Monthly Archives: September 2011
Sympathetic doctors are not hard to find. Many doctors do have a bedside manner, they are sympathetic, and they make us feel good. We have confidence in them. But the truth is that while sympathy can be dished out quite readily by physicians with charismatic personalities, their advice may be influenced by the current thinking, which is not always the best thing for us. That is, there is a lot unknown, and doctors fear taking a leap by going with their gut, so they vie on the safe side. You may be thinking, that’s a good thing. Doctors should not take unnecessary risks.That seems logical, but what about the risks that interventions come with? Screening, surgery, radiation and chemotherapy are not risk-free choices. For many conditions outside of the breast cancer realm, the cure is sometimes worse than the disease, so even with a diagnosis of cancer, patients need to exercise caution and not hurry into treatments just because one doctor makes a recommendation.
Dr. Laura Esserman is one doctor who does understand the issues and more than merely sympathizing, she understands the frustration that patients experience. Interviewed at the San Antonio Breast Cancer Symposium, Dr. Esserman speaks about the problems that patients experience when they are diagnosed and treated. This is an excellent video to view whether you are just curious about the mammogram controversy, the difference between high and low risk cancers, and the importance of clinical trials.
In the video, Dr. Esserman announces the creation of the Athena Breast Health Network in California and recommends that patients be proactive and look into clinical trials when they are faced with decisions about breast cancer treatment. She refers listeners to breastcancertrials.org where breast cancer trials around the nation are listed.
The present thinking is to treat DCIS early, but there are really no studies to back up this manner of thinking. It is defensive medicine at its worst. Take a look at Part 3 of a wonderful interview with Dr. Laura Esserman who makes a case for possibly not intervening even when DCIS is discovered. It is an enlightening and refreshing take on this controversial issue.
While most doctors do treat DCIS with surgery, there are some who see watchful waiting as an option.
Thanks to this month’s issue of More Magazine, an article by Nancy Smith entitled “A Breast Cancer You May Not Need to Treat” provides the latest information on DCIS. In it, a handful of doctors who advocate for the watchful waiting approach are interviewed and that part of the piece appears on page 4.
It should be said that while some doctors believe that not taking drastic measures, or even having a biopsy, is possible, it does not seem to be typical. That is, most doctors who see something awry on the mammo will probably advocate for biopsy, and if something turns up there, well, the protocol says to treat it like invasive breast cancer.
It should be emphasized that when a doctor says that one should watch and wait, it should not be construed as “do nothing” and one should not get the impression that everything is fine. Monitoring is key to watchful waiting. It means that you have your mammograms or sonograms or whatever is recommended to make sure that everything is under control. In other words, what the doctors call active surveillance in the Smith article means that you take an active role in watching the cells. You don’t run the other way, terrified of getting the next mammogram. You wait with optimism, and reverence for the process. You listen to your doctors. It seems to be a non-invasive way of potentially saving your life.
The answer to the question posed by the title of this blog is well, yeah, of course. On some level, there should be a screening process whether it is assessing risk factors or having yearly mammograms or going to a primary care physician for an examination.
Yet, the title of this blog is really there because this post will discuss material from the book by Dr. H. Gilbert Welch called Should I Be Tested for Cancer?
I read the entire book several years ago as I became curious about cancer screening tests. In the book, Dr. Welch suggests that many cancers found during the screening process are small and slow-growing, and that the dangerous, fast growing cancers are the kinds of things that cause symptoms and are generally not caught during a screen anyway. That is just a generalization. Many different tests are taken into consideration and in fact, a case is made for certain screening tests. If you are interested in the science, pick up the book. It was published in 2004 but it’s an interesting read. Also, in looking for more material, I noticed that Dr. Welch co-authored a 2011 book titled Overdiagnosed that also contains information on DCIS and breast cancer.
The reason I am blogging about this is that the author has a section on breast cancer in the book Should I Be Tested for Cancer?, and focuses on DCIS. He writes: “Because the idea of simply ‘watching’ a small breast cancer is sacrilegious in our current clinical culture, DCIS is almost always treated (with mastectomy, lumpectomy, or radiation). We therefore know very little about the dynamics of this emotionally charged cancer” (58). Dr. Welch reports on studies of women whose biopsies incorrectly came back negative when they actually had DCIS; the result of some of these studies suggest that DCIS does not often go on to become invasive breast cancer. Later, Dr. Welch claims that for the most part, DCIS is pseudodisease. He therefore concludes that watchful waiting could be a reasonable approach for women diagnosed with DCIS.
Dr. Welch is quoted in a 2008 article about DCIS. The article entitled “Fears of Recurrence Linked to Anxiety After DCIS Diagnosis” is quite interesting and includes observations and recommendations.
Hi. As soon as I titled this blog, I had a good number of hits. Indeed, people are hungry for information on DCIS. Please be patient as I have just begun. I will start with an article titled Prone to Error published in the New York Times last year.
There are so many errors made trying to save women from breast cancer that it brings into question the validity of going on the investigation in the first place. What is the purpose of finding cancer early if diagnosis is full of holes? Most of the examples come from small communities where there are inexperienced pathologists, but even when one receives a DCIS diagnosis from the best pathologist in the world, the diagnosis is still an opinion.
My question is, why not wait? Why not wait to see if the tiny bits of calcification actually grow into something before engaging in last resort treatment, or any treatment at all? Why attempt to even diagnose DCIS if a woman is okay with watching and waiting? These are the questions I am asking, and I know that it is easy to say that a case of DCIS might grow into cancer, and while cure for DCIS is like 98 or 99%, the problem is that even if the DCIS never comes back, it may never have gone on to become invasive breast cancer in the first place. It is a conundrum. I get that. But what I don’t get is why women don’t have a choice in the matter, given the lack of knowledge on the subject. Why can’t the doctors say, “we don’t know what will happen. We don’t know whether these cells will kill you, or won’t do anything at all. Given that, what do you want to do?”