Richard Margolese, surgical oncologist at McGill, says, "The management of ductal carcinoma in situ ... is controversial. It is not clear whether all carcinomas are preceded by DCIS or if all DCIS leads inexorably to carcinoma.... A better understanding of the biology of DCIS would lead to better clinical management."33 Because of the confusion surrounding the sequelae to DCIS, many current breast cancer studies include women with DCIS, because they regard it as a malignancy; thus the outcomes of these studies are skewed. According to William Silen of Harvard, "Twenty-five or thirty years ago, it was taught that there was no such thing as noninvasive carcinoma of the breast. In pathology, I was taught that if you looked far enough, you'd always find invasion. I'm absolutely convinced that a lot of the so-called cures achieved with radical mastectomy were patients who actually had noninvasive carcinomas of the breast."33(p358) Unfortunately, the language does not change appropriately every time the explanatory model shifts. Understandably, this causes confusion. The term "carcinoma" is used both to define malignancy and to describe tumors that are not malignant by virtue of the fact that they neither invade nor spread.
Public misconception abounds concerning the concept of "early detection." It is perhaps the most mystifying oxymoron within the vocabulary of the breast cancer paradigm. What is early? Ideally, it is before the local malignancy has spread, or metastasized. Although it's a difficult notion to accept, there is no way of knowing whether malignant cells have spread by the time of detection. Frequently the term "early" is confused with the term "small." Generally a small lump is preferable to a larger one--but this is not always the case. The significant determinant is biological: whether the cancer has infiltrated beyond local boundaries, how fast it is growing, and where it is growing.
It is known that it takes an average of 10 years for a tumor of the breast to grow to 1 cm (a little less than half an inch) in diameter. It is hypothesized by Judah Folkman34 of Harvard that as the number of blood vessels supplying the tumor increases, so does the likelihood of metastatic disease. It is not known precisely how long it takes for tumors to acquire an adequate blood supply. It takes approximately 5 years from the time a cell becomes malignant (de, shows evidence of uncontrolled growth) to the time that it develops enough vasculature for tumor cells to enter the bloodstream. One cubic centimeter of breast cancer tissue contains roughly one billion cells. Based on the doubling rate of cells, it takes 30 replications for one cell to become one billion. If the time of replication is 120 days, tnen there are 3 replications per annum, so over a 10-year period there are 30 replications. It is thought that in the first 5 years (half of the hypothesized 10-year period), the mass is not sufficiently vascularized (does not have an adequate blood supply) to be able to metastasize. But a palpable mass--or one visualized on mammography that is 1 cm in diameter or more--may have been growing for 10 years. l By this stage it has likely become bloodborne and widely disseminated. Local treatment--mastectomy, lumpectomy, or radiation--will not have any impact on survival if malignant cells have been seeded elsewhere (note 11).
Breast surgeon Susan Love,35 testifying before the Senate in 1991, stated that
[w]e have spent a lot of time, energy, and money touting early detection and preserving it as if it were the answer. Unfortunately, we have misrepresented the situation through wishful thinking or just an attempt at simplification. We have acted as if all tumors go through progression from one centimeter to two centimeter[sl and on and on as if all tumors have the potential to be detected at a small size and therefore could be cured. Would that were true. What we are dealing with is a combination of a tumor and an immune system. Some tumors are very aggressive and will have spread before they are palpable. Thirty percent of [the women with] nonpalpable tumors are found to have positive Iymph nodes. Some tumors are very slow growing andwill not have spread even though they have reached a large size (note 12).
The value of"early detection" is complicated by a factor called "lead--time bias." Namely, women appear to live longer when the disease has been identified earlier, but mortality has not necessarily been affected. There is a widespread collective misunderstanding that if only the lump is found "early," the problem can be either aborted or "fixed." This has led to false guilt on the part of women who feel that through their negligence they are responsible for their misfortune, false blame toward doctors even though they could not have discovered the lump sooner (and even if they had, it would not have mattered), and anguish at a cost of millions of dollars in litigation without sound medical foundation.