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Early Breast Cancer Diagnosis Could Be Wrong

By Edward C. Geehr, M.D.,

An early cancer diagnosis often means an improved outcome. But not always. Every year, approximately 50,000 women are diagnosed with ductal carcinoma in situ (DCIS) of the breast. Often called non-invasive or Stage 0 breast cancer, DCIS responds well to treatment. Unfortunately, approximately 20% of cases may be misdiagnosed.

In DCIS, abnormal cells are contained in the lining of the milk ducts. In situ, which means “in place,” the cancer cells haven’t left the ducts to invade nearby breast tissue. Although DCIS is considered to be non-invasive, if left untreated, about 20%-30% of women will progress to invasive cancer.

Experts believe misdiagnosis happens because doctors disagree over which criteria they use. For example, some pathologists hold that lesions less than 2 millimeters preclude the diagnosis regardless of cell appearance, while others rely on the presence of characteristic changes regardless of lesion size.

But even appearance can lead to disagreement. One expert reviewed approximately 600 breast cases and found discrepancies in 141 of them, including 27 cases where DCIS was misdiagnosed. DCIS is typically diagnosed from microscopic core needle biopsies. It can be difficult to distinguish between low-grade DCIS and benign conditions, such as atypical ductal hyperplasia which can be misread as much as 20% of the time.

Another factor may be that many breast biopsies each year are performed in community hospitals where pathologists have limited exposure to DCIS or unusual breast cancer tumors. This has led the College of American Pathologists to call for a voluntary certification program for pathologists who read breast tissue. They’ve proposed a minimum requirement of 250 breast cases a year to be certified.

The potential for misdiagnosis and overtreatment of DCIS was recently disputed in a discussion about the age to begin mammography. Before the widespread use of mammography in the 1980s, DCIS was rarely diagnosed. Until that time, most biopsies were performed after feeling lumps in the breast. By then, most lesions were usually well established as cancer, benign tumor, or cyst.

As noted, in a percentage of cases untreated, DCIS will progress to invasive cancer. And even though DCIS is 90% curable, many experts are concerned that patients and their doctors may decide on more aggressive therapy than is necessary, such as a combination of mastectomy, radiation, and drug therapy. In fact, the rate of double mastectomy for DCIS rose to 5% in 2005 from 2% in 1998.

So the benefits of earlier diagnosis are offset by potential misdiagnosis and over-treatment.

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Male Circumcision Originally Created To Prevent Masturbation

When circumcision was introduced, it was believed that masturbation caused a lot of different illnesses. It was considered extremely immoral and many children, both male and female, have been circumcised through the years because parents found them “in the act.”

It was already known at the end of the 1800s that the removal of the foreskin, which is the only moveable part of the penis would reduce sexual sensitivity and restrict movement of the penile shaft.

It was believed that masturbation caused blindness, mental illness, alcoholism, epilepsy and several other ills. It therefore made sense to some physicians that circumcision would stop masturbation and prevent the onset of these illnesses.

Non-religious circumcision in English-speaking countries arose in a climate of negative attitudes towards sex, especially concerning masturbation. In her 1978 article The Ritual of Circumcision, Karen Erickson Paige writes: “In the United States, the current medical rationale for circumcision developed after the operation was in wide practice. The original reason for the surgical removal of the foreskin, or prepuce, was to control ‘masturbatory insanity’ – the range of mental disorders that people believed were caused by the ‘polluting’ practice of ‘self-abuse.'”

“Self-abuse” was a term commonly used to describe masturbation in the 19th century. According to Paige, “treatments ranged from diet, moral exhortations, hydrotherapy, and marriage, to such drastic measures as surgery, physical restraints, frights, and punishment. Some doctors recommended covering the penis with plaster of Paris, leather, or rubber; cauterization; making boys wear chastity belts or spiked rings; and in extreme cases, castration.” Paige details how circumcision became popular as a masturbation remedy:

“In the 1890s, it became a popular technique to prevent, or cure, masturbatory insanity. In 1891 the president of the Royal College of Surgeons of England published On Circumcision as Preventive of Masturbation, and two years later another British doctor wrote Circumcision: Its Advantages and How to Perform It, which listed the reasons for removing the ‘vestigial’ prepuce. Evidently the foreskin could cause ‘nocturnal incontinence,’ hysteria, epilepsy, and irritation that might ‘give rise to erotic stimulation and, consequently, masturbation.’ Another physician, P.C. Remondino, added that ‘circumcision is like a substantial and well-secured life annuity…it insures better health, greater capacity for labor, longer life, less nervousness, sickness, loss of time, and less doctor bills.’ No wonder it became a popular remedy.”

At the same time circumcisions were advocated on men, clitoridectomies (removal of the clitoris) were also performed for the same reason (to treat female masturbators). The US “Orificial Surgery Society” for female “circumcision” operated until 1925, and clitoridectomies and infibulations would continue to be advocated by some through the 1930s. As late as 1936, L. E. Holt, an author of pediatric textbooks, advocated male and female circumcision as a treatment for masturbation.

One of the leading advocates of circumcision was John Harvey Kellogg. (yes, the Kellogg from the famous Corn Flakes!) He advocated the consumption of Kellogg’s corn flakes to prevent masturbation, and he believed that circumcision would be an effective way to eliminate masturbation in males.

“Covering the organs with a cage has been practiced with entire success. A remedy which is almost always successful in small boys is circumcision, especially when there is any degree of phimosis. The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment, as it may well be in some cases. The soreness which continues for several weeks interrupts the practice, and if it had not previously become too firmly fixed, it may be forgotten and not resumed. If any attempt is made to watch the child, he should be so carefully surrounded by vigilance that he cannot possibly transgress without detection. If he is only partially watched, he soon learns to elude observation, and thus the effect is only to make him cunning in his vice.”

Robert Darby, writing in the Australian Medical Journal, noted that some 19th century circumcision advocates—and their opponents—believed that the foreskin was sexually sensitive:

In the 19th century the role of the foreskin in erotic sensation was well understood by physicians who wanted to cut it off precisely because they considered it the major factor leading boys to masturbation. The Victorian physician and venereologist William Acton (1814–1875) damned it as “a source of serious mischief”, and most of his contemporaries concurred. Both opponents and supporters of circumcision agreed that the significant role the foreskin played in sexual response was the main reason why it should be either left in place or removed. William Hammond, a Professor of Mind in New York in the late 19th century, commented that “circumcision, when performed in early life, generally lessens the voluptuous sensations of sexual intercourse”, and both he and Acton considered the foreskin necessary for optimal sexual function, especially in old age. Jonathan Hutchinson, English surgeon and pathologist (1828–1913), and many others, thought this was the main reason why it should be excised

When it was finally realized that masturbation did not cause illnesses, the foreskin got blamed for penile and cervical cancers, urinary tract infections and sexually transmitted diseases.

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I believe that relating the non-religious history of circumcision is important in understanding why the procedure came to be.

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