Findings published in last week’s Journal of the American Medical Association suggest that many women have had unnecessary surgical procedures done in the name of curing their breast cancer. The study’s results are indeed groundbreaking and are already changing clinical practice. However, I’d like to argue today that these results are also a reminder to all of us risk scientists that risk perceptions are not just a function of what might happen to you. They are also a function of what has already happened to you.
It has long been believed that women diagnosed with breast cancer should have “sentinel” lymph nodes near the affected breast checked to see if cancer has spread to them. If cancerous cells were found, standard practice was to have surgery to remove many nodes near the breast and under the arm. This procedure was supposed to help prevent the spread of cancer throughout the body. However, it comes with significant side effects, including infection and lymphedema, a type of chronic and often painful swelling.
In the JAMA study, however, researchers found that some women with early stage breast cancer gained no survival benefit from removal of the lymph nodes even though cancer had been found in the lymphatic system. This finding sparked a wave of publicity, including an insightful Room for Debate feature in the New York Times that included 7 authors’ perspectives on whether American surgeons promote unnecessary surgery.
I have no doubt that many of the issues raised by the New York Times commentators are important. Surgeons do have financial incentives, established practices, and natural responses to clinical uncertainty that lead them to suggest surgery in some cases where there is no clinical evidence to support such an action.
Yet, I think we also need to acknowledge that we, the public, also contribute to overuse of surgical procedures. We do not often complain when our doctor recommends surgery. Many times, in fact, I think patients are relieved when a doctor suggests surgery. We trust that the physical act of cutting out a cancerous tumor, fusing vertebrea in our back, or replacing an aging hip will “fix” our problems. We do not stop to consider whether other approaches might work just as well or better. We do not worry about the fact that someone will cut us open and potentially cause us pain and expose us to significant complication risks.
Why is that? Why are we so comfortable with the obvious risks of surgery? One answer may lie in the distinction between risks of omission and risks of commission.
A harm of omission is harm that happens because we do not do something. Diseases that could be prevented, e.g., by vaccination, are harms of omission. If we get the flu or our child gets pertussis, that is a harm that resulted at least in part from our inaction.
A harm of commission, by contrast, is harm that happens because of our intentional acts. Treatment side effects and complication risks, such as lymphedema following lymph node removal, are harms of commission.
There is a long history of research in psychology and ethics that demonstrates that in most cases, people find harms of commission much worse than harms of omission. If flu vaccinations were equally as likely to cause harm as our risk of getting the flu, pretty much no one would get vaccinated. Most of us need to believe that vaccines are much, much safer than the risks we face through failures to vaccinate before we are willing to consider taking a vaccine that has a known chance to cause harm.
Do we ever take vaccines that are known to potentially cause harm? Sure. Before it was replaced with the newer, inactivated polio vaccine, the live polio vaccine caused a certain number of cases each year. Most people accepted that risk (at that time) because it was miniscule compared to the polio epidemics that it prevented.
What does all this have to do with overuse of surgery? A lot, I think. A few years ago, my colleagues Angela Fagerlin, Peter Ubel, and I published a simple paper titled “Cure me even if it kills me: preferences for invasive cancer treatment.” In it, we showed that people who were presented with hypothetical cancer treatment scenarios tended to choose surgical interventions even when those interventions increased the total risk of death. The effect was much reduced for medication therapies versus surgeries.
Harms of commission scare us when we are feeling well. “Why take on a new risk?” we say. “I’m fine!”
Women who have just been diagnosed with breast cancer, however, are not “fine.” Emotionally and cognitively, they are grappling with a profound sense of loss and the reality that their lives are in danger. In that context, we all tend to become (to use the terminology of decision science) “risk seeking” and see the balance between action and inaction very differently. Harms from commission from an invasive treatment? Well, we were already hurt, and at least we did something, even if it ended up hurting us more. Reject a therapy that might have even the slightest chance impacting the risk of cancer spreading and live with that possible harm of omission? Now that seems unconscionable.
I won’t be surprised at all if 3 years from now we still see many breast cancer patients continuing to get their lymph nodes removed even if they fall into one of the groups for whom that surgery is no longer recommended. Surgeons may (or may not) tell them that it isn’t needed, but I suspect some patients will ask for it anyway. Because it will make them feel better.
Patients asking for surgery “just to be safe.” I would say “imagine that!” But, I don’t have to imagine it, because it happens every day.
Brian J. Zikmund-Fisher is an Assistant Professor, Health Behavior & Health Education, in the University of Michigan School of Public Health, and a member of the University of Michigan Risk Science Center. He specializes in risk communication to inform health and medical decision making.
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