June 6, 1997

Cancer Politics

More people are living off cancer than are dying of it.

Author unknown

You would think that policies with regard to health issues would simply involve doing the research that determines the best way to deal with a disease, and then acting accordingly -but it isn't. Anything that involves people gets complicated and political.

Take what should be a simple matter: how to deal with breast cancer. Everything that we know to date tells us that there are a relatively small percentage of breast cancers that will spread even when the original tumor is very small. There are some others that can get quite large without spreading. With most breast cancers, the earlier they are detected and treated, the better the chance of a cure. Virtually all of the efforts of the American Cancer Society(ACS), the National Cancer Institute(NCI) and other organizations concerned with the problem, has been directed toward getting people to find tumors and removing them while they are small. Before the advent of mammography, that effort was directed at breast self examination and regular physical examinations.

The effectiveness of mammography was demonstrated in several fairly large studies. It clearly reduced deaths from breast cancer in women over 50. We can assume that this represents women who have passed the menopause. The reasons for this are still somewhat obscure. Several things to consider are that women's breasts are structurally different before and after menopause, and that x-rays are known to cause breast cancer -something that is never mentioned in the media. More significant is the fact that the risk of getting breast cancer is much higher in older women and we would expect that the benefits of early detection would be greater in older women.

Most authorities seems to agree that it is not a good idea to do mammograms on women under 40. Despite this, I have no idea how many mammograms are performed on young women who have been terrified about breast cancer and have been led to believe that mammography will protect them from the ravages of the disease. I suspect that it is a substantial number. I have noticed that advertisements for mammography do not mention age.

It is that age group between 40 and 50 that has generated controversy, with the ACS recommending mammography, and the NCI not recommending it.

This was very confusing to the public, so NCI formed an panel of independent people, mostly scientists who were not involved in the controversy -who had no ax to grind- to evaluate the evidence. Those who organized the panel hoped that NCI would recommend the same thing that ACS did. They did not. They concluded that the available evidence still did not support annual mammography for women between 40 and 50. They hedged a bit by recommending that it be left to the woman and her doctor. The mammography evangelists and many reporters were outraged. Soon after the announcement, it was announced that the head of NCI, Richard Klausner, did not agree with the findings of the panel.

I was amazed that Klausner would undercut his own panel. I wondered what kind of a person he was. I found out at the meeting of the American Association for Cancer Research, which I attended in April. I found him to be intelligent, perceptive, a competent scientist and much more than the "politician" that I expected. I also found out what he was up against.

What Klausner had to contend with was the nasty brand of politics that is engaged in by the grand inquisitor himself, Arlen Specter(R. Pennsylvania). You remember Specter, don't you? He was the senator who, during the Clarence Thomas hearings, treated Anita Hill as though she was a criminal on trial. A newspaper article on the subject reported that Specter threatened to call for Klausner's resignation if the advisory board's recommendation differed from the one he, Specter, wanted, which was for NCI to recommend the same thing that ACS recommended.

I remember the politics of ACS when it was headed by radiologist Phil Strax, an evangelistic mammography enthusiast -which does not seem to have changed. I did not figure that it would cloud the objectivity of NCI.

NCI, under Klausner's leadership, is embarking on a large and expensive genetic study aimed at pinpointing all of the genes related to cancer. This may well be one of the most important bit of government-directed cancer research that has ever been done. What Specter claims that he said was "I did not say Dr. Klausner ought to resign or be replaced, but I did raise a question about whether they are using their funds properly. They are funded $2.3 billion." In other words, if you don't do things my way, you may not get the research funds that you need.

So now you know why the NCI has now recommended that women between 40 and 50 have regular mammograms.

If you, as informed citizens, are willing to go along with the recommendations, knowing how that decision was made, go ahead -It's your life. I am deeply troubled that someone like Arlen Specter can influence the deliberations and conclusions of the National Cancer Institute.

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