Person A isn’t completely persuaded that human activity is the greatest contributor to climate change. Person B believes men can give birth. In 2018, guess which person is more likely to be decried as “anti-science.”
That political fashions can influence what is and isn’t acceptable in the world of science was pointed out to me nearly 30 years ago by David Plotkin, an iconoclastic physician-cancer scientist I met while pursuing a possible book about a man whose life he’d saved. Complementing his clinical practice as one of the first physicians to specialize in oncology, Plotkin had spent two decades researching the nature of different cancers to learn why the injected doses of poison we call chemotherapy sometimes worked and usually didn’t. Could there ever be a magic bullet, he wanted to know.
At the time we met, breast cancer was much in the news and on Plotkin’s mind. From 1935 to 1990, its reported incidence had doubled, with 180,000 American women expected to develop the disease annually. Worse, after half a century of relative stability, mortality had started to rise.
No wonder mammography was being marketed so aggressively as a lifesaver to every woman 40 and over. Early detection equals lives saved, studies had implied, until the largest trial, conducted in Sweden in the 1970s, concluded that annual mammograms could lower breast cancer’s mortality rate by 25 percent or more. Almost overnight, “Mammography saves lives” became both conventional wisdom and slogan.
Plotkin’s particular interest in breast cancer dated to 1960, when as a new physician he’d examined a distraught young woman who had undergone a radical mastectomy. Sobbing, she opened the gown to reveal what he described as a diagonal slash of red-pink scar tissue running from armpit to lower rib cage.
“I had to keep myself from crying,” he recalled.
Plotkin didn’t believe early detection through annual mammograms for all women 40 and over would save lives. He said that the majority of cancers typically found in screening are slow-growing and might never become lethal anyway, but their discovery needlessly alarms the patient and often subjects her to unnecessary treatments that are devastating both physically and emotionally. Then there’s the high false-positive rate.
As for the deadly cancers, human physiology, he reasoned, was the culprit: The malignant cells of virulent, lethal breast cancer rapidly double into an invasive, destructive mass, one that has the ability to spread and create havoc almost anywhere in the body. While mammography, compared to palpation, does lower the detection threshold of those masses, the smallest tumor it can detect is still a giant in terms of potential destruction. Even at a quarter of an inch, a tumor may have been growing for years, with abundant opportunities to split off metastatic clones.
Plotkin believed that the overwhelming majority of cancers that will prove deadly metastasize early in the tumor’s life, long before they can be detected by any means, even mammography. While some of these cells fail to thrive, many—enough to become lethal—breed successful colonies. The eventual cause of death is typically not the primary tumor, which was removed through either lumpectomy or mastectomy, but metastases elsewhere in the body.
“The ultimate survival rates for women whose invasive cancer was diagnosed through mammography,” he said, “are statistically identical to women whose cancer was discovered after palpation. Earlier diagnosis equates only to earlier diagnosis.”
Studying the Swedish trial’s data, Plotkin found math errors to go along with biology and logic errors and compiled his findings in a paper for submission to prestigious medical journals. Yet even before licking the first stamp, he predicted that his work would be returned without comment.
“Fighting the medical establishment,” he joked, “is like Galileo trying to convince the pope that Earth moves around the sun.”
A few months after every leading journal had rejected him, Plotkin suggested that we collaborate on a book intended to be his Grand Unified Theory of Cancer. Though I had no background in science, he knew how to translate for laymen—his ultimate audience anyway. Maybe with his ideas in the public arena, he said, the professionals would have a go at trying to debunk the book’s conclusions and reasoning.
We wrote a short proposal titled “When Cancer Can’t Hurt You As Much As the Treatment Can,” and editors at two publishing houses expressed serious interest, both of them women. In our two meetings, Plotkin focused his remarks on breast cancer, having assumed they’d be acutely riveted by some of his ideas that had not been included in the proposal.
It was a painful irony, he began, that progress in women’s rights and equality in the work world were indirect contributors to the rise in breast cancers.
How so, they asked.
His answer: In a woman’s menstrual cycle, the breast is bathed monthly in estrogen and progesterone, which can cause cells to multiply. With delayed childbearing, modern women experience far more of these of these “unrequited ovulations”:
In both meetings, Plotkin spoke like a dispassionate instructor to students hungry for knowledge. But these women were not his students, and judging both by their perturbed faces and how quickly we were shown the door, this was not knowledge for which they were hungry. Nor, we later heard from the agent, did they want any part in exposing Plotkin’s “offensive” ideas to the public. There would be no book.
A year later, in June 1996, Plotkin wrote a cover story for the Atlantic Monthly titled “Good News and Bad News About Breast Cancer,” a lengthy summary of what he understood about the disease (including the passage quoted above). Owing to long lead times back then, the first angry letters to the editor appeared in October, then continued into November.
One woman, the mother of a breast cancer victim, was “appalled at his lack of understanding, his brazen thoughtlessness, his disregard for the impact his words might have on those who are already suffering.” Because of him, her daughter “now believes that she is absolutely doomed.” Another writer was “sorry” that the magazine had published his “biased polemic.” Yet another asked, “Does David Plotkin seriously believe, as his article suggests, that better nutrition, increased job opportunities, longer life expectancy, and the natural processes of the female body (menstruation) are the root causes of increased rates of breast cancer among women today?”
Plotkin died, of bone cancer, 16 years later. In a cosmic coincidence, on the morning of his memorial service came mainstream news reports about an article in the BMJ (formerly British Medical Journal) that accused a powerful breast-cancer charity, Susan G. Komen for the Cure, of vastly overstating mammography’s benefits in its ads. The authors were two Dartmouth Medical School professors, Lisa M. Schwartz and Steven Woloshin, who had studied the subject for years and concluded there was little difference in survival rates between screened and unscreened patients.
Finding an email address, I wrote to Dr. Woloshin and asked if he’d heard of Dr. David Plotkin. Yes, he said, he and Dr. Schwartz remembered the Atlantic article from when they were finishing their fellowships. “It had a big influence on us.”
Today, the United States Preventive Services Task Force no longer recommends annual mammograms. It now advises women 50-74 “at average risk for breast cancer” to get one every two years and women 40-49 to consult with their doctors “about when to start and how often to get a mammogram.” Meanwhile, the American Cancer Society has raised from 40 to 45 the age at which it recommends women begin having annual mammograms, with biannual ones beginning at age 55.
Plotkin didn’t live to see himself vindicated on mammography, and the consensus reasons for breast cancer’s rise do not (and may never) include his notion of “unrequited ovulations.” But physiology, like physics, doesn’t accede to politics, so someday the truth or truths will out. It would be nice, though, if someday came sooner rather than later in all the sciences—which it can’t as long as name-calling and feelings impede scientific inquiry.
Joel Engel is the author, most recently, of L.A. ’56: A Devil in the City of Angels.
