Thursday, April 8, 2010

Martina's breast cancer: double fault!

Martina Navratilova has grade 3 DCIS. What a shame! I am a huge fan. I was sad to hear the news -- but as I listened to her speak I became annoyed. As a public figure who has chosen to disclose her diagnosis she should get her facts straight. 

Fault one
In her Good Morning America exclusive disclosure, the 53-year-old Navratilova castigated herself for waiting four years between mammograms and encouraged women to "scrape together the money" to get annually screened. But in many parts of the country there are programs available for un-and-underinsured women. It's insensitive (at best) to urge women living in poverty to pay out-of-pocket for mammography without mentioning those resources. There is even some evidence that publicly funded mammography is underutilized by women receiving Medicaid - so perhaps the waiting times aren't too long.

On the other hand, maybe she should think twice about urging mammography at all! It's a complicated, tricky subject beyond the scope of this post.

Fault two
Without giving us enough clinical information to trust her assessment, Navratilova said she was lucky. Her lesion was apparently detected in its first year. "Lucky," she said, because "if it would have started three years ago I would be in deep trouble...the cancer would have spread." Sorry, but you can't back up that claim. Maybe your doctor told you your biopsy results were serious and your DCIS was aggressive. But neither your doc nor the rest of medical science understands the natural history of breast cancer well enough to predict that. We simply do not know with certainty which DCIS will become invasive and which will stay within the confines of the duct.

In fact, there is evidence that some DCIS spontaneously regresses. That's right: it may just disappear. When I spoke to her in 2008 Dr Laura Esserman was particularly excited about that finding. Esserman, director of the Breast Care Center at the UCSF Helen Diller Family Comprehensive Cancer Center, is a tireless advocate for women. As a surgeon she would be ecstatic to be able to determine which lesions were dangerous and which would fade away.

What's the big deal?
When misinformation is allowed to stand unchallenged it perpetuates, leading to several types of undesirable consequences. The misinformed Navratilova is so frightened by her diagnosis that she called it her "personal 9/11."

I am not being dismissive of Navratilova's medical issues or any anxiety they are causing her. But she is an intelligent woman who will benefit from a more nuanced understanding of DCIS and breast cancer screening. I wish her the very best throughout the rest of her course of treatment (external beam radiation coming up) and the rest of what I hope is a long and healthy life. Fortunately the odds favor exactly that.


Laura said...

Right on, Eve. The natural history of DCIS is unknown and her cancer could spontaneously regress. It's too bad most American women don't have that information at their fingertips.
And for the sake of news, didn't her announcement occur on a weekend. Unfortunately, that's the worst time for discussion because fewer people are paying attention. It's when corporations make cuts, etc. Congratulatons on posting this. I'll get the word out too and refer people to your post. For maximum impact, though, I wonder whether tweeting it Monday am would help it go viral.

Jenni said...

This is a wonderful, sophisticated commentary. Not to minimize breast cancer, but I find the level of hysteria that sometimes accompanies public discussion upsetting and misleading.