The Breast Cancer Conundrum: Review of “Radical” by Kate Pickert

Much has changed in how we treat breast cancer over the past half century. Awareness and research dollars are focused on breast cancer more than any other type of cancer. And improvements in treatment, along with screening, are reflected in a decline of about 39% in U.S. breast cancer mortality from the peak level reached in 1990.

And yet, deaths from breast cancer remain extremely high at over 41,000 per year. Other than the approvals of one or two true “breakthrough” drugs a number of years back, progress has been slow and incremental.

This is the big conundrum about breast cancer. Why aren’t we making more rapid progress?

Kate Pickert, in her book “Radical: The Science, Culture, and History of Breast Cancer in America”, tells the story of how our approach to breast cancer has evolved over the decades. And in telling that story she also highlights the impact that our “culture”, or societal attitudes, has had on that history.

Her Breast Cancer Story and Treatment Advances

Pickert is a former staff writer for Time magazine who is currently a journalism professor at Loyola Marymount University. Along with taking us through breast cancer history in this country, Pickert shares the story of her own breast cancer experience, beginning with her diagnosis in 2014.

Pickert’s breast cancer story resonated with me as she and I were both diagnosed at the age of 35 and had no family history of the disease. We both had few of the risk factors known to be associated with breast cancer and no inherited mutations known to increase breast cancer risk.

But Pickert’s diagnosis came more than twenty years after mine. You would expect her experience to be different. And some aspects of her treatment journey were, including “neoadjuvant” chemotherapy, or chemo before surgery rather than afterwards, and use of a device known as a “cold cap” to prevent hair loss.

But still, surgery and chemotherapy were major pillars of Pickert’s treatment as they have been for many decades.

Controversies, Successes and Trends

In her book, Pickert takes us through the major elements of breast cancer care, from screening to diagnosis to treatment, and many of the issues, controversies and recent research trends in these areas.

The two chapters on breast cancer screening were excellent. Pickert explains the politics around breast cancer screening and how the public perception of what can and cannot be accomplished with mammography is not aligned with the scientific evidence. She suggests that these attitudes may actually be holding back progress toward better diagnostic tools.

Although there has been much discussion of the problem of “overdiagnosis”, Pickert points out that the big drawback of mammography is really that it fails to find many lethal breast cancers. And she describes some interesting research underway to develop better tools, such as the “abbreviated MRI” and molecular breast imaging (MBI).

Surgery may be one of the areas in breast cancer treatment where progress has been the most pronounced over the years. We’ve gone from “more is better” and the radical mastectomy to now a realization that “less is more”. Most breast cancer patients today have more limited surgeries, and Pickert notes that the future holds the possibility of even eliminating surgery altogether in many cases.

Another major trend has been the movement toward treatment that is more aligned with the characteristics of an individual’s disease rather the “one size fits all” approach of the past. This includes the development of targeted therapies, which are designed to be both more effective and less toxic than chemotherapies.

There have been a couple of big successes in targeted therapy for breast cancer, one of which is the drug Herceptin for HER2-positive breast cancer, which Pickert herself received. Another is CDK 4/6 inhibitors, such as Ibrance, for hormone receptor-positive breast cancer. But, as Pickert points out, the development of new targeted therapies is a long and complex process and that is to be expected, given the extremely complex nature of the set of diseases called breast cancer.

The Impact of Pink Ribbon Culture

In addition to discussing research advances, Pickert also writes about the “pink ribbon culture” around breast cancer. As a result of extensive corporate promotions, this depiction of the breast cancer cause is unfortunately the one that most of the public sees.

And, tragically, the result of this culture being so dominant is that we’re not focused on the questions we need to be to make more progress. She says this:

Breast cancer awareness is at an all-time high. But despite the attention, there has been no successful large-scale effort to learn what causes breast cancer beyond the small percentage of cases tied to hereditary genetic mutations and the identification of risk factors so ubiquitous among American women that they are virtually useless as warnings. Doctors do not know how or precisely why breast cancer spreads, nor do they know how to kill it off once it does. We have spent relatively few research dollars trying to answer these questions. Despite the races, ribbons and scientific breakthroughs, women are just as confused and frightened as ever.

The book includes a pretty compelling chapter on metastatic breast cancer–breast cancer that has spread from the breast to other organs in the body. MBC is responsible for nearly all of the 40,000+ deaths from breast cancer in the U.S. each year.

Pickert points out that, despite the billions of dollars that have been spent on breast cancer research, relatively little has been devoted to studying metastatic breast cancer patients and the specific characteristics of their diseases. Patients with MBC are treated with one drug after another until treatment options are exhausted, but we don’t know how to permanently stop the disease.

Researchers working on MBC face particular challenges, such as the difficulty in obtaining samples of metastatic tissue for study and fact that breast cancer cell lines used in lab studies are nearly all from early-stage breast cancer. Something that is helpful in treating early stage disease may not be relevant for metastatic disease because the disease characteristics at this stage are much different.

In addition to the many issues Pickert has covered, I would add that a history of breast cancer in America also needs to address the substantial disparities in breast cancer outcomes across populations that are our reality. For African American women, breast cancer mortality is a striking, and unacceptable, 39% higher than for white women in the United States.

Another major issue is the extraordinarily high costs of cancer treatment, including the pricing of the newer targeted cancer medications. The financial burden of out-of-pocket costs and other treatment related expenses, as well as loss of income while in treatment, has become so large that it effectively limits access to care for many, worsening their outcomes.

These issues are also an important part of why progress has been slower than it should be.

Overall, this book is an absorbing read and Pickert captures well many of the key issues behind the breast cancer conundrum. It gives the reader a good sense of where we are with the science and also some of the ways our societal attitudes hold us back from making more rapid progress.

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