“Any sufficiently advanced technology is indistinguishable from magic” -Arthur C. Clark
If there was ever a time to feel as though we were living in the future, that time is now. What we’ve been able to do with modern medicine can only be described as magic, and what we’ve been able to achieve is miraculous when we consider the breadth of human history. We’ve eradicated numerous diseases, we’ve cured countless illness, and we’ve trivialized prehistoric pathologies. People are living longer, healthier, and more meaningful lives, fewer and fewer children die young, and for nearly anyone suffering, medicine can offer the possibility for a better tomorrow. If there is anything that makes me optimistic about the future, it’s what we’ve been able to give people with medicine — a second chance at life, a future that’s filled with hope, a choice beyond simply dying.
As a medical student, I’m constantly astounded by the what we’ve been able to achieve with modern medicine. But the one disease that truly saddens me is breast cancer. It kills young women in the prime of their lives; it robs children of their mothers; it makes widowers of husbands; it’s an omnipresent concern to all women of all ages. As a man, the likelihood that I’ll be affected by it is exceedingly low. Moreover, I’ve been fortunate enough to have never had anyone close to me affected by the disease. Yet none of this changes the fact that millions of women have lost their lives to this disease, and millions more have been affected by it. And what truly saddens me about breast cancer isn’t how powerless we’ve been to treat it — it’s how much harm we’ve inflicted on women with the intention of helping them.
After 3 decades, it feels like we’ve made no progress — what was it all for?
From blood letting to leeches to snake oils, the history of medicine is filled with examples of doctors harming their patients under the false belief that what they were doing was beneficial. But in my opinion, what distinguishes breast cancer treatment is the modernity in which our shortcomings have occurred and how little we’ve managed to progress despite our technological achievements.
Starting in the 1900s and continuing for decades, the standard operation to treat breast cancer was radical mastectomy, which involved removing not only the cancerous breast but also the underarm lymph nodes and the chest wall muscles on the same side of the cancer. This operation left women horribly disfigured, and some women even underwent amputation of their upper arm along with their breast. The thought underlying the “radicality” of the procedure was that removing all of this tissue was necessary in preventing future metastasis and recurrence. Do you know where the origin of the word, “lumpectomy” is derived? The term was meant to be derogatory because the idea that you could successfully treat breast cancer with such a diminutive procedure was preposterous. But even after the development of modified radical mastectomy and breast-conserving treatment (what we now call lumpectomy), even after evidence suggested that these less disfiguring and less radical approaches were just as effective, women were still undergoing radical mastectomy — women were still being horribly disfigured when an equally effective alternative was available. For all those women that we disfigured and left disabled, what did we ultimately manage to achieve with it?
And it’s not just the operations we subjected women to that are saddening; it’s also the medical therapies we forced them to endure as well. There was a time when we believed that high-dose chemotherapy with bone marrow transplantation resulted in better outcomes in patients with breast cancer. Think about that for a moment. We were giving women higher and higher doses of chemotherapy with worsening side effects and sometimes increased mortality. And when we found the maximum tolerable dose of chemotherapy that the human body could withstand, we devised a means by which to deliver even GREATER doses of chemotherapy. Yet despite all of the chemotherapy we were giving, despite the bone marrow transplants we were doing, there was no evidenced that it provided any more benefit than standard therapy. How many women were subjected to truly devastating chemotherapy regimens for no benefit?
Even today, a recent paper published in the New England Journal of Medicine (Breast-Cancer Tumor Size, Overdiagnosis, and Mammography Screening Effectiveness) highlights how little we’ve managed to achieve. Screening Mammography has decreased the incidence of large tumors by 30 case per 100,000 women, but it’s also increased the incidence of small tumors by 160 per 100,000. That means about 5 out of 6 times we find breast cancer on screening mammography and treat it, we probably didn’t need to. On top of that, after 3 decades of screening mammography, the incidence of metastatic breast cancer remains unchanged. How many women were treated unnecessarily? How many women did we emotionally and psychologically torture with the C-word of oncology when we didn’t need to? And despite all of this, we didn’t even make a dent in the type of devastating breast cancer we were aiming to prevent.
They did the best they could with the knowledge they had for women in hopelessly terrible situations. This hasn’t changed.
It hasn’t been that we’ve made no progress because we’ve made enormous strides in the medical therapies available and improvements to surgical technique used to treat breast cancer. And if you think I’m suggesting that we’ve helped no one with breast cancer, then you’re gravely mistaken. The fact of the matter is that breast cancer mortality has decreased due to advancements in therapy, and there is not a doubt in my mind that we’ve saved countless lives. However, the one metric that we should be measuring ourselves by is the one metric that we utterly fail at — the treatment of young women with triple negative breast cancer.
I don’t doubt for a second that all of the surgeons, all of the physicians, and everyone involved in taking care of these women believed they were doing the right thing. They did the best they could with the knowledge they had at the time for women in hopelessly terrible situations. None of this has changed, and that’s what saddens me about the history of breast cancer treatment. Women are still hopelessly sick, but our knowledge is still incomplete and some of our therapies still unproven.
I know that I can never be sure that what I’m doing benefits my patients; I can never be certain that I’m improving people’s lives. But what breaks my heart is knowing that someday I’ll have to come to terms with the question of how many people will I hurt unnecessarily under the belief that I’m helping? Armed with the assumption that I’m helping my patients, how much suffering and pain will I unintentionally cause with my actions? During my practice as a physician, what will I do that I ultimately come to regret?
I went into medicine with the idea that I would be helping people, and all I can do is work-hard and hope that I’m moving the needle in the right direction most of the time. -GP