When Christina Applegate recently revealed that she had an inherited form of breast cancer and had bilateral mastectomies, there was an outpouring of media interest and genuine concern. When she said she was cured, a lot of breast cancer survivors and doctors scratched their heads wondering what message she was sending.
There is something in our national psyche that makes the diagnosis of cancer in a celebrity something more important. They rise above the rest of us when sadness impacts their lives, and for many of us their disease becomes our disease.
One of the things I have learned over the years is that when it comes to someone else’s illness, there is little we know and much we don’t. Celebrities and politicians in particular—since they are constantly in the public spotlight—have to make decisions as to how much to say and what not to say.
What we know about Ms. Applegate is that she has an inherited genetic mutation that is known to be associated with a high risk of breast and ovarian cancer. She was screened regularly, which was the right thing to do. Apparently a screening MRI—also the right thing to do for a young woman like Ms. Applegate with this genetic abnormality--found the cancer, and she was provided her treatment options.
She selected bilateral mastectomies, which is a recommended treatment for women with BRCA1-related breast cancer. That’s because these cancers have a high likelihood to be bilateral at some time, and the mastectomy reduces the risk of additional breast cancer significantly.
There is a lot we don’t know about Ms. Applegate’s breast cancer, its diagnosis and treatment, her public comments notwithstanding.
We don’t know whether this was a pre-invasive cancer, which is commonly known as DCIS (ductal carcinoma in situ), which in fact has an excellent prognosis. Or, was it an invasive cancer, which is a more serious situation? We don’t know what additional treatments were recommended.
This list of questions could go on, such as whether or not she is considering an oophorectomy given the fact that BRCA mutations are also associated with an increased ovarian cancer.
But that is beside the point of the concerns that I have and are shared by others who have experienced this disease, treat it or are otherwise familiar with breast cancer.
When celebrities make statements, people notice. When Betty Ford had a mammogram that diagnosed an early breast cancer, the use of mammography soared. The same can be said for Katie Couric when she had her colonoscopy to screen for colorectal cancer live on television.
But in the case of Ms. Applegate, there are a lot of women with breast cancer—including those who are BRCA positive—who are wondering why their doctors haven’t delivered a similar message to them that they have been cured.
For those women, they have probably been told that the chances of their breast cancer recurring are slim, modest or considerable depending on their individual circumstances. But they are probably not told at the time of initial treatment that that they are cured. Breast cancer, in fact, is a life long disease. That’s what many women live with every day.
That is the message that has been very confusing and even upsetting to many of us familiar with breast cancer. It simply is not a realistic or truthful statement for many women who have had similar conversations with their surgical, radiation and medical oncologists.
The medical facts are that bilateral mastectomies as a treatment for breast cancer are not a cure, especially in BRCA positive women. They are the best strategy we have to reduce the risk of another breast cancer in the opposite breast, but they don’t remove risk completely.
Even in the hands of the best surgeons, bilateral mastectomies in a BRCA positive woman who has not had breast cancer reduces the risk of a new primary breast cancer to about 10%. That’s because even in the best surgical hands, there is still some breast tissue left behind after these procedures.
There is also the question of adjuvant therapy for breast cancer. Most women with this form of cancer would receive a recommendation for additional preventive therapy. We don’t know what recommendations were made to Ms. Applegate, but the media reports suggest she isn’t getting any further treatment. Again, we must be very careful in making assumptions, but it does raise the question for other women in similar circumstances as to why they had to go through more chemotherapy and/or hormonal after their surgery?
I guess it all comes down to this: we work hard as doctors and advocates to be certain that our messages are as clear as possible.
We have struggled for years to help women improve their outlook with new treatments for breast cancer. We have struggled within the profession to convince doctors that more limited treatment approaches are as effective as the old radical treatments, in appropriate circumstances. We have researched treatments with hormonal drugs, chemotherapy and radiation to come up with the best evidence as to how to prevent breast cancer from coming back.
We don’t know if Ms. Applegate’s breast cancer is cured. We hope and pray it is—as we do for every woman who is diagnosed with this disease.
For most women with breast cancer, we know that the risk of recurrence stays with them throughout their lives. Recent research reemphasized that point. Women with breast cancer live with that reality every day of their lives.
We do applaud the awareness Ms. Applegate has brought to the issue of understanding your risk of breast cancer, and getting screened appropriately. That means for women at high risk getting an annual MRI and mammogram, as recommended by recently released American Cancer Society guidelines.
But women at risk and women who have been diagnosed with breast cancer must always remember that each situation is unique. They must have open and honest discussions with their doctors as to what the best treatment is for them. They should understand their options, their risks, and the implications of their disease for their lives.
Our progress in the treatment of breast cancer—and we have made a lot of progress--doesn’t come without the need to make certain that women are accurately informed about their breast cancer and their treatment options.
Giving false hope has been a hallmark of much of our past experience with cancer.
As we have matured in our knowledge of the disease and how we treat it, we know that giving hope is important. But false hope doesn’t help.