Bone Marrow or Stem-Cell Transplant
In 1995 an independent technology-assessment organization conducted a thorough review of studies, concluding that there is no evidence of any prolonged disease-free or overall survival benefit from the use of either bone-marrow or stem-cell transplants compared with conventional chemotherapy under any circumstances. Reimbursement for these therapies is controversial, and breast cancer patients are seeking insurance coverage ranging between S50,000 and $200,000 for this therapy. Several states have mandated such coverage. This is perhaps another example of both doctors and patients wanting to believe I that if a little is good, more must be better. But 31 studies between 1984 and 1994 showed either no improvement or slightly increased early death rates. Substantial evidence of harm exists for these therapies (note 15).

Making Sense of What We Know: Popular Intuitive Assumptions vs. Counterintuitive Evidence
An advertising concept called "positioning" refers to securing a place for a product in the consumer's mind that, ideally, I will become identified with the function served. Examples of this are the brand Kleenex, which has become synonomous with tissues, and Xerox, which has become a verb for photocopying. Analogously, the paradigm for the mechanical spread of breast cancer has become fixed securely within doctors' minds, and "removal before it spreads" has become the corollary kneejerk response. The delusion lingers that if enough malignant tissue is excised, then the cancer can be evicted and the patient cured.

Prior to and in the absence of prospective, randomized, controlled, double-blind studies, treatment protocols are inevitably the fruit of speculative clinical postulates to be tested over time. This holds true for regimens of chemotherapy, radiation, and surgical procedures. When clinical studies throw those habitual behaviors into question, rather than behaviors adapting, studies are often functionally disregarded. Perhaps this is because habits have encouraged theories to be mistaken for facts. It is within this context that the the Office of Technology Assessment issued a report stating that only 17% to 20% of conventional medical practices are based on scientifically validated evidence, and that 80% to 83% are based solely on anecdotal data (Office of Technology Assessment, US Government Printing Office, Washington, DC; 1988).

For example, it was hypothesized that positive axillary nodes served as a predictor for the spread of the disease. When evidence indicated otherwise, only a few doctors altered their clinical behavior. Similarly, bone scans, chest x-rays, and blood work have been shown to be of little use, yet more than half a billion dollars are spent each year when a physical exam, history, and mammogram are sufficient. Even though radiation following surgery reduces local recurrence, it is clearly established that the reduction of local recurrence does not impact survival. Radiation following surgery is akin to the ancient Greek custom of killing the messenger who has delivered bad news. Still, only a few physicians perform lumpectomies without recommending radiation therapy. Finally, though mastectomy is popularly perceived to be the safest treatment, there is comparable survival benefit between mastectomy, lumpectomy with radiation, and lumpectomy alone--women live the same length of time regardless of which intervention they or their doctor choose. Neither mastectomy nor radiation eradicates the possibility of recurrence--they merely reduce it, and local recurrence itself does not suggest that a woman's chance for a long life is less. Thousands of women and their doctors nevertheless elect mastectomy.