Tag: Breast cancer

Good News About Breast Cancer? Not So Fast …

Posted on by asitoughttobemagazine
While this is not a real campaign, it represents the pinkwashing dilemma: does supporting breast cancer research make up for toxic products? Ad and caption from Johanna Björk's excellent essay on pinkwashing at http://www.goodlifer.com/2010/10/pink-ribbons-pink-products-pinkwashing/; reproduced by permission.

I’ve written about cancer previously in these pages. In Against Medical Advice, I recounted what I learned when someone I loved (I called her Bonnie) was diagnosed with breast cancer. In Poisoned, I traced Bonnie’s and my efforts, once her treatment was over, to identify the root causes of our cancer epidemic and comprehend why forty years of the “War on Cancer” have failed to dramatically reduce cancer rates. Finally, in Not Your Median Patient, I paid tribute to my two of my scientific idols, evolutionary biologist Stephen Jay Gould and climate scientist Stephen Schneider, who applied their own scientific expertise and methods to understanding and fighting their own cancer.

One organization I commended in “Poisoned” was Breast Cancer Action for their efforts to eliminate the root causes of cancer in our environment. BCA’s seminal Think Before You Pink™ campaign urges consumers to resist buying pink-ribbon products from companies that actually worsen the cancer epidemic. BCA has recently stepped up their outreach, including a new blog and an informative monthly webinar series. For example, I learned in this month’s webinar that National Breast Cancer Awareness Month (NBCAM) was co-founded by the American Cancer Society and the pharmaceutical division of Imperial Chemical Industries. ICI is now part of pharmaceutical giant AstraZeneca, which manufactures not only several breast cancer drugs but also the herbicide Acetochlor, a known carcinogen, thus profiting from both causing and alleviating cancer.

So I’m pleased today to reprint an essay by BCA’s communications manager, Angela Wall, about the need to go beyond breast cancer “awareness” (as if we’re not already aware of breast cancer) to identify and eliminate the toxins that cause it. If the beginning of wisdom is to call things by their right names, as the Chinese proverb says, then calling NBCAM “Breast Cancer Industry Month” is wise indeed. My thanks to Ms. Wall and BCA for permission to reprint her essay here.

Good News? Not So Fast …
By Angela Wall

Good news on breast cancer, says Sadie Stein writing for Jezebel. Why? Well, because of pink ribbon awareness campaigns more women are getting screened and diagnosed earlier. Hold on. Does this ring false to anyone else?

Awareness only got them to make a screening appointment to detect the cancer that was already developing.

Ordinarily, I celebrate an article that tacitly suggests that we’ve had enough pink awareness. I’d certainly celebrate the end of the pink noise and hypocrisy that accompanies breast cancer industry month because then instead of having our attention distracted by pink awareness campaigns, we could all start addressing the real issues that increase our risk of developing breast cancer and we might actually be able to focus on reducing diagnoses rather than celebrating them.

I doubt that’s going to happen though. There’s too much money to be made every October from slapping a pink ribbon on a product. Plus and the feel good rewards that accompany  pink ribbons can really boost a company’s image regardless of whether or not the product being sold actually contributes to breast cancer. Heaven forbid we make consumers aware that the products they are purchasing actually contain ingredients that might cause cancer. Awareness apparently doesn’t need to go that far. It’s no surprise then that awareness never prevented anyone from developing breast cancer.

Awareness campaigns have never addressed why more white women get diagnosed with breast cancer but more women of color die from it. Awareness and pink ribbon campaigns have only ever distracted us. Awareness campaigns don’t demand we demand tighter state and federal regulations around the manufacturing and production of cancer causing chemicals or their being included as “ingredients” in the products we use to clean our homes.

I’ve never seen anything to celebrate about breast cancer and I certainly get deeply troubled by the idea that we might have done enough simply because people are being screened more regularly even though more cancer is being detected. Surely, screening rates are only to be celebrated when fewer people receive a cancer diagnosis.

I would agree that awareness has served its purpose. Now it’s time to demand that chemical corporations stop manufacturing products known to cause cancer. I would celebrate if Eli Lilly announced that they were stopping production of their cancer-linked recombinant bovine growth hormone (rBGH), which contaminates a third of US dairy products. I would celebrate if the FDA declared that rather than meeting with Roche Pharmaceuticals to reconsider approving Avastin as a treatment for metastatic breast cancer (despite evidence demonstrating that it doesn’t work), they refined their approval guidelines and insisted that treatments cost less, do more than existing options, and improve the quality of life of women with breast cancer who take them. So I think I’ll hold off on my celebrating if nobody minds until the studies start to show real systemic changes are reducing breast cancer diagnoses over the long term.

Poisoned

Posted on by asitoughttobemagazine
Breast Cancer Action's "Think Before You Pink" logo
Breast Cancer Action's "Think Before You Pink™" campaign cautions consumers to resist buying pink-ribbon products from companies that worsen the cancer epidemic. Source: Breast Cancer Action.

Poisoned
By John Unger Zussman

When Bonnie was diagnosed with breast cancer almost two years ago, she was unwilling to chalk it up to random chance. She took it personally. “I wasn’t unlucky,” she said. “I was poisoned.”

Last month, I wrote about Bonnie (a pseudonym), her decisions about cancer treatment, and what I learned from watching her make them. Bonnie and I both appreciate the support, comments, and stories you shared after that post. Now I want to talk about what we learned from her quest to find out who, or what, poisoned her—like an infected film-noir heroine who has just 24 hours to identify the poison, catch the culprit, and find the antidote.

It was in 1971 that President Nixon declared war on cancer, one of the few actions of his presidency that I applauded. Since then, many billions of dollars have been spent and millions of lives lost. We now have innumerable new treatments touted as “cures” for cancer. Yet cancer is still prevalent and survival rates have improved only slowly if at all (much of the decrease is attributable to reduced smoking and earlier detection). Post-menopausal breast cancer in particular is now common, and Bonnie is a member of a large and ever-growing community.

In my opinion (and Bonnie’s), the war on cancer has been undermined, like many wars, by a failure to cast the mission correctly. It placed all its reliance (and budget) on screening and treatment, on detecting cancers early and on finding a “cure.” And although it’s laudable to “race for the cure,” at some point you’ve got to wonder what is causing all this cancer.

But causation gets very little attention, probably because there’s a lot of money to be made in screening and treatment, but not so much in prevention.

How do we prevent cancer? An obvious place to start is our lifestyle, especially diet and exercise. The American diet is overloaded with fat, salt, and high-fructose corn syrup. We pig out on fast food and snack food while we sit on the couch watching “The Biggest Loser” and ignore the treadmill in the corner. Obesity is at record levels and increasing.

So is our diet predisposing us to cancer? Studies are suggestive. As Nicholas Kristof points out in a New York Times column called “Cancer from the Kitchen?,” most women living in Asia have low rates of breast cancer. But ethnic Asian women born and raised in the U.S.—including the daughters of Asian immigrants—have higher rates.

In a recent book called Anticancer, David Servan-Schreiber talks about the “terrain” of the body as being more or less hospitable to cancer. The idea is that cancer cells need a certain environment in which to flourish, and there are things we can do to make that more or less easy for them. For example, the antioxidants in certain fruits and vegetables, such as green tea, cabbage, and pomegranate juice, seem to antagonize cancer cells. “Eat your veggies,” it turns out, was not just maternal nagging.

This is not to say that green tea will cure cancer, and in fact, early studies of the impact of diet on breast cancer survival produced only mixed results. But a recent comprehensive study of diet and exercise—the Women’s Healthy Eating and Living (WHEL) study—was more definitive. For survivors of early-stage breast cancer, eating at least five servings of vegetables and fruits a day, and walking briskly for 30 minutes, six days a week, cut their risk of death from breast cancer by 50%! This should have made headline news—and would have if a drug company could have patented it.

(The link above is a summary, or you can read the actual journal report here.)

Now, Bonnie’s diet has always been reasonable. She hasn’t eaten fast food for 20 years, eats minimal snack food, and isn’t obese. Since her diagnosis, she eats more vegetables (especially the “anticancer” cruciferous ones like broccoli, cauliflower, and cabbage), less meat, little processed food, and no soda. This is far from being a burden. Bonnie’s a terrific chef, and the new meals are delicious.

But in her quest to prevent a recurrence or metastasis, Bonnie is focusing on a more insidious cause of cancer—carcinogens in our environment.

This is not just her opinion. It is shared by the 2009 report of the President’s Cancer Panel, which was released last month. (The link above is to the full, 200-page report. You can also read commentaries on it in another Nicholas Kristof column or in a Huffington Post article by Alison Rose Levy.)  Here is a sampling of the panel’s findings:

  • “A growing body of research documents myriad established and suspected environmental factors linked to genetic, immune, and endocrine dysfunction that can lead to cancer and other diseases.”
  • “Only a few hundred of the more than 80,000 chemicals in use in the United States have been tested for safety.”
  • “Weak laws and regulations, inefficient enforcement, regulatory complexity, and fragmented authority allow avoidable exposures to known or suspected cancer-causing and cancer-promoting agents to continue and proliferate in the workplace and the community…. Many known or suspected carcinogens are completely unregulated.”

Why is our world filled with toxic chemicals? Because it’s profitable. Because the corporations that put them there do not want to be troubled to clean up their mess. And neither do the legislators they bankroll.

What kind of chemicals are we talking about? Since we’re talking about diet, let’s start there. Commercially processed food—in additional to its fat, salt, and high-fructose corn syrup content—is full of additives, preservatives, artificial colorings, hormones, antibiotics, and pesticide residues. This is a result of our “modern” food system, which over the past 50 years has replaced family farms and conventional farming methods with factory farms, monoculture, overreliance on pesticides and fertilizers. If you have any doubts that mainstream food is poisoning us, check out the Oscar-nominated documentary, “Food, Inc.”

But the problem doesn’t end with what’s in the food and the way it’s produced; it’s also how it’s packaged, stored, and cooked. It comes to us in cans and plastic containers that contain bisphenol A (BPA) and leach phthalates and endocrine disruptors. We microwave it in the same plastic containers or cook it in Teflon pans that begin to degrade at cooking temperatures above 500° F. (In the case of microwave popcorn, we get both—the bags contain perfluorooctanoic acid, or PFOA, a known carcinogen related to Teflon.) We are living laboratories for artificial chemicals. Kristof’s column gives a good introduction to some of these toxins.

Now, not all of these chemicals are proved to cause cancer.  But that’s the cancer panel’s point. Since the research hasn’t been done, it only makes sense to be wary of them. We are so concerned that the medications we take be both safe and effective, and the FDA generally takes a hard line at enforcing this. Why aren’t we (and they) equally concerned about food additives?

So, in Bonnie’s quest to transform her diet, the food she eats is almost less important than where it comes from. She now buys the vast majority of her (mostly organic) produce from farmers’ markets, and has found a local farm that raises natural lamb, pork, chicken, and eggs, without added hormones or antibiotics. She thinks it’s essential to avoid factory-farmed anything, since mass farming techniques use so many questionable chemical additives. She abandoned her non-stick skillet, bought glass containers for storage, and microwaves food in a Pyrex pie plate.

And she’s found that she has to be eternally vigilant. Tricks and traps are everywhere. For example, “fresh” orange juice from cartons, according to Alissa Hamilton, author of Squeezed: What You Don’t Know About Orange Juice, may have been picked and squeezed months earlier. It’s stored without oxygen, and then flavored with synthetically produced “flavor packs” produced by fragrance manufacturers. The manufacturers don’t have to label these additives because they’re made from orange byproducts.

But toxins aren’t just in food and our kitchen utensils; they’re also in our air, our water, our cosmetics, at work, and at home—they even find their way into newborn babies.  As the Cancer Panel points out:

“To a disturbing extent, babies are born ‘pre-polluted.’ … [They] can be exposed to toxins in utero via placental transfer and/or after birth via breast milk. Tests of umbilical cord blood found traces of nearly 300 pollutants in newborns’ bodies, such as chemicals used in fast-food packaging, flame retardants present in household dust, and pesticides.”

The study they cite was conducted by the Environmental Working Group, one of the premier groups working to remove toxins from our environment. You can hear more about it in a recent address to the Commonwealth Club of California by Kenneth Cook, EWG’s president.  You can listen to it for free here , or download it as a podcast here or from iTunes.

It’s essential to become smarter, toxin-avoidant consumers, and the EWG website offers abundant helpful information.  For example, you can find a series of tips for making your home a healthier place.

Companies that pollute the environment with carcinogens are particularly insidious when they present themselves as green—or pink. Breast Cancer Action, a small but effective activist organization, has focused on this “pinkwashing” problem with a campaign called “Think Before You Pink™” It urges consumers to resist buying pink-ribbon products from companies that actually worsen the cancer epidemic.

A recent and egregious example of pinkwashing is KFC who, in partnership with Susan G. Komen for the Cure, is now selling pink buckets of factory-farmed, fat-laden fried chicken to “cure breast cancer.” We expect this kind of deception from KFC, but the Komen foundation should know better.  You can tell them to stop by sending a message from BCA’s site—and by not patronizing this product.

Since BCA first criticized the KFC/Komen partnership, outrage about the hypocrisy has gone viral. It was featured on The Colbert Report and has been roundly criticized by bloggers like John Robbins.

BCA successfully persuaded General Mills to stop putting the bovine growth hormone rBGH, a known carcinogen, in Yoplait yogurt. They are now trying to get Eli Lilly to stop manufacturing rBGH at all. Unlike other breast cancer organizations, they accept no donations from pharmaceutical companies, health insurers, or other companies whose products are involved in cancer diagnosis or treatment. They also accept no money from chemical manufacturers, oil or tobacco companies, or others who might possibly contribute to cancer incidence.

As Bonnie says, there are no certainties in life or cancer. No one can guarantee that eating organic food will keep you cancer-free. Bonnie relies on Western medicine and the guidance of doctors who are trained in it.

But she is not going to sit back and simply wait for them to cure her. She is also doing everything she can to strengthen her immune system and keep herself healthy. And that involves eating right, exercising, avoiding toxins, and supporting organizations that are trying to remove them from our environment. Nothing about this cancer epidemic is going to change unless we become proactive. Bonnie’s message to you is: Don’t wait until you get cancer to take responsibility for your own health.

Let me repeat the disclaimer from last month’s post: I am not a medical doctor, so my reflections are meant to be descriptive and not prescriptive. I wouldn’t pretend to tell anyone else what to do. Again, I invite your comments and, especially, your own stories.

My thanks to “Bonnie” for her input and inspiration.

Copyright © 2010 by John Unger Zussman. All rights reserved.

Resources and Notes:

David Serban-Schreiber, MD, PhD, Anticancer: A New Way of Life (2008).

Keith I Block, MD, Life Over Cancer: The Block Center Program for Integrative Cancer Treatment (2009).

Rick Smith & Bruce Lourie, Slow Death by Rubber Duck: The Secret Danger of Everyday Things (2009).

Food, Inc. (documentary written and directed by Robert Kenner, 2008)

President’s Cancer Panel 2008-09 Annual Report, Reducing Environmental Cancer Risk: What We Can Do Now (2010)

Environmental Working Group website

Breast Cancer Action website

Think Before You Pink™ website

Breast Cancer Action’s “Think Before You Pink” campaign cautions consumers to resist “pinkwashing.”

Against Medical Advice

Posted on by asitoughttobemagazine
Human pink ribbon 2005

Against Medical Advice
By John Unger Zussman

A woman I’ll call Bonnie sat in the exam room with her husband, waiting for her oncologist. They held hands without speaking, wearing thin, brave smiles.

(I’ve given Bonnie a pseudonym, and refrained from identifying my relationship to her, out of respect for her privacy. Suffice it to say we are close.)

Three months earlier, after a suspicious mammogram, a biopsy came back positive. Bonnie had a malignant breast tumor.

The diagnosis was a shock to Bonnie, who had no history of cancer in her family. She had to learn to cope with her brand-new reality. But watching someone I love face cancer set off land mines in my brain. My father died from rhabdomyosarcoma at age 35, when I was ten; my sister died of breast cancer at 45. My mother survived breast cancer in her 30s and spindle-cell sarcoma in her 70s, just after my adoptive father (her second husband) was treated for prostate cancer.

So I lived with a sword hanging above my head, expecting that someday I’d have to face that diagnosis myself. Once, my doctor’s office left a message on a Friday asking me to repeat a Hemoccult test. I spent an angst-filled, sleepless weekend convinced I was dying of colon cancer. It turned out that only one of the three samples had read positive—a fairly common occurrence—and the retest came out normal. Still, cancer is my demon, and Bonnie’s cancer let it loose.

The doctors put Bonnie through an exhausting battery of X-rays, MRIs, and CT scans to find out how much it might have spread. Meanwhile Bonnie worked her way through denial, anger, and depression, the first three stages of grief. She scoured the Internet medical sites and joined her local breast cancer support center.

After all the test results were in, her surgeon arranged for her to appear before the tumor board at his hospital, a celebrated university cancer center. First, a group of surgeons and oncologists came in to examine her. “It was strange, sitting there,” Bonnie’s husband said later, “as that parade of medical people took turns feeling her up.” Then she waited while the doctors reviewed her case.

Finally, they met with the hospital’s top breast cancer expert. He presided over the tumor board and was to be her oncologist.

“We’ve reviewed your case,” he told Bonnie, “and we all agree. If your surgery goes as we expect, you’re going to go through six months of hell. But then you’ll be fine.” Although the tumor was small, he explained, it was an aggressive type and might have spread to her lymph nodes. She would probably need radiation followed by chemotherapy.

Bonnie looked at her husband uneasily. She dreaded the thought of radiation and chemo, which had taken a physical and emotional toll on every breast cancer patient she knew.

As Bonnie’s lumpectomy date approached, she moved on to bargaining. Her research said that if her lymph nodes were not affected—that is, if she had stage 1 cancer— she would probably need no chemo, maybe not even radiation. And the less stress she subjected her body to, the better.

Bonnie’s hopes were fulfilled when the surgeon brought good news. She had caught it early. The tumor was small, the surgical margins were clear, and no lymph nodes were affected. Her cancer was only stage 1, and the surgeon was confident he had gotten it all.

Relieved, she settled into acceptance. And now, a few weeks later, she and her husband looked up as her oncologist entered her exam room and sat down. He congratulated her on her successful surgery and her positive test results.

And then he dictated a full course of radiation followed by aggressive chemotherapy.

This wasn’t what Bonnie had bargained for. She questioned him, but he was relentless. He couldn’t be sure that some cancer cells hadn’t escaped or that they wouldn’t metastasize. And that’s what you really want to avoid, he said. When she continued to resist, especially the chemo, he became defensive. “Why are we having this conversation if you’ve already made up your mind?” he demanded. He wasn’t used to mere patients questioning his authority.

Finally, Bonnie asked directly, “What if I go without chemo?”

“It’s risky,” he replied, “I wouldn’t recommend it.”

“What if I skip radiation?”

“I’ll strap you to the table.”

Bonnie doesn’t cotton to being told what to do. “I don’t believe in hell,” she said later. She quickly regressed back to anger—and stayed there.

The first thing she did was fire her oncologist. She couldn’t believe the good results had not altered his treatment plan even a millimeter. “I want a doc who’ll treat me, not my cancer,” she said.

I tried to be supportive, but challenging medical authority is not my nature. I didn’t even know you could fire your oncologist. I wanted her to explore every avenue, use every medical weapon to beat this disease. Foregoing further treatment seemed a great risk, tempting fate, taking a chance with her life. Of all my fears, this was the oldest and most devastating. Bonnie’s cancer unleashed my demons and awakened my nightmares.

Bonnie stepped up her research and sought a second opinion. She also got access to a website, widely used by medical professionals, that estimates the risk of breast cancer relapse and mortality based on characteristics of the patient, her tumor, and potential chemotherapy.

And when she described that research, to my surprise, it was my mind that began to change. Bonnie’s prognosis was good no matter what she did. Radiation would cut the chance of recurrence, but it would have no effect on her survival and might cause long-term heart damage. Chemo would increase her chance of survival by a few percent, but she would be flooding her system with poisons that would cause nausea, hair loss, and the possibility of long-term cognitive and systemic impairment. That made her decision easy: no radiation, no chemo.

Her surgeon, whom she liked and trusted, tried to dissuade her. “What will happen,” he asked, “if the worst happens and you get a recurrence or even a metastasis? How will you feel then? Won’t you regret this?”

“Not for a minute,” she said without hesitation.

We often talk about patients waging a “courageous battle with cancer.” This usually means they try every means available, suffer every side effect, in the attempt to conquer their disease. But it also takes courage to forego treatment—to understand the odds and trust them, to know your own body and what’s best for it, to realize that, for you, the treatment might be worse than the disease.

Most cancer professionals are courageous too, and dedicated. They take their best shot and watch their patients die and then have to come back the next day and do it all again. It’s no wonder that they want to use every possible tool to beat this damn disease.

So they develop a standard treatment and apply it across the board. No doubt this is partly dictated by insurance and liability concerns. “Radiation? Of course you want radiation. It reduces the risk of recurrence by 40% or more.” But when that risk is low to begin with, when it doesn’t increase your chance of survival, and when you add the risks of radiation itself—the choice is far from obvious. Women need the option to make their own decision.

In the end, ironically, it’s not the oncologists’ job to cure cancer. Their job is to treat their patients—and it’s not the same thing.

Twenty-one months later, Bonnie is both healthy and steadfast, without a moment of doubt or regret. The odds are in her favor. I try not to second-guess her, even if I know that disaster might lurk in every screening exam and mammogram, even if just writing these words seems like tempting the gods. It’s her body and her decision, not her doctor’s.

The health care establishment and the breathless media sometimes tout new treatments as medical miracles. But they have risks and cause damage, which have to be weighed against their benefits. I hope to explore this calculus in future posts, and explore what it’s taught me about medicine and the state of our culture. I’ll also describe the ways Bonnie has chosen to manage her risk of recurrence and metastasis. She is not going gentle unto that good night.

Please note that I am not a medical doctor (nor do I play one on TV), so my reflections are meant to be descriptive and not prescriptive. I wouldn’t pretend to tell anyone else what to do. I invite your comments and, especially, your own stories.

Shortly after Bonnie made her decision, she learned that her original oncologist was running a clinical trial with, coincidentally, the same chemo medications he prescribed for Bonnie.

By that time, Bonnie had found a new oncologist. He gives her options, not orders.

Copyright © 2010 by John Unger Zussman. All rights reserved.

Against Medical Advice By John Unger Zussman   A woman I’ll call Bonnie sat in the exam room with her husband, waiting for her oncologist. They held hands without speaking, wearing thin, brave smiles.    (I’ve given Bonnie a pseudonym, and refrained from identifying my relationship to her, out of respect for her privacy. Suffice it to say we are close.)   Three months earlier, after a suspicious mammogram, a biopsy came back positive. Bonnie had a malignant breast tumor.    The diagnosis was a shock to Bonnie, who had no history of cancer in her family. She had to learn to cope with her brand-new reality. But watching someone I love face cancer set off land mines in my brain. My father died from rhabdomyosarcoma at age 35, when I was ten; my sister died of breast cancer at 45. My mother survived breast cancer in her 30s and spindle-cell sarcoma in her 70s, just after my adoptive father (her second husband) was treated for prostate cancer.    So I lived with a sword hanging above my head, expecting that someday I’d have to face that diagnosis myself. Once, my doctor’s office left a message on a Friday asking me to repeat a Hemoccult test. I spent an angst-filled, sleepless weekend convinced I was dying of colon cancer. It turned out that only one of the three samples had read positive—a fairly common occurrence—and the retest came out normal. Still, cancer is my demon, and Bonnie’s cancer empowered it.   The doctors put Bonnie through an exhausting battery of X-rays, MRIs, and CT scans to find out how much it might have spread. Meanwhile Bonnie worked her way through denial, anger, and depression, the first three stages of grief. She scoured the Internet medical sites and joined her local breast cancer support center.   After all the test results were in, her surgeon arranged for her to appear before the tumor board at his hospital, a celebrated university cancer center. First, a group of surgeons and oncologists came in to examine her. “It was strange, sitting there,” Bonnie’s husband said later, “as that parade of medical people took turns feeling her up.” Then she waited while the doctors reviewed her case.   Finally, they met with the hospital’s top breast cancer expert. He presided over the tumor board, and was to be her oncologist.    “We’ve reviewed your case,” he told Bonnie, “and we all agree. If your surgery goes as we expect, you’re going to go through six months of hell. But then you’ll be fine.” Although the tumor was small, he explained, it was an aggressive type and might have spread to her lymph nodes. She would probably need radiation followed by chemotherapy.    Bonnie and looked at her husband uneasily. She dreaded the thought of radiation and chemo, which had taken a physical and emotional toll on every breast cancer patient she knew.    As Bonnie’s lumpectomy date approached, she moved on to bargaining. Her research said that if her lymph nodes were not affected—that is, if she had stage 1 cancer— she would probably need no chemo, maybe not even radiation. And the less stress she subjected her body to, the better.   Bonnie’s hopes were fulfilled when the surgeon brought good news. She had caught it early. The tumor was small, the surgical margins were clear, and no lymph nodes were affected. Her cancer was only stage 1, and the surgeon was confident he had gotten it all.   Relieved, she settled into acceptance. And now, a few weeks later, she and her husband looked up as her oncologist entered her exam room and sat down. He congratulated her on her successful surgery and her positive test results.   And then he dictated a full course of radiation followed by aggressive chemotherapy.    This wasn’t what Bonnie had bargained for. She questioned him, but he was relentless. He couldn’t be sure that some cancer cells hadn’t escaped or that they wouldn’t metastasize. And that’s what you really want to avoid, he said. When she continued to resist, especially the chemo, he became curt. “Why are we having this conversation if you’ve already made up your mind?” he demanded. He wasn’t used to mere patients questioning his authority.   Finally, Bonnie asked directly, “What if I go without chemo?”    “It’s risky,” he replied, “I wouldn’t recommend it.”    “What if I skip radiation?”    “I’ll strap you to the table.”   Bonnie doesn’t cotton to being told what to do. “I don’t believe in hell,” she said later. She quickly regressed back to anger—and stayed there.    The first thing she did was fire her oncologist. She couldn’t believe the good results had not altered his treatment plan even a millimeter. “I want a doc who’ll treat me, not my cancer,” she said.   I tried to be supportive, but challenging medical authority is not my nature. I didn’t even know you could fire your oncologist. I wanted her to explore every avenue, use every medical weapon to beat this disease. Foregoing further treatment seemed a great risk, tempting fate, taking a chance with her life. Of all my fears, this was the oldest and most devastating. Bonnie’s cancer unleashed my demons and awakened my nightmares.   Bonnie stepped up her research and sought a second opinion. She also got access to a website, widely used by medical professionals, that estimates the risk of breast cancer relapse and mortality based on characteristics of the patient, her tumor, and potential chemotherapy.   And when she described that research, to my surprise, it was my mind that began to change. Bonnie’s prognosis was good no matter what she did. Radiation would cut the chance of recurrence, but it would have no effect on her survival and might cause long-term heart damage. Chemo would increase her chance of survival by a few percent, but she would be flooding her system with poisons that would cause nausea, hair loss, and the possibility of long-term cognitive and systemic impairment. That made her decision easy: no radiation, no chemo.    Her surgeon, whom she liked and trusted, tried to dissuade her. “What will happen,” he asked, “if the worst happens and you get a recurrence or even a metastasis? How will you feel then? Won’t you regret this?”   “Not for a minute,” she said without hesitation.    We often talk about patients waging a “courageous battle with cancer.” This usually means they try every means available, suffer every side effect, in the attempt to conquer their disease. But it also takes courage to forego treatment—to understand the odds and trust them, to know your own body and what’s best for it, to realize that, for you, the treatment might be worse than the disease.   Most cancer professionals are courageous too, and dedicated. They take their best shot and watch their patients die and then have to come back the next day and do it all again. It’s no wonder that they want to use every possible tool to beat this damn disease.    So they develop a standard treatment and apply it across the board. No doubt this is partly dictated by insurance and liability concerns. “Radiation? Of course you want radiation. It reduces the risk of recurrence by 40%.” But do the math. When that risk starts at 5%, when radiation reduces that risk (by 40% of 5%) to 3%, when it doesn’t increase your chance of survival, and when you add the risks of radiation itself—the choice is far from obvious. Women need the option to make their own decision.   In the end, ironically, it’s not the oncologists’ job to cure cancer. Their job is to treat their patients—and it’s not the same thing.    Twenty-one months later, Bonnie is both healthy and steadfast, without a moment of doubt or regret. The odds are in her favor. I try not to second-guess her, even if I know that disaster might lurk in every screening exam and mammogram, even if just writing these words seems like tempting fate. It’s her body and her decision, not her doctor’s.    The health care establishment and the breathless media sometimes tout new treatments as medical miracles. But they have risks and they cause damage, which have to be weighed against their benefits. I hope to explore this calculus in future posts, and explore what it’s taught me about medicine and the state of our culture. I’ll also describe the ways Bonnie has chosen to manage her risk of recurrence and metastasis. She is not going gentle unto that good night.   Please note that I am not a medical doctor (nor do I play one on TV), so my reflections are meant to be descriptive and not prescriptive. I wouldn’t pretend to tell anyone else what to do. I invite your comments and, especially, your own stories.   Shortly after Bonnie made her decision, she learned that her original oncologist was running a clinical trial with, coincidentally, the same chemo medications he prescribed for Bonnie.   By that time, Bonnie had found a new oncologist. He gives her options, not orders.