Breasts, lumps and choices

Ignorance in a crisis can have a heavy price. Not knowing what you need to know, when you do need to know it can lead to major problems. So breast cancer – take out the lump or remove the whole breast? What leads to better survival? Then mastectomy - is it worth the risks?

A common experience I encounter is the aftermath from when people have been faced with a major life crisis, been asked to make life-changing decisions when in a frazzled state of mind, and while not knowing all the facts, they have made choices with unhappy consequences that they later regret.

So this week, we go Out on a Limb, check out some pivotal recent research that in my view, everyone needs to be aware of. Maybe a good post to share with friends , but first

Thought for the day
The ultimate measure of a man 
Is not where he stands 
in moments of comfort and convenience, 
But where he stands 
at times of challenge and controversy.

        Martin Luther King, Jr.








Lumpectomy - the best option for early breast cancer
Breast cancer – what to do? Have the lump taken out? Have the whole breast removed? What about radiotherapy?

Clearly the answer will vary from woman to woman and an article like this is not meant as personal medical advice and should not be taken as such, but a recent landmark study just published and claimed by its authors as probably the first of its kind highlights the issues.

This research and the answers it provides are well worth knowing by all women, so that if, heaven forbid, they are ever faced with these choices, they know what the current best evidence base is and as such they can make informed decisions.

This is important as separate research confirms many women may well have been led into making poor choices.

Defining early-stage breast cancer as having a tumor size of 4 cm or smaller with 3 or less positive lymph nodes, researchers examined the records of 132,149 women with early-stage invasive ductal carcinoma who had been treated with breast conserving therapy (BCT), mastectomy alone, or mastectomy with radiation during the period from 1998 to 2008.

Breast conserving therapy (BCT) may be defined as a combination of conservative surgery for resection of the primary tumour (commonly known as lumpectomy – just removing the cancer mass with a margin of surrounding tissue – not the whole breast - which is known as mastectomy) with or without surgical staging of the axilla- armpit (removing the lymph nodes near the breast and checking to see if cancer has spread into them – if so, the prognosis is poorer and medical treatment recommendations are likely to change and become more aggressive), followed by radiotherapy for the eradication of any residual microscopic disease of the breast, with or without adjuvant systemic therapy (commonly chemotherapy, maybe hormonal treatment).

What types of treatment were provided?
Breast conservation therapy (BCT) was used to treat 70% of patients, mastectomy alone was used to treat 27% of patients, and mastectomy with radiation was used to treat 3% of patients.

What were the survival rates?
The 5-year breast cancer–specific survival rates of patients who underwent BCT, a mastectomy alone, or a mastectomy with radiation were 97%, 94%, and 90%, respectively (P < .001).

The 10-year breast cancer–specific survival rates were 94%, 90%, and 83%, respectively (P  < .001).

Multivariate analysis showed that women undergoing BCT had a higher survival rate than those undergoing mastectomy alone (hazard ratio, 1.31; P < .001) or mastectomy with radiation (hazard ratio, 1.47; P < .001).

The researchers concluded 
Patients who underwent BCT have a higher breast cancer–specific survival rate compared with those treated with mastectomy alone or mastectomy with radiation for early-stage invasive ductal carcinoma. Further investigation is warranted to understand what may be contributing to this effect.

Reference: Agarwal, S et al. Effect of Breast Conservation Therapy vs Mastectomy on Disease-Specific Survival for Early-Stage Breast Cancer. JAMA Surg. Published online January 15, 2014. doi:10.1001/jamasurg.2013.3049 Link here

What is happening in real life?
While this latest research indicates lumpectomy actually has better results than mastectomy, it has been known for many years that lumpectomy is at least as good. Fifteen years ago the American College of Surgeons (ACS) acknowledged identical overall survival with the two treatments, yet despite this, they also stated that 50% of all women with early stages of breast cancer were surgically treated by mastectomy.

More recent analysis published in 2013 found very high frequency of mastectomy vs. BCS, again despite the stage of the disease being low. The 2014 study cited above records nearly 30% of women being treated by mastectomy. All the indications are that this is way too many.

When is BCT not a good idea?
These same researchers noted only 20% of absolute contraindications for BCT. The most frequent contraindication for BCT was reported to be multi-centricity of the tumour (with micro calcifications), especially in ductal-in-situ carcinoma.

Reference: Fajdic J et al; Acta Inform Med. 2013 March; 21(1): 16–19.
doi:  10.5455/AIM.2013.21.16-19

What about implants?
I know of no research on this, but from feedback received over the years I wonder if the use of implants following mastectomy may not be related at least in part to the poorer outcomes. I certainly hear of quite a few complications from implants.

Mammography – at what cost?

The issue of potential harm from mammography continues to be raised by major authorities.

In a recent commentary to an article on this theme in one of the world’s leading medical journals, JAMA, 2 researchers from Dartmouth University in New Hampshire, estimate that of 1000 US women aged 50 years who are screened annually for a decade, 0.3 to 3.2 will be spared from dying of breast cancer, while 490 to 670 will have at least 1 false-positive result, and 3 to 14 will be over-diagnosed and over-treated.

Discussing the findings in the New York Times, Dr. Welch said that a "screening program that falsely alarms about half the population is outrageous" and that "whether you blame the doctors or the system or the malpractice lawyers, it's a problem that needs to be fixed."

H. Gilbert Welch, MD, MPH; Honor J. Passow, PhD Criteria and Procedures for Breast Conserving Surgery; JAMA Intern Med. Published online December 30, 2013. Link Here


MEDITATION RETREAT – PRE-EASTER in the YARRA VALLEY


Meditation in the Forest : April 11 – 17, 2014



This is the regular Pre-Easter retreat Ruth and I present in the Yarra Valley each year. In 2014, as well as providing the opportunity for some meaningful time out - including the space in your life to regain balance and to be revitalized - you will be gently guided to learn more about relaxation, mindfulness and meditation, and to deepen your experience of these wonderful techniques.


        The meditation sanctuary at the Gawler                 Foundation's yarra Valley oasis.



Each year we have a particular focus or theme for this meditation retreat and in 2004 we will be giving particular attention to the theory and practise of that invaluable (and in my view, seriously undervalued) skill of contemplation.

This retreat is designed to meet the needs of a broad range of meditators. It is well suited to beginners as well as the more experienced, those who are interested in teaching meditation (we hold specific sessions through the retreat for these people), those on the healing path and anyone keen to rest, reflect and deepen their meditation.

For details CLICK HERE


RELATED BLOG
Overmedicalisation, mammography and PSA testing

Ian Gawler Blog: Over-medicalisation, mammography and PSA screening

This week, big questions posed by new research concern the over-medicalisation of our health and wellbeing. Key examples cast big doubts over the merits of mammography for 50 yo women and PSA blood tests for prostate cancer in healthy men.

Next come telling comments from the MJA re why they did not publish the controversial article on me, The Age has another go at the Foundation, while another massive review of evidence comes out connecting nutrition with breast cancer.

But first, please do not believe what I say, just because I said it!

Thought for the day: Arrive at your own truth.

At the end of my early workshops I would often say “Everything you may have heard today could be untrue”. Some people were understandably unsettled and required an explanation. Why did I say it? Because I see the truth in the quote that follows, and have always been guided by it. 

"Don't blindly believe what I say. Don't believe me because others convince you of my words. Don't believe anything you see, read, or hear from others, whether of authority, religious teachers or texts. Don't rely on logic alone, nor speculation. Don't infer or be deceived by appearances.

"Do not give up your authority and follow blindly the will of others. This way will only lead to delusion.

"Find out for yourself what is truth, what is real. Discover that there are virtuous things and there are non-virtuous things. Once you have discovered for yourself, give up the bad and embrace the good."

- The Buddha

If someone leaves a program I have presented and says something like “I am eating this way now because Ian said so”, they have really missed the point and I would be very disappointed. 

If they say “I heard what Ian said, have considered it, and have chosen to eat this way”, then I am happy.


Research claims over half breast cancers would amount to nothing if left untreated, and raises questions about breast screening

Writing in the prestigious British Medical Journal, academics from Australia and Canada, claim up to 54% of breast cancers detected in women in their 50s by breast cancer screening would never have manifested clinically.

The article goes on to identify the phenomenon of over-medicalisation, saying healthy people are increasingly harmed by a barrage of unnecessary tests, procedures and drugs. The tendency to over-screen, over-diagnose and over-treat has become rampant in modern medicine, and poses a “significant threat to human health”.

 “Screening programs are detecting early cancers that will never cause symptoms or death, sensitive diagnostic technologies identify ‘abnormalities’ so tiny they will remain benign, while widening disease definitions mean people at ever-lower risks receive permanent medical labels and lifelong treatments that will fail to benefit many of them.”

ADHD, chronic kidney disease, gestational diabetes and prostate cancer were also key areas for concern, they said. Even asthma is over-diagnosed in up to 30% of cases, the authors said.

The article was timed to promote a new international conference called Preventing Overdiagnosis, that will aim to better assess the problem and begin working on solutions.

Click here for the reference: BMJ 2012; online.


Healthy men do not need PSA screens

Controversy has raged for some years about men being routinely screened for prostate cancer using blood PSA tests. I remember cringing while being a part of an SBS TV Insight program where Prof Alan Coates suffered the most vitriolic and personal attack from a prominent and highly emotional politician really suffering from prostate cancer and abusing Coates mercilessly for suggesting the scientific evidence did not support routine PSA testing. Coates was CEO of the Cancer Council of Australia at the time and he endured ongoing professional and personal criticism for his stance.  

However, recently the prestigious US Preventive Services Task Force (USPSTF) has added to this debate, claiming that PSA-based screening could not be widely recommended, due to the “inevitable” risk of over-diagnosis and harms of treatment.

It acknowledged that some men would continue to demand PSA tests, and that some doctors would continue to offer them, but said this should only occur through fully informed, shared decision making. The USPSTF said community and employer-based screening should be stopped altogether. It based its recommendations on an extensive literature review.

“The mortality benefits of PSA-based prostate cancer screening through 11 years are, at best, small and potentially none, and the harms are moderate to substantial,” said the final statement, published in the Annals of Internal Medicine.

The Prostate Cancer Foundation of Australia branded the recommendations “unhelpful”, and not directly applicable to Australia.


NEWS

1. The Medical Journal of Australia explains why it did not publish 

- with direct quotes

First: I did not give my permission and they value patient rights

Second: The article "presented supposition, nothing new in the way of facts".

Finally:  The Editor, Annette Katelaris summarised, and again I quote "patient consent, accountable editorial processes and an articles validity, significance and potential to advance medical practice are primary considerations in the MJA's editorial decisions...  These principles were applied in the MJA's final decision not to publish the article".

Conclusion: The Journal of Internal Medicine Journal obviously has different standards that allowed them to publish.

The letter that provoked the response, along with the editorial, will be linked to on my website soon.


2. Good nutrition may reduce the progression or recurrence of breast cancer.

Following on from last week’s blog on nutrition and cancer, comes news of a major work citing 353 references put together by Natalie Ledesma from the University of California, San Francisco.

Link here for the full work which makes for compelling reading:

Here is Natalie’s summary:

Good nutrition may reduce the incidence of breast cancer and the risk of breast cancer progression or recurrence. There are many studies in progress to help further understand how diet and cancer are related. We do know, however, that improved nutrition reduces risk of chronic diseases, such as diabetes, obesity, hypertension and heart disease, and also enhances overall quality of life. It is estimated that one third of cancer deaths in the U.S. can be attributed to diet in adulthood.


3. The Age is at it again!

A personal account has been published in the Medical Journal of Australia by a Melbourne psychiatrist who attended the Gawler Foundation’s 12 week non-residential cancer program. Writing under the strident headline “Doctor denounces Gawler program's 'harsh' healing”, health editor Julia Medew quotes and comments on the patient’s concerns regarding the rigours of the dietary approach, perceived guilt around the cancer prone personality, and the suggestion her group leader said there was no evidence chemotherapy works.

Join the link, read and decide for yourself.

I wish the psychiatrist good health and a long and happy life. Discussion, feedback and constructive criticism is always welcome, even when it turns up for the first time in a medical journal.

Comments from the Foundation’s CEO, Karin Knoester and the oncologist from Peter Mac seem worth quoting directly.

“Ms Knoester said although no independent evaluations had shown the Gawler programs were an effective cancer treatment, there was evidence that nutrition, exercise, meditation and positive thinking could all on their own help people overcome illness.

Deputy Head of Oncology at Peter MacCallum Cancer Centre, Associate Professor Michael Jefford, said he got the impression from patients that the Gawler Foundation's staff were ''overvaluing'' their therapies while telling people conventional treatments were less effective and more toxic than they really are.

''There is very good evidence for the efficacy of chemotherapy … so to say it doesn't work is blatantly wrong,'' he said. “There is also good evidence that chemotherapy improves quality of life … so to say it's toxic is incorrect.''

My comment. 

1. The Morgan study of 2004 reviewed the 5 year increased survival benefits of chemotherapy for the major 22 cancers at an average of 2.3%. Modest efficacy overall, although chemotherapy does have major benefits for a number of the less common cancers, including some of those that affect children. (I know of no more recent comprehensive review since that of Morgan in 2004. It was not very popular in oncology or the popular press at the time, but not refuted, apart from Prof Boyer who claimed on ABC radio he could “massage” the figures up to 5 - 6%!).

2. There is good evidence that chemotherapy impacts adversely on some people’s quality of life and that most chemotherapy is given with palliation in mind, not cure. Therefore the equation of pluses and minuses has to be considered carefully when making decisions regarding this form of treatment. No doubt good oncologists inform their patients of the risks and benefits, encourage open dialogue and assist in the making of good clinical choices.

3. If chemotherapy is not toxic, why is it called cytotoxic therapy? I wonder if Professor Jefford was quoted accurately.

People who do choose to have chemotherapy will benefit from a healthy, therapeutic lifestyle that is highly likely to reduce the risk of side-effects, improve survival and improve quality of life. The two, chemotherapy and a therapeutic lifestyle, work well together. This should be a co-operative venture.

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