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G. Zajicek. The Cancer J. 9: 172-173 1996 |
Although health is the main concern of medicine its exact meaning is not
at all clear. Medicine is more concerned with non-health, known as disease.
Yet not every disease may be regarded as non-health. Many young adults carry
in their arteries arteriosclerotic plaques without any apparent health deterioration.
Are these plaques non-health and should they be treated? Obviously health and
disease are not complementary. How then to handle diseases that do not impinge
upon health? Sophisticated technology reveals slight aberrations that in the
past were unknown, e.g., mild hypertension, a slightly elevated blood sugar
or, breast cancer precursor lesions. Are these aberrations real diseases? Modern
technology confronted medicine with a new problem, how to deal with aberrations
in a patient that feels healthy?
Technology revealed also that diseases evolve. They start as small aberrations
without clinical manifestations, while the patient feels healthy. Advancing
technology reveals more and more pre-clinical aberrations, and medicine lacks
clear guidelines for dealing with them. To wait until they become more pronounced
is generally regarded as malpractice. Medicine presumes that the traditional
guideline "primum non nocere" results from ignorance and helplessness, and is
not advised. Yet technological innovations endow this concept with a new meaning,
e.g., "Do not harm, and don't interfere until the aberration ripens for treatment".
Medical confusion is most pronounced in the treatment of breast cancer.
Apparently cancer starts as a lump that gradually spreads from the breast into
remote sites. For years breast cancer was treated by radical mastectomy with
axillary lymph node dissection and irradiation. Yet this treatment failed since
patients continued dying at the same rate. For fifty years, age adjusted mortality
of breast cancer, remained virtually constant (1). Treatment failed since at
the time of diagnosis, the disease was already systemic, involving the breast
and remote sites. Chemotherapy entered the lime light yet it did not affect
the age adjusted mortality, either. Two technological innovations, mammography
and genetic markers, promise to improve the prospect of cancer patients, yet
medicine is at a loss how to interpret their findings, and the controversy mounts.
Apparently mammography helps mainly women aged 50 or more, while younger
women do not benefit (2). Should they be advised to be screened? Mammography
is not harmless, particularly since x-rays are carcinogenic, why then irradiate
the breast if the procedure is useless? Yet the real threat to young women results
from the thoughtlessness that accompanies mammography. Medicine shies away from
the real issue; how to interpret mammographic findings. Should the detected
aberrations be regarded as cancer?.
DCIS is a benign lesion that may or may not evolve into clinical cancer.
Despite its name, it is not a cancer. Similar lesions appear in other organs,
e.g., colon, and urinary bladder. 30-40% of mammographically detected aberrations
are DCIS, and in women aged 30-39 years, 92% of aberrations are DCIS (3). Since
DCIS is detectable only with mammography its incidence continually rises. Between
1983 and 1989, DCIS incidence rates among white women, increased 213% (4), and
in 1992 its incidence rate rose 12.1%. Before mammography was known, DCIS was
hardly ever treated. Today, all women with DCIS are treated. In 1983, 71% of
the patients were treated by mastectomy. In 1992, 42% were treated by mastectomy.
Only about 3% had no surgery (3). Many healthy women may carry DCIS, which was
documented in several autopsy series of women without breast cancer, who died
of causes other than breast cancer. 6%-18% of the women had a latent DCIS.
Mammography initiated an epidemic of DCIS. A iatrogenic disease with appalling
consequences. Survival with DCIS up to 9 years is 100% (3). Who can assure the
young DCIS carriers that they will benefit from mastectomy? A similar benefit
might be realized by waiting until age of 50. And yet more of them are treated
by mastectomy than women with localized cancer, who usually undergo lumpectomy.
This is an epidemic of thoughtlessness and helplessness that could be resolved
by a simple measure, watchful waiting. Primum non nocere! Wait until the aberration
ripens for treatment.
Technology conjured a breast cancer gene, BRCA1, that was found in families
with breast cancer. Instead of giving it a innocuous name, e.g., factor-x or
gene-13462, arrogant scientists named it "the breast cancer gene". Soon it was
followed by other genes, e.g., BRCA2, BRCA3. Finally it was discovered that
many patients with breast cancer lack this gene, which raises the possibility
that BRCA1 may not be a cancer gene after all. At best it might indicate which
families have a higher risk of getting breast cancer. Yet this could be determined
also by asking the patient about her family history. If some of her relatives
had cancer, she would be advised to check her breasts now and then. On the other
hand, would anyone advise her to remove her breasts? Absurd? Not at all, since
this advice is given by some genetic councilors, to patients carrying the BRCA1
gene.
An innocuous gene which received a demonic name, initiated another epidemic
of futile mastectomies, and more. It raised ethical debates, e.g., should women
be tested? Accordingly, a woman with a BRCA1 gene, suffers from a genetic disease
and ought therefore to consult a genetic councilor, whose only concern would
be whether to remove her breast, or not. This absurd situation raised the concern
of several advisory committees. None was concerned with the scientific and medical
relevance of these genes. After all, they do not meet the necessary requirements
of genes that cause other genetic diseases, e.g., specificity. Since many patients
do not have BRCA genes, they are unreliable cancer markers. All this did not
concern the advisors. Instead, they tried to obviate the difficulty by political
means, and in vain. The Advisory Committee on Research on Women's Health could
not even agree to ban these tests. A top level advisory panel on women's health
issue to the US National Institutes, advised that such genetic testing should
be carried only within cautious guidelines (5).
What's in a name? An innocuous gene endangers the lives of young women since
some arrogant scientists called it a breast cancer gene. Exactly as done previously
with oncogenes. These household genes, that operate in every cell, were first
discovered in cancer cells, and named by arrogant scientists, cancer genes.
Many still regard oncogenes as cancer genes. Even then, they are less dangerous
than BRCA1 because they do not drive the patient to remove her breast.
1 McKay FW, Hanson MR, Miller RW. Cancer mortality in the U.S.: 1950- 1977 (1982) NIH Publ. No. 82-2435.
2 Margolese R. Screening mammography in young women:
a different perspective. Lancet 347: 881-882, 1996.
3 Ernster VL Barclay J, Kerlikowska K, Grady D, Henderson IC. Incidence and
treatment for ductal carcinoma in situ of the breast. JAMA 275: 913-949,
1996.
4 Swanson GM, Ragheb NE, Lin C-S, et al. Breast cancer among black and white
women in the 1980s. Cancer 72: 788-798, 1993.
5 Wadman M. Panel softens gene test warning. Nature 380:573, 1996.
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