Reporting Cancer

The Cancer Information and Support Society wrote to the Council to express its concern at the lack of objectivity in the press relating to the treatment of cancer. The Council invited the society to express its view in an article - provided by Don Benjamin - and sought the comments of the National Breast Cancer Centre to comment on it.

Cancer Information and Support Society

There is a distinct bias in the media's reporting of the treatment of cancer in Australia. It is most profound in the newspapers. It applies to all treatments, surgery, radiotherapy and chemotherapy. This has been the subject of scholarly research.

One recent example of this is a paper by Pam McGrath and Geoff Turner entitled "The ethics of hope: newspaper reporting of chemotherapy" (Australian Studies in Journalism 1995; 4: 50-71). They analysed all articles mentioning the word chemotherapy in The Courier-Mail and The Sunday Mail (Queensland) from January 1990 to March 1992. What they found was a consistent portrayal of "the myth of a breakthrough to hide the frustration of the present reality". This was done by the use of headlines creating the impression of success whereas the content was about hope and promise which was rarely justified by the evidence. They stated that "such reporting is powerful in terms of the mindset it produces, and the subconscious individual and community attitudes it creates". German biostatistician Ulrich Abel analysed the results of clinical trials using chemotherapy in advanced epithelial cancer and found that "with few exceptions there is no good scientific basis for the application of chemotherapy in symptom-free patients" (Biomed & Pharmacother 1992. 46. 439-452).

In the area of surgery and radiotherapy a recent example occurred in The Sydney Morning Herald on Saturday 9 August under the page 1 headline "Breast Cancer Hope for Younger Women". This was the story about the possible use of mammogram screening. (This has not been found to help younger women.) A group of medical scientists with a vested interest in screening had looked at the literature again. The report said "everybody is agreed there is now some evidence of benefit".

Behind the scenes the reality is rather different. Over the past 20 years there has been an increasing number of leading cancer specialists throughout the world who have been questioning the current paradigm of what cancer is, and therefore how it should be treated. In the field of breast cancer this concern has been expressed by The Lancet in organising a special international conference "The Challenge of Breast Cancer" in 1994 using the theme of their editorial of 6 February 1993 "Breast cancer. Have we lost our way?" The keynote speaker James Devitt concluded that none of the current treatments for breast cancer had any effect on survival or mortality and questioned the current paradigm of breast cancer being a localised disease.

Political pressures from women demanding that something be done have resulted in mammogram screening being given extra funding in many countries, despite the absence of any scientifically acceptable evidence that mammograms save lives.

Cancer experts justify the use of screening by pointing out that results of randomised trials show that women offered screening have a reduced mortality when compared to those not offered screening. Claims for reduced mortality range from 0 - 30 percent depending on the bias of the researcher. These claims rely on ignoring the equal increase in mortality from other causes caused by the post-screening treatments, particularly radiotherapy. When all causes of death are considered there are no randomised trials that demonstrate any net benefit of screening. (see Benjamin DJ, "The Efficacy of Surgical Treatment of Breast Cancer", Medical Hypotheses 1996. 47. 389-397). None of these findings were reported in the Australian press except for The Herald Sun (Melbourne). This is despite an AAP release dated 4 November 1996 entitled "Mammograms don't save lives - scientist".

A similar finding for surgery and radiotherapy was reported by the Early Breast Cancer Trialists' Collaborative Group in the New England Journal of Medicine on 30 November 1995 after reviewing results of all 36 randomised trials involving 28,405 women with early breast cancer. The 6% decrease in deaths from breast cancer was accompanied by a 24% increase in deaths due to other treatment-related causes. Again the finger was pointed at the damage caused by the radiotherapy. There were no net saving of lives in either older or younger women. This finding again went unreported in the Sydney press. This situation was identified as long ago as 1975 by journalist Daniel Greenberg in his article "A Critical Look at Cancer Coverage" (Columbia University Journalism Review, Jan/Feb 1975, 40-44), which was reprinted in The Washington Post on 19 January 1975.

An analysis of mortality rates for the different forms of cancer over the 20 years from 1950-1970 showed that surgical treatment could not have had any effect on survival for any form of cancer (Benjamin DJ, "The Efficacy of Surgical Treatment of Cancer", Medical Hypotheses 1993. 40. 129-138). Similar analyses by John Bailar III, a member of the US President's Cancer Advisory Panel, have confirmed this situation for the period 1970-1994 (Bailar JC and Gornik HL, "Cancer Undefeated", New England Journal of Medicine [29 May] 1997; 336 [22]. 1569-74). None of this information appeared in The Sydney Morning Herald for example.

The myth of the efficacy of cancer treatment has been perpetuated by journalists from newspapers publishing news releases from cancer specialists with vested interests without questioning their claims. After all they are experts aren't they?

How could this happen? The answer lies in developments in the last century when most state governments conferred on the allopathic school of medicine a strict monopoly on the treatment of cancer, without any evidence that they could treat cancer successfully. Over the years legislation in NSW, for example, has changed slowly from a situation where it was illegal for anyone who was not a medical practitioner to provide any service to a cancer patient, to the present one where it is illegal for anyone other than a doctor to claim to have a cure for cancer.

The allopathic school of medicine is based on the principles that all disease arises from external causes, and therefore must be fought by applying external solutions such as drugs, an assumption influenced greatly by the claims of Louis Pasteur and the later discovery of penicillin. Modern developments in the drug industry have reinforced this approach to the treatment of cancer with marketing pressures leading to a situation where chemotherapy, shown to help fewer than 4 percent of cancer patients (a few systemic cancers such as leukemias and lymphomas in children) is now used for about 80 percent of cancer patients. Court cases on medical negligence in the field of cancer are decided on the basis of "evidence" that is no more than the opinion of experts without any scientific evidence to back it up.

An editorial in the British Medical Journal on 5 October 1991 "Where is the wisdom?... The poverty of medical evidence" pointed out that only 15 percent of medical interventions are supported by solid scientific evidence. The figure for cancer is closer to 6 percent. This is not the picture that is being painted by the Australian newspapers.

As a result we have a situation where there is about $500 billion spent on cancer research and treatment every year throughout the world based on a set of treatments that for the most part don't work. The figure for the US is about $200 billion. For Australia it is about $2 billion. Yet there is not a single newspaper in the country prepared to investigate this situation.

Don Benjamin

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National Breast Cancer Centre

Dr Benjamin's comments about the lack of accurate reporting in the media about cancer would be endorsed by many health professionals working in breast cancer.

For example, in a recent survey of 3,000 well women across Australia, the media were cited as the most common source of advice about breast cancer. [1] The survey found that 40 percent of women incorrectly regarded women under the age of 50 years as being most at risk of developing breast cancer. It seems likely that these views are the result of media reporting of breast cancer among younger women.

It appears that there may be a media perception that the rare cases of breast cancer in women under the age of 35 years are in some way more 'newsworthy' than the vast majority of cases which occur in older women. This may result in older women failing to take part in early detection programs which could save their lives, due to a belief that their risk of breast cancer is lower than it was earlier in their life.

Dr Benjamin is also correct in claiming that the likely impact of new treatments is often overstated. The fact that we do not yet know what causes breast cancer prevents us from offering simple messages about prevention. However, the enormous public interest in breast cancer creates a temptation to publish stories which promise breakthroughs in treatment. However, in reality these are often reports of early laboratory studies which will not impact on outcomes for women for a number of years if at all. On other occasions the benefit of the treatment may be real but only capable of improving survival in a small proportion of women with the disease. Such stories of so-called breakthroughs offer false hope for some women, most tragically for women in advanced stages of the disease.

However, several other aspects of Dr Benjamin's article require correction.

First, he makes several erroneous claims in relation to mammographic screening. There has been evidence for some time from a number of randomised trials that there is a reduction in mortality from screening in women aged over 50 years, in the order of about 30 percent. [2]

Dr Benjamin appears to misunderstand the nature of these trials; women are randomly allocated to be offered, or not offered, screening over the same period. Any differences in deaths from breast cancer between the two groups cannot be due to post-screening treatment or radiotherapy since both groups are equally likely to receive these treatments. The only difference between the groups is in their experience of mammographic screening. There is very good evidence that mammographic screening can reduce the numbers of deaths from breast cancer, and this is the basis on which the Commonwealth and State governments fund the national screening program, BreastScreen Australia.

Dr Benjamin goes on to comment that there is no evidence of benefit of mammographic screening in younger women. Over the past two years, there have been very important developments in this area, with new data emerging from the randomised trials. There is now evidence of some benefit of screening among women aged 40-49. It shows that, on average, 7 deaths will be prevented per 10,000 women screened every two years. [3] This needs to be balanced against some of the downsides of screening in this age group, such as an increased rate of investigations, but nonetheless the evidence of benefit has been established.

Second, we would all like to see improvements in the treatment of breast cancer and there is a considerable research effort currently in Australia and internationally.

However, Dr Benjamin's claims about the effectiveness of current treatments for breast cancer are incorrect. There are a number of randomised trials of radiotherapy in breast cancer, which show that the treatment is very effective in reducing the rates of recurrence of breast cancer among women who have previously had the disease.[4,5] Likewise, a range of other drug and hormonal therapies such as tamoxifen, multiagent chemotherapy and removal of the ovaries, have all been shown to reduce the risk of recurrence and death for women with breast cancer under the age of 50.[6,7,8] Tamoxifen significantly reduces recurrence-free survival at all ages and reduces the incidence of breast cancer in the other breast. [6,9] The benefits of these treatments have been summarised in the NHMRC Clinical Guidelines for the Management of Early Breast Cancer.[10]

In contrast to Dr Benjamin's claims, there is some evidence that early detection and management strategies are reducing deaths from breast cancer. The NSW Central Cancer Registry reports that the 5 year survival rates for breast cancer are 70 percent overall and 90 percent if the cancer is diagnosed while it is still localised in the breast. [11] Data from the Registry indicate that survival from breast cancer has been slowly improving over the past twenty years - due to improvements in both early detection and treatment. [11]

The concept of randomised trials is central to the establishment of scientific proof of the effectiveness of treatment strategies. The National Health and Medical Research Council has published recommendations about different levels of evidence of the effectiveness of treatments and they recommend that meta analyses of randomised trials are the best standard of evidence (level 1) followed by individual randomised trials (level 2). [12] In such research, the only difference between groups of patients is in their exposure to the treatment being evaluated and we can therefore be confident that any difference in outcomes is due to the treatment. For breast cancer, there are many aspects of treatment that have level one or two evidence supporting their use.

If Dr Benjamin has evidence of other treatments with level 1 or 2 evidence supporting their effectiveness, we are sure that practitioners of 'conventional medicine' would be very interested in seeing them.

Sally Redman, Ph. D., Director, NBCC
Janet Pelly, Communications Manager, NBCC

References

1. Barratt A, Cockburn J, Lowe J, Paul C, Perkins J, Redman S, "Report on the 1996 Breast Health Survey". Woolloomooloo (NSW):NHMRC National Breast Cancer Centre; 1997. [return to article]
2. Hurley SF, Kaldor JM. "The benefits and risks of mammographic screening for breast cancer". Epidemiologic Reviews 1992; 14: 101-30. [return to article]
3. Irwig L, Glasziou P, Barratt A, Salkeld Gl, "Review of the evidence about the value of mammographic screening in 40-49 year old women", NHMRC National Breast Cancer Centre; 1997. [return to article]
4. Liljegren G, Holmberg L, Adami H-O et al. "Sector resection with or without postoperative radiotherapy for stage I breast cancer: five year results of a randomized trial". Upsalla-Orebro Breast Cancer Study Group. Journal of the National Cancer Institute 1994; 86: 717-22. [return to article]
5. Gelber RD & Goldhirsch A. "Radiotherapy to the conserved breast: is it avoidable if the cancer is small?" Journal of the National Cancer Institute 1994; 86: 652-54. [return to article]
6. "Systemic treatment of early breast cancer by hormonal, cytotoxic or immune therapy: 133 randomised trials involving 31,000 recurrences and 24,000 deaths among 75,000 women". Early Breast Cancer Trialists' Collaborative Group. Lancet 1992; 339: 1-15. [return to article]
7. "Systemic treatment of early breast cancer by hormonal, cytotoxic or immune therapy: 133 randomised trials involving 31,000 recurrences and 24,000 deaths among 75,000 women". Early Breast Cancer Trialists' Collaborative Group. Lancet 1992; 339: 71-85. [return to article]
8. Anonymous. "Adjuvant systemic therapy for early breast cancer" [editorial]. Lancet 1992; 339: 27 [return to article].
9. Fisher B, Costantino J, Redmond C et al. "A randomized clinical trial evaluating tamoxifen in the treatment of patients with node-negative breast cancer who have oestrogen receptor-positive tumours". New England Journal of Medicine 1989; 320: 479-484. [return to article]
10. National Health and Medical Research Council (Australia). Clinical practice guidelines for the management of early breast cancer. Canberra: 1996. [return to article]
11. Taylor RJ, Smith D, Hoyer A, Coates M, McCredie M. Breast "Cancer in NSW 1972-1991". Sydney: Cancer Epidemiology Research Unit, NSW Cancer Council; 1994. [return to article]
12. Quality of Care and Health Outcomes Committee. Guidelines for the development and implementation of clinical practice guidelines. Canberra: Australian Government Publishing Service; 1995. [return to article]

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