Changing a medical axiom to ‘maybe’

Prof. Michael Baum seeks to overturn some of most commonly accepted medical practices regarding breast cancer detection and treatment worldwide.

By
January 22, 2012 02:59
PROF. MICHAEL BAUM.

PROF. MICHAEL BAUM 311. (photo credit: Judy Siegel-Itzkovich)

 
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His views on breast cancer screening and the growing epidemiological evidence behind them are so counter-intuitive and contrary to what we’ve been told for decades they seem hard to believe. As one listens to Prof. Michael Baum – one of Britain’s most prominent oncologists and a veteran breast surgeon – long-accepted medical axioms seem as dependable as claims that junk food is good for your health.

“At the risk of making myself very unpopular, I wish to expose some of the myths and misconceptions that surround screening for breast cancer,” he wrote in a just-published editorial in the British Journal of Hospital Medicine.

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“I speak with the authority of one of the architects of the [National Health Service’s] Breast Screening Program in the UK.”

Baum, who returned to London last week after making a short visit (one of many dozens) to Israel, told The Jerusalem Post during a lengthy interview at Jerusalem’s Mishkenot Sha’ananim guest house that “in good faith, [I] swung from zealot to skeptic” on breast cancer screening. At Kings College School of Medicine and Dentistry in the late ‘80s, he was asked to implement in London and southeast England the recommendations of the Forrest Report to provide mammography screening for breast cancer in postmenopausal women.

“I therefore had a huge intellectual investment in the future success” of the NHS program, he said.

His mother died of breast cancer at a young age. His younger sister contracted it young as well, but her four daughters did not carry the mutation in the defective BRCA gene (which causes early-onset breast cancer in a large percentage of carriers). “I suspect a maternal grandmother was the founder of it in the family,” he said.

Having performed surgery on many women found to have tumors, Baum noted that many symptomless women who were discovered to be harboring multi-centric duct carcinoma in situ [DCIS], which refers to noninvasive abnormal changes in the milk ducts of the breast, were advised to undergo a radical mastectomy. DCIS is commonly regarded as “pre-cancer.”

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The problem, said Baum, is that DCIS usually doesn’t become malignant, and women don’t die of DCIS unless it turns into invasive breast cancer. Thus although women with DCIS needed to be watched, in his opinion, they were being overtreated and exposed to unnecessary suffering and possible complications. Many of the studies on which the Forrest Report was based claimed that mammography screening and surgical and other treatments could reduce breast cancer deaths by 25 to 30 percent. They were “of very poor quality,” Baum insisted.

Instead, “the numbers [of women] needed to screen over 10 years to prevent one breast cancer death is of the order of one in 2,000.”

In addition, if DCIS is treated as invasive breast cancer, he continued, there are between five and 10 cases unnecessarily treated for every breast cancer death avoided, he said.

As there are a dozen kinds of breast cancer with different prognoses and treatment, they should not all be regarded as the same and requiring extreme intervention, he said.

Treatments have improved so much in the past two decades that they could be partly responsible for the lowering of death rates.

He recommends that risk-assessment facilities be established, with nurses giving women questionnaires or having women answer questions via computer. Those at the highest risk should be referred to a clinical geneticist. Those with a very low risk should be advised how to change their lifestyle.

Those with an intermediate risk could be offered mammography screening, he said.

“To carry on [with existing policies] is simply political expedience, but to so so without offering women informed choice is frankly unethical.”

Baum said that self-examination at home is “a waste of time. Women themselves find most breast cancers by chance while dressing or showering. There is no difference in mortality between those who do self-examination and those who don’t. There have been huge trials on this, and it has been shown not to mean a longer life. It makes women very nervous by doing this routine, and it can lead to unnecessary intervention.

It impairs quality of life, and such women endure many more biopsies. Screening with a surgeon’s clinical exam is better. But awareness of one’s body is important,” he said. “If a woman finds something suspicious, she should get it checked.”Baum suggests that the real lifetime risk of breast cancer is not one out of eight or nine but one in 10, with the higher figure stemming from overdiagnosis due to DCIS.

While every death is a tragedy, he believes that the disease is not regarded proportionately, as “five times more women die of cardiovascular disease. If you watch your diet, exercise regularly and don’t smoke, you have reduced your cardiovascular disease risk as well as the risk of breast cancer. I am on the side of women. If nothing else, they should know the truth. I resigned from the NHS screening committee years ago because they didn’t tell whole story. Women must know the downside of mammography – not danger from the small amount of radiation but from overdiagnosis and too much intervention in those cases when it won’t be effective. I feel passionately about the fact that women are not always told the pluses and minuses so they can give their informed consent.”

Prior to the gradual shift of scientific opinion away from automatic and universal mammograms for women aged 50 to 70, the same policy changes have affected men, who have long been told as they got older to have a PSA (prostate-specific antigen) blood test.

But this test resulted in overdiagnosis and interventions even though some men would have died of other causes. Now, prostate cancer screening should combine an adjusted blood test with other factors including the size of the gland and the patient’s overall weight and family history. This can help up to a quarter of men with high PSAs avoid biopsies and the risks associated with them, according to researchers at Beth Israel Deaconess Medical Center in Boston writing in the journal Cancer.

They said that that instead of using “onesize- fits-all” levels of PSA to determine who should have a biopsy, considering other factors can substantially improve the ability of PSA testing to identify aggressive prostate cancers for which treatment is warranted, while avoiding detection of slowly growing cancers that are better left undiagnosed because they do not require treatment.

Although in Israel, cancer screening, testing and diagnoses are performed almost solely by public physicians who do not have a vested interest, in America the situation is very different.

“I have an ideological conflict of interest, but not a financial one. I am a scientist, and I go with the data. I do not profit from it,” said Baum. “I have made myself very unpopular for my views.” Years ago, he recalls, he gave a lecture on universal screening at a meeting of the American Cancer Society.

“Half walked out and some threw chairs at me,” said the iconoclastic Baum, who is also a severe critic of homeopathy and other unproven complementary medicine techniques.

“The political conflict of interest is also huge. And cancer associations should do what they do best – raise money for research and buying equipment for treating cancer.

They should campaign for women’s right for self-determination, no longer for universal mammography for all.”

Asked to comment on Baum’s strong positions, The Post contacted Prof. Gad Rennert, a leading cancer epidemiologist, director of Clalit Health Services’s national cancer control center, head of the Health Ministry’s and Israel Cancer Association’s (ICA’s) breast and colorectal cancer detection programs and chairman of the department of community medicine and epidemiology at Haifa’s Carmel Medical Center.

Baum said he speaks to Rennert regularly and “admires him enormously.”

Rennert explained that “in every medical intervention we take, there are benefits and some risks. You have to balance them.

Nobody would [deny] that mammography screening can reduce mortality from breast cancer. Some claim there is a 30% reduction in mortality, but others think it’s a maximum of 15% or even 10%. There are hundreds of radiologists and technicians in the country, and some places are less than optimal.

Even Michael can’t [dispute] that mammography is a tool that saves lives. Randomized, controlled trials have shown this. The main issue now is at what cost.”

Rennert said the establishment once praised self-examination, but it stopped years ago. “The added value was either minimal or nonexistent. Women who do it have biopsies taken at twice the rate of other women. If mammography, which has high sensitivity, detects 90% of tumors, a clinical exam probably won’t [be any more effective].

“Mammograms are much less effective in detecting breast cancer in premenopausal women; in the US, women get screened from age 40 and many every year rather than here, where it is every two years.

In the US, there is a certain amount of overtesting due to financial reasons. Mortality rates are down, mostly because of better drugs and other treatment and from major changes in lifestyle.”

Rennert added that the Israeli screening program must always control its quality, including the reduction of abuse or overuse.

He agreed with Baum on DCIS. “Not many of these lead to invasive tumors; they can disappear on their own. But he [Baum] doesn’t believe in the ability to [regulate] screening and the behavior of radiologists.”

The Haifa epidemiologist added that the four health funds no longer mail women letters telling them to go for screening, even if they are in a low risk group. “We changed the wording to say that studies show benefits of mammography, but the insurer is aware of the fact that there is also downside, such as false negatives or false positives and overdetection.

The ICA has written materials that will in time become mellower – and justifiably so.” Seventy-two percent of women in the relevant age group for mammograms go every two years. “This is good. I am not really annoyed when Michael says what he says.

He keeps us on our toes,” said Rennert, who as a public health expert can speak for the ICA as its adviser for cancer control.

Baum, who came to attend opening of the Israel Society of Clinical Oncology and Radiotherapy in Eilat, speaks good Hebrew, as 45 years ago he moved from England to Israel to work as a surgeon at Emek Medical Center in Afula and served as medical officer at archeology Prof. Yigael Yadin’s digs at Masada. But the young doctor decided to leave Israel after 18 months because he didn’t see his career going anywhere. Yet he is a devoted defender of Israel, a trustee of the Hadassah Medical Organization and a very frequent visitor. His three children are modern Orthodox, and he has nine grandchildren.

A niece lives in Jerusalem’s Nahlaot neighborhood.

“I was from a poor family. My grandparents were all Jews who left Poland 100 years ago. My mother was born in London, but my father arrived from Warsaw when he was 11 years old and got no education. He was a failed businessman. We lived during the Blitz during World War II,” he recalled of his boyhood. But they raised five children in an Orthodox home, and all of their descendants did very well. Baum’s eldest brother was a doctor, and the next was a chemistry professor and dean of Kings College. The youngest, David, died suddenly 10 years ago from a heart attack during a bike ride to benefit the health of Palestinian children.

“He was president of the Royal College of Pediatrics and Child Health. He was the most prominent pediatrician in the US,” said his now-72-year-old brother. “And he set up a vaccination clinic in the West Bank.”

Michael established the charitable David Baum Foundation in his memory, among others, to set up a vaccination and has raised tens of thousands of dollars for Save a Children’s Heart to train Palestinian doctors to help children. “That is why it hurts when some in the UK have called me a Nazi.”

Active in opposing academic boycotts against Israel, Baum recalls sadly that his support for the then-Israel Medical Association (IMA) chairman Dr. Yoram Blachar led to a campaign to punish him professionally.

Anti-Israeli activists charged that Blachar and his organization were “complicit in the torture of Palestinian prisoners,” and Baum was under personal attacks because of his stance. “There are 35 Arab and Muslim embassies in London, and one Israeli Embassy. Huge sums of money supporting Palestinian activists are used. The liberal Left supports the underdog. There is nascent anti-Semitism in the UK, but while people don’t like to be called anti-Semitic, they regard it as OK to be anti-Israel,” Baum asserted. “Some young people sincerely believe there was a Palestinian state that Israel fought and [that the IDF] is an army of occupation. They are unaware that 20% of the Israeli population are Arabs with civil rights. There are many things wrong with the occupation, but this single-minded deligitimization of Israel is awful.”

Baum also occupies himself non-medical subjects. He is currently writing his first novel (and looking for a publisher) trying to weave together a molecular and biblical genealogy of the Jews. From his experience at Masada, he dreamed up the story of twin girls who escaped the destruction of the Second Temple, one going to north to Peki’in and other exiled to India. The women develop breast cancer, but think it’s a curse, while it is in fact the BRCA mutation. A woman and a man from the family meet 2,000 years later. To make a long story short, they both come on aliya, fall in love and... you’ll have to read the book.

May there be a happy ending for all with breast cancer or any other kind.

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