take years. So while it is very true that cancer does not progress along the orderly pathway seen in text books a decade or so ago, and that cancer cells spread earlier than we thought, time is still an important factor. A major achievement is that we can now screen early for breast cancer.

Just think that without the screening we have done, we would not be in a position to even discuss DCIS and its significance. I totally agree with Orenstein that we need to know which DCIS will become cancer, and which won’t, so that we can stop over treatment. But you have to accept that if we couldn’t see them in our screening programs, we wouldn’t even be in a position to make this statement.

Similarly, when considering Dr. Woloshin’s 100 women [why no men 😦 ] I can’t therefore hope that the tumor at age 64 still offers opportunities that were gone by age 67. Maybe that span is not enough. But lets say we saw those tumors at age 54?

This biology is borne out by most cancer patient’s personal journeys. Again, rarely do cancers appear at the metastatic stage, though of course some do, and in some instances we have no known primary even. However, for most people afflicted with cancer that is not controlled, that progresses, the experience is a series of treatments that lead to periods of remission, usually with shorter and shorter remission times interspersed with more and more aggressive treatments.

Another thing to consider is that in breast cancer early screening is somewhat the victim of effective treatment for most people. The fact that it doesn’t matter so much whether the tumor is caught at stage I or stage II is related to the fact that we have a pretty good treatment plan for stage II patients. As a breast cancer patient whose tumor was recently “upgraded” from stage II to stage III because my doctors found 6 positive lymph nodes in surgery, I can tell you that I would love to have those months back when my cancer was still stage II.

So while I agree with Orenstein about where we are today, I am optimistic that it is a stage we are in where the benefits of broad-based awareness and screening have not yet been what they should be. As our understanding of the disease and ability to distinguish and treat subtypes improves, screening will be vital. Once we can distinguish which DCIS (or early prostate cancer) is a bad actor and which isn’t we can act appropriately. And once the screening is better and more in tune with the biology of the cancer – think blood test for breast cancer subtype rather than x-ray finding a visual abnormality – we will no longer question the need for early detection as we rightly do now.

As to pinkitude, I am not a fan as such, but I acknowledge a great debt to the movement. We, as patients and scientists, are riding a big wave of awareness, cultural acceptance and funding towards better answers for breast cancer, and all cancer, and that wave is largely pink.

(PS After posting this, I came across an article on how even a brief delay in surgery can affect outcome in young women with breast cancer – very relevant to this whole debate.)