When Cancer Is Not Cancer
Hundreds of thousands of women have likely been overtreated for breast tumors as others continue to die. One doctor says it’s time to make a change.
I walk past the unadorned doors at the Carol Franc Buck Breast Care Center at the University of California, San Francisco, along a corridor decorated in shades of mauve so soothing that they barely register as colors. All is generic, aggressively nondescript, until, that is, I reach the office of Laura Esserman, the center’s director. Her entryway is papered over with cartoons that mock right-wing pundits. There are inspirational quotes from Abraham Lincoln and Niccolò Machiavelli, among others, all boiling down to one sentiment: When you challenge people’s deeply held beliefs, well, haters gonna hate.
Esserman has helped to catalyze some of the most contentious debates about breast cancer. She has risked the ire of conservatives, liberals, the media, and pink-ribbon advocacy groups for suggesting that the health care system could save billions of dollars and better serve women by beginning screening biennially at age 50, rather than annually at age 40. As studies continue to indicate that yearly mammograms do not reduce a woman’s chances of dying of cancer, Esserman is pushing the discussion even further, questioning whether certain “Stage 0” tumors, almost exclusively detected through screening, are cancer at all.
Esserman bustles up behind me, still dressed in scrubs from her afternoon surgeries, apologizing for keeping me waiting. Fifty-seven years old, she is blonde, with enviable cheekbones and a throaty chuckle. Although we’ve never met, she flings her arms wide to embrace me. For the next 90 minutes, as she talks rapid-fire, she never breaks eye contact. Her intensity can be unnerving. Then again, lives are at stake. “More than 40,000 women are still dying,” she says, “and we’re going down a rabbit hole with screening, finding all kinds of stuff that’s just noise. We need to get at these serious and dangerous cancers and figure out how to treat and prevent them.”
If screening worked as it should, Esserman says, there would be one fewer case of late-stage disease for every early-stage cancer it found. But that hasn’t happened. Despite the skyrocketing rates of tiny, easily treated tumors, diagnoses of advanced breast cancer have barely budged since the test became routine in the mid-1970s. That’s partly because the most lethal cancers grow quickly, often cropping up between mammograms. Equally troubling, all those “extra” early-stage cancers would indicate that, similar to prostate screening in men, mammography is catching tumors that may never have needed treating.
Esserman has focused on ductal carcinoma in situ (DCIS), an overgrowth of cells in the milk ducts. DCIS was rare before universal screening. It now accounts for 30 percent of breast cancers — nearly 65,000 cases a year. With its near 100 percent cure rate, DCIS would seem like a triumph of early detection. Except for this: In 50 to 90 percent of cases (estimates vary widely), it will stay where it is — “in situ” means “in place.” It lacks the capacity to spread, so by definition, it will never become life threatening. Yet because there has been no way to predict which cases might morph into invasive cancer, all are treated as potentially lethal. By 2020, 1 million women will likely be living with a DCIS diagnosis. If, conservatively, half are harmless, that means hundreds of thousands of women will have been overtreated, enduring the physical risks and psychological devastation of any cancer patient.
On her computer, Esserman pulls up an image of a milk duct. Purple-dyed dots of cancer spread across hot-pink-tinted breast tissue, kept in check by a perimeter of neat, symmetrical cells. “DCIS is not cancer,” she says. “It is a risk factor for cancer. Many of these lesions have only a 5 percent chance of becoming cancer over ten years.” Last year, as leader of a working group of the National Cancer Institute, she called for renaming the condition, removing its big “C.” That’s not simply semantics. In one survey, nearly half of women said they would choose surgery over surveillance or medication if told they had “noninvasive breast cancer,” but only a third would opt for surgery if told they had “abnormal cells” or a “lesion.” Esserman’s recommendation has gone unheeded.
Risk is a tricky thing. Those like actress Angelina Jolie, who carry mutated genes predisposing them to as high as a 65 percent lifetime probability of breast cancer, are offered surveillance as an option (along with more aggressive choices, like prophylactic mastectomy). Yet a woman diagnosed with low-grade DCIS, whose cancer risk is exponentially lower — and chances of dying of the disease even lower still — is rushed into surgery. “It doesn’t make any sense,” Esserman says. “We need to focus on the people where intervention is meaningful and leave the other people alone.”
After years of arguing, Esserman is about to test her theories and, she hopes, transform women’s health care. This spring, she’ll head a trial of 100,000 women across the University of California and Sanford Health hospital networks. The study will assess an individual’s risk of cancer, then suggest an age to begin screening, a recommended frequency, and an age to stop.
“My goal is to show that personalized screening is safe,” she says. “It won’t increase advanced-stage cancers, because I don’t think they have to do with screening. Could we also see a reduction in breast cancer incidences?” She slaps a hand against her thigh. “If you don’t ask, it will never be possible!”
When DCIS is diagnosed, its relative virulence, along with individual risk, will guide the response. Some patients will be offered the option to watch and wait; others will require intervention. “We’re not going to tell people what to do,” Esserman says. “We’re going to tell them, ‘This is the range of things you can do, and we think that these options are the most reasonable.’”
When Esserman was a young doctor, women who found a breast lump were sent into surgery without a diagnosis. They didn’t know if they would wake up intact or recovering from a mastectomy. And not just a mastectomy, but mutilating, radical surgery — anything less extreme was considered unsafe. Today, that sounds barbaric. Perhaps in a few years, Esserman says, the current approach to DCIS will seem equally excessive. Perhaps homing in on those truly at risk will improve treatment, create opportunities for prevention, and save lives. “I don’t want to be here in ten years saying, ‘Oh, 40,000 women are still dying of breast cancer, and I’m still doing the same thing every day.’ Let’s put some trials in place. Let’s let the facts speak for themselves. I’m just saying there’s a different way to think about these things.”