Avoiding the Breast Cancer ‘Warrior’ Trap

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A few months ago, I was at a lunchtime fund-raiser for Gilda’s Club, a support organization for those living with cancer, when I heard Good Morning America's news anchor Amy Robach describe her own recent brush with breast cancer. It’s a story she’s rolled out in television interviews and in talks like this one, and it’s a story about cancer that is both wrong and hurtful.

I should know. I’m a doctor at a cancer hospital, so I’ve taken care of many patients who have breast cancer. I run a group that does health-care-policy work, so I know how patients with cancer get treated. I have led cancer guideline panels and advised organizations that set the standards for cancer screening and overall care. And my wife died of breast cancer a few years ago. 

Every inch the network TV star with four-inch heels, runway model legs, a Mentos smile, and a light southern lilt wrapping broadcaster’s diction, Robach was off track right from the start. A mammogram saved her life, she told us. But that is not something she could possibly know. 

Decades of research show that most women, if they get proper treatment, are going to have the outcome they’re going to have, whether their cancer is found by mammogram or another means. Mammograms will shift a few to a better outcome. Some experts say about one in five deaths from breast cancer are stopped by mammograms. But others say it’s closer to zero. The stance of United States Preventive Services Task Force is that starting mammograms at age 50 is utterly reasonable, as is doing them only every other year.  

Even starting then, only one in 200 women who is regularly screened over ten years will reduce their risk of dying from the disease. Some organizations, such as the American Cancer Society, are more aggressive, advocating for starting at age 40 and screening every year. The organization acknowledges that only an additional 1 in 2,500 women will reduce their risk by starting so much earlier. In a magazine interview, Robach, who is 40, trampled over this rich debate: “Get screened. Every year. No excuses.” 

But the effectiveness of mammograms isn’t the only thing Robach got wrong in her talk. She went on to tell us about having her healthy breast removed along with the one that had cancer, labeling it “the most aggressive treatment.” She told People magazine that she went this route because she wants to be around for graduations and grandchildren. But women at average risk of breast cancer (i.e., who lack the genetic defect that Angelina Jolie carries) increase the likelihood that they are alive in 20 years by less than one half of one percent through the surgery Robach chose. No expert or guideline advocates Robach’s choice as the standard for care; many warn it is inappropriate.  

Her misinformation didn’t surprise — “Get screened” is an easier message to comprehend than the complex tradeoffs of the actual disease. What did surprise me is that these arguments were being made by  a journalist whose job should be to appreciate and explain nuance, not look away from it.

Robach’s core thesis also troubled me. “I kicked cancer’s butt!” she told us, hitting each syllable, pausing for applause. She recently buttoned an interview with the phrase “Fight like a girl!” Using the pugilistic "fight metaphor" is nothing new — the American Cancer Society has a sword in its logo. So I shouldn’t have even blinked. But I winced.  

If Robach kicked cancer’s butt, then what about the 40,000 women this year who will die of breast cancer, just like my wife did? In Robach’s lexicon, they must just not be up to the fisticuffs, to taking the schoolyard bully outside and showing him a thing or two about standing up for oneself. They must be dying for their lack of fortitude. 

I started wondering if Robach thinks breast cancer is a zero-sum game where survivors are all Muhammed Alis, summoning the strength to rise from their stool for one more round in Manila, while those who die are all Joe Fraziers, just too fatigued and dehydrated to get up one more time; a deterministic world, framed by a medieval notion that ascetic denial and self-mutilation are guarantors of salvation, while all other paths lead to agony. 

All told, that world view is damaging. I basically agree with the American Cancer Society's recommendations — but by claiming that a mammogram saved her life, Robach implies that those women who are now dying of the disease and did not have a mammogram before age 50 have only themselves to blame, even though many organizations say they made a reasonable choice. And those who did not have their healthy breast removed when they were diagnosed? They just don’t care enough about their kids, even though no expert would recommend the surgery she had.

Picking through my lunch entrée, looking around the room, I realized Robach had clearly missed the point of that day’s lunch: To raise money for Gilda’s Club, as in Gilda Radner, as in the woman who died tragically of ovarian cancer 25 years ago. The club is a sanctuary where people suffering from cancer can connect with others experiencing similar plights. It’s full of Joe Fraziers, who go to share in their loss and fears; to feel less alone; to play card games.

Families can attend meetings and support groups; children of those with cancer go on field trips and participate in “Noogie Nights.” It is a place suffused by joy and tinged with sadness, because the simple truth is that many of its guests are having their butts kicked by cancer, not the other way around.   

In her interview in the magazine of the Federal Government’s National Institutes of Health, Robach declares that “there are nearly 2 million breast cancer survivors in this country, and we are thriving, excelling, living." Later in the article, she promises that having breast cancer leaves you stronger. Damn near invincible, actually. 

But what about those women who now have heart disease or disabling limb swelling from their treatment? Are they thriving? Among these 2 million survivors she lists, does she know sprinkled among them are thousands and thousands who have metastatic disease and are terminally ill? Leaves you stronger? WTF?

I wish for Ms. Robach a long, joyful, and healthy life. I hope she never needs Gilda’s Club. But unlike Robach, I know as a doctor and a spouse that the disease has a lot more control over the person’s fate than the other way around. Positive attitudes are great; receiving appropriate care is critical. But if you want to understand cancer, you have to first understand that the die is often cast well before any doctor finds the first patch of mutated cells.     

I know of what I speak. My wife also looked great in heels.