Breast Cancer: A Puzzling Plague

In the bad old days, some 20 years ago, no one had the heart even to talk about it. Breast cancer struck the most evident of a woman's assets, where the motherly and the erotic are joined. And treatment of the disease was a nightmare of pain, disfigurement and uncertainty too terrifying to contemplate. A seemingly healthy woman with nothing more than a tiny lump in her breast (and a larger one forming in her throat) could agree to have a biopsy performed and not know whether she would awake from surgery with a small bandage on her breast -- or no breast at all.

Much has changed since then. For one thing, breast cancer is widely discussed. Celebrity after celebrity -- a veritable Breast Cancer Hall of Fame -- has stepped forward to demystify the disease and soften its stigma, beginning with Shirley Temple Black, Ingrid Bergman and Betty Ford, and more recently including Nancy Reagan and Gloria Steinem. Lessons on cancer detection and the importance of mammograms are the subject of elaborate public information campaigns.

More important, the surgical and post-surgical options have multiplied. Chastened by better educated and more demanding patients, doctors now wait after a positive biopsy to discuss these options before moving in to amputate. Just last year a consensus meeting convened by the National Institutes of Health formally recommended lumpectomy, the removal of a cancerous lump plus a small amount of surrounding tissue, followed by radiation therapy, as an equally effective alternative to breast removal in many cases. And the success rate for treatment is up -- not dramatically, but up. Nowadays, 76.6% of breast-cancer patients survive five years after surgery, and 63% are alive 10 or more years later. In 1970 the five-year survival rate was 68%.

But there is also bad news about breast cancer. The number of cases continues to soar. According to the National Cancer Institute (NCI), the U.S. incidence increased 32% between 1982 and 1987. Only lung cancer is rising faster. Cancer is the leading cause of death for women 35 to 50, and breast cancer is the most common malignancy in this age group. All in all, an American woman has a 1-in-10 chance of developing breast cancer over the course of her lifetime, and that risk keeps on rising.

The big question is why. Most experts on the disease agree that part of the increase can be attributed to earlier detection of tumors. Some 65% of American women over 40 have had a mammogram, up from about 20% in 1979. The widespread use of this tool, a low-dose X ray of the breasts, has meant that more women are discovering their tumors in the early stages, before a lump can be felt. In past decades, prior to the spread of mammography, such women might have died of other causes before their breast cancer was diagnosed.

Nonetheless, most investigators of the epidemic believe early detection is only part of the story. They look at the fact that breast cancer is far less common in other parts of the world and conclude, ominously, that the answer lies in some facet of the American life-style. "Something in our environment is contributing," contends Dr. Marc Lippman of Georgetown University.