Tuesday, May 1, 2012


Well.... it turns out we really CAN prevent breast cancer..... If you read this blog, you know that my tongue is so firmly planted inside my cheek....... or, my teeth have left marks on my tongue from biting it.  Generally, I'm not one to bite my tongue.  In another life, I was a big tongue biter.  No more.  That person is gone and now, I just call it like I see it.  And, I don't care if people get upset.  Change the channel.  Tune me out and tune in elsewhere.  Freedom of speech and all that jazz.  Feel free to share information.  Use the proper caveats.  Are you expressing an opinion?  Then do not frame it as a medical fact.  It insults my intelligence.  I feel like Al Pacino handing that glass to Carlo before he meets his fate in that last scene of The Godfather.  Me and Al.  We don't like having our intelligence insulted.  That's a grammatical mess but frankly, I don't really care about that at this moment, either.

This appeared in an article back in November and I like this point of view.  I know the link to the original Medscape article is likely not going to work unless you set up an account with a login and a password.  The words below were spoken by Dr. Kathy Miller from Indiana University.  There are video blogs on the Medscape site.  She is an oncologist whose advice, if followed, as she says, will put her "blissfully out of business."

The point of the article and the video is to explain how primary care physicians should be doing more to incorporate breast cancer risk reducing conversations into their practices.  I'm sure many do but I'm sure many more do not.  She compares this to cardiology.  Your primary doctor will do blood work and test your lipids (cholesterol, triglycerides).  They check your blood pressure.  Issues with either of those things can be controlled once a person is made aware they may be at risk for heart disease or stroke.  We all know what constitutes high cholesterol or high blood pressure.  If our doctors find we are prone to either, they will discuss ways in which we can attempt to change our diet and incorporate exercise and stress reducing activities into our lives.  They may prescribe medications.  These situations, unless the numbers are off the charts, do not set off the "you need to see a cardiologist" bell. 

Are our primary care physicians discussing things we can do to reduce our risk of developing breast cancer?  I'm trying to think back to those years I was "blissfully NOT in this club."  I had two excellent gynecologists. Aside from a breast exam and a prescription for a mammography, I'm not sure we ever discussed the importance of exercise, a healthy diet, maintaining proper weight, alcohol intake.... that list.  The list of things we can do to give ourselves the best possible edge and then, it does, and is, and for the time being shall remain: a crap shoot.  But..... there are things.

According to Dr. Miller, the PCP's "simply don't think this is their job."  It is not said in a deragatory fashion.  It's a simple observation and perhaps a suggestion for ways in which to incorporate more whole body health into the hands of our internists, our primary care physicians.  She goes on to say they are not equipped or well trained..... they are not comfortable discussing oncology drugs.  Considering the damn toxicity of most oncology drugs, I can't say I blame those PCP's ONE iota!

The thing is this.  If I understand her correctly, statins would need to be prescribed to 275-325 patients in order to prevent ONE heart attack or ONE stroke.  These drugs are being prescribed by the PCP. Interestingly enough, in order to prevent just ONE breast cancer, SERM's or AI's (like tamoxifen or femara) would need to be prescribed to the same 275-325 patients.  Dr. Miller's point is well taken.  Why aren't our PCP's provided with guidelines to follow so they might perform the necessary tests to determine which women might benefit from tamoxifen or an aromitase inhibitor?

Her point is valid.  I was a high risk patient.  Then I was a breast cancer patient.  Might I have benefitted from tamoxifen? Maybe I was one of the 275-325 patients in the group that fit the guidelines.  If I were in that group, maybe the tamoxifen would have done its job before those cells went rogue.  I know me and I would have wanted better odds than one in 300 to deal with the risks associated with tamoxifen but that's a whole other issue.  The thing is.... the option was never even on the table for discussion.  I like her train of thought.  It makes sense.

As for the word prevent...... I make no apologies for the sour taste that word leaves in my mouth.  Too many of us feel could have, should have done something... that the cancer was somehow our fault.  This is the way Dr. Miller explains we CAN prevent breast cancer.......

"I was talking about breast cancer prevention and screening in our Department of Medicine grand rounds today. In reality, we could prevent breast cancer today.

Here is what we would need to do: Mandate that every woman has her first child, the first of at least 7 or 8, at about age 15, with a prophylactic mastectomy after delivery of that last child, and absolutely mandatory breastfeeding, for at least a year per child, with a prophylactic mastectomy after the last child is weaned. Everybody has to do an hour of exercise daily and follow a diet with a maximum of 20% of calories from fat.

Obesity is outlawed, or at least taxed, particularly postmenopausal weight gain. We would return to Prohibition -- so no more cocktail hour, no more wine with dinner. Prempro® would be absolutely removed from every pharmacy. Think about selling selective estrogen receptor modulator (SERM) or aromatase inhibitor (AI)-fortified foods (particularly for women) in health food stores. If you do all of these things, I am blissfully out of business."

(Me again... obviously, she was finished with the 1984 Orwellian rant and I do love a woman with a good rant.......But she went on to further explain.......)

"I know we are not going to do these things."

But there is something we could do, which is take a lesson from our cardiology colleagues. Cardiologists have made preventive cardiology internal medicine's bread and butter. In reality, we treat hypertension primarily to prevent heart disease and strokes, and also to prevent kidney disease, but primarily to prevent heart disease and strokes. We also treat hypercholesterolemia to prevent heart disease and strokes. When was the last time your internist said, "Oh, my dear, your cholesterol is 250. That puts you at risk for heart disease, so I'm going to send you to a cardiologist." Cardiologists have made primary prevention a primary care priority. We have not done that.
We have kept preventive oncology in the realm of oncology. That means that primary care physicians simply don't think this is their job. They don't feel equipped and well trained. They are not comfortable with our medicines. In their minds, the benefits of a SERM or an AI for prevention are too small to justify prescribing it.
If you look at the number of patients you need to treat with a statin to prevent 1 heart attack or 1 stroke, depending on which study and which statin you look at, you come up with a number-needed-to-treat of somewhere between 275 and 325 people. That is identical to the number of patients needed to treat with a SERM or the number of patients needed to treat with an AI to prevent 1 case of breast cancer.
So here is my plea: Make primary oncology prevention an internal medicine primary care issue. There is no reason not to, and if it takes off, we could be a lot less busy.

I love a woman with a brain.... and I love a woman who isn't afraid to use that brain.... and I most especially love a woman who isn't afraid to open her mouth when something makes sense.  It's time for us to start being more sensible, don't you think?  I know this isn't going to change a damn thing and really, what I do want is meaningful change....... but having spent yesterday in a building where each of the ten floors is devoted to one specific cancer specialty..... and getting stuck on the elevator that, of course, stopped on every single floor..... I looked into the eyes of the woman who was using those calming breathing techniques, I watched the brother and sister who were about my age talking to their dad about the need for him to get stronger before they could even entertain any of the options laid before them by the doctor, I listened to the woman in the waiting room who was a bit louder than necessary telling the person on the other end of the phone that her drains were removed but no, she can't drive just yet and her flight was expected to land by 4PM...... 

If just one of the many people who I encountered might be spared jumping on the cancer bus because of this change, I'll take it.  It's not nearly enough but if you happen to be that one person, it's surely MORE than enough. 


  1. AnneMarie, this is a powerful post. Dr. Miller ROCKS! She makes SO much sense. Think what Miller and Love could do together! I wonder if they know each other.


    1. Thanks Renn....

      I just want to make sure everyone carefully reads HOW Dr. Miller says we can **prevent** breast cancer!!! Because what she's really saying is, "we can't" .... but we don't all need to WAIT for the disease to come knocking. SOME of us MIGHT be helped by "precautionary" tamoxifen or aromitase inhibitors. Might only be one of us.... but that's the same odds they are getting by prescribing heart drugs.

      You know and pretty much everyone I communicate with agrees..... "No Prevention of Breast Cancer" ... and I don't want anyone to think I'm inferring otherwise. Perhaps clarification of the title is in order???


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