Linda Ellerbee Poisons the Breast Cancer Screening Debate

On the one hand, her column is simply her story: She's a woman who found a painful lump in her breast at age 47 upon a routine self-exam, got a mammogram, and lives today 18 years after treatment. (Good for her on that! I've survived two cancers myself. And while the survivor's club ain't exactly one that anybody seeks to join, it beats the alternative.)

But Ellerbee turns her tale into a "feminist" screed against the scientists who are now advising that routine breast exams and annual mammograms for all women under 40 might not be the smartest and most effective way to save lives. Here's the paragraph that really twisted my shorts:

"I know I'll be called a nasty old feminist (such an unpopular word these days), but one cannot help but wonder -- would we be playing games about the risk/benefit of X-rays and the value of copping a feel on our own lady-things, would we know more about breast cancer, would we have a test for it, maybe even a cure, if breast cancer weren't primarily a women's disease?"

One cannot help but wonder whether she is implying that any man or woman who disagrees with her about this is therefore anti-woman. And I hope that I won't be called a male chauvinist pig when I offer a two word counterpoint: prostate cancer. Which is even more a men's disease (duh) than breast cancer is a woman's disease.

In October, a month or so before the latest kerfuffle, the Journal of the American Medical Association published an article that takes on both breast and prostate cancer screening. The article is titled "Rethinking Screening for Breast Cancer and Prostate Cancer," by Laura Esserman, Yiwey Shieh and Ian Thompson.

Here's an excerpt:

"Breast cancer and prostate cancer account for 26% of all cancers in the United States, with an estimated 386,560 patients diagnosed annually: 194,280 for breast cancer and 192,280 for prostate cancer. For both, there are remarkable differences between outcomes of localized vs. advanced disease (breast cancer: 5-year relative survival rates of 98.1% vs. 27.1%; prostate cancer: 100% vs. 31.7%)."

So the two cancers are statistically roughly comparable. And guess what? As with breast cancer, the tests for prostate cancer are dubious, too. The doctor's "finger wave" is about as much fun as a mammogram and even less specific about what it finds. And a blood test that once was considered the gold standard for early detection of prostate cancer turns out to produce more false results than a Bernie Madoff ethics test. (The JAMA piece is all about how routine screenings for both of these cancers, using current technology, may not be the best way to save lives. I wish that, as a matter of public interest, JAMA would take it out from behind the paywall. )

Spare me, therefore, the "feminist" horsepucky. Women and men are pretty much equally frustrated by the current reach of medical science regarding their most gender-specific cancers.

Let's get one other howler out of the way: Even had the new suggested guidelines been in force 18 years ago, they might not have affected what happened to Ellerbee. The proposed guidelines deal with routine annual screening. A woman with a painful lump, who therefore would have an obvious reason for further testing, isn't even part of the discussion. (Read the guidelines yourself if you don't believe me.)

Which leaves us with questions that Ellerbee does not address in her column: When would she have discovered that painful lump without the monthly routine self-exam? And would the delay have made any difference in her treatment? Those details go to the heart of the actual debate. In Ellerbee's case, she admits that there was already a six-month delay (due to bonehead advice from her doctor) between her discovery of the lump and her mammogram. What if instead she hadn't discovered that lump for a year? Or even a couple of years? Would her treatment or survival have been different?

Ellerbee implies that the answer is obvious. But it's not. Many breast cancers are slow-growing, and a delay in treatment of a year or even several makes little difference. Many more of those "indolent" cancers are identified by routine screening than those that are just about to take off into life-threatening metastasis. (Ditto for prostate cancer, by the way.)

And forgive me for seeing some value in an issue that Ellerbee dismisses: "I've also heard one doctor call routine mammograms for women younger than 50 an 'injudicious' use of medical resources," she sniffs. As someone who has made all-too-frequent, necessary use of limited medical resources, let me offer a vote in favor of their judicious use.

Strip out the personal details, and Ellerbee is offering a form of the "starfish" story. Surely you've been subjected to a version:

One man confronts another on a beach strewn with starfish. The second man is taking one starfish after the other and tossing them back to the sea. The first man reflects on the enormous number of stranded starfish and asks whether the second man is making much of a difference. "To this one, for sure" the starfish tosser replies, as he flings another. But what if the tosser can't tell which of the starfish are healthy enough that getting tossed would save them? What if some of those living starfish -- he can't tell which ones -- would get back to the water on their own? What if the act of tossing inevitably injures some starfish -- including some that would have returned otherwise unhurt to the sea?

None of those questions matter to the relatively few starfish that would have died but now are saved. And maybe Ellerbee is one of those starfish. But if you are aiming for large-scale starfish-saving, and your resources are imperfect and limited, these are all damned important questions.

What the scientists who propose the new guidelines are saying is that the routine screenings waste resources without commensurate benefits and -- because no medical procedure is risk-free -- lead to needless injuries and even deaths for some women. And yet everyone admits that a few lives are probably saved annually by those screenings.

So what's the right answer? That's a question well worth a broad, informed debate. Which is not advanced by implying political motives without offering a scintilla of evidence. And that takes me to my final point of outrage: Ellerbee grants credence to the birther-level calumny that these new suggested guidelines represent no more than a new and politically driven conspiracy to push health care rationing. "Only a fool would completely discard such a notion," she says.


Look, there is value in anecdote. It can suggest a direction for investigation and provide a face to a complex issue. But as an old Yiddish proverb tartly puts it: " 'For instance' is not proof." For Ellerbee to imply that she 's an expert on breast cancer because she survived it would be like me claiming that living through a hurricane makes me a meteorologist. Had Ellerbee taken her story and then added a bit of -- what do you call it? -- reporting, she might have added something of value to the discussion.

And that's why my objections are as much about morality as they are about science: Ellerbee is no rookie. She knows the potential power of the media. In fact, she's trying to invoke it. She should have known better. If we lived in a fairy-tale world where medical resources were unlimited and treatments were either beneficial or harmless, Ellerbee's column might make sense.

But we don't. And it doesn't.