Respectful Insolence

Breast cancer in TIME Magazine

Here we are, a third of the way into Breast Cancer Awareness Month, and I haven’t yet written a piece about breast cancer. Given that it’s my primary surgical specialty, perhaps some readers were wondering why not. Truth be told, I’ve always been a bit ambivalent about Breast Cancer Awareness month. Perhaps it has something to do with the fact that my job makes every month Breast Cancer Awareness month. Or maybe it has something to do with the crassness of some of the promotions designed to attract donations, well-meaning though such campaigns undoubtedly are. From my perspective, any month is a good month to give to breast cancer-related charities, such as the Breast Cancer Research Foundation or the Susan Komen Foundation. Both do fantastic work in funding breast cancer research and advocacy. You shouldn’t wait until October every year to do it. However, if the attention each October brings results in more donations and does raise awareness about the importance of early detection, I suppose I shouldn’t complain.

One article, however, that did catch my attention was the cover story this week in TIME Magazine entitled The Changing Face of Breast Cancer. To someone like me, who has been spoiled practicing in the U.S., where decades of advocacy have resulted in a situation where most women at risk for breast cancer undergo at elast every other year screening mammography. That’s why tumors here tend to be caught at an early stage, unlike 50 years ago, when most tumors weren’t detected until they could be felt on physical examination.

The article points out that dealing with breast cancer in the rest of the world is a much different affair than it is in the U.S. and Europe:

While the risk factors for a disease may cross borders freely, the cultural understanding it takes to treat it doesn’t. Americans may live in a world of pink ribbons and LIVESTRONG bracelets, but in other parts of the globe, breast cancer is still a shameful secret. Every three minutes an Egyptian woman is informed that she has the illness, and one of her first fears is that her husband will leave her. Secrecy leads not only to misery but also to misinformation. In India, women with breast cancer may be forced to use separate plates and spoons because of the widespread belief that the disease is contagious. “There’s fear to feed the children with her own hands,” says Vijaya Mukerjee, a breast-cancer survivor living in Kolkata, formerly Calcutta. Brazilian nurse Gilze Maria Costa Francisco, a breast-cancer survivor herself, recalls a young mother asking her whether she could contract breast cancer if her daughter burped during breast-feeding.

Even in a technologically advanced country like China, attitudes and treatment are only now starting to catch up with what has happened over the last few decades in the West:

Six months ago, Liu Lichun didn’t know her breast could contain cancer. No one had taught the 40-year-old Chinese woman from Inner Mongolia what the disease was. She’d never heard of a mammogram or mastectomy. It had thus never occurred to her that she would lose her left breast to the mysterious illness nor that such a loss would probably save her life.

The lump that transformed Liu’s world was not much larger than a marble. A company physician found it in June during the routine checkup that her employer, a Swiss firm in Shanghai, encouraged its sales staff to undergo each year. Once a biopsy proved the tumor was malignant, Liu believed that the diagnosis was a death sentence. “I’d never heard of anyone in China with cancer who didn’t die,” she says.

Five years ago, Liu might well have been among them. Breast cancer is the most lethal form of cancer for women in the world. An estimated 1 million cases will be identified this year, and about 500,000 new and existing patients will die from the disease. In the U.S., breast cancer will be diagnosed in 1 in 8 women.

But in China, as in most other emerging economies, breast cancer is a relatively new concern, something that both patients and doctors are only haltingly learning how to treat. Previously a malady that mostly afflicted white, affluent women in the industrial hubs of North America and Western Europe, breast cancer is everywhere. Asia, Africa, Eastern Europe and Latin America have all seen their caseloads spike. By 2020, 70% of all breast-cancer cases worldwide will be in developing countries.

Much of the problem comes down to attitude. Breast cancer remains highly treatable with relatively low technology methods if found early. Surgery remains the mainstay of treatment for earlier stage cancer, with radiation and chemotherapy representing the “icing on the cake,” so to speak. Besides attitudes and superstition that lead to a serious stigma for breast cancer victims, what’s also a factor in many developing countries that is not so much of a consideration here is sheer cost. The brutal calculation is very succinctly and accurately described in the article:

Money is a problem too. In Egypt, mammograms cost about $50, in many cases a month’s income. Onyango, the Kenyan breast-cancer survivor, remembers that when her doctor told her she should have a mammogram, her first thought was, “How much will it cost?” The answer may be only $20 in Kenya, but for people who live on less than $1 a day, that could easily be out of reach.

Even in Japan, nobody’s idea of a struggling country, cost is a barrier. In 2000 the Ministry of Health, Labour and Welfare called for the introduction of mammography for all women over 50. As of 2005, only 7% of women follow that recommendation. The price tag of a single machine is about $262,000, and a mammogram generally costs a patient $90 out of her own pocket. Says Dr. Fujio Kasumi, breast-cancer chief at Juntendo University Hospital: “People don’t do [tests], thinking it’s a waste of money.”

It’s not a waste of time or money, particularly for women over 50.

This same consideration of cost results in many more mastectomies in the developing world than we do here:

These days fewer than 40% of American women opt to have mastectomies. That percentage, however, soars in other countries. In Korea more than 50% of patients have mastectomies, mostly because they are afraid of secondary cancers. Frequently, such radical surgery is the only option offered a patient. When Ye Danyang, a 41-year-old editor at Beijing TV, found a tumor in 2002, doctors hinted that her resolve to preserve her breast was to choose beauty over life. And, in most cases, a mastectomy is cheaper. “A lumpectomy requires additional, expensive treatment,” Xu, the Beijing surgeon, says bluntly. “Patients believe, with a mastectomy, you cut off the breasts for $125, and they’re done.”

Distance can also be a consideration, even if money isn’t. After a lumpectomy, radiation therapy is necessary. It takes generally 6 or 7 weeks of daily treatments. If a woman lives a long way away from a radiation oncology facility, this becomes a major consideration that is not always obvious initially.

The depressing thing about this story is that, at least in the case of early stage breast cancer, surgery, radiation, chemotherapy, and hormonal therapy represent highly effective treatments with an excellent chance of curing the cancer. Even in the case of more advanced tumors that have not yet metastasized to the rest of the body, chances for a cure are not to shabby if proper evidence-based treatment is given. What this article reminded me of is that not nearly enough women outside of developed countries have access to this hope.

Although in general TIME Magazine’s coverage of breast cancer was good, there was one aspect of it that bothered me. Ensconced seamlessly in an article on Breast Cancer Basics is something that struck me almost as an advertisement for the MammoSite catheter. It’s presented as if it’s the standard of care. In fact, it’s presented almost as though it’s the first option for radiation therapy after a lumpectomy.

It’s not.

For one thing, not all patients who have undergone lumpectomy are candidates for the MammoSite. For another thing, the standard of care is still to irradiate the entire breast, given that there is not yet long term data to show that partial breast irradiation with the MammoSite catheter is equivalent to the usual longer course of whole breast irradiation. Also, the catheters are still quite expensive. At our institution at least, we generally do not use the MammoSite catheter except in the context of a clinical trial. I rather suspect that the prominent play given to the MammoSite catheter in this article probably derives from a desire on the part of the journalist writing the story to include the latest cutting edge treatments, which the MammoSite might turn out to be if long term results turn out to be good enough.

At least they got the controversy over MRI in screening for breast cancer pretty much correct. Theirs the short version; I presented the long version a few months ago.

The MammoSite emphasis aside, I have to admit that I’m fairly impressed with what TIME has accomplished with this issue. Not only did it make me appreciate the resources that I have at my disposal in the U.S. to treat breast cancer, but the information it presented was about as accurate as can be expected in a lay publication.

ADDENDUM: If you’re inclined to use the opportunity of Breast Cancer Awareness Month to do so, don’t forget to donate to my two favorite breast cancer charities, the Breast Cancer Research Foundation and Susan G. Komen for the Cure.

Comments

  1. #1 Coin
    October 10, 2007

    Previously a malady that mostly afflicted white, affluent women in the industrial hubs of North America and Western Europe, breast cancer is everywhere. Asia, Africa, Eastern Europe and Latin America have all seen their caseloads spike. By 2020, 70% of all breast-cancer cases worldwide will be in developing countries.

    Wait. What?

    Surely what’s being described here isn’t the number of actual cases increasing in these places, but the number of diagnosed cases increasing. Right?

  2. #2 Ben
    October 10, 2007

    Great post, and thanks for pointing us to the story. It’s an interesting read.

    I personally wish Lung Cancer Awareness Month (next month!) were a bigger deal here. The article is right – breast cancer is the most common cancer killer of women worldwide, but yearly mortality due to breast cancer is only 35% of its yearly incidence. Contrast that with lung cancer, in which the annual mortality is 85%(!!!!) of the incidence.

    I guess what I’m trying to say is: Can you breast cancer research people spare us some money? :)

  3. #3 Amy Alkon
    October 10, 2007

    When somebody asked my late friend Cathy Seipp whether she had breast cancer (seeing that she had chemo-head), she’d say, “I wish!” And she’d point out that the survival rate of breast cancer was “the un-survival rate” of lung cancer.

    And no, she didn’t smoke or live or work with smokers.

  4. #4 David D.G.
    October 10, 2007

    Amy Alkon, please accept my sympathies for the loss of your friend Cathy. Cancer is a rotten way to die, regardless of any source for it, known or unknown.

    ~David D.G.

  5. #5 KeithB
    October 10, 2007

    I just bought a pink hamster cage:
    http://www.superpetusa.com/catalog/viewone.asp?itemNumber=60513

    as some sort of breast cancer promotion. While the company website above says nothing, this is on the box:
    “From May 2006 through May 2007, Super Pet will make a guaranteed donation of $50,000 to the Susan G. Komen Breast Cancer Foundation. The mission of the Komen Foundation is to eradicate breast cancer as a life-threatening disease through research, education, screening and treatment. For more information, about breast health, breast cancer, or the Komen Foundation, please call 1.800.I’M AWARE or visit http://www.komen.org.”

    My son wants to stickers on it so it isn’t so…pink.

  6. #6 Mary
    October 10, 2007

    Right, I’m booking my mammogram tomorrow. It’s been over 2 years since my last one.

  7. #7 Not telling this time
    October 11, 2007

    Where I live it’s ultrasound, not mammogram, if you have risk factors (family history, physician referral asking ‘what on earth is that) but are
    a) youngish
    b) flattish
    c) both of the above.

  8. #8 bug_girl
    October 11, 2007

    In the universe of crass breast cancer promotions, you missed one:
    http://www.jinglejugsforlife.com/

    Profits go to Komen Foundation!
    Ugh. Here’s my opinion:
    Jugs For Life

    I (and my relatives who are breast cancer survivors) are not very impressed with Komen. They’ve made cancer a commodity.

    Why not promote the Young Survival Coalition?
    http://www.youngsurvival.org/

    ACS has good info, but proved not to be a very *young* survivor friendly group for my relatives. :(

  9. #9 Diora
    October 11, 2007

    It’s pretty clear from studies that mammograms reduce mortality from breast cancer. However, when I weight in 1/1000 chance in 10 years of my life being prolonged (less when younger, more when older) against 20-50% probability (probably 50 in the US, less in Europe) of at least one false positive during the same 10 years a quarter of which will result in biopsy; and more importantly, the risk of overdiagnosis (10% of all mammographically-detected cancer based on Malmo data, 25%-30% if their math is corrected), the choice becomes less than obvious to me. Granted I could be this one in a thousand who benefits; but I could also be the one who has complications from treatment for an overdiagnosed case…

    Maybe when I am 50 I’ll reconsider.

  10. #10 Perrin
    October 11, 2007

    I’m with Ben.

    I would add: What about all the women with other types of cancer that are not considered a “women’s cancer”?

    My sister had non-Hodgkins lymphoma when she was in her 30s. There was nothing – and I mean *nothing* – in the way of support services for her. We used to joke that if she’d waited until she was in her 60s or if she’d been smart enough to get breast or ovarian cancer, she would actually have been on someone’s radar.

    These diseases shouldn’t have to compete for attention, but that’s the sad reality, I guess.

  11. #11 baker
    October 12, 2007

    On the topic of crass breast cancer promotions, I think the Pink Ribbon Bagel is right up there with the slogan of a local team in what I think was a Komen “run for the cure” event – “Save the Boobies!”