Conflicts and health are frozen accidents

medical equipmentIt turns out my story falls right into the confusion about how and when to test for breast cancer and whether doctors order too many diagnostic tests. Throughout my forties, I followed the routine wisdom of annual mammograms. Then, the wisdom changed. Had I followed the new recommendation to skip a year after a normal mammogram, I’d have waited for 2011 and been dead in 2010. Late stage Triple Negative Breast Cancer was overlooked in the 2009 mammogram. So, in theory, I shouldn’t agree with the changed recommendation. Yet, based on my experience, I do agree.

Some of the injected uncertainty surrounds good questions: What’s an effective test – Breast Self exam? Mammogram? Ultra Sound? Needle Biopsy? How many is too much? What is over-testing? When is standard cancer treatment necessary? The Medical Associations say it isn’t about the money spent on over testing and over treating, but I doubt real people believe that. People aren’t statistics. I ache for the 24 year old who’s stage 4. Her doctor, damn him, didn’t diagnose it because his guidelines ruled out breast cancer at her age. But my perfectly healthy breasts were over-tested and over-treated for about a dozen years and then, when I did have breast cancer, the radiologist missed it.

I had dense breasts. Mammograms throughout my forties were unclear so next I’d get sent for ultrasound. Those showed anomalies, which landed me in the needle biopsy lineups. Ambiguous results there got me an excision under local anesthetic with regular Oncology followups. That happened almost every year. And, my breasts going into my fifties were great (as in normal pathology as well as nice breasts).

I got upscale diagnostics and that saved my life, and yet, I intuitively support the new recommendations to reduce testing. How’s that again? Well, it depends on where one draws the boundaries. Short term, if I hadn’t had the 2010 mammogram I’d be dead. Those boundaries are linear and close in time.

But health is a time series and nonlinear. So, let’s expand the boundaries. My medical intervention started long ago with breast cysts that doctors poked, radiated, and needle biopsied.

MR900281051Had they not stuck needles multiple times into cystic breast tissue, would I have gone on to develop breast cancer? That’s the nonlinear question without answer.

There’s some research that suggests a connection between screening tests and cancer outcomes decades later. I read the pathology reports of the tissue formerly known as my left and right breasts. The cancerous micro-calcifications in my late fifties were at the sites of all those unnecessary diagnostic needle biopsies in my forties.

My correlation between where the needle went in and where the cancer was found isn’t proof of anything. However… Maybe the new guidelines will contribute to some young woman not having her breasts over-investigated now, and then she won’t develop breast cancer later. There’s no do over button to go back in time and try the other path, to see if I wouldn’t have gotten cancer had I not been over-tested. I’ll never know if the outcome could have been different. Life doesn’t come with an eraser.

MR900233887Dr. Murray Gell-Mann dubbed the events that create our current life ‘frozen accidents’ – that is, what we think of as history is just a series of coincidental cascades where events happened in a particular order to bring us to today. The answers to our good questions can depend on where we draw the boundary around the history. If I look from 2009, the cancer missed in the tests, to 2010 when it was found, I support all the testing money can buy. If I push the boundary back ten years, to 1999 or more, I was way over-tested. What I see depends on where I stand – it’s path dependent.

And that’s how it is with conflicts. Short term, we see a direct effect or reaction from whatever happened last. But, the helicopter view of the field shows lots of contributions to the situation, some of which were seeds planted years ago by people who aren’t currently participants in the fray. Effects can be disproportionate and indirect to causes. People aren’t statistics in conflict either.

Health and conflicts are both nonlinear time series where anything can happen in any order until the accidents freeze. Then, we call it history. We could as easily call it a randomized crapshoot.

I can’t do it over. If I could, I’d be tested less, just like the new guidelines recommend.

Meanwhile, here are some links to the medical controversy over diagnostic screening and breast cancer.

http://www.ncbi.nlm.nih.gov/pubmed/2828910

[Relationship between biopsy and prognosis of breast cancer].

[Article in Japanese]

Fujimori M, Senga O, Terai N, Miyagawa M, Iida F, Tsuchiya S, Koike Y.

Source

Second Department of Surgery, Shinshu University School of Medicine Matsumoto, Japan.

Abstract

Clinical data from 131 patients who underwent primary radical operation for breast cancer at the Second Department of Surgery, Shinshu University Hospital during five-years from January 1976 to the end of December 1980 were analyzed to investigate for the relationship between biopsy and prognosis. The incisional biopsy group had a significant higher recurrence rate as compared with the no biopsy group, cytology group and the cancer negative group after excisional biopsy. Although the puncture aspiration cytology group did not show significant difference in recurrence rate, an any more than 3 weeks of interval between puncture aspiration cytology and radical surgery associated with a significant high recurrence rate. This suggests that the interval also exerts an unfavorable influence upon prognosis. Puncture aspiration cytology was recognized to be apt to result in distant metastasis than any other biopsy methods and also it is tended to have a higher recurrence rate in scirrhous and mucinous carcinoma of the breast.

PMID: 2828910 [PubMed – indexed for MEDLINE]

http://www.ucsfhealth.org/education/breast_cancer_risk_factors/index.html

http://www.breastcancerchoices.org/faqbiopsies.html

Background: Needle biopsies pierce the suspicious breast mass to draw out tissue for analysis.  Some researchers fear these procedures may spread (or seed) the cancer, causing something called “needle track metastasis.” Others feel this possibility is not a significant concern or that the immune system, surgery and/or radiation that follows will clean up the area. Each individual must review the information that is presented in this BIOPSY section with her doctor and decide for herself whether or not to undergo these procedures.

In June 2004, the results of the bombshell Hansen study, “Manipulation of The Primary Breast Tumor and The Incidence of Sentinel Node Metastases From Invasive Breast Cancer,” were published in the American Medical Association’s prestigious journal, Archives of Surgery, revealing that patients undergoing fine needle biopsies were 50% more likely to have micrometastases spread to the sentinel lymph node than those patients having the entire tumor removed for biopsy.

Over the years, several researchers have voiced serious reservations about routine needle biopsies, but they were mostly ignored by their colleagues. Hansen’s research team cited their predecessors, and the research path leads back several decades. It’s hard to understand why The Archives of Surgery study, which embodies all of these reservations about needle biopsies, didn’t make the front page of the New York Times.

…. Chen (2002) suggested needle biopsies may not only raise the risk of spreading cancer cells within the breast tissue itself to such a degree that radiation therapy is recommended, but Hansen (2004) biopsies may also spread them farther, beyond the breast, to the sentinel node.

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