I find myself sitting here to write a blog in recognition of Breast Cancer Awareness month, and frankly it's not as easy as I anticipated. And I am asking myself why that is.
We have made considerable progress in the early detection of breast cancer. I have commented frequently about the differences in breast cancer detection, treatment and survival today and when I started my medical training and career in the 1970's.
Early detection is clearly a success story if the measure of success is whether or not we can find breast cancer when it is "small" in most women. Our technology lets us do that with mammography techniques that are far more accurate and sophisticated than they were a few decades ago. Much of our discussion today centers around what role newer approaches, such as MRI, ultrasound, and most recently 3-D mammography have in early detection of breast cancer.
Our treatments are much more refined than they were in 1970, as well. We now have lumpectomy and radiation as a valid replacement for many mastectomies. We have sentinel node biopsy instead of axillary node dissection, which for some women adds nothing but long term misery caused by swelling of the arm. We have hormone-related treatments, chemotherapies, and biologic therapies that can prevent cancer from recurring; and we have an increasing number of promising approaches to treat the disease if it does come back.
We have genetic tests that can help pinpoint women at higher risk of developing breast cancer, and others that can help some women and their doctors decide whether or not they need to receive chemotherapy as part of their adjuvant (preventive) treatment after primary treatment with surgery.
We certainly have increased awareness of breast cancer beyond anything imagined in 1970. It's hard to imagine, but back then, cancer was not discussed in polite company (really). Some women did everything they could to hide their disfigurement and even what they thought was their "shame." Today, breast cancer is discussed openly and frankly (most of the time), and the voice of advocates is being heard at levels never dreamed of decades ago.
So with all this progress, why shouldn't I be celebrating our successes?
I don't want to be too pessimistic, so I will agree that we do have reason to be proud of our progress. We are saving lives; we have reduced disfiguring treatments; we can make a difference as individuals and communities concerned about this disease.
But I fear that at times we have oversold our magic. I fear that despite all the progress and all the understanding about the disease, we still have too many women who either can't get access to quality mammography, who can't afford treatment, or who go bankrupt in the process. I fear that we have set expectations too high, while we are learning that our science is not as perfect as we would like it to be. I fear that we have too many tests chasing too few women for whose benefit some of the prescribed "solutions" are far from proven. I fear we have overpromised and sometimes underdelivered.
But this is a month of celebration, isn't it?
Perhaps celebration isn't the right word. Perhaps this is a month to celebrate awareness, to celebrate our successes, but also to acknowledge our limitations and recommit ourselves to improving our science and better applying our knowledge. Perhaps we should take an opportunity during this month to reflect on what we know, what we don't know, what we would like to know, and how we can marshal our collective will to do better.
Just so the record is clear: I do think mammograms save lives. Perhaps their role has been less dominant with the emergence of effective surgical approaches and treatments to reduce the risk of cancer's return. But they do still have a role. I do believe we are on the cusp of significant advances in the understanding of the basic biology of breast cancer, as reflected in comments I made recently about a new study reporting on the most comprehensive analysis of breast cancer genes done to date.
At the same time, I understand the anger of women with advanced breast cancer who say, "What about me?" Among these women are those who did everything "right" when it came to early detection and treatment. And among these are women who couldn't do everything "right" because they couldn't access the system or couldn't find someone to treat them in a proper and timely fashion. These are women who pray for a breakthrough, who pray for a cure and wonder whether those who have not been diagnosed with breast cancer or who don't have advanced disease really understand.
So here is the way I look at my dilemma: I praise the successes, but I also accept the limitations. And I pray for the day when our science takes us to the place where breast cancer is indeed a remnant of the past-for all women. I search for science that will help guide us through some of the confusing messaging surrounding early detection, and ways to be certain all women have access to care.
So maybe I am out of the mainstream of the "celebration." I know our limitations. We aren't there yet, and frankly we have a long way to go. But I remain eternally optimistic that we are going to get to a better place, when celebration is justified. But for me, it's just a bit early right now. There is still much to learn, and much to do.