The Battle We Didn’t Choose – My Wife’s Fight with Breast Cancer

Hi Everyone! There’s a beautiful love story between Angelo Merendino and his wife Jen. Angelo is an extremely talented photographer. He was also an incredible husband to his wife Jen who got metastatic breast cancer. He photographed her as she lived with this disease all the while loving and caring for her in such a special way. He has a web site that you will find fascinating at: http://mywifesfightwithbreastcancer.com/, where you can read and find out much more about this beautiful story as well as see some incredible photography.

Angelo Merendino’s Book is Now Available for Sale!

The Battle We Didn’t Choose – My Wife’s Fight with Breast Cancer

The Battle We Didn't Choose - my wife's fight with breast cancer

Angelo Merendino writes:

I am proud to announce that our story is now available in digital book format! Aside from taking care of Jennifer, putting this book together has been the biggest challenge of my life. More than a story about loss, this is a story about love and life. Above all else I have realized that this book is a love letter from me to Jen.

The book includes many photographs that have not been shown anywhere, as well as a Resources section, audio narrations and videos. It is available in English, Italian, Spanish, French, German and Russian. (Note that if you are hoping to view the book on an iPad, be aware that audio and visual elements will not function. I am currently waiting for approval from Apple on the full-featured, iPad-specific eBook. Please check my website again soon for details on this release.)

Fifty percent of the net profits of all book sales will be donated to The Love You Share*, a non-profit organization I am starting in honor of Jennifer. The mission of The Love You Share is to provide financial assistance to cancer patients in need while they are receiving treatment for cancer. The hope is that by sending a gift card from a local grocery delivery service and reimbursing patients for transportation costs to and from hospital and doctor appointments, The Love You Share will be able to make life easier, even if only for a short time, for someone who is fighting for her life.

Available in English, Italian, Spanish, French, German and Russian.

*The Love You Share has applied to the Internal Revenue Service for 501(c)(3) tax-exempt status.  Donations to The Love You Share are not currently tax-deductible while its application is pending. If The Love You Share receives tax-exempt status, donations received while its application was pending may be treated as tax-deductible contributions retroactive to the date of its formation.

To Buy this Great Book

clickhere

 

While Flying – Frustration surrounds Me

For starters I was on a flight for a happy family event. The day started great. I got a lot of work done on our official Advocates for Breast Cancer website. I got to the airport at the right time even though LAX was so crowded because there’s a problem with the TSA and there’s long lines and less TSA agents to help move the lines faster.

airplaneI was a little mad at myself because I was lazy and went through the machine that I have been told by a radiation oncologist (whom I have great respect for) I should probably skip and not expose myself to the radiation. It just seemed faster. I started in an airport lounge with my computer figuring I’d work a little more on my Breast Cancer News at: http://www.scoop.it/t/breast-cancer-news and my Breast Cancer Advocacy stories at: http://www.scoop.it/t/breast-cancer-advocay. Sounds simple enough.

I searched the internet for abstracts and news stories about breast cancer and found what I hoped would make a difference with advocacy for breast cancer (and other cancers). I even discovered I spelled advocacy wrong today. Certainly I’m human and can make a spelling mistake. I sent out all of my good wishes to my fearless friends and organizations on Twitter trying to make pretty graphics while I sent energy to all of these incredible people who I have met either personally or through social media. So it seemed like it was time to get ready to enjoy a special family weekend.

#BCSMmagesI plugged my computer in and I saw a note from AnneMarie to look at Jody’s blog. I already suspected it’s bad news. Jody Schroger is one of our great moderators every Monday night at 6pm PST for #BCSM (breast cancer social media). It’s very bad. After years of NED (no evidence of disease), Jody has joined the 30% of breast cancer thrivers that has metastatic breast cancer (MBC).

And Jody. Why? She is a fantastic person who runs our #bcsm (breast cancer social media community) meetings with Alicia Stales and Dr. Deanna Attai. Why her? Welcome to the world of breast cancer. It’s all bad luck. Whoever gets Stage IV it has nothing to do with them not taking care of themselves or what stage they started with the disease.

I keep thinking everyone knows that I have talked about the statistic that about 30% of early stage breast cancer patients will go on to become metastatic. That’s Stage IV. Early stage breast cancer is what I had when I did chemo, radiation, and had a recurrence a year and half later. Stage IV means that the breast cancer has managed to travel from the breast to other body parts. With breast cancer it’s usually the bones, brains, liver, or lungs. Stage IV is a chronic disease. It is not curable, but can be contained. It depends on many factors how long it can be “contained”. Usually certain pathologies help because there are more targeted therapies that can work on keeping the cancer at bay. For those that don’t understand Stage IV breast cancer is breast cancer that has traveled to another body part. Let’s say it goes to the bones. It’s not bone cancer but still breast cancer that has metastasized to another body part.

MBC_Infographic_01_v14I am angry. This disease is like dominoes. This disease is so cruel. I watch as friends that I care about get the bad news. The reason I did the chemo-hoping no bad cells could hide from all the nasty toxic chemo that I did because my breast cancer made it in to my lymph nodes giving it a chance to enter my blood stream. We never know if some cells hid out and they are just waiting to say- GOT YA.

OK here’s the Stage IV lesson. They have drug regimens that patients go through that can keep the cancer at bay for some time and then the cancer finds a way to outsmart the therapy. So the MBC patient moves on to the next drug. The trick is to try to find regimens with quality of life for as long as you can until the cancer outsmarts the drug. Then it’s time for nerve-racking scans to see if the drug is working. If the medications are working it’s great. The patient stays the course. Eventually though comes the scan that shows the cancer is growing and trying to get to more body parts. Many MBC patients can live a very long time especially with certain pathologies that lend itself to drug therapies that can help contain the disease. Today’s MBC patient can even have a chance of seeing NED (no evidence of disease). But the cancer still comes back and outsmarts the treatment. I respect everyone who has metastatic disease because they have to live knowing they are on a slope that eventually their disease will no longer respond to the drugs we have available today.

At the same time I want to be clear that today’s MBC patient is quite alive and can have a long quality of life.

At the beginning when diagnosed there is so much shock to the body and mind. I have watched my best friend Li Bailey go through the process quicker than others because unfortunately (bad luck) she had a pathology that today we have less medications to fight it with.

This is just not fair.

think-before-you-pink-1024x574So why am I so frustrated? I am running a non-profit that aligns itself with breast cancer organizations that are working to help breast cancer patients. After learning that Komen’s  junk campaigns were based on lies like telling women if they got mammograms they had a 98% chance of beating breast cancer. This is so not true. Komen also raised the most money of any breast cancer organizations. There was a great article in the New York Times, written by journalist Peggey Orestein that I scooped today called “Our Feel-Good War on Breast Cancer,” I published the article in my last blog. Meanwhile Katherine O’Brien of the Secretary of the MBCN (Metastatic Breast Cancer Network) wrote a great summary, overview and response to the article called Our Feel-Good War on Breast Cancer: MBCN Responds. In her response to Komen’s use of funds towards metastatic research, she writes, According to a Fortune magazine analysis, only an estimated .5 percent of all National Cancer Institute grants since 1972 focus on metastasis; out of more than $2.2 billion dollars raised over the last six years, Komen has dedicated $79 million to such research — a lot of money, to be sure, but a mere 3.6 percent of its total budget during that period.”

pinkcultureThere has been a a lot of backlash against Komen and as some of you understand the overselling of pink culture I don’t have to explain the issue. I hope that you had time to read these articles. They are so well written.

I think there is another problem with Komen. I think the biggest backlash against them is that they became arrogant. People called them out for having pink parades that did not include the metastatic community because they didn’t want sick people marching in their parades, since it didn’t give you that warm fuzzy feeling of survivors raising their pink pom poms because they survived the disease. Komen thumbed their nose at the metastatic community.

I have to fight for the mets community. I can’t help it. People are dying around me. I don’t like that. People are doing all sorts of difficult medical regimens to stay alive. I have to open my big mouth and do all I can.

I promise you I won’t stop until MBC is a disease that can be reversed or people can live with Quality of life. I will continue to see that we don’t continue having corporations making known toxins that cause breast cancer.

One positive thing that happened is when the #BCSM Community group met we all rallied around Jody. Ironically I was flying back from the weekend on Monday night and joined the meeting on a flight that had wifi. At first I was confused if the timing would work. Then I realized as long as I started the meeting at the right time, the hour would be the same no matter if I flew in to a different time zone. So many of us were frustrated, angry and wanted Jody to know we have her back. This community means so much to me and I am grateful that at least we can come together during the good and bad times.

I have a lot more to say about all of this. For now I am going to publish this first part and continue talking about some other things that have added to my frustration. Stay tuned.

Read all About It – Our Feel Good War on Breast Cancer

I scooped the article, Our Feel Good War on Breast Cancer in my “Breast Cancer Advocacy” news articles at the end of last week and it also came out in the New York Times weekend edition. There was a wonderful response to this article by Katherine O’Brien, who is the MBCN (Metastatic Breast Cancer Network) Secretary called Our Feel-Good War on Breast Cancer: MBCN Responds.

I have another post that refers to some points in these articles, so I want to first have them on my blog. Although the original article is long, for those of you who haven’t heard about or had a chance to read the article, it explains so much of what I (and lots of other patient advocates) have written about when referring to “pinking responsibly” and telling the truth about breast cancer, pink culture, and the reason we haven’t come very far when it comes to metastatic breast cancer.

Katherine O’Brien’s response is not as long and picks out the major points of the article so well that I am going to publish it first. I will finish cleaning up my next post that refers to this article as well as other things happening that are very disconcerting to me. You can either follow the link to: Our Feel-Good War on Breast Cancer: MBCN Responds and/or the link to Our Feel Good War on Breast Cancer here or read below.

Our Feel-Good War on Breast Cancer: MBCN Responds

Tony Cenicola/The New York Times; Gabrielle Plucknette/The New York Times (umbrella, socks, oven mitt); A.J. Mast/Associated Press; Nam Y. Huh/Associated Press; Kyle Kurlick/The Commercial Appeal, via Associated Press; Dr. Scott M. Lieberman/Associated Press

By Katherine O’Brien, MBCN Secretary

Editor’s Note: Peggy Orenstein’s April 25, 2013 article–the cover story for this Sunday’ s New York Times’ Magazine, demonstrates a remarkable depth and thoughtfulness. It is long–but well-worth the effort to read. For those looking for a quick overview, we’ve prepared the following summary and added our observations where appropriate. We hope it will aid readers’ understanding of this important article as well as prompt further discussions. Please share your insights in the comment section below.

Initial Treatment and Recurrence | Journalist Peggy Orenstein wrote “Our Feel-Good War on Breast Cancer,”   subtitled “The battle for awareness has been won. So why aren’t more lives being saved?” Orenstein frames the article within her own breast cancer experience.  Sixteen years ago at 35, Orenstein had a screening mammogram that revealed early stage breast cancer. Her treatment, at that time, was a lumpectomy, as well as six weeks of radiation.

In 2012, at age 52, Orenstein had a nonmetastatic recurrence. She found the lump herself, nine months after her annual mammogram. Because of her prior treatment, Orenstein’s doctor recommended a unilateral mastectomy as well as Tamoxifen.

Early Detection Doubts | In 1996, at the time of her first diagnosis,  Orenstein credited her screening mammogram with saving her life. (“I considered myself a loud-and-proud example of the benefits of early detection,” she writes.) In 2013, following  the cancer’s recurrence, she has changed her mind.

Orenstein  details the US screening mammogram debate. The popular perception,  fueled in part by some nonprofits and pink-ribbon themed efforts,  is that screening mammograms save lives. Evidence of actual mortality reduction is, in fact, conflicting and continues to be questioned by scientists, policy makers and members of the public. According to Orenstein:

“Mammograms, it turns out, are not so great at detecting the most lethal forms of disease — like triple negative — at a treatable phase. Aggressive tumors progress too quickly, often cropping up between mammograms. Even catching them “early,” while they are still small, can be too late: they have already metastasized. That may explain why there has been no decrease in the incidence of metastatic cancer since the introduction of screening.”

We Say: This article can be summed up in one sentence: “Early Detection is Not a Cure.” Metastatic breast cancer can occur 5, 10,  15 or even 20 years after a person’s original diagnosis and successful treatment checkups and annual mammograms.

Overtreatment | Orenstein explains that  breast cancer isn’t a single disease. But early mammography trials were conducted before variations in cancer were recognized: “before Herceptin, before hormonal therapy, even before the widespread use of chemotherapy.” She then raises the question of overtreatment. Dartmouth’s Gilbert Welch  co-authored a study that estimates that only 3 to 13 percent of women whose cancer was detected by mammograms actually benefited from the test.

We Say: We agree with author and patient advocate Musa Mayer who says: “If we had spent a fraction of the dollars devoted to promoting screening on research to determine which DCIS lesions and tiny invasive breast cancers actually need treatment beyond surgery, and which do not, we’d be way ahead now.” Without knowing which tumors will metastasize, we must treat all of them alike. Worse, “good” mammograms may give some women a false sense of security.

DCIS Dilemma | The article says mammograms and improved imaging technology have resulted in a dramatic increase in the number of people diagnosed with ductal carcinoma in situ (D.C.I.S.),  in which abnormal cells are found in the lining of the milk-producing ducts. DCIS and the less common lobular carcinoma in situ account for about a quarter of new breast-cancer cases — some 60,000 a year. “D.C.I.S. survivors are celebrated at pink-ribbon events as triumphs of early detection,” writes Orenstein. “Theirs was an easily treatable disease with a nearly 100 percent 10-year survival rate.”

We Say: One of our few quibbles with this article is its depiction of DCIS. We agree that most DCIS is successfully treated. But  the article cites an expert who says DCIS is “not cancer but a risk factor.”  This statement creates the overall impression is that DCIS is not a big deal. Again, in most cases DCIS does NOT go on to become invasive breast cancer, but unfortunately it can and does.

Confusing Statistics |  Orenstein say that the Komen organization, a mammogram/early detection proponent,  has been accused of citing deceptive five-year survival rates. Since these allegations first surfaced, Komen has stopped using the statistic in question.

We Say: NBCC does an excellent job of addressing this common misperception:

Mortality numbers tell the story more precisely than survival numbers. Screening skews the survival numbers:  The more we screen, the more we diagnose and treat women with breast cancers that would not have been a threat to their lives,  so it looks like survival for early stage breast cancer is 98 percent.

This is only a 5-year survival number—and includes the 20-30 percent of women who will have recurrence and may die of the disease later. . . Women die of metastatic disease, not primary breast cancer.

Incidence has risen during the past 20 years from 1 in 11 to 1 in 8, it’s now leveling off; mortality has declined slightly but a key point is incidence of stage IV breast cancer—the cancer that is lethal—has stayed the same; screening and improved treatment has not changed this.
Source: http://www.breastcancerdeadline2020.org/get-involved/tools-and-resources/toolkit/resources-and-tools-for-advocates

We Can’t Manage What We Don’t Measure: When will we start collecting meaningful statistics on metastatic breast cancer recurrence?  US cancer registry data captures data at the time of diagnosis and death. The registries don’t track what happens in between.

As Orenstein notes, 30% of those originally diagnosed with early stage breast cancer will have a metastatic recurrence. But this information is not tracked–until people die:

  • NCI and SEER database record  incidence, initial treatment and mortality data. Most people do NOT present with metastatic diagnosis. The cancer registry does not track recurrence—which is how the majority of people are thrust into the metastatic breast cancer ranks.
  • We say that there are 150,000 US people currently living with metastatic breast cancer, but that’s basically a guess.
  • We know for sure that 40,000 US people die from breast cancer every year. We know that 5 to10 percent of those with metastatic breast cancer were Stage IV from their first diagnosis. So what about the 90 to 95% of those 150,000 currently living with metastatic breast cancer  who were previously treated for early stage breast cancer? The cancer registry does not track them—until they die.

Funding Research | We need more metastatic breast cancer research. Orenstein confirms what MBCN and METAvivor have said for years. Metastatic breast cancer research is appallingly underfunded:

According to a Fortune magazine analysis, only an estimated .5 percent of all National Cancer Institute grants since 1972 focus on metastasis; out of more than $2.2 billion dollars raised over the last six years, Komen has dedicated $79 million to such research — a lot of money, to be sure, but a mere 3.6 percent of its total budget during that period.

There’s also the intertwined issue of funding research for the prevention of metastatic breast cancer vs. treatments that will extend the lives of those currently living with the disease:

“A lot of people are under the notion that metastatic work is a waste of time,” said Danny Welch, chairman of the department of cancer biology at the University of Kansas Cancer Center, “because all we have to do is prevent cancer in the first place. The problem is, we still don’t even know what causes cancer. I’d prefer to prevent it completely too, but to put it crassly, that’s throwing a bunch of people under the bus right now.”

We Say: MBCN’s slogan is “Fighting for Treatments to Extend Life.” So we appreciate Welch’s candor and dedication.  And, if we want to prevent metastasis, we may need to rethink our current approach to clinical trials.  During last year’s annual Metastatic Breast Cancer Conference, NIH’s Dr. Patricia  Steeg made a case for redesigning clinical trials to do what she termed “phase II randomized metastasis-prevention trials.” Currently, phase I and phase II clinical trials are done in patients with advanced, refractory metastatic cancer, patients who have had many therapies. In phase II trials, researchers typically are trying to determine if a drug shrinks metastases.“But a drug that prevents metastasis may not shrink a large, refractory tumor,” said Steeg. “It has a different mechanism of action that is not picked up by the clinical trial system.”

Know The  Breast Cancer Facts | In her final paragraphs, Orenstein says we may have more breast cancer “awareness” but this “awareness” is fundamentally flawed: “All that well-meaning awareness has ultimately made women less conscious of the facts: obscuring the limits of screening, conflating risk with disease, compromising our decisions about health care, celebrating “cancer survivors” who may have never required treating. And ultimately, it has come at the expense of those whose lives are most at risk.”

We Say: Nicely done, Peggy. We’d be honored if you would join us at our 2013 Annual Metastatic Breast Cancer Conference, Sept. 21 at MD Anderson in Houston!

NMBCAD logo black smallMark Your Calendar: Peggy Orenstein’s article will go a long way in helping people understand breast cancer. As women living with metastatic breast cancer, we are committed to educating people about this disease. This article is a good start, but our reality remains poorly understood. That is why MBCN fought to establish  Oct. 13 as National Metastatic Breast Cancer Awareness Day. 

Let’s Keep Talking: On her Facebook post announcing the publication of this article, Orenstein said she hopes it will change the national conversation about breast cancer. We hope so, too. Peggy started the dialogue. Won’t you help us continue it?

4/29/2013 Editor’s Note: This copy has been revised to remove a disputed statistic concerning Stage II and Stage III metastatic recurrence, material that was directly quoted, as indicated,  from http://www.breastcancerdeadline2020.org/get-involved/tools-and-resources/toolkit/resources-and-tools-for-advocates. We will provide additional clarification if available.

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Our Feel-Good War on Breast Cancer

Tony Cenicola/The New York Times; Gabrielle Plucknette/The New York Times (umbrella, socks, oven mitt); A.J. Mast/Associated Press;
Nam Y. Huh/Associated Press; Kyle Kurlick/The Commercial Appeal, via Associated Press; Dr. Scott M. Lieberman/Associated Press.
By PEGGY ORENSTEIN
Published: April 25, 2013

So when the radiologist found an odd, bicycle-spoke-like pattern on the film — not even a lump — and sent me for a biopsy, I wasn’t worried. After all, who got breast cancer at 35?

It turns out I did. Recalling the fear, confusion, anger and grief of that time is still painful. My only solace was that the system worked precisely as it should: the mammogram caught my tumor early, and I was treated with a lumpectomy and six weeks of radiation; I was going to survive.

By coincidence, just a week after my diagnosis, a panel convened by the National Institutes of Health made headlines when it declined to recommend universal screening for women in their 40s; evidence simply didn’t show it significantly decreased breast-cancer deaths in that age group. What’s more, because of their denser breast tissue, younger women were subject to disproportionate false positives — leading to unnecessary biopsies and worry — as well as false negatives, in which cancer was missed entirely.

Those conclusions hit me like a sucker punch. “I am the person whose life is officially not worth saving,” I wrote angrily. When the American Cancer Society as well as the newer Susan G. Komen foundation rejected the panel’s findings, saying mammography was still the best tool to decrease breast-cancer mortality, friends across the country called to congratulate me as if I’d scored a personal victory. I considered myself a loud-and-proud example of the benefits of early detection.

Sixteen years later, my thinking has changed. As study after study revealed the limits of screening — and the dangers of overtreatment — a thought niggled at my consciousness. How much had my mammogram really mattered? Would the outcome have been the same had I bumped into the cancer on my own years later? It’s hard to argue with a good result. After all, I am alive and grateful to be here. But I’ve watched friends whose breast cancers were detected “early” die anyway. I’ve sweated out what blessedly turned out to be false alarms with many others.

Recently, a survey of three decades of screening published in November in The New England Journal of Medicine found that mammography’s impact is decidedly mixed: it does reduce, by a small percentage, the number of women who are told they have late-stage cancer, but it is far more likely to result in overdiagnosis and unnecessary treatment, including surgery, weeks of radiation and potentially toxic drugs. And yet, mammography remains an unquestioned pillar of the pink-ribbon awareness movement. Just about everywhere I go — the supermarket, the dry cleaner, the gym, the gas pump, the movie theater, the airport, the florist, the bank, the mall — I see posters proclaiming that “early detection is the best protection” and “mammograms save lives.” But how many lives, exactly, are being “saved,” under what circumstances and at what cost? Raising the public profile of breast cancer, a disease once spoken of only in whispers, was at one time critically important, as was emphasizing the benefits of screening. But there are unintended consequences to ever-greater “awareness” — and they, too, affect women’s health.

Breast cancer in your breast doesn’t kill you; the disease becomes deadly when it metastasizes, spreading to other organs or the bones. Early detection is based on the theory, dating back to the late 19th century, that the disease progresses consistently, beginning with a single rogue cell, growing sequentially and at some invariable point making a lethal leap. Curing it, then, was assumed to be a matter of finding and cutting out a tumor before that metastasis happens.

The thing is, there was no evidence that the size of a tumor necessarily predicted whether it had spread. According to Robert Aronowitz, a professor of history and sociology of science at the University of Pennsylvania and the author of “Unnatural History: Breast Cancer and American Society,” physicians endorsed the idea anyway, partly out of wishful thinking, desperate to “do something” to stop a scourge against which they felt helpless. So in 1913, a group of them banded together, forming an organization (which eventually became the American Cancer Society) and alerting women, in a precursor of today’s mammography campaigns, that surviving cancer was within their power. By the late 1930s, they had mobilized a successful “Women’s Field Army” of more than 100,000 volunteers, dressed in khaki, who went door to door raising money for “the cause” and educating neighbors to seek immediate medical attention for “suspicious symptoms,” like lumps or irregular bleeding.

The campaign worked — sort of. More people did subsequently go to their doctors. More cancers were detected, more operations were performed and more patients survived their initial treatments. But the rates of women dying of breast cancer hardly budged. All those increased diagnoses were not translating into “saved lives.” That should have been a sign that some aspect of the early-detection theory was amiss. Instead, surgeons believed they just needed to find the disease even sooner.

Mammography promised to do just that. The first trials, begun in 1963, found that screening healthy women along with giving them clinical exams reduced breast-cancer death rates by about 25 percent. Although the decrease was almost entirely among women in their 50s, it seemed only logical that, eventually, screening younger (that is, finding cancer earlier) would yield even more impressive results. Cancer might even be cured.

That hopeful scenario could be realized, though, if women underwent annual mammography, and by the early 1980s, it is estimated that fewer than 20 percent of those eligible did. Nancy Brinker founded the Komen foundation in 1982 to boost those numbers, convinced that early detection and awareness of breast cancer could have saved her sister, Susan, who died of the disease at 36. Three years later, National Breast Cancer Awareness Month was born. The khaki-clad “soldiers” of the 1930s were soon displaced by millions of pink-garbed racers “for the cure” as well as legions of pink consumer products: pink buckets of chicken, pink yogurt lids, pink vacuum cleaners, pink dog leashes. Yet the message was essentially the same: breast cancer was a fearsome fate, but the good news was that through vigilance and early detection, surviving was within their control.

By the turn of the new century, the pink ribbon was inescapable, and about 70 percent of women over 40 were undergoing screening. The annual mammogram had become a near-sacred rite, so precious that in 2009, when another federally financed independent task force reiterated that for most women, screening should be started at age 50 and conducted every two years, the reaction was not relief but fury. After years of bombardment by early-detection campaigns (consider: “If you haven’t had a mammogram, you need more than your breasts examined”), women, surveys showed, seemed to think screening didn’t just find breast cancer but actually prevented it.

At the time, the debate in Congress over health care reform was at its peak. Rather than engaging in discussion about how to maximize the benefits of screening while minimizing its harms, Republicans seized on the panel’s recommendations as an attempt at health care rationing. The Obama administration was accused of indifference to the lives of America’s mothers, daughters, sisters and wives. Secretary Kathleen Sebelius of the Department of Health and Human Services immediately backpedaled, issuing a statement that the administration’s policies on screening “remain unchanged.”

PR Newswire, via Associated Press; Tom DiPace/Associated Press; Gabrielle Plucknette/The New York Times (apron, sunglasses, flip-flop); Simon Fergusson/Getty Images.

Even as American women embraced mammography, researchers’ understanding of breast cancer — including the role of early detection — was shifting. The disease, it has become clear, does not always behave in a uniform way. It’s not even one disease. There are at least four genetically distinct breast cancers. They may have different causes and definitely respond differently to treatment. Two related subtypes, luminal A and luminal B, involve tumors that feed on estrogen; they may respond to a five-year course of pills like tamoxifen or aromatase inhibitors, which block cells’ access to that hormone or reduce its levels. In addition, a third type of cancer, called HER2-positive, produces too much of a protein called human epidermal growth factor receptor 2; it may be treatable with a targeted immunotherapy called Herceptin. The final type, basal-like cancer (often called “triple negative” because its growth is not fueled by the most common biomarkers for breast cancer — estrogen, progesterone and HER2), is the most aggressive, accounting for up to 20 percent of breast cancers. More prevalent among young and African-American women, it is genetically closer to ovarian cancer. Within those classifications, there are, doubtless, further distinctions, subtypes that may someday yield a wider variety of drugs that can isolate specific tumor characteristics, allowing for more effective treatment. But that is still years away.

Those early mammography trials were conducted before variations in cancer were recognized — before Herceptin, before hormonal therapy, even before the widespread use of chemotherapy. Improved treatment has offset some of the advantage of screening, though how much remains contentious. There has been about a 25 percent drop in breast-cancer death rates since 1990, and some researchers argue that treatment — not mammograms — may be chiefly responsible for that decline. They point to a study of three pairs of European countries with similar health care services and levels of risk: In each pair, mammograms were introduced in one country 10 to 15 years earlier than in the other. Yet the mortality data are virtually identical. Mammography didn’t seem to affect outcomes. In the United States, some researchers credit screening with a death-rate reduction of 15 percent — which holds steady even when screening is reduced to every other year. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and co-author of last November’s New England Journal of Medicine study of screening-induced overtreatment, estimates that only 3 to 13 percent of women whose cancer was detected by mammograms actually benefited from the test.

If Welch is right, the test helps between 4,000 and 18,000 women annually. Not an insignificant number, particularly if one of them is you, yet perhaps less than expected given the 138,000 whose cancer has been diagnosed each year through screening. Why didn’t early detection work for more of them? Mammograms, it turns out, are not so great at detecting the most lethal forms of disease — like triple negative — at a treatable phase. Aggressive tumors progress too quickly, often cropping up between mammograms. Even catching them “early,” while they are still small, can be too late: they have already metastasized. That may explain why there has been no decrease in the incidence of metastatic cancer since the introduction of screening.

At the other end of the spectrum, mammography readily finds tumors that could be equally treatable if found later by a woman or her doctor; it also finds those that are so slow-moving they might never metastasize. As improbable as it sounds, studies have suggested that about a quarter of screening-detected cancers might have gone away on their own. For an individual woman in her 50s, then, annual mammograms may catch breast cancer, but they reduce the risk of dying of the disease over the next 10 years by only .07 percentage points — from .53 percent to .46 percent. Reductions for women in their 40s are even smaller, from .35 percent to .3 percent.

If screening’s benefits have been overstated, its potential harms are little discussed. According to a survey of randomized clinical trials involving 600,000 women around the world, for every 2,000 women screened annually over 10 years, one life is prolonged but 10 healthy women are given diagnoses of breast cancer and unnecessarily treated, often with therapies that themselves have life-threatening side effects. (Tamoxifen, for instance, carries small risks of stroke, blood clots and uterine cancer; radiation and chemotherapy weaken the heart; surgery, of course, has its hazards.)

Many of those women are told they have something called ductal carcinoma in situ (D.C.I.S.), or “Stage Zero” cancer, in which abnormal cells are found in the lining of the milk-producing ducts. Before universal screening, D.C.I.S. was rare. Now D.C.I.S. and the less common lobular carcinoma in situ account for about a quarter of new breast-cancer cases — some 60,000 a year. In situ cancers are more prevalent among women in their 40s. By 2020, according to the National Institutes of Health’s estimate, more than one million American women will be living with a D.C.I.S. diagnosis.

D.C.I.S. survivors are celebrated at pink-ribbon events as triumphs of early detection: theirs was an easily treatable disease with a nearly 100 percent 10-year survival rate. The thing is, in most cases (estimates vary widely between 50 and 80 percent) D.C.I.S. will stay right where it is — “in situ” means “in place.” Unless it develops into invasive cancer, D.C.I.S. lacks the capacity to spread beyond the breast, so it will not become lethal. Autopsies have shown that as many as 14 percent of women who died of something other than breast cancer unknowingly had D.C.I.S.

There is as yet no sure way to tell which D.C.I.S. will turn into invasive cancer, so every instance is treated as if it is potentially life-threatening. That needs to change, according to Laura Esserman, director of the Carol Franc Buck Breast Care Center at the University of California, San Francisco. Esserman is campaigning to rename D.C.I.S. by removing its big “C” in an attempt to put it in perspective and tamp down women’s fear. “D.C.I.S. is not cancer,” she explained. “It’s a risk factor. For many D.C.I.S. lesions, there is only a 5 percent chance of invasive cancer developing over 10 years. That’s like the average risk of a 62-year-old. We don’t do heart surgery when someone comes in with high cholesterol. What are we doing to these people?” In Britain, where women are screened every three years beginning at 50, the government recently decided to revise its brochure on mammography to include a more thorough discussion of overdiagnosis, something it previously dispatched with in one sentence. That may or may not change anyone’s mind about screening, but at least there is a fuller explanation of the trade-offs.

In this country, the huge jump in D.C.I.S. diagnoses potentially transforms some 50,000 healthy people a year into “cancer survivors ” and contributes to the larger sense that breast cancer is “everywhere,” happening to “everyone.” That, in turn, stokes women’s anxiety about their personal vulnerability, increasing demand for screening — which, inevitably, results in even more diagnoses of D.C.I.S. Meanwhile, D.C.I.S. patients themselves are subject to the pain, mutilation, side effects and psychological trauma of anyone with cancer and may never think of themselves as fully healthy again.

Yet who among them would dare do things differently? Which of them would have skipped that fateful mammogram? As Robert Aronowitz, the medical historian, told me: “When you’ve oversold both the fear of cancer and the effectiveness of our prevention and treatment, even people harmed by the system will uphold it, saying, ‘It’s the only ritual we have, the only thing we can do to prevent ourselves from getting cancer.’ ”

What if I had skipped my first mammogram and found my tumor a few years later in the shower? It’s possible that by then I would have needed chemotherapy, an experience I’m profoundly thankful to have missed. Would waiting have affected my survival? Probably not, but I’ll never know for sure; no woman truly can. Either way, the odds were in my favor: my good fortune was not just that my cancer was caught early but also that it appeared to have been treatable.

Note that word “appeared”: one of breast cancer’s nastier traits is that even the lowest-grade caught-it-early variety can recur years — decades — after treatment. And mine did.

Patrick Hamilton/Newspix/Getty Images; Matt Born/The Star-News, via Associated Press; Gabrielle Plucknette/The New York Times; Sharpie, via Associated Press; U.S. Postal Service, via Associated Press.

Last summer, nine months after my most recent mammogram, while I was getting ready for bed and chatting with my husband, my fingers grazed something small and firm beneath the scar on my left breast. Just like that, I passed again through the invisible membrane that separates the healthy from the ill.

This latest tumor was as tiny and as pokey as before, unlikely to have spread. Obviously, though, it had to go. Since a lumpectomy requires radiation, and you can’t irradiate the same body part twice, my only option this round was a mastectomy. I was also prescribed tamoxifen to cut my risk of metastatic disease from 20 percent to 12. Again, that means I should survive, but there are no guarantees; I won’t know for sure whether I am cured until I die of something else — hopefully many decades from now, in my sleep, holding my husband’s hand, after a nice dinner with the grandchildren.

My first instinct this round was to have my other breast removed as well — I never wanted to go through this again. My oncologist argued against it. The tamoxifen would lower my risk of future disease to that of an average woman, he said. Would an average woman cut off her breasts? I could have preventive surgery if I wanted to, he added, but it would be a psychological decision, not a medical one.

I weighed the options as my hospital date approached. Average risk, after all, is not zero. Could I live with that? Part of me still wanted to extinguish all threat. I have a 9-year-old daughter; I would do anything — I need to do everything — to keep from dying. Yet, if death was the issue, the greatest danger wasn’t my other breast. It is that, despite treatment and a good prognosis, the cancer I’ve already had has metastasized. Preventive mastectomy wouldn’t change that; nor would it entirely eliminate the possibility of new disease, because there’s always some tissue left behind.

What did doing “everything” mean, anyway? There are days when I skip sunscreen. I don’t exercise as much as I should. I haven’t given up aged Gouda despite my latest cholesterol count; I don’t get enough calcium. And, oh, yeah, my house is six blocks from a fault line. Is living with a certain amount of breast-cancer risk really so different? I decided to take my doctor’s advice, to do only what had to be done.

I assumed my dilemma was unusual, specific to the anxiety of having been too often on the wrong side of statistics. But it turned out that thousands of women now consider double mastectomies after low-grade cancer diagnoses. According to Todd Tuttle, chief of the division of surgical oncology at the University of Minnesota and lead author of a study on prophylactic mastectomy published in The Journal of Clinical Oncology, there was a 188 percent jump between 1998 and 2005 among women given new diagnoses of D.C.I.S. in one breast — a risk factor for cancer — who opted to have both breasts removed just in case. Among women with early-stage invasive disease (like mine), the rates rose about 150 percent. Most of those women did not have a genetic predisposition to cancer. Tuttle speculated they were basing their decisions not on medical advice but on an exaggerated sense of their risk of getting a new cancer in the other breast. Women, according to another study, believed that risk to be more than 30 percent over 10 years when it was actually closer to 5 percent.

It wasn’t so long ago that women fought to keep their breasts after a cancer diagnosis, lobbying surgeons to forgo radical mastectomies for equally effective lumpectomies with radiation. Why had that flipped? I pondered the question as I browsed through the “Stories of Hope” on the American Cancer Society’s Web site. I came across an appealing woman in a pink T-shirt, smiling as she held out a white-frosted cupcake bedecked with a pink candle. In a first-person narrative, she said that she began screening in her mid-30s because she had fibrocystic breast disease. At 41, she was given a diagnosis of D.C.I.S., which was treated with lumpectomy and radiation. “I felt lucky to have caught it early,” she said, though she added that she was emotionally devastated by the experience. She continued screenings and went on to have multiple operations to remove benign cysts. By the time she learned she had breast cancer again, she was looking at a fifth operation on her breasts. So she opted to have both of them removed, a decision she said she believed to be both logical and proactive.

I found myself thinking of an alternative way to describe what happened. Fibrocystic breast disease does not predict cancer, though distinguishing between benign and malignant tumors can be difficult, increasing the potential for unnecessary biopsies. Starting screening in her 30s exposed this woman to years of excess medical radiation — one of the few known causes of breast cancer. Her D.C.I.S., a condition detected almost exclusively through mammography, quite likely never would become life-threatening, yet it transformed her into a cancer survivor, subjecting her to surgery and weeks of even more radiation. By the time of her second diagnosis, she was so distraught that she amputated both of her breasts to restore a sense of control.

Should this woman be hailed as a survivor or held up as a cautionary tale? Was she empowered by awareness or victimized by it? The fear of cancer is legitimate: how we manage that fear, I realized — our responses to it, our emotions around it — can be manipulated, packaged, marketed and sold, sometimes by the very forces that claim to support us. That can color everything from our perceptions of screening to our understanding of personal risk to our choices in treatment. “You could attribute the rise in mastectomies to a better understanding of genetics or better reconstruction techniques,” Tuttle said, “but those are available in Europe, and you don’t see that mastectomy craze there. There is so much ‘awareness’ about breast cancer in the U.S. I’ve called it breast-cancer overawareness. It’s everywhere. There are pink garbage trucks. Women are petrified.”

“Nearly 40,000 women and 400 men die every year of breast cancer,” Lynn Erdman, vice president of community health at Komen, told me. “Until that number dissipates, we don’t think there’s enough pink.”

I was sitting in a conference room at the headquarters of Susan G. Komen, near the Galleria mall in Dallas. Komen is not the country’s largest cancer charity — that would be the American Cancer Society. It is, however, the largest breast-cancer organization. And although Komen’s image was tarnished last year by its attempt to defund a Planned Parenthood screening program, its name remains virtually synonymous with breast-cancer advocacy. With its dozens of races “for the cure” and some 200 corporate partnerships, it may be the most successful charity ever at branding a disease; its relentless marketing has made the pink ribbon one of the most recognized logos of our time. The ribbon has come to symbolize both fear of the disease and the hope it can be defeated. It’s a badge of courage for the afflicted, an expression of solidarity by the concerned. It promises continual progress toward a cure through donations, races, volunteerism. It indicates community. And it offers corporations a seemingly fail-safe way to signal good will toward women, even if, in a practice critics call “pinkwashing,” the products they produce are linked to the disease or other threats to public health. Having football teams don rose-colored cleats, for instance, can counteract bad press over how the N.F.L. handles accusations against players of rape or domestic violence. Chevron’s donations to California Komen affiliates may help deflect what Cal OSHA called its “willful violations” of safety that led to a huge refinery fire last year in a Bay Area neighborhood.

More than anything else, though, the ribbon reminds women that every single one of us is vulnerable to breast cancer, and our best protection is annual screening. Despite the fact that Komen trademarked the phrase “for the cure,” only 16 percent of the $472 million raised in 2011, the most recent year for which financial reports are available, went toward research. At $75 million, that’s still enough to give credence to the claim that Komen has been involved in every major breast-cancer breakthrough for the past 29 years. Still, the sum is dwarfed by the $231 million the foundation spent on education and screening.

Though Komen now acknowledges the debate over screening on its Web site, the foundation has been repeatedly accused of overstating mammography’s benefits while dismissing its risks. Steve Woloshin, a colleague of Welch’s at Dartmouth and co-author of the Not So Stories column in The British Medical Journal, points to a recent Komen print ad that reads: “The five-year survival rate for breast cancer when caught early is 98 percent. When it’s not? It decreases to 23 percent.” Woloshin called that willfully deceptive. The numbers are accurate, but five-year survival rates are a misleading measure of success, skewed by screening itself. Mammography finds many cancers that never need treating and that are, by definition, survivable. Meanwhile, some women with lethal disease may seem to live longer because their cancer was found earlier, but in truth, it’s only their awareness of themselves as ill that has been extended. “Imagine a group of 100 women who received diagnoses of breast cancer because they felt a breast lump at age 67, all of whom die at age 70,” Woloshin said. “Five-year survival for this group is 0 percent. Now imagine the same women were screened, given their diagnosis three years earlier, at age 64, but treatment doesn’t work and they still die at age 70. Five-year survival is now 100 percent, even though no one lived a second longer.”

When I asked Chandini Portteus, vice president of research, evaluation and scientific programs at Komen, in January why the foundation continued to use that statistic, she didn’t so much explain as sidestep. “I don’t think Komen meant to mislead,” she said. “We know that mammography certainly isn’t perfect. We also know that it’s what we have and that it’s important in diagnosing breast cancer.” (The statistic was subsequently removed from its Web site.)

In “Pink Ribbon Blues,” Gayle Sulik, a sociologist and founder of the Breast Cancer Consortium, credits Komen (as well as the American Cancer Society and National Breast Cancer Awareness Month) with raising the profile of the disease, encouraging women to speak about their experience and transforming “victims” into “survivors.” Komen, she said, has also distributed more than $1 billion to research and support programs. At the same time, the function of pink-ribbon culture — and Komen in particular — has become less about eradication of breast cancer than self-perpetuation: maintaining the visibility of the disease and keeping the funds rolling in. “You have to look at the agenda for each program involved,” Sulik said. “If the goal is eradication of breast cancer, how close are we to that? Not very close at all. If the agenda is awareness, what is it making us aware of? That breast cancer exists? That it’s important? ‘Awareness’ has become narrowed until it just means ‘visibility.’ And that’s where the movement has failed. That’s where it’s lost its momentum to move further.”

Before the pink ribbon, awareness as an end in itself was not the default goal for health-related causes. Now you’d be hard-pressed to find a major illness without a logo, a wearable ornament and a roster of consumer-product tie-ins. Heart disease has its red dress, testicular cancer its yellow bracelet. During “Movember” — a portmanteau of “mustache” and “November” — men are urged to grow their facial hair to “spark conversation and raise awareness” of prostate cancer (another illness for which early detection has led to large-scale overtreatment) and testicular cancer. “These campaigns all have a similar superficiality in terms of the response they require from the public,” said Samantha King, associate professor of kinesiology and health at Queen’s University in Ontario and author of”Pink Ribbons, Inc.” “They’re divorced from any critique of health care policy or the politics of funding biomedical research. They reinforce a single-issue competitive model of fund-raising. And they whitewash illness: we’re made ‘aware’ of a disease yet totally removed from the challenging and often devastating realities of its sufferers.”

I recalled the dozens of news releases I received during last October’s National Breast Cancer Awareness Month, an occasion I observed in bed while recovering from my mastectomy. There was the one from Komen urging me to make a “curemitment” to ending breast cancer by sharing a “message about early detection or breast self-awareness that resonates with you”; the one about the town painting itself pink for “awareness”; the one from a Web site called Pornhub that would donate a penny to a breast-cancer charity for every 30 views of its “big-” or “small-breast” videos.

Then there are the groups going after the new hot “awareness” demographic: young women. “Barbells for Boobies” was sponsoring weight-lifting fund-raisers to pay for mammograms for women under 40. Keep A Breast (known for its sassy “I ♥ Boobies” bracelets) urges girls to perform monthly self-exams as soon as they begin menstruating. Though comparatively small, these charities raise millions of dollars a year — Keep A Breast alone raised $3.6 million in 2011. Such campaigns are often inspired by the same heartfelt impulse that motivated Nancy Brinker to start Komen: the belief that early detection could have saved a loved one, the desire to make meaning of a tragedy.

Yet there’s no reason for anyone — let alone young girls — to perform monthly self-exams. Many breast-cancer organizations stopped pushing it more than a decade ago, when a 12-year randomized study involving more than 266,000 Chinese women, published in The Journal of the National Cancer Institute, found no difference in the number of cancers discovered, the stage of disease or mortality rates between women who were given intensive instruction in monthly self-exams and women who were not, though the former group was subject to more biopsies. The upside was that women were pretty good at finding their own cancers either way.

Beyond misinformation and squandered millions, I wondered about the wisdom of educating girls to be aware of their breasts as precancerous organs. If decades of pink-ribboned early-detection campaigns have distorted the fears of middle-aged women, exaggerated their sense of personal risk, encouraged extreme responses to even low-level diagnoses, all without significantly changing outcomes, what will it mean to direct that message to a school-aged crowd?

Young women do get breast cancer — I was one of them. Even so, breast cancer among the young, especially the very young, is rare. The median age of diagnosis in this country is 61. The median age of death is 68. The chances of a 20-year-old woman getting breast cancer in the next 10 years is about .06 percent, roughly the same as for a man in his 70s. And no one is telling him to “check your boobies.”

“It’s tricky,” said Susan Love, a breast surgeon and president of the Dr. Susan Love Research Foundation. “Some young women get breast cancer, and you don’t want them to ignore it, but educating kids earlier — that bothers me. Here you are, especially in high school or junior high, just getting to know to your body. To do this search-and-destroy mission where your job is to find cancer that’s lurking even though the chance is minuscule to none. . . . It doesn’t serve anyone. And I don’t think it empowers girls. It scares them.”

Rather than offering blanket assurances that “mammograms save lives,” advocacy groups might try a more realistic campaign tag line. The researcher Gilbert Welch has suggested, “Mammography has both benefits and harms — that’s why it’s a personal decision.” That was also the message of the 2009 task force, which was derailed by politics: scientific evidence indicates that getting mammograms every other year if you are between the ages of 50 and 74 makes sense; if you fall outside that age group and still want to be screened, you should be fully informed of the downsides.

Gabrielle Plucknette/The New York Times; Adrian Keating/Associated Press

Women are now well aware of breast cancer. So what’s next? Eradicating the disease (or at least substantially reducing its incidence and devastation) may be less a matter of raising more money than allocating it more wisely. When I asked scientists and advocates how at least some of that awareness money could be spent differently, their answers were broad and varied. Many brought up the meager funding for work on prevention. In February, for instance, a Congressional panel made up of advocates, scientists and government officials called for increasing the share of resources spent studying environmental links to breast cancer. They defined the term liberally to include behaviors like alcohol consumption, exposure to chemicals, radiation and socioeconomic disparities.

Other researchers are excited about the prospect of fighting or preventing cancer by changing the “microenvironment” of the breast — the tissue surrounding a tumor that can stimulate or halt its growth. Susan Love likened it to the way living in a good or bad neighborhood might sway a potentially delinquent child. “It may well be,” she told me, “that by altering the ‘neighborhood,’ whether it’s the immune system or the local tissue, we can control or kill the cancer cells.” Taking hormone-replacement therapy during menopause, which was found to contribute to escalating rates of breast cancer, may have been the biological equivalent of letting meth dealers colonize a street corner. On the other hand, a vaccine, the current focus of some scientists and advocates, would be like putting more cops on the beat.

Nearly everyone agrees there is significant work to be done at both ends of the diagnostic spectrum: distinguishing which D.C.I.S. lesions will progress to invasive disease as well as figuring out the mechanisms of metastasis. According to a Fortune magazine analysis, only an estimated .5 percent of all National Cancer Institute grants since 1972 focus on metastasis; out of more than $2.2 billion dollars raised over the last six years, Komen has dedicated $79 million to such research — a lot of money, to be sure, but a mere 3.6 percent of its total budget during that period.

“A lot of people are under the notion that metastatic work is a waste of time,” said Danny Welch, chairman of the department of cancer biology at the University of Kansas Cancer Center, “because all we have to do is prevent cancer in the first place. The problem is, we still don’t even know what causes cancer. I’d prefer to prevent it completely too, but to put it crassly, that’s throwing a bunch of people under the bus right now.”

One hundred and eight American women die of breast cancer each day. Some can live for a decade or more with metastatic disease, but the median life span is 26 months. One afternoon I talked to Ann Silberman, author of the blog “Breast Cancer? But Doctor . . . I Hate Pink.” Silberman started writing it in 2009, at age 51, after finding a lump in her breast that turned out to be cancer — a Stage 2 tumor, which she was told gave her a survival rate of 70 percent. At the time she was a secretary at a school in Sacramento, happily married and the mother of two boys, ages 12 and 22. Over the next two years, she had surgery, did six rounds of chemo, took a trio of drugs including Herceptin and, finally, thought she was done.

Four months later, a backache and bloated belly sent her to the doctor; the cancer had spread to her liver. Why didn’t the treatment work? No one knows. “At this point, you know that you’re going to die, and you know it’s going to be in the next five years,” she told me. Her goal is to see her youngest son graduate from high school next June.

It isn’t easy to face someone with metastatic disease, especially if you’ve had cancer yourself. Silberman’s trajectory is my worst fear; the night after we spoke, I was haunted by dreams of cancer’s return. Perhaps for that reason, metastatic patients are notably absent from pink-ribbon campaigns, rarely on the speaker’s podium at fund-raisers or races. Last October, for the first time, Komen featured a woman with Stage 4 disease in its awareness-month ads, but the wording carefully emphasized the positive: “Although, today, she has tumors in her bones, her liver and her lungs, Bridget still has hope.” (Bridget died earlier this month.)

“All that awareness terminology isn’t about us,” Silberman said. “It’s about surviving, and we’re not going to survive. We’re going to get sick. We’re going to lose parts of our livers. We’re going to be on oxygen. We’re going to die. It’s not pretty, and it’s not hopeful. People want to believe in ‘the cure,’ and they want to believe that cure is early detection. But you know what? It’s just not true.”

Scientific progress is erratic, unpredictable. “We are all foundering around in the dark,” said Peter B. Bach, director of the Center for Health Policy and Outcomes at Memorial Sloan-Kettering Cancer Center. “The one thing I can tell you is some of that foundering has borne fruit.” There are the few therapies, he said — like tamoxifen and Herceptin — that target specific tumor characteristics, and newer tests that estimate the chance of recurrence in estrogen-positive cancers, allowing lower-risk women to skip chemotherapy. “That’s not curing cancer,” Bach said, “but it’s progress. And yes, it’s slow.”

The idea that there could be one solution to breast cancer — screening, early detection, some universal cure — is certainly appealing. All of us — those who fear the disease, those who live with it, our friends and families, the corporations who swathe themselves in pink — wish it were true. Wearing a bracelet, sporting a ribbon, running a race or buying a pink blender expresses our hopes, and that feels good, even virtuous. But making a difference is more complicated than that.

It has been four decades since the former first lady Betty Ford went public with her breast-cancer diagnosis, shattering the stigma of the disease. It has been three decades since the founding of Komen. Two decades since the introduction of the pink ribbon. Yet all that well-meaning awareness has ultimately made women less conscious of the facts: obscuring the limits of screening, conflating risk with disease, compromising our decisions about health care, celebrating “cancer survivors” who may have never required treating. And ultimately, it has come at the expense of those whose lives are most at risk.

Peggy Orenstein is a contributing writer for the magazine and the author, most recently, of  “Cinderella Ate My Daughter: Dispatches From the Front Lines of the New Girlie-Girl Culture.”

Editor: Ilena Silverman

This article has been revised to reflect the following correction:

Correction: April 28, 2013

An article on Page 36 this weekend about breast cancer awareness misidentifies the reduction in the chance that a woman in her 50s will die of breast cancer over the next 10 years if she undergoes screening. It is .07 percentage points, not .07 percent.

Donna Peach – Danced in to the Light

donnaLast night , Donna Peach danced in to the light. It is her beautifully poetic expression for those that have died. Yesterday was Donna’s time. Every night I check my email and look for Donna Peach’s blog. She had stage IV metastatic breast cancer and I met her through her blog when I started blogging around ten months ago. Donna was a choreographer and a dancer and because of all my ballet and modern dance training, we became social media #fearless friends immediately. Her incredibly wonderful husband Marvin aka Don also would write on her blog to let us know how she was when she couldn’t.

Last night I was visiting my sister for a holiday and it’s the first night I did not check Donna’s blog. Of course Marvin was there to tell us what happened and to those who are interested in Donna’s blog please click here: at her site: http://donnapeach.com/. Unfortunately she was in the hospital and although she had been in and out of the hospital during these past 10 months, I had hoped she would get better and be able to go home with her incredible husband.

This is the part of breast cancer that I hate. When someone is diagnosed with Stage IV, their disease is not curable but there are various regimens of chemotherapy that can extend life. This is so unfair. The trick is trying to keep quality of life while extending it with regimens that have terrible side effects but are able to extend one’s lifetime.

My focus today is about the beautiful living Donna who participated in so many events with breast cancer social media including her web site and a site where others with cancer can express themselves through poetry and words. To see this great site go to: http://cancerpoet.com/. She always joined our meetings on Twitter with #BCSM (the breast cancer social media community) and I was always so happy to see that she was part of this incredible group.

I was supposed to meet her when the Los Angeles group of the #BCSM community met on a Saturday in West Hollywood, but unfortunately my dog Shelby had a terrible urinary tract infection and her urine was bloody. Leave it to Donna when I wrote her a long email explaining how sorry I was I missed the meeting, she just said not to worry I would see her the next meeting. Although deep down I knew time was getting limited, we all have to live in the moment and make the best of it.

I am frustrated that we have not found a way to help those with metastatic cancer. I have watched too many dance in to the light this way. But for today I just want to remember Donna and the beautiful soul that she was.

I know that sometimes this blog is hard for some. Who wants to hear about death and breast cancer? Yet this is a harsh reality of the disease. When I was first diagnosed I didn’t want to hear about anyone dying from the disease. All we want to hear is that we can be cured and we do what the doctors tell us and that’s the end of it.

Unfortunately when someone is diagnosed with metastatic cancer whether breast, esophageal, lung, pancreatic, colon, etc., many people don’t understand that no matter how much someone tries to grin and bear treatment there is no hope of a cure. There is only a chance of extending life through various chemo regimens depending upon one’s pathology.

I am not trying to be grim. I just want everyone to understand how special Donna was as well as so many I have watched with metastatic cancer that tried as hard as they could to stay with us as long as they could. I hope that through my advocacy this will change. I hope we can find a vaccine to end breast cancer while we learn how to reverse metastatic cancer. Only then will I believe that all of my time and energy was worth it – for truly this is a goal worth achieving.

Meanwhile, dear sweet Donna I hope your beautiful soul is at peace and you can feel all the love that so many of us are sending you.

Valerie Harper Inspires

I am so touched by Valerie Harper. As I am sure my readers are aware , not only is Valerie an incredibly accomplished actress, but her warmth and grace has been so touching during this terrible diagnosis of leptomeningeal carcinomatosis, a rare condition that happens when cancer cells invade into the fluid-filled membrane that surrounds the brain. She has been told by her doctors she will likely be able to survive about three months.

I had the good fortune to meet Valerie at a hair salon that I used to go to. She was always down to earth and always friendly while at the salon to others. When I thought her appointment was ahead of mine she told me it was not and that I was to take my turn.

valerie-harper-00-300She has bravely gone on television, visiting The Today Show, The Doctors, The Talk, Good Morning America , and spoken with People Magazine. Each interview had her glowing with life accepting her diagnosis when you know she is in shock. It is so wonderful to see such a loving relationship with her husband.

She is also a lung cancer survivor. She never smoked. So many lung cancer survivor’s never  smoked or quit a very long time before their diagnosis. I think that lung cancer is the cruelest of all cancers because so many people assume it’s only from smoking and I know many people who have had or are living with lung cancer and they are all non smokers. It’s a disease that deserves no blame. There is a campaign around lung cancer where we attach the words, “no stigma”. Meanwhile Valerie caught the lung cancer early and survived it.

Now she faces such a difficult diagnosis. We see her looking healthy and beautiful and as so many with metastatic cancer do. People are surprised because they not look as though they are very ill especially at the beginning of their diagnosis. Different cancers at different metastatic stages are like that and each one has a different set of statistics for how much time a patient has a chance of living. With my close friend Li when she was metastatic we often talked about living through the dying and making the most of the time we have. Like Valerie we wanted quality of life, not quantity.

There is a wonderful article by Donna Kaufman in I Village that talks about the 10 most inspiring things we’ve learned from Valerie Harper that I am going to copy and paste here. Valerie’s courage and willingness to share this private part of her life with all of us teaching us so much is just beautiful.

The 10 Most Inspiring Things We’ve Learned from Valerie Harper

1. Don’t blame yourself for tragedy. “If you die, you’re not a failure,” Harper said on Today. ‘You’re just somebody who had cancer. And that’s the outcome.”

2. Live in this moment, right now. “I’m not dying until I do,” Harper told Today. “I have an intention to live each moment fully.”

3. Remember that death is part of life. “I really want Americans, all of us, to be less afraid of death,” Harper said on The Doctors. “Know that it’s a passage, but don’t go to the funeral before the funeral. While you’re living, live.”

4. Let yourself be sad — but stay hopeful. “I don’t mean this to be Pollyanna! I allow myself the grief,” Harper told Today‘s Savannah Guthrie, when asked if she ever felt sad. “What I’m saying is keep your consciousness, your thoughts open to infinite possibility and keep yourself open to miracles.”

5. Don’t give in to despair when there’s more pasta to eat. When Harper first heard her diagnosis, she said on The Doctors, “I broke down. I absolutely sobbed. I let myself do it. Then I said, ‘Okay, you’ve been the drama queen. Now get over it and make the pasta.'”

6. Deal with your battles in the way that makes sense to you. When one of the Doctors asked Harper why she was spending her final days on a press tour, she responded, “Dr. Travis, this is not for everyone. This is my way of dealing with it.”

7. Don’t live in denial. “I’m trouble,” Harper admitted in a video message for People, “but when the smoke clears, I’ll be standing. Until I’m not. And I’m ready for that, too.”

8. Don’t forget to live just because you’re dying. “‘Incurable’ is a tough word. A lot of people were calling — ‘Can I come by the house?’ ‘Are you in a wheel chair?’ — because they hear it as this death sentence,” Harper said on Today. “Which it may be. But I’m not dying until I do. I promise I won’t.”

9. Never be afraid of what’s next. “I don’t know what’s ahead, but I’m ready for it. Onward!” Harper told fans in her People message. “I love you. And know that I’m okay. I am okay on this venture.”

10. Keep your loved ones close. Harper says she’ll be spending her last months with her husband and daughter while she undergoes treatments to try to slow the progress of her disease. “My doctor said it’s incurable — so far,” Harper said on GMA. “And I love that possibility. We all need to live in infinite possibility.”

Valerie speaks of how important it is not to blames oneself for a cancer diagnosis. She talks about living in the moment and not focusing on the dying. She says to deal with your battles in your way. For her it was going on Television and speaking to her fans. Most important she speaks of keeping family close. Even though she knows that her disease is “incurable”, she still lives in a world of “infinite possibility.”

Her message is one of so much hope for so many that have faced incredible obstacles in their lives. I just love everything about Valerie!

My Fearless Friend Li Bailey

I first met Li in February 2005 at a conference table with a great breast cancer support group. The group was for early stage breast cancer and everyone in the group that day were all in the middle of chemotherapy while I was about to start my first round of adriamiacin and cytoxin. I had to do chemo because they found the cancer in my first lymph node. I had no problem undergoing a surgical lumpectomy, sentinel node biopsy, or axillary dissection, but when I heard I needed to do chemotherapy and I would lose my hair, I knew I needed some help.

It was ironic that in November my hair stylist of several years chopped my hair very short when I asked her for a little trim. I was furious that my long hair was gone, so I went and got hair extensions until my hair grew longer again. I told the group I had extensions and Li picked up immediately that I was not going to do well losing my hair.

IMG_3127_2The next time I saw Li was in my oncologist’s office when I was about to leave.  As I looked up from my papers she came out into the waiting room. I saw her and immediately gave her a huge hug and realized she went to the same office with a different oncologist.

Since she was alone I asked her how she was getting home and she said she was going to call a cab. Li lived in Santa Monica near the oncology office and managed to get around by bus, friend’s rides or taxis. I offered her a ride in my car parked far away. As we walked she was getting out of breath, because her red cells were very low from the chemo, but I kept telling her we were close to the car.

We started calling each other and found that we had a lot in common. I had a graphics arts background with a degree in architecture and she had worked as a designer at the Smithsonian. She left her job taking a very early pension and after seeing the Pentagon in flames from her apartment window on 911. She moved back to California where she and her ex-husband had lived before she went to DC.

The day my hair fell out we spent the day on the phone talking for hours. She was so supportive since she knew this was something I was not comfortable with at all. From that day forward we spoke with each other practically every day, and it was so comforting for both of us going through chemo together. Her regimen was adriamyacin every 3 weeks for 6 rounds totaling 18 weeks of treatment. Mine was “dose-dense” adriamyacin and cytoxin every two weeks for four weeks, followed with taxol every two weeks for four weeks totaling 16 weeks of chemo.

We talked about breast cancer and chemobrain plus our lives, side effects, research and managing to get through treatment, and we thought we knew a lot about breast cancer. We went out for meals together and one of our favorite places to eat was a Chinese restaurant run by a family we called “Lucy’s”, since Lucy always served us while her mother was in the kitchen. We both had terrible stomach issues during chemo. I had trouble keeping any food down and her food just seemed to run out of her little body.

We became extremely close because we were experiencing the same “trauma” at the same time. We would lose ourselves in conversations and never missed a Saturday to get together. We could both talk without our wigs on and I laughed when she made fun of me for holding on to whatever strands of hair would stay on my head. Truthfully, I did look a little  bizarre with 20 stands of knotted up blonde hair and probably should have just had my head shaved!

She also helped me through the crying jags since my hormones were going crazy. When one of my front crowns kept falling out, she made me laugh at myself being bald and toothless as I would call the dentist to glue the tooth in one more time till I finished treatment and could take care of the tooth properly.

We both needed surgeries and we never missed being the person to go with each other for surgeries. Li also got a dog named Shelby who is part shih-tzu and part maltese. Li had moved from a studio to a one bedroom so she could have more room and be able to take care of Shelby. She bought puppy gates and it was so much fun to visit her with Shelby, who I fell in love with from the day I saw her fitting in the palms of Li’s hands.

When Li had some cysts that she was not sure were cancerous she had an oophorectomy. Fortunately they were not cancer. She woke up crying which was so unusual for her. I think her mind knew that her female plumbing was missing and her tears were her hormones and her mind realizing that her breast and her ovaries etc. were missing.

In February 2007, I had a recurrence in the same breast, which my breast surgeon said had to have a mastectomy. I had finished treatment a year and a quarter earlier and had several biopsies that were false alarms in both breasts. My breast surgeon handed me business cards of plastic surgeons that he worked with.

The first surgeon saw me right away and it turned out he did Li’s reconstruction when she had her mastectomy and her results were awful. He wanted to do a Diep Flap (taking the tissue from my tummy and putting it in my breast). He also wanted $30,000.00 dollars over my co pays with my insurance to do the procedure.  I ended up picking the plastic surgeon that accepted my insurance, but that decision left me with many extra surgeries because I had a radiated breast that caused multiple surgical failures.

Like every other surgery, when I had the bilateral mastectomy surgery,  Li was with me. I encouraged her to go back to the first surgeon and get him to fix her botched job. She had her surgery after mine and when I went to talk to her doctor the first thing he said to me was “It’s very hard for a woman to lose her breasts”. I could not believe he didn’t recognize that I was in his office only two months before Li’s surgery. I said “Tell me about it . I have had a bilateral mastectomy with reconstruction”.  The next thing he said was that Li’s insurance probably wouldn’t pay for her stay that night. I explained she had a pre-approval letter and let him know that I saw him for a consult making him have to say he remembered me even though he didn’t. Awkward!

I knew how organized Li was with her paperwork, so when I went to her hospital room after speaking with her surgeon. Li pointed me to the paper with the pre-approval from her insurance. I called her insurance right from the hospital to make sure they were covering her hospital stay for the night. The plastic surgeon was wrong.

The next morning, Li had trouble breathing and she felt very out of sorts. We called the nurse who got hold of her Doctor. He said “When I did the surgery I may have kind of sort of nicked her lung”. I asked him, “In what percentage of patients does this occur”? He replied, “only her”.  I asked what they were going to do about it and he told me they would do a surgical procedure right in her hospital room by surgically placing a large tube in her side to build her collapsing lung back up. I couldn’t resist asking, “Are you sure her insurance will cover her to stay at the hospital longer after the procedure”? Of course the answer was yes, and I am so glad Li knew to get approval to stay overnight for her procedure, because if she had gone home and her lung collapsed I don’t want to think about how that would have gone down.

I stayed with my friend Li to hold her hand as long as I could while they prepped her for the surgery. They told me I had to leave the room while they did the surgery or I might faint. They don’t know me. I am very good in hospitals and I can handle blood and surgery.

When I needed my tissue expanders out and got my first implants, Li was with me. That surgery eventually failed.  After my recurrence I was very beaten down and I really wanted to spend some time with my family living in Tennessee. I ended up selling my LA condo and moved part-time to Nashville so I could be closer to them. But I kept my doctors and especially my oncologist in LA. I was lucky that another great friend in the group of 8 women breast cancer survivors (that now met at each other’s houses), rented a room to me in LA, so I could travel back and forth.

In February 2009, I flew to LA  for the monthly group meeting and hung out with Li for most of the time like we always did when I came to LA. We would go together to doctor appointments, restaurants, meetings and I also would bring my computer over and get work done while she did her work since she had wifi. She looked the healthiest I had ever seen her. She had gained some weight and her hair looked so beautiful and healthy. I told her how awesome she looked and we were so glad we made it through all that treatment. Li mentioned the last time she saw her oncologist she was told that it was a great sign that she was 4 1/2 years out with her pathology.

She was supposed to have her appointment with her oncologist when I was there and we were going to go together, but her oncologist had to change it, so Li changed the appointment for her birthday on February 19th. Li told me she had a small rash on her breast that she thought her bra must have caused. We both ate very well as we were enjoying the fact that our stomachs were returning to a new normal.

I returned to Tennessee and I called her later in the day on February 19th to wish her a Happy Birthday, assuming her oncology appointment went well since she looked so healthy. Li was a mess. She said that her doctor sent her to her breast surgeon for an immediate biopsy and the look on her doctor’s face made her feel like this was extremely serious. It was. The rash was skin legions from Metastatic Breast Cancer (MBC) and she also had it in her bones. She was Stage IV and had to start chemo again right away.

I ended up moving back to LA permanently in July 2011. I was very glad that I could be with Li so much during the last seven months of her life.

Li’s strength, courage and determination throughout her treatment were amazing. I felt awful especially thinking back to the day when we were going through primary treatment and she was going to have what I thought was  her last chemo the next day. We were together in front of our favorite restaurant “Lucy’s” in Santa Monica. Li’s red cells were awful so she had to sit down on a bench. I said to her “Li this is the last chemo you will ever have to do again in your life”. Sadly I was wrong.

Li worked very hard putting her affairs in order before the cancer traveled too far for her to have treatment anymore. As soon as she was sick with MBC she asked me if I would take care of her dog Shelby. I said, “of course” yet I hoped she was around for a very long time to enjoy the joy that Shelby brings. I remember when she was getting close to the end and I asked her if she was afraid. She said, “I’m not afraid of death but it’s the indignity of all of it that bothers me.” I knew that losing her mobility and not being able to do things for herself plus ending up thin, bald, and with a huge stomach from her liver metastasis building up fluid was no picnic. Luckily we found the most wonderful caretaker, Cora, who Li and I adored. She was such a comfort to Li constantly cleaning and making Li’s home beautiful plus running any errands Li needed done.

A few days before she died the caretaker Cora, Li and I had dinner. Li sat up in her hospital bed that we had in her room at home while Cora and I sat in chairs surrounding her. I said, “Li remember when we first went through chemo and we thought we knew so much about breast cancer? Boy were we wrong”. Li and I just laughed. We were trying to be normal having dinner, but truthfully there was nothing normal about anything that was going on. Li was getting more tired and going from moments of extreme clarity to moments of disorientation and confusion.

The last night of her life I came to join Li for dinner and she was particularly tired and didn’t feel like eating. I held her hand for some time while she went in and out of sleep. She said to me “I always love when you come by for dinner”. I told her that I loved her and was so grateful for our friendship, which I said at the end of so many of our conversations. She said she loved me too and went back to sleep.

She died that night and I received the call from another great friend who had also been by Li’s side through this daunting process. Li donated her body to science and did not want a funeral. When they came to get her body for UCLA, I was so impressed by how dignified they wrapped her up in a beautiful white sheet.

Since I promised her I would take care of her dog Shelby, I took Shelby and all of her things back to my home that day.  I miss my friend a lot. Thanks to her incredible gift of Shelby I feel Li’s presence every day.

Li’s death from MBC along with the friends I know who have cancer that has metastasized has made me determined to make an impact on seeing that we have an end to this disease.

I know that 1 in 8 women will get breast cancer in their lifetime and 109 women in the US die a day from breast cancer. (I haven’t forgotten that there are also men that get breast cancer too). This means one death every 14 minutes. With each person there is an important story.

I feel guilty sometimes that it wasn’t me instead of Li. It still could be me. That’s what is so cruel about the disease. We think we know so much more about the disease, but when it comes to the loss of lives we haven’t made much progress. True we can keep someone alive longer with chemotherapy drugs, but eventually cruel cancer figures out a way to outsmart the drugs so they no longer work.

My fearless friend Li, was not just another statistic. We had an incredible bond as a result of breast cancer and we cemented our friendship with being supportive of each other as breast cancer was always with us.

I know her spirit lives on through the memories of her.  I especially get comfort every day from Shelby. I am truly lucky that I got to know Li and I treasure the time that we got to spend together.

Patient Advocacy in Research: Merely an Afterthought? : The Patient: Patient-Centered Outcomes Research

HELPA8FC549B4C08CBC78-main(I found this article very interesting for all of us who are patient advocates. It was written by Musa Mayer of advancedbc.org.)

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In 20 years of breast cancer advocacy, I’ve witnessed major changes in attitude toward advocates on the part of basic researchers, clinical investigators, and others involved with the science of the disease.

Not so long ago, even a seat at the table – much less a vote – was hard to come by. Advocate presence was met with puzzlement, if not outright resistance. How could we possibly understand the complex scientific issues under discussion? What, exactly, was our expertise?

Within the space of a very few years – not coincidentally with the increase in advocate-driven research funding – waves of change began to wash away this resistance. Appreciation for our fundraising efforts, mixed with grudging recognition that people who actually live with a disease have useful perspectives, were contributing factors. In the wake of the 1970s and the women’s health movement, medical paternalism was relaxing its grip, and a new generation embraced the patient-doctor relationship as a partnership of equals. In the late 1980s, AIDS activists demonstrated the power of organized pressure on access and policy when lives were at stake. In the early 1990s, the Internet began to connect and empower a steady stream of newly informed patients.

It was in just such an online community, the first breast cancer mailing list, that my own advocacy was born, from a desire to ‘pay forward’ the information and support offered me when I was diagnosed. What began as a small, personal ripple expanded outwards as I recovered from treatment and moved from helping the members of my support group to reaching out to women in emerging organizations and communities, then to all women with breast cancer.

I joined with other advocates. Not satisfied with offering only emotional support, we called for better, less toxic treatments available to everyone. The standard of care seemed harsh and crude. Some referred to chemotherapy, surgery, and radiation as ‘poison, slash, and burn.’ Rejecting the metaphors of war, we called for gentler, targeted therapies with less ‘collateral damage.’ To accomplish this, more and better research was needed.

We were not content with just handing over the research funds. We looked with suspicion at the minor progress made in Nixon’s war on cancer1 and began to raise questions about the direction of cancer research, and the lack of collaboration and support for novel ideas. Funded through the efforts of advocates, programs such as the US Department of Defense Breast Cancer Research Program[1] were born.

In the years since, the presence of advocates has become commonplace in the world of cancer research. We sit on US FDA advisory committees as voting members, on Institutional Review Boards (IRBs), and data safety monitoring boards for clinical trials. We serve on Specialized Programs of Research Excellence (SPOREs) and in the Cooperative Groups.2 We rate grant proposals in study sections, and help determine research priorities. We speak at conferences, and are co-authors of papers, posters, and abstracts. We offer input to industry about trial design and enrolment, drug safety, and access to new therapies in the pipeline. Our activism runs both ways. By translating what we learn of the research back to the patients we serve, we help them to make better, more informed treatment decisions.

In preparing this article, I shared my concerns with Patient Advocates in Research (PAIR), a long-standing mailing list. The flood of responses spoke candidly about our difficulties, as well as our roles and strengths.

Several emphasized the important role we play in encouraging collaboration rather than competition among researchers, helping them to concentrate more on meaningful goals, and less on professional and career concerns. This is no easy task. It is the nature of research to “meander from one disparate place to another,” explains Deborah Collyar, President and co-founder of the PAIR mailing list, “which keeps the focus on the individual PIs [Principle Investigators] who compete with each other for grants. It’s like a game of musical chairs.” To make an impact, she suggests, “We have to speak up, and remind them to act like big boys and girls to get something done.”

Colorectal cancer advocate Kate Murphy agrees, “Research can answer interesting but irrelevant questions, provide statistically significant but clinically insignificant results … but in the end, does it matter to patients? Researchers can lose sight of the real goals, and we can keep them honest.”

The very presence of advocates can make a difference. “Not only does my face and my story inject reality into the cancer research enterprise, it seems to add some sense of urgency,” says Murphy. “We need to get the job done now without quibbling and without egos.”

Sometimes, advocates are the only ones who bring a real-world perspective to research discussions, says breast cancer advocate Cheryl Jernigan. “We’ve got to get beyond incremental steps that simply add to already unsustainable growing healthcare costs, to research that makes a substantial difference in the length and quality of life, that will be accessible in the community setting and not break the bank.”

An education in the language and methods of science is critical. Trained advocates challenge biases researchers may have had, by presenting themselves as thoughtful and intelligent peers and colleagues, well versed in the research process. But still they are underutilized at times, and unsure of their roles. “Most researchers who have engaged with us seem to really appreciate our involvement,” says Jernigan, “but don’t really know when, where, or how to engage us, and we don’t always know what it is we can do.”

Joyce Graff, advocate for patients with Von Hippel-Lindau (VHL) disease, a genetic blood vessel malformation, has experienced little support from the SPORE on which she serves: “Periodically, they will turn to me in a meeting and ask whether a proposed clinical trial design will appeal to patients.” But her opinion is solicited only after trial proposals and informed consent documents have been submitted to the IRB.

Being invited to endorse, or recruit for, research studies without participating in their creation is a familiar complaint. I’m not alone in having been invited to join steering committees for registries and clinical trials only after the important initial decisions are made. Substantive roles for advocates can be hard to come by.

But when we are brought in early in the process, we can make a genuine contribution, Collyar feels, “We help them think about how they will actually implement the trial and how to reach as broad an audience as possible, ethnically speaking, as well as eliminating bogus eligibility requirements.”

Many of us have experienced last-minute calls and emails from researchers a day or two before grant proposals are due. Clearly, the PI has discovered that advocate involvement is required and is scrambling to find someone. We become an obstacle to be surmounted, not a resource to be used.

I’ve been fortunate enough to have also had the opposite experience. Involved in a major research grant to study brain metastases in breast cancer,[2] my input, and that of other advocates, has been invited and welcomed at all stages of planning and implementation, with the complete confidence and trust of an enlightened PI who has worked with advocates for years.

Central to drug development, regulatory policy is also of intense interest to advocates. I first served as a voting Patient Representative[3] on the FDA’s Oncologic Drugs Advisory Committee a decade ago. At the open public hearings, diverse advocacy perspectives are on display, ranging from passionate pleas for access to calls for tightened regulations. While some view the agency as a bureaucratic and unfeeling barrier to access, the FDA’s mandate always made sense to me. I too was concerned about risks and benefits of new treatments, about levels of evidence and adequate proof of safety and efficacy. Having witnessed the rise and fall of bone marrow transplants in breast cancer, I knew how catastrophic the premature adoption of unproven therapies could be.

As a graduate of Project LEAD, the National Breast Cancer Coalition’s science training course,[4] I fervently believed that advocates needed to understand the research process, and to be able to look beyond immediate needs to what would offer current and future benefit for all patients. To that end, I co-developed a free, online training curriculum for the US Cochrane Center in evidence-based healthcare specifically for advocates.[5]

If advocates only understood the research process, I reasoned, they would surely take more nuanced, thoughtful positions on issues of evidence and access. But reason trumps emotion only rarely when lives are at stake, and desperation fuels inflated hopes for treatment efficacy. Described by ethicist Rebecca Dresser as “advocacy’s emphasis on the bright side of medical research,”[6] this unwarranted optimism has the potential to increase demand for unproven treatments, and to make it harder to recruit definitive studies. Patient bitterness and public disillusionment with the research enterprise are sure to follow.

Science is hard. “Most of our experiments fail,” a researcher I work with reminded me recently. For advocates, removing the blinders of wishful thinking, replacing them with a clear-eyed, cautious view of scientific research, is sobering but necessary. To do so while maintaining a hopeful stance with the patient communities we represent is harder still. But then, no one promised the truth would be easy.

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References

1. Congressionally Directed Medical Research Programs, Department of Defense. Breast Cancer Research Program [online]. Available from URL: http://cdmrp.army.mil/bcrp/default.shtml [Accessed 2011 Jan 30]
2. Center of Excellence, DoD Breast Cancer Research Program [online]. Available from URL: http://brainmetsbc.org/en/content/about-center-excellence [Accessed 2011 Jan 30]
3. US FDA. Patient Representative Program [online]. Available from URL: http://www.fda.gov/ForConsumers/ByAudience/ForPatientAdvocates [Accessed 2011 Jan 30]
4. National Breast Cancer Coalition. Project LEAD [online]. Available from URL: http://www.stopbreastcancer.org/learn/project-lead/vision [Accessed 2011 Jan 30]
5. Mayer M, Dickersin K. Understanding evidence-based healthcare: a foundation for action. US Cochrane Center [online]. Available from URL: http://us.cochrane.org/understanding-evidence-based-healthcare-foundation-action [Accessed 2011 Jan 30]
6. Dresser R. When science offers salvation: patient advocacy and research ethics. New York: Oxford University Press, 2001: 153

: Patient-Centered Outcomes Research:

1 June 2011 – Volume 4 – Issue 2 – pp 69-71
doi: 10.2165/11590710-000000000-00000
Editorial

Author Information

 AdvancedBC.org, New York, USA

Correspondence: Ms Musa Mayer, MS, AdvancedBC.org, 250 W 82nd Street, Apt #42, New York, NY 10024, USA.

E-mail: musa@echonyc.com

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