ACS myths: Part 2

Townsend Letter for Doctors and Patients,  Nov, 2005  by Ralph W. Moss

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Last month, I discussed an influential article by an American Cancer Society (ACS) spokes-person, detailing what he felt were persistent 'myths' that the public held about cancer. I conclude my discussion in this month's column.

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The American public is ignorant about cancer--or so the American Cancer Society concludes from the results of its recent survey. The study in question was designed and carried out by the ACS in order to gauge the prevalence of some allegedly "dangerous" misconceptions held by the American public concerning cancer and its treatment.

Over 900 adults were interviewed by telephone. They were asked whether they believed a series of statements about cancer to be true, possibly true, or definitely not true. A particularly insidious aspect of this study is the way in which it draws a direct association between low income and ignorance. The very title of the paper--"Sociodemographic determinants of cancer treatment health literacy"--offers a revealing glimpse of the authors' preconceived--and thoroughly condescending--ideas. In not so subtle ways, it implies that poverty ("sociodemographic determinants") is the root cause of ignorance in the cancer field.

Another disturbing feature of the study is embedded in the questions themselves. By defining in advance what is and is not a 'cancer myth,' the ACS effectively controls the parameters of the debate, assigning participants to the category of ignorance or enlightenment depending on how closely they adhere to ACS-defined standards of truth. But the fact is, those standards leave a lot to be desired. In fact, it is the ACS leadership itself whose beliefs and attitudes should more properly be made an object of study.

For example, among the questions investigators asked was this: "Treating cancer with surgery causes it to spread throughout the body. True or false?" More than half of those polled thought that yes, surgical procedures could indeed spread cancer. The ACS authors label this a classical example of a "cancer myth," and interprets the fact that more than half of those polled believed it to be true, as symptomatic of an alarming and potentially dangerous ignorance of the American public concerning cancer.

Yet is this idea really a myth? Is it an old wives' tale that surgery can spread cancer? No, it is not. This is an unfair and one-sided characterization. In fact, it has been known since antiquity that surgical procedures in the presence of cancer are capable of causing dissemination of the tumor. Procedures as seemingly routine as needle biopsy or fine needle aspiration, as well as more invasive surgical procedures aimed at the control or excision of tumors, are capable of inadvertently spreading the disease. There are abundant studies and case histories in the medical literature documenting instances of surgically-triggered ('iatrogenic') tumor spread and warning of the intrinsic dangers of certain surgical procedures in the presence of cancer.

As long ago as 1930 the great American cancer pathologist James Ewing, MD explicitly advised against the surgical sampling of tumor tissue. "It is especially to be avoided with ... tumors of the breast, and all growths in which incisions of the skin involve also incisions through the tumor capsule," wrote Ewing (after whom Ewing's sarcoma is named). His concern was that the mechanical disturbance of the tumor--and in particular the disruption of its exterior wall or capsule--would result in the spillage of tumor cells into nearby blood and lymphatic vessels, thereby encouraging spread.

When tumors are perforated, sliced or penetrated by surgical instruments, so-called tumor spillage or seeding can occur. That is, tumor cells or clumps of cells can be accidentally spilled into the body's cavities, sucked into the withdrawal track of a needle or catheter, or introduced directly into the bloodstream or lymphatic system. Even rough handling during surgery can cause clusters of tumor cells to break away from the primary tumor. And since the physical insult of surgery itself is well known to be immunosuppressive (i.e., to hinder the normal functioning of the immune system), any accidentally released tumor cells would have a head start over the body's natural defenses in the days and weeks following surgery.

The work of Nora M. Hansen, MD and colleagues, of the John Wayne Cancer Institute in Santa Monica, California, has shown that surgical instrumentation--even something as simple as a diagnostic needle biopsy--may be capable of causing tumor spread. In a paper published in 2004, Dr. Hansen and her fellow researchers presented evidence that needle biopsy of isolated breast tumors can cause the spread of malignant cells to nearby sentinel lymph nodes. As I wrote in a previous newsletter describing this research, "The authors reluctantly concluded that a needle biopsy may indeed increase the spread of the disease by 50% compared to patients who receive the more traditional excisional biopsies (or lumpectomies)."