Late one afternoon this summer, Dr. Laura J. Esserman, a breast cancer surgeon at the University of California, San Francisco, sat in a darkened room scrutinizing a breast M.R.I. With a clutch of other clinicians at her side, she quickly homed in on a spot smaller than a pencil eraser.
She heard the words “six-millimeter mass.” Her response was swift:
Meaning no biopsy.
Most doctors, including the radiologist seated next to her, would have said yes. But Dr. Esserman, who has dedicated much of her professional life to trying to get the medical establishment to think differently about breast cancer, foresaw only unnecessary anxiety for the patient, who had had several biopsies in the past — all benign.
Dr. Esserman, 58, is one of the most vocal proponents of the idea that breast cancer screening brings with it overdiagnosis and overtreatment. Her philosophy is controversial, to say the least. For decades, the specter of women dying for lack of intervention has made aggressive treatment a given.
But last month, her approach was given a boost by a long-term study published in the journal JAMA Oncology. The analysis of 20 years of patient data made the case for a less aggressive approach to treating a condition known as ductal carcinoma in situ, or D.C.I.S., for which the current practice is nearly always surgery, and often radiation. The results suggest that the form of treatment may make no difference in outcomes.
Dr. Esserman, who directs the Carol Franc Buck Breast Care Center, is one of only a few surgeons in the United States willing to put women with D.C.I.S. on active surveillance instead of performing biopsies, lumpectomies or mastectomies. She and other critics of vigorous intervention point to the potential side effects and risks of sometimes disfiguring treatments for premalignant conditions that are unlikely to develop into life-threatening cancers.
She has also challenged the conventional wisdom surrounding screening, arguing that while mortality from breast cancer has decreased over the past three decades, the approach to screening needs to change. She points out that the most lethal breast cancers appear between screens, while mammograms are finding more slow-growing cancers with a very low chance of metastasis. In addition, screening has revealed a reservoir of D.C.I.S., also known as Stage 0, which now accounts for 20 percent to 25 percent of all breast cancer diagnoses.
So convinced is Dr. Esserman that most patients will not benefit from early detection of such lesions that she has recommended to the National Cancer Institute that for many D.C.I.S. lesions, the ominous word “carcinoma” be dropped from the medical term for them and that they be renamed “indolent lesions of epithelial origin,” or IDLEs.
Much of this unsettles cancer specialists, who believe that aggressive treatment is prudent given that D.C.I.S. can be a precursor to invasive cancer in some patients.
“What do you do if you hear a gunshot — duck or not?” asked Dr. Larry Norton, medical director of the Memorial Sloan Kettering Evelyn H. Lauder Breast Center, who nonetheless said he admired Dr. Esserman’s professionalism and rigor.
In an era of 15-minute doctor visits, Dr. Esserman is known to spend hours with a patient (a practice that can be maddening to those in the waiting room) even if it means staying at the office until 10 p.m. She sends late-night text messages to patients and calls whenever she can.
One recent Sunday afternoon, she stood in the large, art-filled kitchen of her house in the Ashbury Heights district of San Francisco, rehearsing the song “Defying Gravity” from the musical “Wicked.” It was a request from a patient.
For nearly two decades, Dr. Esserman has sung to her patients as they go under anesthesia. With enough notice, she takes requests.
“Ask for an aria and I might need a week, but most songs take about 15 minutes to learn,” she said.
“Unlimited. My future is unli-mi-ted,” she sang full-throated in her kitchen, for a visitor.
Then she stopped. “You see, that’s the thing,” she said, her gaze intense enough to double as a Vulcan mind meld. “You have to believe in the possible. The minute you think your future is limited, it is.”
Dr. Esserman received national attention five years ago with an innovative, adaptively randomized drug trial called I-SPY 2, aimed at reducing the cost and time required to test new medications for breast cancer. The trial matches drugs with patient subtypes, allowing drugs from different companies to be assessed simultaneously, and much earlier in the disease process, while quickly phasing out those that do not appear to be working.
Trials for drugs to treat other cancers, as well as Alzheimer’s disease and Ebola, have adopted the design, said Donald Berry, a statistician at M.D. Anderson in Houston who designed I-SPY 2 with Dr. Esserman.
Dr. Esserman’s approach to D.C.I.S. has been much slower to gain acceptance in the medical community.
“Laura is one of the people who’s actively engaged in research in this area and will help us push the field forward to determine whether or not there is a group of people for whom surveillance will be appropriate,” said Dr. Elisa Port, chief of breast surgery at Mount Sinai Hospital in New York and author of “The New Generation Breast Cancer Book.” “But no one has these tools now to know whether or not it’s safe, and the biggest factor is we know that when we do surgery on D.C.I.S., about 10 percent of the time, commingled with the D.C.I.S. is invasive cancer.”
She added: “When we talk about watching and waiting with D.C.I.S., the question is, ‘How do we know it’s just D.C.I.S.?’ The answer is that we don’t.”
But Dr. Esserman’s minimally invasive approach is beginning to win some converts in clinical settings. One of the highest compliments she has received, she said, came recently from a colleague at U.C.S.F., Dr. Barbara Fowble, a radiation oncologist who has tended to favor more conventional treatment.
The two physicians were discussing a patient whose nodes showed no cancer after chemotherapy and surgery. Dr. Esserman said she assumed Dr. Fowble would favor radiating that region. To her surprise, Dr. Fowble said, “Absolutely not.”
Dr. Esserman asked, “What happened to you?” Dr. Fowble’s reply: “You happened to me.”
When asked about the remark by a reporter, Dr. Fowble laughed. “Yes,” she said. “I think we’ve both influenced each other. She was willing to do more surgery, and I was willing to back off on the radiation.”
“She advances us forward,” Dr. Fowble said of Dr. Esserman. “And you can either go with her or live in the past. I would rather go with her.”
One day last January, Ilene Katz, a registered nurse at the university, went to see Dr. Esserman. It was not about work. Ms. Katz had just learned that she had a 12-centimeter tumor in her breast. Frightened and in shock, she told Dr. Esserman she wanted to have both breasts removed.
The appointment lasted three hours. Scans showed that the tumor was self-contained.
That night Dr. Esserman called her new patient again, with pointed questions.
“She asked me why I was going to hurt my body when it wouldn’t do any additional good,” Ms. Katz, 45, recalled. “She asked me a bunch of questions that really made me think.”
By the next day, she decided to have breast reduction surgery instead.
Several weeks later, Ms. Katz got a call from Dr. Esserman at 9:30 p.m. Dr. Esserman had just sat down to dinner.
“I could tell she couldn’t stand knowing I was confused and scared,” Ms. Katz said. “She wouldn’t hang up until she was sure I felt better. She was talking between bites.”
Peggy MacDonald, 51, is currently under Dr. Esserman’s care, on a watch-and-wait course. She was diagnosed with D.C.I.S. in April 2013. “I didn’t even know what it was,” she recalled. “But there was cancer in the word and it was scary.”
The first surgeons Ms. MacDonald saw in Portland, Ore., where she lives, immediately discussed surgery as a given. Then Ms. MacDonald heard about Dr. Esserman and flew to San Francisco for another opinion. Before the appointment, Dr. Esserman requested a few additional tests, including a high-resolution M.R.I. and blood tests to check hormone levels.
“She walked into the room and sat down and said, ‘I don’t think there’s anything urgent going on here. We have time,’ ” Ms. MacDonald said.
Dr. Esserman put Ms. MacDonald on a course of ovarian suppression drugs and a hormonal agent. Last December, nearly two years after the diagnosis, Dr. Esserman told Ms. MacDonald that an M.R.I. showed no evidence of D.C.I.S.
Dr. Esserman is quick to point out that by no means should all cases of D.C.I.S. be treated with active surveillance. In contrast to Ms. MacDonald, she pointed to another patient, Courtney Hollander, 47, who received a diagnosis of D.C.I.S. last January. A surgeon Ms. Hollander saw in Los Angeles led her to believe she would need immediate surgery.
“I found myself being angry at having a double mastectomy for not having cancer,” said Ms. Hollander. She sent Dr. Esserman an email and Dr. Esserman replied that night.
Ms. Hollander’s D.C.I.S. did not respond to hormone therapy as hoped, and she is now planning to have a mastectomy.
“I didn’t rush her into surgery,” Dr. Esserman said. “And I think that’s the essence of it. People don’t want to think that a mastectomy is the first choice.”
Dr. Esserman did not grow up around physicians. Her father was a car dealer in Miami, her mother a teacher. Gifted in science, she worked in a research lab at the University of Miami while still in high school, then went to Harvard.
Even then, her assertiveness was hard to miss. Dr. H. Gilbert Welch, a professor of medicine at Dartmouth, has known Dr. Esserman since they were undergraduates at Harvard, and he coached her on an intramural crew team.
“I cannot tell you who else I coached in that boat, but I never forgot coaching Laura,” Dr. Welch said. “It was a lot of fun, but it wasn’t quiet.”
After Dr. Esserman finished her surgical training at Stanford University in 1991, she was recruited to the university’s business school. She earned a master’s in business while remaining part time on the School of Medicine surgical faculty and caring for her infant daughter, Marisa, the first of two children with her husband, Michael Endicott, a professional photographer and environmental activist.
Over the years, Dr. Esserman’s philosophy has evolved away from the mainstream. “For years, I operated on people and felt that what I was doing was helpful,” Dr. Esserman said, describing her treatment of D.C.I.S. “But the evidence started to show that we had made a mistake.”
Over a decade, Dr. Esserman said, she saw the incidence of invasive breast cancer increase — in spite of the removal of some 60,000 D.C.I.S. lesions each year in the United States. “I had to be brutally honest, change my mind, and search for better answers,” she said.
“It makes no sense to keep arguing about this,” Dr. Esserman was saying one night in her kitchen, pointing to the need for more robust and innovative clinical trials to determine the value of breast cancer screening. Gathered with her were a visiting biostatistician from Sweden and several local colleagues.
She made her point while painstakingly extricating the bones from a five-pound salmon she planned to grill for dinner, using a surgical instrument meant for suturing that resembled a pair of nail scissors.
Dr. Esserman frequently holds meetings in her kitchen, cooking for the group while hatching, say, a new idea for a paper. On this night, she was sautéing arugula, which seemed to vanish, only to resurface 30 minutes later in the potatoes she had mashed by hand.
The culinary magic occurred while she steered her colleagues through a gamut of complex topics, including the longstanding debate over breast cancer screening.
In 2009, the United States Preventive Services Task Force revised its breast cancer screening guidelines, recommending that women wait until age 50 to start regular screening, and that women 40 to 49 who were at a high risk for breast cancer discuss with their physicians the best time to start getting mammograms. Dr. Esserman and others had been pushing for such changes for years, but the revised guidelines were met with outrage from breast cancer support groups, as well as some researchers and physicians, who argued that early detection had saved millions of lives. (The American Cancer Society continues to recommend regular mammograms starting at age 40.)
Asserting the need for better evidence about the value of screening, Dr. Esserman paused briefly from her salmon deboning. “The only way to do better is to know better,” she said, crediting the poet Maya Angelou for that thought as she waved her small tool in the air. “The point is to try to move the field and do right by our patients.”
To this end, Dr. Esserman has embarked on an ambitious project — a multiyear trial involving some 100,000 participants. Called “Women Informed to Screen Depending on Measures of Risk,” or Wisdom, the five-year study will test participants for genetic markers and other factors that point to a risk of breast cancer, and screen those at risk more frequently than the current federal task force guidelines. Those deemed at less risk will receive fewer mammograms. A control group will receive annual mammograms.
Dr. Esserman is careful to point out that no one in the trial will receive screening that is less aggressive than the task force guidelines. “We’ll stay within the bounds,” she said, “but over time the goal is to learn what risk factors are the most important and how we can adapt screening accordingly.”
Even Dr. Esserman’s most outspoken critics respect her. “I think fundamentally she’s on the right track, and I’d be delighted to be disproved,” said Dr. Daniel Kopans, a professor of radiology at Harvard Medical School, who has long disagreed with Dr. Esserman about screening. Dr. Kopans, who specializes in breast imaging, cited studies showing that death rates of breast cancer patients who were not screened had declined at a much lower rate than those who were screened.
“Mammography isn’t the answer to breast cancer, by any means,” he said. “But don’t give up on mammography. And don’t stop screening because we haven’t figured out how to treat D.C.I.S. properly.”
As for her own screening, Dr. Esserman is aware that her risk for breast cancer is increasing with age. She said she planned to participate in the Wisdom trial. “I’m asking everyone else to be randomized, so I’ll probably be randomized,” she said. “I try to design trials that I would want to participate in.”
Dr. Esserman has received her share of angry letters, particularly from women with D.C.I.S. who chose to have mastectomies. “People have said, ‘How could you invalidate everything I’ve gone through?’ ” she said.
Every time she performs surgery, she hopes to help one more woman survive.
One morning earlier this summer, Dr. Esserman entered an operating room at UCSF Medical Center at Mount Zion, carrying a printout of the lyrics to the Beatles’ “With a Little Help From My Friends.” Ms. Katz had requested the song for a second surgery on her breast to remove any residual tumor cells.
As the anesthesiologist fit a mask to the patient’s face, Dr. Esserman cupped Ms. Katz’s hand tightly around her own, and together the physician and her frightened patient broke into song. Even after Ms. Katz had lost consciousness, Dr. Esserman kept singing, while stroking her patient’s cheek. She switched briefly to one of her favorites: “Sweet dreams that leave all worries behind you. But in your dreams, whatever they be, dream a little dream of me.”
Then she got to work.
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