Yet in 1951 Scotsman Wallace Park and Englishman James Lees29 theorized that treatment has little, if any, influence on the natural history of the disease, maintaining that the type of tumor and its biology are determinant.29,30 It is curious that in Europe there has been less resistance to this view than in America. There has yet to be a modern prospective randomized trial of how women fare with and without treatment.
There was, however, a unique study of 250 untreated women between 1805 and 1933 at Middlesex Hospital in London, where women were diagnosed without benefit of mammography--only by the naked eye or palpation of a mass. Middlesex, founded as a hospice for cancer patients in 1792, housed only women with extensive and measurable disease. According to an analysis comparing the Middlesex patients with those treated by Halsted, the untreated women did about as well as those who received the Halsted mastectomy between 1889 and 1933 (note 8). Many did as well as women today who obtain the most advanced therapies.
Highly regarded medical oncologist Craig Henderson, formerly of Harvard's Dana Farber Cancer Institute and the University of California-San Francisco's Breast Cancer Center, uses the Middlesex patients as an example. "The median survival time of the untreated patients was 2.7 years," he says, "and several patients lived almost two decades without treatment after the first symptom or sign of cancer in the breast. The survival of treated patients in the earliest radical mastectomy series was not very different ... [anal strikingly similar to that of this subset of American patients with apparently aggressive disease whose tumors were diagnosed and treated more than a century later" (note 9).
Nancy Evans of Breast Cancer Action--herself diagnosed with breast cancer 7 years ago--points out that, as with people diagnosed with HIV, it is unlikely that breast cancer is a curable disease, despite the reality that many women live with it a long time, dying finally of other causes (note 10). In patients followed for 20 to 30 years after initial diagnosis and treatment, 75% to 85% showed some evidence of tumor persistence at the time of death.3t Although "the earliest possible diagnosis" is sometimes helpful, it is not necessarily so.
The notion of a "cure" can be misleading, implying that we are fixed, inoculated against death, our existential state of impermanence magically remedied. There are several different medical uses of the term "cure." Clinical cure refers to a 10-year period in which there are no known symptoms and no known recurrence. Statistical cure means that a woman diagnosed with breast disease has the same relative survival chances as does the normal population--even though she may die "of" or "with" her tumor. Biological cure means that there is no evidence of malignancy at autopsy (verbal communication, Nat Berlin, MD, February 1996).
Continue to Part 2