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The scandal of mastectomy

MagazineDecember 2010 (Vol. 21 Issue 9)The scandal of mastectomy

Tragically, leading oncologists are now saying that half these women had their breasts removed unnecessarily, as many mastectomies are carried out on women who don't have breast cancer at all

Tragically, leading oncologists are now saying that half these women had their breasts removed unnecessarily, as many mastectomies are carried out on women who don't have breast cancer at all. Instead, they have DCIS (ductal carcinoma in situ), a precancerous and non-invasive condition of the milk ducts around the breast.

More than 60,000 new cases of DCIS are detected by mammography every year in the US alone, yet less than 5 per cent become breast cancer, says Dr Laura Esserman, from the University of California at San Francisco (UCSF). UK cancer expert Professor Michael Baum thinks the figure is slightly higher, but accepts that at least 80 per cent of DCIS cases never become cancer (Breast J, 2000; 6: 331-4).

Esserman's colleague at UCSF, Virginia Ernster, a cancer statistician, reviewed the records of 7000 women who had been diagnosed with DCIS before and after the introduction of mass mammography. Before the advent of such national screening programmes, around 3.4 per cent of the women died from breast cancer, and this ratio dropped only slightly to 1.8 per cent after screening was introduced. In either case, the risk was low, said Ernster (Arch Intern Med, 2000; 160: 953-8).

Despite these established facts, DCIS is treated as aggressively as if it were full-blown breast cancer with mastectomy, lumpectomy-where only part of the breast is removed-or chemo- and radiotherapy. Indeed, half of all breast cancer diagnoses every year are, in fact, DCIS.

Esserman is now heading a campaign calling for a radical change in the way DCIS is seen and treated. One of the keys is to rename the condition and remove 'carcinoma' from the name. "Minimal-risk lesions (such as DCIS) should not be called cancer," she says. "Methods exist to identify low- and high-risk cancers. Tests for prognosis and prediction of breast cancer are available and provide better discriminatory information than clinical features alone" (JAMA, 2009; 302: 1685-92).

She is joined in her campaign by oncologist Dr Carmen Allegra, chief of hematology and oncology at the Shands Cancer Center, University of Florida, in Gainesville. Allegra agrees that DCIS needs a new name, and also advocates the watchful-waiting approach, as is done with prostate cancer (J Natl Cancer Inst, 2010; 102: 6-8; doi:10.1093/jnci/djp497).

More controversially, Baum and others believe that the real problem is mass mammography screening, which he wants to see scrapped. Before mammograms became part of the national health regime, few women knew they had DCIS, which can't be palpated. Before the widespread use of mammography, in 1983, around 4900 cases of DCIS were diagnosed in the US; by 2002, this had risen to 48,000 new cases, and now the technique is detecting 60,000 cases each year in the US alone.

Baum points out that detection triggers an expensive and invasive series of treatments for a problem that is rarely cancerous. In a contro-versial speech to the Royal Society of Medicine in London, Baum called for the scrapping of the national mammo-gram screening programme even though he himself was instrumental in creating the lb50-million-per-year service in the first place (The Evening Standard, 10 December, 2002).

In fact, DCIS can be considered a byproduct of mammography, which is designed to detect malign tumours in breast tissue. As Esserman points out, the detection of DCIS was never part of the screening programme, and she believes it should be entirely removed from the agenda. Radiologists who detect low- and intermediate-grade DCIS should merely take note of their presence, but should then take no immediate action.

Unfortunately, both oncologists and women immediately press the panic button when the C word is used, and no one appears to be willing to adopt the watchful-waiting strategy.

However, to encourage such an approach, Esserman is leading a UCSF pilot study to develop a surveillance protocol that would identify those few cases of DCIS that might turn into cancer. She is currently working with 40 women diagnosed with DCIS (BMC Cancer, 2009; 9: 285; doi:10.1186/1471-2407-
9-285). Ultimately, she wants to find non-surgical ways to stop DCIS pro-gression to cancer and preserve the breast (J Natl Cancer Inst, 2008; 100: 228-9).

Esserman is bucking against a trend in medicine that has seen more mastectomies being performed than ever. The UK's National Mastectomy and Breast Reconstruction Audit reports that the 37-per-cent increase rate from 1997 to 2006 would be rising even more rapidly if sufficient resources could be found. Yet, according to the No More Breast Cancer campaign, the mastectomy rate is already higher than the official figures indicate. When researchers were able to obtain the unpublished statistics, they found that the rate has actually increased by 44 per cent overall in the UK, and by 41 per cent among younger women aged between 15 and 44 years (Hospital Episode Statistics, 1990-2005. London: HMSO).

"We are regularly told that breast cancer is solely due to certain risk factors. In fact, fewer than 50 per cent of breast cancer cases can be explained by these risks, and many are due to unknown factors," says the campaign's Clare Dimmer, a breast-cancer survivor.
Tragically, these unknown factors include cases of DCIS.

What to do if you're diagnosed

So-called 'watchful-waiting' may be the best strategy if you've been diagnosed with DCIS (ductal carcinoma in situ), but you can also help yourself, as suggested by the international non-profit public-interest group People Against Cancer (www.peopleagainstcancer.com), which recommends:

o a strict wholefood, non-processed diet (with no sugary and fatty foods, dairy or wheat);

o an intensive nutritional programme, including high-dose vitamin C, beta-carotene, vitamin B, selenium, zinc, coenzyme Q10, fish oils and vitamin B17 (apricot kernels);

o an intensive detox programme, including elimination of mercury from amalgam fillings;

o coffee enemas; and

o heat therapy, as temperatures of 44 degrees C and over can kill cancer cells.

WDDTY VOL. 21 ISSUE 4


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