Dr. John Niederhuber, acting director of the NCI

[Alan Meyer]

As some of you know, I work as a computer programmer at the
National Cancer Institute. There's been quite a stir there over
the recent recommendations regarding mammograms for women. Some
support it, some oppose it, some don't know what to think.

The Acting Director of the Institute periodically sends out
emails to all of the staff and I get them too. I thought this
one was interesting. Given that the message has gone out to
many thousands of people I have to assume that he has no
objection to my posting it in this cancer newsgroup. He doesn't
take a specific position on the mammogram decision, but I found
his thoughts of interest.

Here it is for anyone who wonders how the director of NCI thinks.

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As a physician � and as a cancer surgeon � I know all too well the
expression of fear that overtakes a patient when there is so much as a
suspicion that she might have breast cancer, whether she has a
self-discovered lump or something far too small to be felt but
discovered during a regularly scheduled mammogram. Even the small
possibility of cancer quite understandably sets off a sequence of worry,
about surgery and disfigurement, difficult anti-cancer treatments
lasting many months, and yes, even mortality. To that list, patients may
add individual concerns, for family responsibilities, job security,
children, husbands, and partners.

Over the course of my years in the clinic and the operating room, I have
too frequently had the sad responsibility of delivering bad news. Like
any oncologist, I witnessed the death of too many patients, and like
most any American, I have felt the emotional pain of cancer loss in my
own life. On the other hand, I have also seen and often marveled at
unexpected great successes of patients who persevered through multiple
cancer therapies when the statistics said they likely would not, of
complex therapies that worked in every way we could possibly have hoped.

Too often, the patients we tend to forget are those who live daily with
lingering fear: the 12 million cancer survivors in the U.S. who worry
about cancer�s return and those with elevated risk factors who are
deeply concerned that today�s cancer scare might be tomorrow�s cancer
fact. In many ways, it is those patients at increased risk for cancer
who most depend on the wisdom and expertise of their physicians: doctors
who act as counselors, who try to answer a barrage of questions, most of
which start with �What if�� These are the patients we must never
overlook in our discussions about the value of cancer screening.

Biomedical science and optimal clinical care today rightly value
evidence. By studying cancer at a variety of scales, from large
populations to individual genomes, we accumulate vital new knowledge
that we strive to apply, in order to establish best clinical practice.
Yet there will always be a certain tension between knowledge gained from
averaging large populations and knowledge learned with each patient.
During my years in academic medicine, during daily rounds, we often told
students that it wasn�t our sins of commission we should most worry
about, but our sins of omission. Each patient is quite unique, and we
should strive to learn from each one.

The other day, a woman asked me what my reaction is to �all this
business.� I said, quite honestly, that it concerns me that our patients
will not receive the message that science is continually making
progress, and that we are constantly enhancing what we know about breast
cancer. I worry that we are making decisions principally on the basis of
knowledge viewed retrospectively, and that we should also be cognizant
of how research in the next few years � research that moves beyond
imaging and into genomic detection � is going to make decision-making
even more accurate and personalized. Science is constantly progressing;
consequently, our understandings and our recommendations for decreasing
risk and early detection will need to keep current with that new
knowledge. Perhaps that is the message that is most important:
Recommendations will change as our knowledge and technology continue to
progress.

NCI�s challenge is, and will remain, striking the correct balance, but
we must not forget or discount the importance of care � and decisions
made one patient at a time.

In a statement on Wednesday, Health and Human Services Secretary
Kathleen Sebelius said, �Mammograms have always been an important
life-saving tool in the fight against breast cancer and they still are
today� talk to your doctor about your individual history, ask questions,
and make the decision that is right for you.�

I couldn�t agree more. The fact is that screening mammography has made a
very major contribution to the decrease in the mortality of breast cancer.

John