MEDICINE

A debate over early cancer detection

NORA UNDERWOOD January 27 1986
MEDICINE

A debate over early cancer detection

NORA UNDERWOOD January 27 1986

A debate over early cancer detection

MEDICINE

No form of cancer kills more women than breast cancer, and as a result most doctors strongly encourage their patients to check for signs of the disease. Supported by such agencies as the Canadian Cancer Society, they emphasize self-examination and other methods of early detection as valuable aids in fighting the cancer. But last year doubts about early detection’s effectiveness arose out of a malpractice trial in Ottawa. After hearing extensive expert testimony, Ontario Supreme Court Justice David Henry ruled in September, 1985, that an Ottawa gynecolo-

gist was not negligent in failing to treat a lump in the breast of one of his patients because it could not be proven that the early detection of her cancer— and even treatment itself—would have had any effect on the outcome of the disease. The judgment, which has profoundly upset many members of the medical community since it was more widely publicized in The Medical Post earlier this month, in effect suggested that the cancer was terminal from the moment of its first appearance.

The events leading up to the trial began when a 42-year-old Ottawa woman, Carolyn Campbell—who is an administrator at the Children’s Hospital of Eastern Ontario—discovered a lump in her breast in 1980. Her gynecologist, Dr. W.P.E. Paterson, told her not to worry about it and, as a result, Campbell did

not see a doctor for a year and a half. Then, after discovering a second lump, she saw a physician at her workplace who referred her to a general surgeon. He performed a mastectomy of her left breast. By 1984 the cancer had spread to her lymph nodes; in 1985 Campbell filed a suit against Paterson. During the trial in June, 1985, Dr. David Stewart, a cancer treatment specialist at Ottawa General Hospital who looked after Campbell following the mastectomy, testified that Campbell’s breast cancer is terminal.

Henry backed up his judgment in a 129-page summary that relied heavily

on the opinions of Dr. James Devitt, a general surgeon at Ottawa Civic Hospital specializing in breast disorders, who testified for the defence. Devitt is also a consulting surgeon for the National Breast Screening Study—a five-year program designed to determine the effectiveness of various, methods of early detection. In his summary, Henry said Devitt told the court that in 1980 Campbell’s cancer was “as incurable, as threatening, as nasty, as bad a breast cancer as its subsequent course has determined it to be.”

In his testimony, Devitt said that breast cancer tumors are either “good” or “bad.” He added that good tumors can be controlled but that bad tumors are extremely aggressive from their outset. Henry wrote that Devitt’s testimony was “persuasive” and he added: “It is

also an attribute of a bad cancer that notwithstanding surgery and treatment by chemotherapy and radiation a cancer will recur and will then progress much faster so the patient dies at the same time as if not treated.”

Last week Devitt told Maclean's that the opinions he expressed in court were “common and widely accepted” among those who have investigated the natural history and/or behavior of breast cancer. But Stewart, who testified on behalf of Campbell, said: “That was a theory that was popular five to 10 years ago for a brief period, but there is overwhelming evidence that it is not correct for breast cancer. There is very compelling theoretical evidence that early detection is beneficial. Good cancers can become bad cancers over time.” Said Dr. Anthony Miller, an epidemiologist at the University of Toronto and founder of the breast screening study: “There is very good evidence that if you have breast cancer it is a question of using the time available to do as much as possible.”

Dr. James Goldie of the Vancouverbased British Columbia Cancer Control Agency told Maclean's that the smallest detectable lump—about one centimetre—contains about a billion cancer cells and that as a tumor grows, chances increase that mutant cells will colonize other tissues and turn into secondary cancers. Said Goldie: “The longer the elapsed time, the more likelihood that a secondary cancer will develop and itself undergo mutations and develop cells that are immune to treatment.”

Still, most specialists acknowledge that despite a growing body of compelling evidence, there is still no absolute proof that early detection techniques are effective in breast cancer. In 1986, according to the cancer society, about 4,000 Canadians will die of the disease— a rate that has not changed in more than 50 years. Miller, for one, says he is confident that new statistics on deaths since 1983 will show the effectiveness of early detection. But in the meantime, Henry’s judgment has posed difficulties for advocates of early detection—and for the cancer society. Douglas Barr, chief executive officer of the society’s national office in Toronto, said that while many aspects in the treatment of breast cancer are still uncertain, the society will not alter its early detection policies. Added Barr: “One witness convincing one judge does not change the weight of scientific evidence.”

-NORA UNDERWOOD in Toronto