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Trevor Smith, Breast Surgeon

Trevor Smith's concerns and outspokenness about some breast cancer issues may make him a bit of a maverick. But this father of two isn't into arm-waving or an aggressive demeanor. Instead he communicates his concerns and his passion quietly and calmly.

Last November, Trevor Smith published an article in the New Zealand Herald, and amid the comments that were bound to stir up the breast cancer community - particularly those who vigorously promote mammograms - perhaps his most important messages were lost.

It was a thought provoking article, and I have to admit, it poked some of the big issues that I'd like to have a poke at. The article came in the middle of our own series on mammography and it seemed like a great opportunity to delve a little deeper and find out what drove Trevor Smith's foray into the popular press.

So here he is...

On Breast Disease

"If you go out with an extreme message a lot of people will take it at face value."

"That's the trouble with the current campaign. It says breast cancer is what's going to kill you. YOU'RE ALL GOING TO GET BREAST CANCER!" he says in a voice loaded with capital letters and exclamation marks. He talks about the emotiveness of the awareness campaigns.

"Your mother, your sister, your daughter. Who will be next." He quotes some of the campaign text from memory, and calls it a campaign of terror.

"Every October I have women of 26, 27, 28 in here in tears, saying 'I have to have a mammogram, I've just read the Next magazine. Look! Here's a 26 year old who is dying!'"

After listening to the symptoms and making a careful clinical and ultrasound examination I say, 'but you've just got some hormonal breast pain. Don't worry.' But 'no, no,' she insists 'I have to have a mammogram.'"

"Where are they getting this message? That a 26 year old with no family history... They are getting it from a campaign that promises that a mammogram can save your life. From a campaign that uses young role models to front their advertising."

Trevor doesn't only treat breast cancer. "Probably one in 20 people I see is a breast cancer patient, the rest have a range of symptoms due to common non-cancerous conditions."

"Ironically, the focus is always on breast cancer, but 90% of breast problems are benign. They had the National Conference on Breast Disease [in Auckland in November 2005]. There wasn't a single talk or poster presentation on anything other than breast cancer," he says, still incredulous. "And yet 90% of the women we see have benign breast conditions - breast pain, cysts, fibroadenomas, mastitis, augmentation, reductions. All those areas of breast pathology were not touched at the conference."

"It is a reflection of this focus on one condition, as if breast cancer is the only thing that ever happens to anyone."

"Look around, see how hard it is to find any information on breastfeeding," he says by way of example.

On Mammography

One of Trevor's big beefs with the current campaign is that they imply that mammograms will stop you getting breast cancer.

"If you want to take the comfortable view, you can say that mammographic screening is a good thing. But there is a problem and that is, that mammography is being oversold."

"The campaigns claim that it is the best thing you can do to stay well and healthy. Now you don't have to be a lawyer to argue the point that it is overselling it at best."

He points out that we don't know what the benefit of mammographic screening is in New Zealand, because no-one is measuring it. "We can say that perhaps it worked in Sweden in the 1980s, but are we reproducing those results here, and what data have we got and what are we collecting to show that it is working here?"

He suggests that there is another level of discussion in which we could engage: does it work at all? We could start to "unravel those original seven studies, looking at what was measured and what was found." We could argue for a week, he says, with people defending both sides.

Trevor knows that this is not a popular question to ask, not a popular view to take. And when I suggest that he would be pilloried for heading down that track, he doesn't step back from the argument and says that he is prepared to do that, and engage with the medical community over the issue.

"I've written to the New Zealand Medical Journal saying... just look at this data. We wouldn't start doing other public health screening on this shaky level of evidence."

"This is the paradox," he continues. "Prostate screening, for example, is discouraged by the same health department, yet many of the arguments against prostate screening apply equally to breast screening."

On the subject of young women having mammograms, Trevor points out that for every young woman with breast cancer (only about 2% of the total number with breast cancer are less than 30 years old) there is a woman with lymphoma, osteosarcoma, etc., and we are not screening for those. Yes cancer is tragic, but screening everyone is not the solution.

While he is clear that screening mammography is not a solution for young women, he is keen that they should get the message that if you find a lump, or have other symptoms, go and get it properly checked.

On Prevention

"There are a whole lot of things that you can do to reduce your long term risk of getting breast cancer. Which, of course, spills over into all the other diseases [cardiovascular disease, diabetes] as well. So you are getting an exponential benefit from your prevention measures; it's not breast cancer specific."

Clearly Trevor is horrified by some of the claims in the breast cancer information provided to women...

"It says in those pamphlets: 'Unfortunately, there is little that women can do to reduce their risk of cancer...' This is the other problem with the campaigns."

He is emphatic: "There are things that you can do, that not only reduce your risk of breast cancer but a whole host of other, equally life threatening diseases."

Trevor rates diet as one of the biggest things which contribute to disease, including cancer. "When you actually sit and talk to people about what they eat and how they eat, you realise how little attention we pay to such a fundamental thing as what you put inside you. Compare that to the effort we make to... go and have mammograms, for example."

A one off mammogram every two years takes less effort than addressing what you eat every day of your life. But it doesn't have to be too complicated or onerous:

"Just eating less and exercising more would be a jolly good start for most people," he says. "Then we can start looking at things like anti-oxidants, selenium, folic acid, etc."

Smoking is another concern:

"I saw a woman come in for a mammogram and she was so stressed that she stood out side having a cigarette." He laughs at the irony. "You know this message is not getting through. Throw your cigarettes away and don't come for a mammogram because that will do you much more good than smoking and having a mammogram."

"These are things that can be tackled. To have any message suggest that there is nothing much you can do for your health, other than go and have a whole lot of tests. It's shocking. To me it's a failure of the medical system. And I really feel very strongly about it."

Ahh. That's what we need. People who feel strongly about things who are prepared to stand up and say so, people who are not afraid to challenge the sacred cows of medicine. Passion and sense.