The quack view of preventing breast cancer versus reality and Angelina Jolie, part 2

After yesterday, I really hadn’t planned on writing about Angelina Jolie and her decision to undergo bilateral mastectomies again, except perhaps as a more serious piece next week on my not-so-super-secret other blog where The Name of the Doctor is revealed on a weekly basis. As I mentioned yesterday, there are a number of issues about the decision that could use my professional attention, from the process, to the evidence, to the issue of how the surgery was handled. Oh, and if I do decide to do that I’m sure I won’t be able to resist a mention of some of the quackery that oozed out from underneath the darker recesses of the quackosphere, but the division of labor I enforce usually reserves the more “Insolent” takedowns for this blog. That means I can’t resist the pull of the other quacks who’ve descended upon Angelina Jolie in droves. As a result, I can’t resist taking a look at a carefully selected subset of them.

First, it was Mike Adams, as I mentioned yesterday. This is Mikey, though, and for Mikey too much is never enough. So he decided to go for another bite at the apple with a post entitled
How Angelina Jolie was duped by cancer doctors into self mutilation for breast cancer she never had. The first thing I noticed is that once Adams latches on to an analogy he never lets go. He’s a lot like a shark ripping into a kill or a Nile crocodile grabbing onto a hapless gazelle who wanders too close. In this case, the analogy is the same. I ignored it last time, but this time around I can’t:

With her breasts removed, she says her risk of breast cancer is now reduced to a mere 5 percent. The same bizarre logic can also be applied to men who cut off their testicles to “prevent testicular cancer” or people who cut out their colons to “prevent colorectal cancer.” But that would be insane, so nobody does that, because one of the most basic principles of medicine is that you don’t subject patients to the considerable risks and costs of surgery and anesthesia to remove organs that have no disease!

Wrong, Mike. Actually, people do remove their colons to prevent colorectal cancer. Adams is even more ignorant than I thought, apparently never having heard of, for example, familial adenomatous polyposis (FAP). It’s a condition in the colon in which there are numerous polyps that predispose patients with condition to colon cancer such that by age 40 or 50 the risk approaches 100%. The treatment? Prophylactic colectomy. Yes, that’s right, removal of the colon to prevent colorectal cancer. There’s also hereditary non polyposis colorectal cancer (HNPCC), which involves a mutation in a gene with a similar function to that of BRCA1, the gene in which Angelina Jolie had a mutation that predisposed to breast cancer, specifically a gene involved in the repair of DNA damage. The risk from HNPCC isn’t as high as it is for FAP, but it’s plenty high, more than high enough to justify prophylactic surgery to avoid colon cancer.

As for the example of testicular cancer, there are no known mutations that predispose to testicular cancer at nearly as high a risk as the risk for breast cancer conferred by BRCA1 and BRCA2 mutations or for colorectal cancer conferred by FAP or HNPCC mutations. Also, testicular cancer is a rather uncommon cancer compared to breast cancer and colon cancer, which means that the chance of getting it in the average man is much smaller than the risk of colorectal cancer. It’s a dumb example, comparing apples and oranges. Of course, dumb examples are Adams’ stock-in-trade.

Next up, Adams tries to make you think that he understands more about cancer than he actually does. First, he claims that women are being “lied to” and that the readers of the New York Times who read it. Then he writes:

The very idea that breast cancer is a “percent risk” is a complete lie. In reality, everyone has cancer micro-tumors in their bodies, including myself. Cancer is not a disease you just “get” like being randomly struck by lightning. It’s something you must “manage” or “prevent” day by day, meal by meal, through a lifestyle choice that involves vitamin D supplementation, nutrition, superfoods, vegetable juices and avoidance of cancer-causing chemicals and radiation.

So when a doctor says you have a “chance” of getting cancer, what he’s implying is that you have no control over cancer, and that’s an outright lie. Cancer quackery, in other words.

In fact, this is a very common theme among the quacks, namely that you have near-absolute control over whether you get cancer or not. For example, it’s echoed by one of my most despised cancer quacks, Robert O. Young, who has also jumped all over the Angelina Jolie case to write Acids From Lifestyle and Dietary Choice Causes Breast Cancer NOT the BRCA1 GENE. Yes, he even uses all caps in his titles, one true sign of a quack. To Young, The One True Cause of Breast Cancer is not any sort of gene mutation, but rather “acid” from diet and organochlorines. I can’t tell for sure. He can’t seem to make up his mind. What is clear based on the evidence is that, even if organochlorides are a major cause of breast cancer (and the evidence cited is not that strong), they are no way as potent a cause as BRCA1 mutations.

Meanwhile, Adams can’t resist flaunting his ignorance:

The very idea that breast cancer is a “percent risk” is a complete lie. In reality, everyone has cancer micro-tumors in their bodies, including myself. Cancer is not a disease you just “get” like being randomly struck by lightning. It’s something you must “manage” or “prevent” day by day, meal by meal, through a lifestyle choice that involves vitamin D supplementation, nutrition, superfoods, vegetable juices and avoidance of cancer-causing chemicals and radiation.

So when a doctor says you have a “chance” of getting cancer, what he’s implying is that you have no control over cancer, and that’s an outright lie. Cancer quackery, in other words.

While it’s true that all of us have “cancer micro-tumors” within our bodies, it’s a complete misunderstanding of risk. The observation that we all have cancerous cells within our bodies says nothing about the risk that one or more of them will progress to a macroscopic cancer that will actually threaten health and life, nor does it mean that you have to “manage” or “prevent” cancer day by day. Yes, there are cancers that are greatly influenced by lifestyle (lung cancer being caused by smoking is perhaps the strongest example), but there are also cancers that have a clear genetic cause. BRCA1-caused breast cancers and ovarian cancers are examples of these, and all the “lifestyle interventions” in the world won’t significantly decrease the risk of cancer. Well, all save one, but the quacks won’t like it. I’m referring, of course, to Tamoxifen, a product of what Adams would view as the evil of big pharma. Adams further claims:

Indole-3-carbinol (I3C), by the way, a natural chemical found in cruciferous vegetables like broccoli and cabbage, offers powerful prevention against BRCA1 gene expression. But you don’t hear cancer doctors telling women to “eat more cabbage” because that doesn’t make the cancer industry any money. You can buy I3C as a potent nutritional supplement from a variety of sources. It’s literally cancer prevention in a capsule.

So the whole “chance” argument is pure quackery. There is no chance involved in whether you get cancer. It’s all cause and effect. You are either living a pro-cancer lifestyle and therefore growing cancer, or you’re living an anti-cancer lifestyle and keeping cancer in check so that it never becomes a problem. Cause and effect is what results in either the growth of cancer tumors or the prevention of cancer tumors. There is no “luck” involved.

First off, Adams gets it wrong (as usual). I3C doesn’t suppress BRCA1 expression. Rather, it increases it. That’s how it’s thought to work to potentially decrease the risk of certain cancers. As one of my readers pointed out, making more BRCA1 doesn’t do much good if the BRCA1 produced is not functional because of a mutation. The second part of Adams’ “argument” (if you can call it that) is even more ridiculous. Every biological process involves a stochastic process; i.e., chance. The claim that there is no “luck” involved betrays such a profound ignorance of biological processes that it’s hard to fathom how Adams can walk and breathe at the same time.

One also can’t help but note that Adams once again takes the opportunity to flog his quack New Cancer Solutions Healing Summit, just as he did last time.

Sadly, Adams is not alone in his denialism of biology. Remember Sayer Ji? He’s the guy who claimed that vaccines are “transhumanism” that subverts evolution and made one of the most spectacularly clueless arguments against evidence-based medicine I’ve ever seen, dismissing it as a “coin flip.” This time around, he’s denying that genes cause cancer, the same way that Adams did yesterday, but he tries to put a “science-y” sounding gloss on the statement:

Despite the commonplace refusal of so-called ‘evidence-based medicine’ to acknowledge the actual evidence of genetics, we moved into a Post-Genomic era over a decade ago following the completion of first draft of the entire human genome in 2000. At that moment, the central dogma of molecular biology – that our DNA controls protein expression, and therefore disease risk – was disproved. Our genome was found to contain roughly 20,000 genetic instructions – not even enough to account for the 100,000 proteins in the human body!

As a result, we must now accept that factors beyond the control of the gene, known as epigenetic factors, and largely determined by a combination of nutrition, psychospiritual states that feed back into our physiology, lifestyle factors, and environmental exposures, constitute as high as 95% of what determines any disease risk. In fact, even the psychological trauma associated with being diagnosed with cancer can drive malignancy via adrenaline-mediated multi-drug resistance,[i] and according to a recent NEJM study, lead up to a 26-fold increased risk of heart-related deaths in the seven days following diagnosis.[ii]

Epigenetics. You keep using that word. I do not think that it means what you think it means.

Yes, when I spoke about how quacks view the word “epigenetics” in much the same way that the view the word “quantum,” basically as a simile for the word “magic.” In the quacks’ eye view, epigenetics is capable of anything, and we can magically control our own gene expression through diet, exercise, and even just thinking happy thoughts, all of which, it is claimed, alter gene activity through epigenetics. Yes, if diet can’t change your gene expression to whatever you like it through epigenetics, then wishing makes it so through happy thoughts. Except that it doesn’t.

Ji also beats on a straw man, namely the belief that you either “have the gene” or don’t when it comes to BRCA1 and BRCA2. Of course, because popular understanding of how BRCA1 mutations predispose to cancer are simplistic does not mean that that’s what physicians tell their patients. Indeed, whenever BRCA1 and BRCA2 mutations are reported, the risk associated with the specific mutation(s) detected is listed alongside the result. Some BRCA mutations confer high risk of breast and ovarian cancer, such as the 87% risk that Angelina Jolie was told that she had. Some confer much less risk. Some are referred to as being of “uncertain significance,” which means we don’t really know how much of a risk they do or do not confer. Ji twists himself in knots (the same way he twists science and logic in knots) when he perseverates over an observation that there is actually a BRCA2 mutation that is associated with a lower risk of cancer. There is a problem, though. The main point of the editorial cited was not that BRCA testing doesn’t matter but that family history should trump gene testing. Of course, that is exactly the way that most genetic counselors practice; they don’t blow off a negative BRCA test in a patient with a strong family history of cancer. Such patients are still treated as being at high risk. The whole point is a bit of a straw man.

Ji is also enamored of the concept of overdiagnosis, just like Mike Adams. Only, he expresses it differently:

Another concerning blind spot in the framing of Jolie’s decision is that approximately 70,000 breast cancers (31% of annual breast cancers diagnoses) are misdiagnosed by the vast breast cancer ‘awareness’ and treatment complex each year.[vi] These are not just so-called “zero stage” breast cancers such as Ductal Carcinoma In Situ (DCIS), which arguably should be reclassified as non-cancerous normal variations in breast morphology, but 50% are known as early-stage “invasive” breast cancers [view NEJM study video analysis here].

How many of these women, having received a mammography-detected diagnosis of breast cancer and then a follow up BRCA test, believed that the gene must have therefore “caused” the “cancer”? The popularization of this crude way of understanding natural, sometimes self-limiting variations in breast morphology as cases of “breast cancer” is itself a malignancy that should be prevented and treated with healthy doses of the very ‘evidence’ that the so-called ‘evidence-based’ medical system claims to possess as a differentiating factor from other, more ancient, plant- and nutrition-based medical traditions.

Uh, no. While it is true that overdiagnosis is a big issue in cancer screening right now, just because there is significant overdiagnosis of cancer does not mean that the imputation of causation to BRCA1 mutations for cancers that might be overdiagnosed is incorrect. Moreover, it goes way too far to advocate reclassifying DCIS as “noncancerous normal variations in breast morphology.” It is not, and it is known to be a lesion that progresses to invasive breast cancer with a high frequency. That many DCIS lesions never progress and some even regress does not make them a “normal variant.” Ji refers to the NEJM study of overdiagnosis in breast cancer published in December, but he clearly doesn’t understand its significance.

It’s clear that Angelina Jolie’s decision to try to lower her very high risk of breast cancer will be the gift that keeps on giving—to quacks. They despise the concept of prophylactic surgery almost as much as they despise the concept of genetic predisposition to disease.