From the New York Times Well Blog, first, a story about tamoxifen. Tamoxifen is an antagonist of the estrogen receptor in breast tissue, and some breast cancer cells require estrogen to grow. It cuts the risk of developing breast cancer in half. The story mentions other chemopreventions drugs, too. Apparently, these aren't popular. This quote stuck out to me:
The pill is tamoxifen, and Ms. Birkhold, now 52, was considered an ideal candidate for it: she tested positive for a breast cancer gene, her mother had ovarian cancer, and her aunt had breast cancer. Yet rather than take tamoxifen, she opted for surgery to remove her breasts and ovaries.
“I even went so far as to get the prescription” for tamoxifen, she said. “But then I started reading more and decided this isn’t the way I’m going to go. I don’t like to take drugs.”
I'm not sure anyone likes to take drugs, at least if they're not fun drugs, but who likes to have surgery? Or do nothing, if already at a high risk for breast cancer?
Second, a story about avoiding injury while skiing. New ski equipment increases the injury risk. This quote stuck out to me:
Similarly, while helmets have reduced the total number of skiing-related head injuries by 30 to 50 percent, Mr. Shealy says, “when you look at the really serious head injuries, helmets aren’t much help.” If you hit a tree at “speeds common in skiing” — 30 miles per hour or more on steep slopes — “you will exceed the capacity of the helmet to save you.” Helmets also “may promote reckless behavior,” Mr. Shealy says. “It’s just human nature.” Skiers still should wear helmets, he adds, but should also practice restraint and common sense on the slopes, the primary means of reducing your risk of injury anyway. “The message,” he concludes “is not: Don’t wear a helmet. It is: Don’t hit a tree.”
The fact that wearing helmets encourages riskier skiing shouldn't be surprising, but what surprised me is that helmets aren't equipped to prevent injury at speeds common in skiing. Sounds kind of useless. So why is this guy recommending wearing one? Yes, it doesn't cause injury, except to the extent it negatively alters behavior, but if it's not going to do any good anyhow, what's the point in wearing one?
As suggested by the title, I find irrationality in both of these stories, the first with regard to patient behavior, the second with regard to safety advice. I don't have anything profound to add beyond that -- maybe a behavioral economist would -- but it is interesting to me.
I guess these are two kinds of rationality at play here - the radical variety in the Tamoxifen vs surgery case (get rid of something that is of no real use to you) and the gentler practical kind in the ski helmet advisory (believe if you want to, but it's of no use to you anyway) :-)
On a more serious note, Birkhold is 52. She may no longer be of child bearing age but can expect to live another 20 - 30 years if she has no serious illness. Tamoxifen protects against breast cancer but I don't know if it has any preventive action on ovarian cancer. It is on the other hand, implicated in raising the risk of endometrial cancer. The drug has many other side effects. Perhaps Birkhold is being overly cautious. But if she doesn't like the odds of her developing breast and ovarian cancers, yet she doesn't want to live with the side effects of Tamoxifen, I don't see her decision for radical surgery as totally irrational. The action is perhaps an overkill because she doesn't yet have cancer and may never develop it. But if she is going to take "preventive" measures of some sort, she may have chosen what seems to her like the less debilitating option of the two. She probably no longer has any use for her ovaries and a pair of breasts to an older woman is not the same thing as it is to a younger woman ... or to a man.
Posted by: Ruchira | December 17, 2009 at 07:36 PM