Breast Cancer ‘War’ Affected by Politics, Culture, Money

"Rather than wondering whether we are winning the fight [against breast cancer], we might ask why we invariably frame our efforts against breast cancer as a war, and whose interests are served by the current battle plan," Barron Lerner, author of The Breast Cancer Wars, writes in an adaptation of his book for the Washington Post. For Lerner, a professor at Columbia University's College of Physicians and Surgeons, American response to breast cancer "cannot be separated from the larger cultural setting," encompassing politics, economics, medicine and patients' desire to actively fight the disease. For example, even though 70% to 90% of women receiving prophylactic chemotherapy for "tiny cancers localized only to the breast" do not benefit from it, the treatment has "proven ... popular" among women and their doctors. Lerner suggests that oncologists "have benefited professionally from being able to offer" the treatment, pharmaceutical companies "know the value of marketing their products as indispensable ammunition in the fight against the disease" and women with breast cancer choose the therapy to "declare war" on their disease.

Lerner presents screening mammography as "one of the clearest examples of how politics has intruded into the medical management of breast cancer." In January 1997, the National Cancer Institute explored whether women younger than age 50 should receive routine mammograms because data on the benefits of screenings among that age group were inconclusive. A consensus panel determined that women in their 40s did not need regular mammograms, "horrif[ying]" screening advocates. Lerner says that in the following "atypical chain of events," the Senate stepped in, voting unanimously to urge the NCI to reject the decision. The National Cancer Advisory Board agreed and recommended women in their 40s receive a mammogram at least once every other year. Lerner notes, "[I]magine the Senate voting on the proper screening guidelines for diabetes or osteoporosis. But in the case of breast cancer, the medical has become the political."

The case of mammograms also "underscores one of the major themes that has characterized the war on breast cancer" -- that such interventions, which are costly and could "lead to many negative consequences," might only help cure breast cancer in a small number of women. Lerner says that to "extend one life," about 2,500 women in their 40s would have to be screened regularly, costing $108,000 for each year of life saved. Meanwhile, healthy women would be subject to "extra doctor visits, unnecessary biopsies and needless anxiety," Lerner adds. Some critics of the "search and destroy" detection methods, including digital mammography and genetic testing, say that such techniques "may have reached a point of diminishing returns," and the "chase ... has become as important as the outcome." And although these critics have called for less emphasis on screening and treatment and more focus on underlying causes of breast cancer, Lerner says that "such a reconfiguration of the breast cancer movement is unlikely to take place soon."

Aggressive screening and treatment "are simply in the best interests of too many groups," including the biotechnology industry, researchers, medical institutions and even women, who "like the current war on breast cancer" and see "mammography and other imperfect screening tests as proactive steps against a dreaded disease," Lerner writes. Lerner concludes that the "battle language" of breast cancer "should serve to remind us of how politics, economics and culture influence medical decisions that are seemingly based on objective science." He adds, "Most important, women with breast cancer and those concerned about the disease should actively question their doctors about all possible options. Theirs is an encounter between a healer and a patient, not between a general and a soldier" (Lerner, Washington Post, 5/22).