Ask the Doctor: The Real Truth About The War Against Breast Cancer

In response to a recent article in The New York Times Magazine, “Our Feel Good War on Breast Cancer,” Dr. Lora Weiselberg, a leading expert in breast cancer from Hofstra North Shore-LIJ School of Medicine, sets the record straight.

“The New York Times article is an opinion piece, not a balanced presentation of the pros and cons of allocating breast cancer resources. Some of the writer’s declarations are potentially damaging. We cannot afford to ignore the 230,000 women per year who will develop invasive breast cancer by cutting down on screening and education.”

In support of the movement to prevent, treat and ultimately eradicate breast cancer, read more of what Dr. Lora Weiselberg has to say. This is a Maurer Foundation editorial.

“Our Feel Good War on Breast Cancer,” (Orenstein, P. The New York Times Magazine, 2013), an engaging, compelling and provocative article interlaces the author’s personal odyssey with breast cancer along with her disappointment with the benefits of mammography and early treatment.

She goes on to examine the expectations from widespread use of mammography and to critique and ridicule the “pink ribbon” movement to raise consciousness (and money) for breast cancer. This is an opinion piece, not a balanced presentation of the pros and cons of allocating breast cancer resources. She liberally uses quotations and vignettes chosen to support her one-sided view that screening is not enough and that dollars raised for breast cancer research are being misspent.

Some of her declarations are potentially damaging—tell the 4,000 to 18,000 women every year (her numbers) whose lives are saved by early detection by mammography that it isn’t worth the money to screen annually for early cancers. She emphasizes the limitations of mammography (a 15 % false negative rate) and its risks—false positives (i.e. abnormalities found which turn out not to be cancer), anxiety and radiation exposure (which is minimal). She does not even mention breast ultrasound, tomosynthesis mammography and breast MRI, other tools which can pick up even earlier cancers.

The death rate from breast cancer has declined by 26% since 1990. While our treatments have unquestionably improved over the past two decades, it is the detection of earlier cancers that accounts for most of this decline.

Ms. Orenstein aptly points out that breast cancer is a heterogeneous group of diseases with very different biological behaviors, something that we have only been able to appreciate in recent years. A “one size fits all” approach to the diagnosis and treatment of breast cancer is overly simplistic and destined to fail. Money is being spent for research on all levels—from the laboratory bench where the basic biology of the disease is being studied to clinical trials looking at better ways to detect breast cancer and to effectively treat it.

Contrary to what Ms. Orenstein states, research on metastatic breast cancer is highly valued. All the treatments to prevent relapse in early stage breast cancer have been developed on the backbone of regimens for metastatic disease where we could directly observe which treatments work and which do not. While all this research is going on we cannot afford to ignore the 230,000 women per year who will develop invasive breast cancer by cutting down on screening and education.

What about “over treatment,” finding and treating cancers which will never give a woman a problem in her lifetime? We are at the very beginning of understanding the biology of which lesions may behave in this fashion. There is an Oncotype test which in some (but not all) situations may help us decide which women do not need radiation therapy for DCIS. We have similar tests to help us decide which women need chemotherapy for invasive breast cancer.

Clearly if we can spare women from having treatments that are expensive, uncomfortable, and have possible long term medical consequences while still giving them adequate treatment for their breast cancer, we have achieved a very worthy goal.

As a physician and as a woman I would never withhold all treatment of a diagnosed breast cancer because “maybe” this cancer will not become a problem. I have held the hands of too many women who have died of breast cancer over the past 35 years to consider this a reasonable option.  I use the clinical tools I have to try to design the most effective and appropriate treatment for each individual while trying to support clinical trials to improve breast cancer care.

The author goes on to bemoan the lack of research on prevention. The National Cancer Institute funded two major breast cancer prevention trials from 1992 to 2006 involving 34,000 high risk women at a cost of over $100,000,000. Both trials yielded positive results. There are 2 drugs which are FDA approved to lower the risk of breast cancer in high risk women (tamoxifen and raloxifene). Lifestyle factors contribute to risk such as obesity (at least 20% of people in every state are clinically “obese”), alcohol consumption, smoking, and hormone use. Education is key in making an impact on future generations. The Long Island Breast Cancer Study Project was the first major environmental research and was initiated twenty years ago. No, we do not have the answers about the causes of breast cancer and yes, we need to do more research. But it is misleading to suggest nothing has been done to evaluate the environment. When the questions are complex the answers may require painstakingly lengthy research.

Sadly, breast cancer is a capricious disease. Once a woman has had breast cancer she is never free of risk of relapse. The author was diagnosed at the age of 35 and had a 16-year disease-free interval before she developed a recurrence at the site of her original cancer.  She is angry and asked if the outcome would have been any different if she did not have a mammogram and if her cancer was found when it was a palpable lump. She understandably expresses concern about her future with her 9-year-old daughter. Perhaps if she had not had that lumpectomy and radiation at 35 and she had waited until she felt a mass in her breast, she would have needed chemotherapy, gone through early menopause and never had that daughter. Or perhaps she would not be here today to voice her opinions.

Lora Weiselberg, M.D., FACP
Chief, Breast Cancer Service
Don Monti Division of Oncology/
Division of Hematology
Monter Cancer Center
Associate Professor of Medicine
Hofstra North Shore-LIJ School of Medicine