Holiday weekend reader mailbag: In which Orac is chastised for “condemning someone who helps people”

The Thanksgiving holiday weekend continues here in the U.S., and, believe it or not, I plan on taking it fairly easy, hanging out with my wife and (hopefully) going to see the new Harry Potter movie later today or tonight. However, even so, I can’t resist doing a bit of holiday mailbag fun, first because it’s easy, but more importantly because this time around it’s instructive. A new reader, who obviously found this blog through a Google search on something or other writes:

Hello Orac, I stumbled across one of your blog pages and I felt compelled to share my story with you.

Seven years ago I noticed a huge lump on my left breast that sprang up quickly and went in for a mamogram. I have really dense fibrocystic breasts so it all looked like a huge mass, the radiologist couldn’t really see anything so they did an ultrasound. What they found was a really huge mass growing on my chest wall (stage 4 – 95% chance of it being malignant) and they told me I needed emergency surgery and I would most likely lose my entire breast. Having no insurance and parents who were ill and counting on me to help them and knowing that even with the best treatment survival for a stage 4 breast cancer would only be 5 years anyway, I opted to do the parasite cleanse. I was terribly frightened but had no choice.

Six weeks later I returned for another ultrasound and the Surgeon yelled at me accusing me of doing something “Where the hell is it – what did you do?” !!!!! I told her nothing but meditation and prayer but actually it was whole food nutrition, the parasite cleanse, meditation, prayer, faith and the sincere desire to get well enough to continue to be of service to others. She was pissed! Why? Because I was WELL !!!!! Of course she lost a huge amount of money by me not following her treatment plan!

So tell me Dr. Orac, how can you condemn someone who helps people. I know people who have had cancer over and over again with conventional treatment and it keeps coming back, time and time again and yet you don’t condemn those doctors? I can only say that any doctor, conventional or alternative, that does not support thier patients beliefs is who operates as a Quack! Here it is 7 years later and I still have my life and my breasts. I sincerely hope you never have to live through the mental torment that a cancer diagnosis brings or the humiliation of being treated by someone who finds it more important to be right than whether thier patient is still alive and in one piece.

Regular readers, I ask you to evaluate this story. I will evaluate it as well, but below the fold. Try not to peak at my answer before coming up with yours.

I had two immediate reactions to this testimonial. My first reaction was, if her story was true, that her surgeon was not only incompetent but an asshole. The first thing any decent breast surgeon (or any general surgeon or surgical oncologist who does breast surgery as part of his or her practice) would want in this clinical situation would be a tissue diagnosis. Given that the mass was large, it would be a chip shot to get a tissue diagnosis using a core needle biopsy. No need for extensive surgery! If the mass is palpable, it wouldn’t even be necessary to use ultrasound to guide the biopsy. Of course, I strongly suspect that my critic is either exaggerating or telling a highly biased version of the story. It’s pretty rare in my experience for a surgeon to yell at a patient in this manner, although it is not uncommon for us to try to persuade a patient who is undertaking a potentially harmful course of action not to proceed with her plans. My guess is that the surgeon would have a very different story to tell. My second reaction was that “stage 4” is a meaningless term when applied to a mass that hasn’t even been shown to be cancer yet. My guess is that this woman confused “stage 4” with “category 4.” You see, radiologists score mammogram and ultrasound studies according to the Breast Imaging-Reporting and Data System (BIRADS). The BIRADS classification system is designed to force radiologists to come up with an estimate of what the likelihood of malignancy is based on imaging studies alone. Scores are as follows:

  • BIRADS 0: More imaging is necessary to make an assessment
  • BIRADS 1: Normal. No evidence of malignancy.
  • BIRADS 2: Benign findings.
  • BIRADS 3: Probably benign. Basically, the standard of care for BIRADS 3 mammogram/ultrasound studies is to recommend a repeat study in 6 months. The rate of malignancy in such studies is well under 1%, and virtually all such malignancies found are stage 0 or 1. That’s why it’s safe to wait 6 months and re-image.
  • BIRADS 4: Suspicious for malignancy. Approximately 20-25% of BIRADS 4 studies turn out to be malignant. We recommend a biopsy for almost every woman with a BIRADS 4 study.
  • BIRADS 5: Very suspicious for malignancy. Approximately 70-90% of BIRADS 5 studies turn out to be malignant. We recommend a biopsy for every woman with a BIRADS 4 study. We also warn them that they have a high probability of having breast cancer–although not 100%.
  • BIRADS 6: Known biopsy-proven cancer.

What almost certainly happened is that my critic had a BIRADS 4 imaging study, in which case she had a 3/4 chance of not even having a malignancy at all! Given that her lesion disappeared, the most likely explanation for her testimonial is that she never had cancer at all, particularly given that she never had a biopsy. This is quite consistent with several other testimonials I have discussed over the years. In general, the explanations for such testimonials fall into a few well-defined categories. Either the woman never had cancer at all, which is most likely what’s going on here. After all, to emphasize the point, in my critic’s case there was never a biopsy to prove that she had cancer, and not all breast masses are malignant. Alternatively, in other testimonials, the woman did have cancer that was properly diagnosed but also had some conventional therapy (such as surgery) and only refused some therapy (such as chemotherapy or radiation, or the woman doesn’t understand the inherent variability in breast cancer biology that produces a subset of breast cancers that have a very slow-growing, indolent course. Often the cancer patient giving the testimonial has serious misunderstandings about her disease and prognosis, often confusing terms like “category” and “stage” or “grade” and “stage.”

As for the last bit. I’ll tell my critic how I can condemn someone who helps people: They don’t. The “parasite cleanse” and prayer might have made this woman think she was feeling better, but neither did anything for her breast mass, which almost certainly was not malignant and almost certainly resolved on its own, as, for example, cysts sometimes do. Breast cancer is not caused by parasites, and, unless a practitioner advocating such quackery can produce scientific evidence sufficiently compelling to make me doubt our current understanding of breast cancer, there is no reason to suspect that such quackery does anything other than put my critic at risk for dehydration and other potential complications. As the saying goes, the road to hell is paved with good intentions, and a quack’s allegedly good intentions do not excuse him for pushing therapies that do no good and have the potential to cause harm, either through delay in seeking known effective, science-based therapy or direct harm from the quackery itself.