The quack view of preventing breast cancer versus reality and Angelina Jolie

I should have known it. I should have known that the reaction wouldn’t take very long. I should have known it based on prior history. The news story to which I am referring is, of course, the revelation yesterday in the New York Times editorial page by Angelina Jolie that she had decided to undergo prophylactic bilateral mastectomies (removal of both breasts) because she had learned that she was a BRCA gene mutation carrier, and the particular mutation that she apparently carried portended an 85% lifetime risk of breast cancer. The reaction to which I am referring is, of course, the same sort of despicable reaction that we see all the time from one of the crankiest of quackery-promoting quacks, Mike Adams, publisher of

This is a man known for not being—shall we say?—shy about using and abusing any celebrity cancer or health story that he comes across in the vilest way his fevered little brain can imagine to promote his favored quackery. He did it, for instance, when Patrick Swayze had pancreatic cancer. Swayze also had the temerity (and smarts) to say that he was eschewing quackery and sticking with science-based medicine, thank you very much:

If anybody had that cure out there, like so many people swear they do, you’d be two things. You’d be very rich, and you’d be very famous. Otherwise, shut up.

This, not surprisingly, infuriated Adams, who wrote up quite the tirade about it. Adams was similarly quick to pounce on the deaths of Michael Jackson of a drug overdose, the death of former Bush administration press secretary Tony Snow of colon cancer, and Tim Russert’s death from heart disease. Then, of course, he worked himself into a fine lather of righteous indignation over her “maiming” when Christina Applegate announced that she had undergone bilateral mastectomies for her breast cancer, who also had a BRCA mutation. So you can only imagine what sorts of vile article Adams came up with in response to Jolie’s decision to undergo bilateral mastectomy as a preventative measure, even though she didn’t have cancer yet. Yes, you can tell a lot by the title, Angelina Jolie inspires women to maim themselves by celebrating medically perverted double mastectomies.

Say what you will about Mikey. He’s consistent. Consistently vile. He’s also dead wrong, as usual.

First, you need to take note. The purpose of this article is blatant, and it’s to sell stuff. After Adams has seemingly gotten his readers all fired up over the horror of Jolie’s decision to “maim” herself, the very last section of the article advertises this:

Inform yourself and you can protect your body from the insane, knife-wielding cancer surgeons. Get the New Cancer Solutions CD set and empower yourself with real answers rather than cancer industry disinformation and deadly propaganda.

It comes complete with a video (included in Adams’ despicable article) that has to be seen to be believed, entitled The female anatomy of Modern Medicine. In any case, the CD includes a talk by Adams himself entitled The Consciousness of Cancer, which is billed as a “new way” of looking at cancer. No doubt it is, but also no cout it is a way that has nothing to do with science. From the title, my guess is that Adams subscribes to something similar to the German New Medicine or Andreas Moritz’s “wisdom of cancer cells” quackery, in which cancer is represented as a survival mechanism. There are also talks by “luminaries” of the “integrative” oncology and alternative cancer cure world, such as Thomas Lodi, Keith I. Block, and Richard Linchitz. It all looks to be a lot about “detoxification” and woo. (One notes that the Pink Lotus Breast Center, where Jolie had her surgery, is not above capitalizingon her announcement either, with a prominent splash page with a picture of her and a link to the details of her decision.”

Now that that point is out of the way (and it’s arguably the most important point, which is why I skipped to the end of Adams’ screed first), Let’s get a real taste of what Adams thinks, if you can stand it and if you can call it “thinking”:

Angelina Jolie announced yesterday that she had both of her breasts surgically removed even though she had no breast cancer. She carries the BRCA1 gene, and she has been tricked into believing that genetic code is some sort of absolute blueprint to disease expression — which it most certainly is not. Countless millions of women carry the BRCA1 gene and never express breast cancer because they lead healthy, anti-cancer lifestyles based on smart nutrition, exercise, sensible sunlight exposure and avoidance of cancer-causing chemicals.

Jolie, like many other women who have been deluded by cancer quackery, decided the best way to prevent the risk of breast cancer was not to lead a healthy, anti-cancer lifestyle, but rather to surgically remove her breasts in what she describes as “three months of medical procedures.”

…just in case, you know. Because you can never be too careful these days, with the cancer industry scaring women half to death at every opportunity. “My breasts might murder me!” seems to be the slogan of many women these days, all of whom are victims of outrageous cancer industry propaganda and fear mongering.

And later:

Oh, what a mess Jolie has made of herself. She has maimed her own body with no medical justification whatsoever, then celebrated this horrible disfiguration through some sort of twisted perception of what womanhood really is. Being an empowered woman doesn’t mean cutting off your breasts and aborting live babies — even though both of these things are often celebrated by delusional women’s groups. Being an empowered woman means protecting your health, your body and your womanhood by honoring and respecting your body, not maiming it.

And, the “coup de grace”:

Wonderful? To cut off parts of your body that have NO disease? With this logic, abortions are cancer prevention, too, because those babies might one day grow up and develop tumors. Better to kill them early and “prevent cancer,” right?

The mind boggles.

One can’t help but note that Adams is indulging in a favorite pastime of quacks every where: Denialism of genetics and wishful thinking that genetics don’t rule. OK, it’s true that in some cases they don’t. If a gene doesn’t have a high penetrance, interacts with other genes, or has an activity that is highly influenced by environment, genetics isn’t always destiny, but in the case of the particular BRCA1 mutation that Jolie reports having, there is an 85% lifetime risk of developing breast cancer. Given that breast cancer is a type of cancer that is not highly lifestyle- and diet-dependent (note, that is not to say that lifestyle and diet have no effect, just that the effect tends to be relatively small), no amount of “anticancer lifestyle, “smart nutrition,” and “avoidance of cancer-causing chemicals” is going to lower that 85% chance of breast cancer by very much, no matter how much Adams’ wishful thinking might try to mislead other women that such interventions can.

Now, it needs to be pointed out here that a BRCA1 mutation, such as the one that Jolie had, is a very special situation, where the risk of cancer is known and very high. I’m normally not a fan of prophylactic surgery, and I tend not to do bilateral mastectomies in my practice except under certain circumstances (such as BRCA1 mutations). Few women fall into that category, and, mutation carriers aside, there is no good evidence that doing bilateral mastectomies for breast cancer improves overall survival and decreases the odds of a woman dying of breast cancer. Personally, I’ve been rather disturbed at how much the demand for bilateral mastectomies has been driven by patients; it hasn’t really been driven by physicians. In this, I’m mostly in agreement with Monica Morrow, one of the most prominent breast surgeons there is, when she says:

“It’s important to make it clear that a BRCA mutation is a special, high-risk situation,” said Dr. Monica Morrow, chief of the breast service at Sloan-Kettering. For women at very high risk, preventive mastectomy makes sense, but few women fall into that category, she said.

For women’s health advocates, the trend toward double mastectomies in women who do not have mutations is frustrating. Studies in the 1970s and 1980s proved that for many patients, lumpectomy was as safe as mastectomy, and the findings were seen as a victory for women.

Even so, there is increasing demand for mastectomy. Dr. Morrow says that she has often tried to talk patients out of it without success. Some imagine their risk of new or recurring cancer to be far higher than it really is. Others think that their breasts will match up better if both are removed and reconstructed.

And it’s true. Jolie is a special case. We don’t see too many BRCA1 carriers. In Jolie’s case, bilateral mastectomy was entirely appropriate and medically indicated. That’s not always the case for a lot of bilateral mastectomies that are being done these days. Not surprisingly, part of what drove Jolie’s decision was the death of her mother at a young age (56). In any case, I’m not alone in being a bit worried that this announcement will provoke a run of patients demanding what Angelina Jolie had, regardless of whether it’s appropriate or not. Expressing concern about that, as some breast surgeons have in the wake of Jolie’s announcement, however, is not what Adams is about. He is about portraying modern medicine as “maiming” women and implying that it is surgeons who are promoting bilateral mastectomy when in fact the vast majority of us are not. Indeed, the drive over the last 30 years has been towards increasingly less invasive surgery for breast cancer (a trend driven, I would point out, not just by breast cancer advocates but by science and surgeons themselves, at the cost of revenue, given that larger surgeries like mastectomies are certainly better reimbursed than smaller surgeries).

There are also other issues brought up by Jolie’s decision. For instance, the way she went about it is not entirely science-based. If you peruse the blog post describing the process, you’ll find that she underwent a “nipple delay” procedure, in which the tissue underlying the nipple is cut in order to rule out cancer right behind the nipple and to “improve the blood flow.” The idea is that the nipple delay procedure cuts the normal blood supply to the nipple and “forces” it to rely on the surrounding skin for its blood supply, thus making the chance of nipple necrosis (in which the nipple turns black and falls off due to low blood flow) much less likely. It’s a procedure for which the evidence, in my estimation, is fairly shaky at best and is usually reserved only for patients who have had previous breast surgery around the nipple. After the surgery, Jolie apparently used a whole bunch of supplements at the instruction of the Pink Lotus Breast Center (which is apparently very much into “holistic medicine“), including vitamin C and a homeopathic remedy, Arnica Forte, which, it is claimed, improves wound healing. In her editorial describing her journey, Jolie herself writes:

I acknowledge that there are many wonderful holistic doctors working on alternatives to surgery. My own regimen will be posted in due course on the Web site of the Pink Lotus Breast Center. I hope that this will be helpful to other women.

Another issue to discuss might have to wait, as this post is getting long, and I need to wrap it up. (I might revisit this issue again next week on my not-so-super-secret other blog that has my real name on it, not unlike The Name of The Doctor.) Specifically, that’s the issue of BRCA1 testing itself. Myriad Genetics holds the patent on all BRCA testing, which means that it holds a monopoly on the process. No other gene test for BRCA1 is legal right now because Myriad holds the patent on the genes BRCA1 and BRCA2. There’s also the issue of Jolie’s extreme wealth, which provides her options average women don’t have, given that insurance companies will sometimes not pay for BRCA testing and preventative surgery. These might well be the topic for another post. In the meantime, contrary to Adams’ spew otherwise, Jolie made a reasonable, medically justifiable decision based on her family history. The only question I have remaining is whether she will remove her ovaries too (no mention was made of it in her op-ed).

That, and how Mike Adams can live with himself, but that’s a question I’ll probably never have the answer to.