Confronting the Breast Cancer Mammography Dilemma

Miss Mosley, afflicted with breast cancer: detail. From Wellcome Images
Miss Mosley, afflicted with breast cancer: detail; 1828. From Wellcome Images


How to balance the risk of missing a cancerous tumor with the risk of treating — at substantial human cost — when treatment may be unnecessary or futile? The new Canadian study of mammography, published Tuesday in BMJ, sharpens this question once again. Most of us who’ve been around a while know people, some dear to us, who’ve walked into a mammography feeling great and found that, according to the doctors, they need to take quick, aggressive, and sometimes brutal measures to save their lives. Most of the time, this understanding is accurate. Some of the time — in about 1 in 5 cases, according to the BMJ study — it’s not. And the BMJ study concludes that in balance, routine mammographies do more harm than good.

Do they also unnecessarily terrify us? We’re quickly getting into extremely touchy, highly personal territory here. The idea that you can be too scared of breast cancer is likely a hard sell to someone, including people dear to me, who has been diagnosed (probably accurately, according to the BMJ study) and undergone treatment to try to prevent or slow the cancer’s fatal spread. How can we tell those people they may have made a mistake, when many and possibly most of them didn’t? Can we? Who am I to do so?

Yet there’s a cost, too, to those who undergo treatment, often disfiguring, sometimes medically harmful, almost always enormously draining, when they did not need to, or when the treatment, on whole, may not actually extend life.

I’m not sure how to sugar this out. I certainly wouldn’t know how to advise an individual. Much will of course be written about this. But one of the most intellectually and emotionally measured considerations I’ve read so far is over at Last Word on Nothing, by Christie Aschwanden. It’s smart, direct, and compassionate, and while its conclusions may sit uncomfortably to many, I like the spirit in which it’s given, and the goal it states: that we should be aiming to save lives, not create as many cancer patients as we possibly can.

Studies show that women — and doctors — grossly overestimate their risk of developing breast cancer and dying from it. One study published in the Journal of the National Cancer Institute found that women in their 40s overestimated, by a factor of 20, their risk of dying from breast cancer over the next decade. I have to think that the media is partly to blame. Fewer than seven percent of breast cancers are diagnosed in women younger than 40, (the median age at diagnosis is 61), but when the disease strikes younger women, it tends to be more aggressive and less responsive to treatment than it is for older women. Scary stories like those of Susan G Komen, who died of breast cancer at age 36, invoke fear, and for good reason. Komen did not bring her cancer upon herself. Her disease was random, undeserved and very aggressive. And if you flip through the women’s magazines during their October “breast cancer awareness” extravaganzas, most of the stories you’ll read are about beautiful young women like Komen who were diagnosed at a young age. The way to prevent such a fate, most of these stories will tell you, is obvious — screen early and often.

Early screening is the only reasonable option if you think of breast cancer as a relentlessly progressive disease that will inevitably kill you if you don’t remove it in time. That story about breast cancer — I call it the “relentless progression” model — has truthiness on its side. It makes common sense and offers a measure of comfort: Every cancer can be cured if you just catch it in time.

There’s just one problem, as I’ve written here numerous times before — research has shown that the relentless progression model is wrong. Despite the one-size-fits-all name, breast cancer is not a single disease, and as the science of tumor biology has advanced, researchers have come to understand that not every breast cancer cell is destined to become one of the life-threatening varieties. It’s only when cancer spreads to other parts of the body — a process called metastasis — that it becomes deadly, and it’s now clear that not every breast cancer is fated to leave the breast. If you detect an indolent cancer early, there’s no life to save.

This may sound as if Aschwanden wants to simply set aside screening and be done with it. But she certainly recognizes that none of this is quite that simple, in any sense of that phrase:

You only benefit from a cancer diagnosis if that cancer is destined to kill you and the diagnosis allows you to treat in a way that prevents you from getting sick and dying. And that’s where things get complicated, because treatment for cancer makes most people feel pretty lousy. It disrupts their lives in a major way. Even a relatively early stage breast cancer can cost you your hair, part or even all of your breast or breasts, and months of treatments that make you feel tired and sick. These treatments are totally worth it if it means that you avoid dying from the cancer. But if they’re aimed at curing a cancer that was never going to become deadly, then what early diagnosis has actually done is made a healthy person sick. I think it’s safe to say that no one wants that. Treatments and awareness about breast cancer seem to have created most of the improvements in breast cancer outcomes, and we should celebrate those accomplishments.

Get the rest at Breast cancer’s latest saga: misfearing and misplaced goalposts : The Last Word On Nothing.

Why people keep writing “Gene for X” cowflop nonsense

Sydney and Kelley, identical twins. By Courtney @ flickr, some rights reserved.
Sydney and Kelley, identical twins. By chintermeyer @ flickr, some rights reserved.

I love this post at Genotopia. The ever-interesting Nathaniel Comfort reviews the usual frustrations about “gene for X” thinking, cites a few efforts to turn it back, and then, with some nice meta, concludes that genetic determinism is, well, multifactorial in origin:

Genetic determinism, then, is not monocausal. It has many sources, including sensationalism, ambition, poor practice, and the eternal wish for simple solutions to complex problems. Science and journalism are united by a drive toward making the complex simple. That impulse is what makes skillful practioners in either field so impressive. But in clumsier hands, the simple becomes simplistic, and I would argue that this risk is multiplied in journalism about science. Science writing is the delicate art of simplifying the complexity of efforts to simplify nature. This is where the tools of history become complementary to those of science and science journalism. Scientists and science writers strive to take the complex and make it simple. Historians take the deceptively simple and make it complicated. If science and science journalism make maps of the territory, historians are there to move back to the territory, in all its richness—to set the map back in its context.

Studying genetics and popularization over the last century or so has led me to the surprising conclusion that genetic oversell is independent of genetic knowledge. We see the same sorts of articles in 2014 as we saw in 1914. Neither gene mapping nor cloning nor high-throughput sequencing; neither cytogenetics nor pleiotropy nor DNA modification; neither the eugenics movement nor the XYY controversy nor the debacles of early gene therapy—in short, neither methods, nor concepts, nor social lessons—seem to make much of a dent in our preference for simplistic explanations and easy solutions.

Maybe we’re just wired for it.

via Genetic determinism: why we never learn—and why it matters | Genotopia.

Related at Neuron Culture:

DNA Ain’t Destiny. No Kidding.

Enough With the ‘Slut Gene’ Already: Behaviors Ain’t Traits

Genes Aren’t Just Architects; They’re Actors

Image by chintermeyer. Some rights reserved 

Watch NutJob Downhillers Almost Completely Out of Control

The clip above comes via a wonderful Nick Paumgarten post at The New Yorker. As Paumgarten notes, it’s rare that film or TV captures the horrifying speeds — 70 to 90 mph at the Olympic level — at which downhill skiers actually race. Seventy to ninety, going down ridiculous slopes, with nothing controlling your speed and direction but some sticks clipped to awkward boots. The noise alone is terrifying.

Continue reading →

Tiger Parenting “a very exciting way to understand studying and piano lessons”.


To Joshua Rothman, over at The New Yorker,

“The Triple Package” might not be convincing as an argument about “the rise and fall of cultural groups in America,” but it’s valuable in another way: it offers a fascinating window onto a particular interpretation of family life. In this interpretation, parents see themselves as dangerous risk-takers (“tiger parents”) who, like Jack Bauer in interrogation mode, push their children right up to the edge (but not too far!), while children come to see themselves as hardened survivors, burdened with the ultimate decision: unleash hell upon their own kids, or give in to weak-willed Westernization? It’s a very exciting way to understand two decades’ worth of studying and piano lessons.

I think he’s spot on. here and throughout this fun, smart, funny essay. He articulates nicely a suspicion that many may hold: that

The persistent rhetorical excess in “The Triple Package” is the tip-off that the book is more of a performative self-interpretation than a sociological argument.

Take the small bit of time required to read this; it’ll pass quickly. At The Battle Hymn of the Tiger Family

Image by garryknight. Some rights reserved.

Bach Was a Bad Bad Boy

St. Thomas Church, of Leipzig, where Bach did most of his work. From a study in an inn across the square. By author.

The thin documentary trail left by J.S. Bach, this rich review of a new biography notes, means that biographies of this peerless composer, more so than of most of the other great composers of the classical and Romantic eras, have been very much works of their time, since “biographers have been forced to fend for themselves, frequently reimagining Bach through the prism of their own life and times.” This latest biography, Bach: Music in the Castle of Heaven, from the immensely talented conductor and musical historian John Eliot Gardiner, sees him as a sort of bad boy turned good. 

Gardiner proposes yet another image of Bach. Moving beyond the hagiographies of the past, he presents a fallible Bach, a musical genius who on the one hand is deeply committed to illuminating and expanding Luther’s teachings through his sacred vocal works (and therefore comes close to Spitta’s Fifth Evangelist), but on the other hand is a rebellious and resentful musician, harboring a lifelong grudge against authority—a personality disorder stemming from a youth spent among ruffians and abusive teachers. Hiding behind Bach, creator of the Matthew Passion and B-Minor Mass, Gardiner suggests, is Bach “the reformed teenage thug.” In the preface we read: “Emphatically, Bach the man was not a bore.”

Gardiner apparently argues that Bach’s experiences gave him particular insight into how to convey  the pain of mortality — “to express the inexpressively, especially with regard to death.” Certainly his family history, like so many family histories in a time when so many died young, supplied plentiful such pain; he was orphaned by ten, lost a wife to sudden death, children too. But for him, perhaps, it started earlier; Gardiner suggests he had “lifelong problems with anger and authority [that] were incubated in the unsavoury atmosphere and environment of his early schooling and in childhood traumas,” including, perhaps, exposure to bullying, beating, and (in what may be a stretcher) rape.

Gardiner’s method, apparently, is not to sieve the biography for clues about the music, but the music for clues about the biography. It appears to be a risky strategy, but one whose results I’m eager to read.

Music in the Castle of Heaven … forces us to rethink Bach’s life and how adversity and faith affected his vocal compositions. And it takes us inside his world, allowing us to see the works from the standpoint of composer, performer, and listener. As Otto Bettmann once remarked, Bach’s “music sets in order what life cannot.”

Which last statement is inarguable.

If you want the shorter, video form, check out Gardiner’s 90-minute BBC program on Bach from a year ago. It’s lovely program. A nice note: Gardiner notes up front that one of the few things well-documented, via Bach’s contract, is how much beer he drank. He liked beer.

And the music …

via Why Bach Moves Us by George B. Stauffer | The New York Review of Books.

“You’ll Die Too.” Texas Evangelicals Top the Week’s Longreads

Water tank, Wells, Texas. Courtesy Texas Monthly.

I have loved Texas Monthly ever since my parents, third-generation Texans raising me in Houston, were wise enough to be among the magazine’s first subscribers. So you betch yer ass I was glad to see the magazine once again among the best of the week as curated by the good folk at Longreads.

Here’s a snip of Sonia Smith in the magazine’s January 27 issue, with “Sinners in the Hands, ” a look at how the town of Wells, Texas, grappled with a church that appears to be a cult. I’ve not read it yet, but about this messing with that grandma you see below — I reckon that proves a mistake.

But as the number of church members crept upward, residents of the tiny town started to feel uneasy. The recent arrivals systematically visited other churches to accuse the congregations of spiritual bankruptcy. They roamed the streets listening to the elders’ sermons on headphones, and they were frequently confrontational. A few church members, including Ringnald, moved in across from Gertrude Hearne, an 84-year-old grandmother of ten. Almost every afternoon, as she sat in a tan recliner in her wood-paneled living room, watching Jimmy Swaggart, church members would drop by to read her the Bible or sing hymns. At the sight of the Pentecostal televangelist, they’d flick off her television and declare Swaggart a false prophet. Finally, she’d had enough. “When I asked them to stop, they told me I was going to die, and I said, ‘You are too.’ ”

via Top 5 Longreads of the Week | Longreads.

Aglitter This Week: Paleo Poo, Contentious Comb Jellies, Dead Butterflies, et alia.

Charles Booth, Life and labour of the people
Map of London Poverty, 1889, by Charles Booth. Courtesy Wellcome Library

Some I read and liked, others just look good.

Not news: Most of us carry Neanderthal genes. News: Collectively we carry about 20 percent of the Neanderthal’s genome. As Ed Yong explains, the influence is huge, and will take time to sort out. Meanwhile, the technique that spotted this may — may — allow us to spot, in our genomes, hominid species that we never actually find in the fossil record. Spooky wonderful stuff.

Comb jelly, a contentious contender for earliest animal still making the rounds. Photo Wm Browne, Univ of Miami.

Evolution, You’re Drunk. (And it will still be drunk in the morning.) This fabulous, lyrical, fun read from Amy Maxmen reminds those eager to forget that we are still very early in discerning whatever order the genome’s real order and workings. Also has many great phrases, such as “the still-contentioius comb jelly project,” “cyanobacteria might be at the pinnacle level,” and “just one hole for eating and excreting.”

Autism researcher Jon Brock considers categories, averages, and  The elusive essence of autism.

Virginia Gov. Bob McDonnell scandal: Star Scientific in trouble with FDA over Anatabloc. Highly unsettling look at the wide and corrupting influence the dietary supplements industry has on elected officials.

Nature has a special issue on crystallography. Quite rich.

The Seven Myths of Mass Murder. Beginning with “They snap.” Journalists, keep his one handy.

Migration of Monarch Butterflies Shrinks Again Under Inhospitable Conditions –  This is starting to look like a death watch.

Another Yong story:  down and dirty with What is a ‘Healthy’ Microbiome?, in which he looks at efforts to characterize the microbiomes of people with more or less paleo lifestyles, like the Yanomani of South America. Fun rich story. Includes poop, naturally. 

Dr Strangelove, Leo Szilard & the Doomsday Men: On the 50th Anniversary  Delicious essay with background to Dr. Strangelove, one of my favorite films and a classic of the Cold War (and cinema), from P.D. Smith, author of Doomsday Men (and the wonderful CITY). Among other gems: the film was originally scheduled to open on November 22, 1963 — the day Kennedy was assassinated. This is wonderful writing stuff with fascinating things.  

Delicious background to “Dr Strangelove” from @PD_Smith, author of Doomsday Men (and CITY).

London calling — with the best London images from the newly free-access treasure of images from Wellcome Library. You’re welcome. The Best London Images From Wellcome Library


Stuff You Wish Would Go In Your Book But Won’t

Whispering Rhesus

Last year I talked to a primatologist in his mid-80s, still sharp, still in his office most days, a pleasant spot in California, surrounded by his books and by younger colleagues who adored him. He wore khakis and a red plaid shirt and desert boots — I didn’t know you could even find desert boots anymore — and had marvelous recall and sense of humor. I was there to ask him mainly about the work of a long-ago colleague of his, someone whose work overlapped with his but not enough to make things too competitive. They both worked for a certain lab early in their careers, though at different times, and had followed each others careers, and he remembered all sorts of gems and insights and stories, always in language colorful and plain and free of jargon. A splendid interview that at two hours was too short.

When we’d covered my main line of questioning, I asked him if he could tell me about the work he was doing back then, 60 years before — work that stirred some fundamental changes in the field. He laughed and said, “Well sure. That’s an interesting story to me. I’ll have to restrain myself.” Then he told me about it, utterly riveting work. I didn’t want to take more of his time at this point, so I skimmed my notebook and memory for things I needed to ask him but had not. My interviews tend to wander a bit. By then he’d grokked to this flightiness of mind.

DD: Oh. Where did you say you grew up?

Subject: You didn’t ask me.

DD: Where did you grow up?

Subject: I was born in Mountain View.

Sometimes you can’t say thank you emphatically enough.

Love Poems About Elephant Skin, Rhino Skin, Hippo Skin, and Snake Skin – For Science

I’ve been reading some of Harry Harlow’s papers, and am in wonder at his seminal “The Nature of Love,” his 1958 Presidential Lecture to the American Psychological Association, to what had to be a stunned room, about cloth-versus-wire mesh monkey mother studies with which he famously kicked aside a behaviorist view of infant love and replaced it with a view foundational to attachment theory. In this studies, he and his lab members showed that an infant monkey would vastly prefer spending time with a cloth-covered mother surrogate rather than a wire-mesh surrogate, regardless of which dispensed milk (as below). From this experiment (and, later, others) he argued that the infant’s love for its mother is not, as behaviorist dicta of the time asserted, a “secondary drive”  derived from the love of milk, but an attachment of its own just as vital. Or as he put it in the talk, “The baby, human or monkey, if it is to survive, must clutch at more than a straw.”


Deborah Blum, lately famous for her marvelously creepy The Poisoner’s Handbook. writes brilliantly about Harlow in her indispensible Love at Goon Park. As she notes there many times, Harlow was a provocative, often wildly entertaining speaker. He’s in top form in this address, getting right in the face of those he wants to displace.

I’ll deal with that talk at more length in my book (which is why I’m currently buried in both Harlow’s paper and my book). But for now I want to share one of the delightful oddities of this talk, which is Harlow’s use of pictures and poems, of his own authoring for God’s sake, to illustrate the primacy of infant-parent bonds in species other than humans and rhesus monkeys. To repeat: Lacking experimental evidence, he used poems. We need more of this.

“We believe that contact comfort has long served the animal kingdom as a motivating agnet for affectional purposes,” he says. “Since at the present time we have no experimental data to substantiate this position, we supply information which must be accepted, if at all, on the basis of face validity.

Then he brings the hippos:


and the rhinos:


and elephants:


and does not forget the snakes: