By Dr. Kate Scannell, Syndicated Columnist
First Published in Print: 02/20/2011
FOR YEARS, I've been writing a book about medical practices that were later found to be wrongheaded, useless or dangerous. It's been a sobering and unsettling project, causing me to question the scientific foundation of my profession a few too many times.
But I am trying to how we doctors sometimes get it all so very wrong. How under our watch, enormous myths can sneak unnoticed into our clinical textbooks and remain there for decades.How our doctorly habits or routines sometimes bypass critical scrutiny and seamlessly morph into "standard medical practice." I am searching for instructive clues to these discomforting mysteries, keeping patients in center vision, hoping to help resolve what I can.
Preparing for this book, I have been collecting medical journal articles whose solid research findings blew some piece of conventional medical dogma out of the water and into oblivion. My collection is housed within a file cabinet labeled "Oops!" that expands at an ever-increasing rate. And today I added to that collection a study from last week's Journal of the American Medical Association (JAMA) that upends thinking about a type of breast cancer surgery routinely performed on tens of thousands of women each year.understand
More than 100 years ago, a surgical technique that removes lymph nodes from the armpit became standard operating procedure for surgeons performing radical mastectomies on women with breast cancer. That surgical technique — known as "axillary lymph node dissection" (ALND) -- aimed to remove a woman's cancer-infiltrated nodes in hopes of limiting further spread of the cancer throughout her body.
Lymph nodes are small structures scattered throughout the body that can act as filters to trap cancer cells; they can also mount immune responses to fight infectious diseases.
That's why, for example, normally invisible lymph nodes often enlarge and become palpable in some people with cancers or infections.
In the past, for fully 10 decades, it had seemed common-sensical to remove armpit lymph nodes to which breast cancer had spread. After all, if the point of breast surgery and chemotherapy and radiation therapy was to reduce the number of breast cancer cells within a woman's body -- why not also surgically remove those cancer-laden lymph nodes?
But the problem is, that what apparently passes for common sense does not always make good medical sense. And we doctors often don't -- or can't -- distinguish one from the other. An adage persists in the medical training of young doctors who are often told by instructors: "Half of what we teach you is wrong; unfortunately, we don't know which half."
In evidence, the new JAMA study convincingly demonstrates that performing ALND makes no sense for a distinct but sizable population of women with breast cancer. Researchers found that this painful and often debilitating surgery provided no health or survival benefit to these women.
Meanwhile, fully 70 percent of the women experienced side effects from that surgery: shoulder pain or stiffness, nerve irritation, wound infections or arm swelling (lymphedema).
It's important to note that the conclusions from any research study technically apply to the unique subgroup of people who took part in the research. With the current study, we are talking specifically about women with newly-diagnosed invasive breast cancer that measured no more than 2 inches in length and had spread to underarm lymph nodes. These women had undergone surgical removal of the breast lump (lumpectomy) and local-area radiation, and most were treated with chemotherapy, hormone-blocking drugs, or both.
In essence, then, we can't reliably know whether women with larger breast cancers, greater degrees of metastatic spread or other varieties of radiation treatment would fare as well without ALND. That will require other courageous doctors willing to question and challenge the status quo, other courageous women with breast cancer willing to undergo the research.
It will be interesting to see how this new study affects the real-world practice of breast cancer care. I worry that some doctors won't be able to shift gears against the counterfeit momentum of powerful professional traditions. I worry that some doctors and breast cancer patients will reject the new study because it is hard to accept that less treatment may be better treatment, especially while fears about health care rationing saturate the public psyche.
Meanwhile, hundreds of untested assumptions sustain routine medical practices regarding many common conditions like heart disease, prostate cancer and back pain. And while our pharmacy shelves may brim with dozens of medications to treat one illness, we often have little idea how those medications compare head-to-head for safety and efficacy in patients.
The new $1.1 billion federal initiative to evaluate and compare competing treatments for common medical conditions offers a step in the right direction toward improving the quality of patient care. Hopefully, its mere existence will also serve as a vibrant reminder to us all that it's important -- even lifesaving, sometimes -- to question what we think we know in medicine, and to seek clarity about what we don't.
Regardless, to some extent, medical practice will always be shaped by science, intuition, tradition, social influences, common sense, best guesses and hope in the midst of considerable uncertainty. It constantly evolves, my file cabinet regularly expands, and my book-in-progress gets longer by the day.
––––––––––––––––––––––––––––––––––––––––––––––––––––
Dr. Kate Scannell is a Bay Area physician, syndicated columnist and author of "Death of the Good Doctor" and "Flood Stage."
© Copyright 2011, Kate Scannell
First Published in Print: 02/20/2011
FOR YEARS, I've been writing a book about medical practices that were later found to be wrongheaded, useless or dangerous. It's been a sobering and unsettling project, causing me to question the scientific foundation of my profession a few too many times.
But I am trying to how we doctors sometimes get it all so very wrong. How under our watch, enormous myths can sneak unnoticed into our clinical textbooks and remain there for decades.How our doctorly habits or routines sometimes bypass critical scrutiny and seamlessly morph into "standard medical practice." I am searching for instructive clues to these discomforting mysteries, keeping patients in center vision, hoping to help resolve what I can.
Preparing for this book, I have been collecting medical journal articles whose solid research findings blew some piece of conventional medical dogma out of the water and into oblivion. My collection is housed within a file cabinet labeled "Oops!" that expands at an ever-increasing rate. And today I added to that collection a study from last week's Journal of the American Medical Association (JAMA) that upends thinking about a type of breast cancer surgery routinely performed on tens of thousands of women each year.understand
More than 100 years ago, a surgical technique that removes lymph nodes from the armpit became standard operating procedure for surgeons performing radical mastectomies on women with breast cancer. That surgical technique — known as "axillary lymph node dissection" (ALND) -- aimed to remove a woman's cancer-infiltrated nodes in hopes of limiting further spread of the cancer throughout her body.
Lymph nodes are small structures scattered throughout the body that can act as filters to trap cancer cells; they can also mount immune responses to fight infectious diseases.
That's why, for example, normally invisible lymph nodes often enlarge and become palpable in some people with cancers or infections.
In the past, for fully 10 decades, it had seemed common-sensical to remove armpit lymph nodes to which breast cancer had spread. After all, if the point of breast surgery and chemotherapy and radiation therapy was to reduce the number of breast cancer cells within a woman's body -- why not also surgically remove those cancer-laden lymph nodes?
But the problem is, that what apparently passes for common sense does not always make good medical sense. And we doctors often don't -- or can't -- distinguish one from the other. An adage persists in the medical training of young doctors who are often told by instructors: "Half of what we teach you is wrong; unfortunately, we don't know which half."
In evidence, the new JAMA study convincingly demonstrates that performing ALND makes no sense for a distinct but sizable population of women with breast cancer. Researchers found that this painful and often debilitating surgery provided no health or survival benefit to these women.
Meanwhile, fully 70 percent of the women experienced side effects from that surgery: shoulder pain or stiffness, nerve irritation, wound infections or arm swelling (lymphedema).
It's important to note that the conclusions from any research study technically apply to the unique subgroup of people who took part in the research. With the current study, we are talking specifically about women with newly-diagnosed invasive breast cancer that measured no more than 2 inches in length and had spread to underarm lymph nodes. These women had undergone surgical removal of the breast lump (lumpectomy) and local-area radiation, and most were treated with chemotherapy, hormone-blocking drugs, or both.
In essence, then, we can't reliably know whether women with larger breast cancers, greater degrees of metastatic spread or other varieties of radiation treatment would fare as well without ALND. That will require other courageous doctors willing to question and challenge the status quo, other courageous women with breast cancer willing to undergo the research.
It will be interesting to see how this new study affects the real-world practice of breast cancer care. I worry that some doctors won't be able to shift gears against the counterfeit momentum of powerful professional traditions. I worry that some doctors and breast cancer patients will reject the new study because it is hard to accept that less treatment may be better treatment, especially while fears about health care rationing saturate the public psyche.
Meanwhile, hundreds of untested assumptions sustain routine medical practices regarding many common conditions like heart disease, prostate cancer and back pain. And while our pharmacy shelves may brim with dozens of medications to treat one illness, we often have little idea how those medications compare head-to-head for safety and efficacy in patients.
The new $1.1 billion federal initiative to evaluate and compare competing treatments for common medical conditions offers a step in the right direction toward improving the quality of patient care. Hopefully, its mere existence will also serve as a vibrant reminder to us all that it's important -- even lifesaving, sometimes -- to question what we think we know in medicine, and to seek clarity about what we don't.
Regardless, to some extent, medical practice will always be shaped by science, intuition, tradition, social influences, common sense, best guesses and hope in the midst of considerable uncertainty. It constantly evolves, my file cabinet regularly expands, and my book-in-progress gets longer by the day.
––––––––––––––––––––––––––––––––––––––––––––––––––––
Dr. Kate Scannell is a Bay Area physician, syndicated columnist and author of "Death of the Good Doctor" and "Flood Stage."
© Copyright 2011, Kate Scannell