What the Dog Saw Part 1 of 4: Breast Cancer
February 12, 2010 by dr. lam
Malcolm Gladwell and my niece Baby Bailey
As many of you know, I love Malcolm Gladwell’s writing, as I have reviewed all of his previously published books in this blog. His latest book, What the Dog Saw is a collection of articles published in The New Yorker and represents so many unique ways for you to change your perception of an issue that has left me simply amazed…once again. This book is extremely dense with profound information, all told with interesting stories, anecdotes and allusions. I have selected only a few tales to tell here and encourage all my readers to get this book because this blog series will only scratch the surface of Gladwell’s writing.
One of the most earth-shattering revelations in this book concerns how we prognosticate, perceive, and treat breast cancer. He starts the chapter discussing Memorial-Sloan Kettering’s head of breast imaging, David Dershaw, who recounts his method for detecting breast cancer on radiography. After a protracted, convoluted paragraph on the subject, the reader is left bewildered at the vagaries of detecting cancer consistently. There are few examples of clearly benign disease and a few examples that would highly suggest cancer, but then there is a tremendous stream of gray in the middle.
A study involved 10 board-certified radiologists reviewing 150 mammograms with 27 having actual breast cancer and 123 without the disease. This cadre of experienced medical experts chimed in with a whole range of responses that were highly inconsistent and betrayed the lack of science to the reading of a mammogram.
Gilbert Welch, a medical-outcomes specialist at Dartmouth Medical School, pointed out that currently nine out of every thousand sixty-year-old women will die of breast cancer in the next 10 years. With frequent mammography, that number will decline by 3. The question is that with 3 three lives saved by mammogram in this subgroup, what is the rate of unnecessary biopsies and other invasive procedures related to a false positive or as we will see in a moment an actual positive?
Take the case of Ductal Carcinoma in Situ (DCIS), a type of early cancer that has only been detected since the early 1980s with advancing radiographic technologies. With the ever increasing detection of DCIS, which when found is promptly removed, what has this meant on cancer survivals? About 50,000 cases of DCIS are found and treated each year. However, the incidence of late-stage cancers has steadily continued to rise during this period of early detection of DCIS. How can this be?
In 1987 Danish pathologists performed a series of autopsies in women in their 40s who died of unrelated causes like automobile accidents. They found that the incidence of DCIS was about 40% of the 275 sampled breast tissues. Since breast cancer only accounts for 4% of female deaths, how do we account for this discrepancy? The answer may be that many of these cancers are corrected by the body through a continual process of repair. We in fact as men and women may have many cancers that we fix without our conscious mind ever knowing about it.
In the book, Gladwell also proves that the size of the tumor has a very negligible role in determining the predilection for the tumor to continue to become larger in size or metastasize. In fact, the genetic coding within the tumor may contain more information about the tumor’s likelihood to progress than anything else. At this time, investigators are continuing to determine what these factors are for progression versus possible regression of the tumor.
A Canadian study in the 1980s has shown that careful finger evaluation of one’s breast under skilled hands had no difference in breast cancer death rates with a second group that underwent combined breast examination and mammography. The conclusion can be drawn that tactile evaluation can be as sensitive as an image but we tend to trust our eyes more than our fingers.
Do mammograms do anything beneficial? Well, yes. For a woman in her 50s, the chance for reducing the risk of dying from cancer is about 10%, which divided over millions of women accounts for thousands of lives saved. Of course, the cost of doing so, false positives and even true positives that might not need treating, should also be accounted for.
Obviously, this blog is not meant to endorse a change in medical policy or behavior. This blog is meant to summarize some spectacular thinking that may spur you forward to think and investigate on your own or with your physician a well healthier dialogue about your health.
For me, it points out a few things. First, cancer is not some kind of ineluctable devil but a part of life that we often and unknowingly correct on our own. That is why good diet, exercise, and a stress-free life can be so important to permit your body a chance to destroy any cancers that may arise. Second, is that science as we know it may not always be a good thing, at least without proper judgment and thinking. Gladwell offers an amazing way to see differently.
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3 Responses to “What the Dog Saw Part 1 of 4: Breast Cancer”
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Niece is saying, “Shh, work with me here, he thinks I’ve read his books…”
Cute!!!
i think she has!
I also love Malcolm’s thinking and his storytelling way of helping us to think broader.
I offer an option for women in Australia to monitor their breast health. We focus on maintaining health, rather than passively waiting for a cancer diagnosis.
Breast cancer is a huge industry, emotionally driven by fear. There is a mind shift in the women that they are researching and forming their own conclusions now.
Cant wait to read the new book!
Jo