(excerpt from The Cancer Chronicles, copyright 2013 by George Johnson)
On the early morning flight from Albuquerque to Boston, the captain was wearing a pink tie, and a pink kerchief was peeking from the pocket of his uniform. The flight attendants were similarly dressed, with pink shirts and aprons. It was National Breast Cancer Awareness Month, and when the plane was in the sky one of the attendants enthusiastically announced that the airline was selling pink lemonade and pink martinis—this on a flight departing at 6 a.m. The proceeds would go for “curing” breast cancer. No more than a hundred years ago cancer was a word spoken only in whispers lest the illness be stirred from its slumber. One might die of “heart failure” or “cachexia,” a latinized way of saying that, eaten by cancer, a loved one had wasted away. Though the fear has not disappeared, “cancer” is no longer the unutterable word. The cheerfulness with which the subject has been embraced and shouted is almost macabre. A cosmetics company was advertising “Kisses for the Cure.” Buy a lipstick and a small donation would be made to the fight. “Pucker up and Kiss Breast Cancer Goodbye.” As I paged through the airline magazine, I thought of the Stand Up to Cancer telethon I’d watched a few weeks earlier, with singing, laughing, and sometimes somber celebrities vowing to “eradicate” cancer of all kinds. Not control it or reduce it or treat its occurrence more effectively. “Someday no child will die from cancer,” a buoyant teenaged actress promised. Not a single one. “We must beat it back and beat it out of existence,” said Stevie Wonder, hunched over a piano. His first wife had died from cancer, and many of the other stars had also been closely struck. “Cancer doesn’t care that you’ve won the Olympic gold medal. Cancer doesn’t care if you’re beautiful or brilliant or just starting college. . . .” One by one in their “Cancer Survivor” T-shirts, the idols and their idolizers took the stage. “Cancer doesn’t care if you have your whole life in front of you. . . . Cancer doesn’t care that you have young children who need their mother. . . . Cancer doesn’t care that it just took your father. . . . It just doesn’t care.” A ticker tape message scrolled across the bottom of the TV screen: “Cancer Doesn’t Discriminate.” But it does. Against the elderly, the obese, the poor. Demographically the young, beautiful people on the show were exceptions. But who could resist their good hearts and cheer? “The stars are taking your calls.” And so the telephones rang, the pledges poured in. At the end of the show a procession of scientists filed across the stage to a rousing chorus of “You’ve got to stand up, stand up, stand up to cancer. . . .” Altogether more than $80 million was raised that night. Stand Up to Cancer is a respected organization reputed to funnel almost all of the money it collects to research. But I wondered if the viewers, as well as the performers, had been left with false hopes. The donations, it was said, would go to “dream teams” of scientists cooperating on a cure instead of competing for recognition and grant money—as if only greed and egos stood in the way of understanding the most complex of medical phenomena. Comparisons were made to Jonas Salk and the March of Dimes, yet polio had been a vastly simpler problem—a disease with a single cause that could be isolated and vaccinated against. Understanding cancer will require no less than understanding the deepest workings of the human cell. One performer invoked the fight against slavery and the triumphs of the civil rights movement. “What if no one stood up for freedom on the Underground Railroad . . . if no one was standing up for injustice at a bridge in Selma?” Cancer was something to demonstrate against or to oppose with a sit-down strike. These didn’t seem like people who were apt to engage in mass acts of civil disobedience like those of ACT UP, the AIDS Coalition to Unleash Power, whose influence lay in its obnoxiousness. Two decades ago, ACT UP demonstrated against the National Institutes of Health and shut down the Food and Drug Administration for a day, demanding more research money and affordable treatments. One way or another more attention became focused on the problem. Now AIDS can be managed as a chronic disease. But not even HIV is as convoluted as cancer. Descending toward Boston, the plane provided a bird’s-eye view of what vies with MD Anderson as the most powerful cancer center in the world. . . . *** With another Breast Cancer Awareness Month almost past, more money has been raised for medical research. But the hype, however well intended, comes at a price -- the spreading of the cruel illusion that by next Pinktober or the next or the next, scientists will have found The Cure. As I've written before, there is no such thing. Cancer is a consequence of entropy, "the legacy of being multicellular creatures in an imperfect world." It is an unfortunate tradeoff of evolution, and against it there can be, at most, incremental progress. As the sloganeers demonize the inevitable, scientists are concentrating on smaller battles, ones they might actually win. They are seeking ways to make screening work more effectively -- to identify tumors before they become fatally metastatic, but without falling into the trap of overdiagnosis. That can lead to disfiguring surgery, chemical poisons, and radiation -- all to treat harmless "Stage 0" growths that would have been better left alone. In an essay that won a prize this year from the National Association of Science Writers, my friend Christie Ashwanden described the dilemma:
The notion that breast cancer is a uniformly progressive disease that starts small and only grows and spreads if you don't stop it in time is flat out wrong. . . . Some breast cancers will never become invasive and don’t need treatment. These are the ones most apt to be found on a screening mammogram, and they’re the ones that make people such devoted advocates of mammography. . . . A healthy person whose life was never threatened by breast cancer is suddenly turned into a cancer survivor. She thinks the mammogram saved her life, and so she becomes an advocate of the test.
But here is the paradox. For the fast growing, life threatening cancers, screening is nearly worthless:
There’s simply no such thing as "early" detection for these cancers. By the time they’re detectable by any of our existing methods, they’ve already metastasized. These are the really awful, most deadly cancers, and screening mammograms will not stop them.
She calls the unqualified promotion of screening "breast cancer's false narrative." That idea could be expanded to include the persistent belief that there is a breast cancer epidemic, with an alarming increase in the number of cases. The epidemic is an illusion. The median age of diagnosis for breast cancer is 61. Every year more women are living longer, so more of them will accumulate enough cellular mutations to trigger a malignancy. Adjust for the distortion caused by this demographic aging and the number of cases has remained steady for years. In the 1990s there was a rise in incidence -- about half a percent a year -- that was attributed to the widespread use of hormone replacement therapy to ease the symptoms of menopause. As the risks of the treatment were recognized it became less popular, and breast cancer rates declined to earlier levels and have been stable ever since. The rate might be further reduced by combatting obesity and discouraging the regular consumption of alcohol. But the changes would be gradual and finite -- more effective than wearing pink lipstick but far short of the irresistible fantasy of a cure. Comments are welcome by email. For public discussion please use Twitter. For a glimpse of my new book, The Cancer Chronicles, including the table of contents and index, please see this website. @byGeorgeJohnson
