Would you take a pill that prevents cancer?

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Gina Kolata points out, once again, that diet and exercise have not been shown to affect breast cancer rates. Massive, well-run observational studies and randomized controlled trials turn up nothing. This finding appears to be unacceptable; popular culture rejects it utterly. Women’s magazines continue to preach the holy gospel of five fruits and vegetables a day. Doctors continue to tell patients at high risk of breast cancer that diet matters. The director of one of the (fruitless?) studies tells Kolata that doctors need to “rethink the studies.” Diet and exercise “are likely quite important, but we just aren’t getting the answers.”

Maybe, says the chairman of the department of epidemiology at Memorial Sloan-Kettering Cancer Center. Or maybe “It’s all sort of nonsense to begin with."

The question is why people so desperately want to believe, in the absence of evidence, that vegetables and treadmills will shield them from cell division. Says surgeon Susan Love, “It’s wishful thinking ... we would like things to be more in our control.”

But it must be something more, because drugs that do help prevent breast cancer—that do put patients in control in a way that accords with scientific findings—go ignored. The drug Tamoxifen cuts the cancer rate in half. The drug Evista does the same, with reduced risk of side effects. And one need only continue the treatment for five years. “It was a spectacular clinical trial,” reports a crestfallen Victor Vogel, who helped run the study. But no one cared: “The world said, so what?” Few doctors bother to recommend the drugs to women at a high risk of breast cancer, and when they do, patients often do not fill their prescriptions. The drugs are not expensive. The message sent to drug companies is that there is no market for cancer prevention drugs, so don’t sink millions into developing them.

My own view is that we want to be in control only in a way that conforms to certain notions of virtue. Eating a healthy diet, exercising regularly, and abstaining from alcohol are all behaviors that suggest a kind of moral rectitude absent from pill-popping. Popular media delights in reporting that smokers vastly increase their risk of various diseases; it seems that this is how things ought to be—indulge and be punished. Taking a pill called Tamoxifen every morning does not suggest anything of virtue or self-denial. It suggests, perhaps, cheating.

We'll take pills to prevent ailments framed as the natural and blameless consequence of aging, as with heart disease. But cancer—swift, random, terrifying—we still regard as cosmic punishment.

Tags: breast cancer, cancer drugs, Gina Kolata

Kerry Howley is a contributing editor at Reason Magazine and an Arts Fellow at the University of Iowa's literary nonfiction program.

Comments

Gina Kolata's Article

By: adina | Tue, 11/17/2009 - 15:31

I found Kolata's article to superficial at best, and in many ways inaccurate. Take, for example, her immediate dismissal of HRT. If you look at various pooled analyses of HRT, then, yes, combined progesterone and estrogen replacement therapy does seem to increase your risk of breast cancer. However, estrogen alone does not. Estrogen alone increases your risk of uterine cancer, but the combined hormonal contraceptives do not. Both estrogen and combined hormones reduce your risk of ovarian and quite possibly colorectal cancers. Even women who took estrogen and later developed uterine cancer had a lower overall mortality rate than women who did not take estrogen and did NOT develop uterine cancer, which is a truly shocking finding. And, of course, there seems to be in a difference in cancer rates, thromboembolisms, and other side effects of HRTs, depending on the route of administration, with the estrogen transdermal patch seemingly more favorable than the estrogen pill, due to the "first pass effect," through the liver, of the latter. And let's not forget that cancer isn't our only fear. I fear Alzheimer's Disease and osteoporosis as well, and the risk of both are decreased by use of HRTs. Even according the WHI study, women ages 50-59 on estrogen had a statistically significant decrease in the rate of MIs, compared to women on placebo controls. There's a lot more to the story, and Gina Kolata omits some very important findings. In fact, the thrust of her review seems to categorize things as "good drugs" versus "bad drugs," when the fact is that people may wish to weigh different costs and benefits, based on their personal risk factors and preferences, some of which have nothing to do with mortality, but may be related to other effects, such as hair loss, loss of libido, vaginal dryness, hot flushes, and other side effects associated with certain selective estrogen receptor modulators. While, of course, much can be done to improve patient care, the idea that doctors and patients are missing out on some sort of magic cures that are really in plain sight is simply not true.

How bout changing the title of the article?

By: Swann | Mon, 11/16/2009 - 06:41

Here's the more accurate title:

If your risk of breast cancer exceeded twice the average risk, would your doctor be able to evaluate the tradeoffs involved with pills that reduce risk? If so, and you were informed that you could take a pill that would significantly reduce your risk of developing breast cancer would you take it?

Wordy, huh? There is no pill that PREVENTS breast cancer. There are pills that lower the risk of developing it and increase the risk of other health problems.

If Vogel is correct that doctors are simply not "bothering" to recommend drugs that clearly benefit women at high risk of breast cancer -- and he may well be -- it's tragic and well worth investigating. You seem to blame women for not taking tamoxifen every morning; and from where I sit, it's a lot more complicated.

A few weeks ago I accompanied my daughter to her gynecology appointment to make sure her doctor understood there were two cases of early breast cancer in our family. The doctor said that if I were really concerned, I'd have us both genetically tested. Tamoxifen was not mentioned. And according to Vogel, it should have been. So yes, your article has opened my eyes. I'm no longer up on the latest treatments -- and it looks like I'll have to do my own research to make sure my daughters take advantage of risk-reducing meds.

But having discussed breast cancer with more oncologists and gynecologists than I care to remember, I will be astonished if breast cancer prevention is as simple as your article implies. My daughter's gynecologist had a point about genetic testing: it would, in fact, clarify a few things. Yet it would also be costly and might disqualify me and/or my girls from insurance coverage.

Hallelujah, if all we have to do is pop a pill. But like one of the other respondents, I am left wondering why the top docs at Stanford don't agree with Vogel's risk/benefit analysis.

P.S. -- The real scandal is the genetic testing

By: ockeghem | Sun, 11/15/2009 - 15:39

Tamoxifen vs. diet isn't the real scandal, though. The real scandal is that a test exists to tell you whether you have one of the identified breast cancer genes, but it is nearly impossible to get because U.S. courts have read patent law too broadly. (Granted, this test only tells you if you have one of the genes we know about; there could be other genetic factors we don't -- but screening out two factors is still a huge relief.)

In my intellectual property class some years ago, we were taught naturally occurring phenomena (e.g., algorithms) could not be patented. However, the U.S. Patent Office has allowed GENES to be patented now -- what could possibly be more naturally occurring?

When I started at the clinics almost 15 years ago, I was told not to take the genetic test because it cost over $1000, but the cost would come down quickly because other teams were working on similar tests. When I finally decided I wanted the test three years ago, I figured I could afford it without insurance help (so I could keep the results private). But no -- in the intervening time, some unscrupulous Utah company managed to wheedle a patent on my genes, so now the test costs over $4000 because competitors have been forced out of the market.

Who has $4000 just sitting around, especially in their late 20s or early 30s when the results are likely to be most important for those of us at high risk of pre-menopausal breast cancer? So you have to go through insurance, if you're lucky enough to have insurance that covers it (quite rare), but then you have to worry about having a disclosed pre-existing condition.

Not prescribing Tamoxifen if the benefits outweigh the risk is sad. But worse is not being able to find out whether you actually need the Tamoxifen or not, just because the U.S. Patent Office is too overworked to think about patent law and precedent. The ACLU has recently taken this on, although I'm not optimistic: http://www.aclu.org/free-speech_womens-rights/aclu-challenges-patents-br....

Tamoxifen doesn't come up -- nor does diet

By: ockeghem | Sun, 11/15/2009 - 15:28

I'm at high risk for breast cancer and have been followed since my early 20s at high-risk clinics in two of the top cancer hospitals in the United States. I've had genetic counseling, mammograms, ultrasounds, MRIs, biopsies, and finally (many years later when I was on excellent insurance) genetic testing. I was aware of the studies on Tamoxifen, but never once has the drug been recommended to me by my doctors, although radical options like double mastectomy and removal of my ovaries have been.

To the best of my knowledge, Tamoxifen is a chemotherapy drug with side effects, which certainly would be a consideration when deciding whether to take it. But the option, with its attendant pros & cons, was never presented. I'm not sure why -- it can't have been ignorance on my doctors' parts, as they're some of the best informed breast cancer experts in the United States.

But also, for the record, not one of these doctors has ever told me that diet was the panacea, either. I think that's more a popular notion that you get if you read the newspaper too much; if you're dealing with the experts, you don't hear a lot about controlling your diet as a silver bullet to breast cancer prevention.

Yes, all drugs involve trade-offs.

By: Kerry Howley | Sat, 11/14/2009 - 21:46

It would seem that your complaint is with the New York Times article here summarised, the entire thrust of which was the reluctance of women and doctors to make use of preventative drugs.

This is irresponsible journalism.

By: Swann | Sat, 11/14/2009 - 13:09

You don't know what you're talking about.

Tamoxifen reduces breast cancer risk and increases the risk of heart disease, stroke, blood clots, uterine cancer, and a host of other things. FOR THAT REASON, it is only taken by women at very high risk for BC.

Evista is only for post-menopausal women. And let me tell you: it's good-bye sex, hello wrinkles. I would and did sacrifice that to prevent a breast cancer recurrence, but you're out of your mind if you think the reason the woman on the street is failing to take these drugs is neglect, stupidity, or mindless bias for more virtuous treatments.

An uninformed person will read this article and completely misunderstand. "Few doctors bother to recommend the drugs to women at high risk?" Oh, really? What may be true is that family practitioners are bad at identifying women at high risk for BC. And there may be a reason for that. I'd love to see proof of all the discarded tamoxifen prescriptions. Right, the streets are littered with them.

Point is your tone is ALL f-ing wrong. There is no easy way to prevent breast cancer. There's a complicated matrix of tradeoffs with these drugs. If risk is very high -- for example, your mother and sister have breast cancer -- taking the drugs keeps the numbers on your side. For the rest of us, it's not worth the risk. And especially with Evista, the long-term effects are not known yet.

I'm on tamoxifen

By: Dudleys Mom | Fri, 11/13/2009 - 19:31

I'm on tamoxifen for breast pain, and coincidentally hoping to avoid ever having to do another horrific biopsy by possibly preventing cancer. It took me a year and 6 surgeons before I found one willing to prescribe tamoxifen for breast pain (it's the standard of care in the UK). And my gyno and endocrinologist are ~~appalled~~ that I'm doing this instead of just suffering with intolerable breast pain that interferes with my daily life in every way (note that I have NO risk factors for any of the dangerous side effects for tamoxifen).

So, you need to do more research. Doctors are HIGHLY reluctant to prescribe tamoxifen in the US, unless you've already tested positive for cancer. You've completely missed this fact in your article. There's NO WAY that the average breast surgeon would prescribe tamoxifen to prevent breast cancer, no matter how much the patient wants it.

Could it be that this generic pill doesn't line their pockets the way biopsies, lumpectomies and mastectomies do?? It certainly seems that way.

I would absolutely take a pill that prevented cancer

By: Kit-Kat | Fri, 11/13/2009 - 16:03

Seriously, I didn't know they existed. And if my doctor prescribed me one, I would take it, even to halve my risk of cancer. Sure, some cancer is the result of bad lifestyle choices (lung cancer/smoking) but who is this "we" who won't take easy steps to reduce the risk of all the other cancers? Seriously?

I have two friends who had cancer--both were in their early 20s, were in great shape and exercised routinely (one was on the crew team in college; the other, a regular runner, hiker, and rock-climber), and neither smoked or did drugs. Their cancer was not punishment for anything--it was the bad luck of the genetic draw.

Would You Take a Pill That Prevents Cancer? Probably Not.