Breast Cancer

Is Spirituality Irrational?

Singapore Slings

Savages and Men

What is worse, my daughter read it too, and she now believes that she is absolutely doomed. She has translated Plotkin's examples of premature death to mean her immediate demise, not in ten or twenty years. Now. No chance to live. No hope. No cure.

Breast cancer was diagnosed in my thirty-six-year-old daughter in August of last year. The cells were poorly differentiated, which is, as Dr. Plotkin points out with thoughtless candor, "bad news, no matter what we bring to bear therapeutically." This doomsday approach may or may not be an accurate prognosis for her. I don't know what will happen.

What I do know is that she has had the best medical care available. She has suffered through breast removal, breast reconstruction, chemotherapy, and radiation treatments. And I know that until she read Dr. Plotkin's article, she had high hopes that she would live to guide her six children through their childhood and on to adulthood. She had made plans for her future with a loving husband. She believed in her treatment, and she had the best possible mental attitude that her hopes would become her reality.

Linda now asks what was the point of all that painful treatment, if metastasis has already begun and she is soon to die. She was very afraid to have the radiation and told her physician she wasn't going to do it. He, thank God, offered her his strong support and advice. He told her that she must fight this insidious disease with everything she's got. He talked with her about the importance of a good, positive mental attitude. Because he is a good physician, she took his advice. Now she questions that decision. Even worse, if cancer cells are found once again, she may well decide to forgo any treatment, based purely on Dr. Plotkin's opinion that she is absolutely doomed, which would make his thesis self-fulfilling and six children motherless before they need be.

Frances Elliott
Milwaukee, Wis.

David Plotkin's assertion that tumor biology is destiny will certainly irk a large number, if not the majority, of his readers. If this is true, and I believe it is for at least three quarters of the women I treat, intensification of therapy and a more widespread use of breast imaging will continue to have little influence on the mortality rate of this disease (a fact that Dr. Plotkin points out has already been true for the past half century). Highly toxic and potentially fatal regimens of treatment are being employed in the naive belief that if we could just push the chemotherapy dose a little higher we could get that last resistant tumor cell. Ultra-high-dose chemotherapy, supported by bone-marrow transplants (or, now more commonly, stem cells derived from the patient's blood), has become safer and less costly over the past five years. However, the question of its utility in breast cancer is unanswered. It has shown a trend toward increasing survival only in women with the lowest tumor burden, who are treated adjuvantly (right after surgery when it appears that all their disease has been removed), but this paucity of evidence has not kept transplant-supported chemotherapy from being routinely employed in patients with the heaviest tumor load, metastatic disease. This is being done while the only scientifically valid trial of high-dose chemotherapy in the adjuvant setting is still collecting patients for study; it will not produce analyzable results for at least five years. If survival is more a function of tumor characteristics than of treatment, we should be investigating the least-morbid treatments, not the most-aggressive, for the former will offer the best combination of prolongation of survival and quality of life.

Charles D. Goldman, M.D.
University of California, Davis
Davis, Calif.

Does David Plotkin seriously believe, as his article suggests, that better nutrition, increased job opportunities, longer life expectancy, and the natural processes of the female body (menstruation) are the root causes of increased rates of breast cancer among women today?

And does he also believe, conversely, that "women in the past" failed to develop breast cancer at the rates we see today because of an insufficient diet, shortened life expectancy, fewer job opportunities, and a decrease in the number of menstrual cycles?

Does improved nutrition, as he suggests, explain why the average age for girls to begin menstruating has fallen from the late teens to twelve? Is this decrease favorable or unfavorable to developing breast cancer?

Our rich, modern, highly processed and refined, animal-centered diet is today more than ever being implicated as the No. 1 cause of diseases and ailments like high blood pressure, heart attack, stroke, heart disease, diabetes, and cancer. For a medical doctor to write a fifteen-plus-page article about breast cancer and not include one sentence on preventive nutrition borders on either the criminally negligent or the blatantly ignorant.

M.A. Lewis
Los Angeles, Calif.

My wife, as an interested layperson, and I, as a recently retired medical oncologist, were both greatly pleased by the recent article on breast cancer by David Plotkin. He very eloquently and clearly presented the problems, after sifting through myriad facts and obviously extensive clinical experience.

I wish that I had had such a reference for many women in my years of practice. I now wish that I had had the time and ability to present the subject so clearly. The article should be disseminated to all physicians dealing with breast cancer, and I would recommend it as reading for all intelligent women.

Charles M. Sinn, M.D.
Mill Creek, Wash.

As a young surgeon I participated in the early U.S. randomized trials of radical mastectomy versus radiation therapy, in the 1970s. This is the best summary I have seen of how difficult it is to translate the tentative and conservative conclusions of scientific research for the public when a disease becomes politicized. David Plotkin's nonpolemical approach and talent for explaining this complex and controversial subject make his article a landmark in science journalism.

Thomas M. Shapiro, M.D.
San Jose Medical Group
San Jose, Calif.

David Plotkin replies:

I offer my sincere sympathy to Frances Elliott and her daughter. The conclusions she has drawn from my article, however, are not entirely justified. First, I emphasized in the article that the pathology term "poorly differentiated" is not very accurate. Only if the clinical course is rapidly progressive -- that is, matches the pathology -- is the outlook no better than bleak. DNA histograms, receptor data, or the like can provide a more optimistic prognosis for some "poorly differentiated" patients. Moreover, there is good news as well: at least half the women with breast cancer have a form of the disease that should cause them virtually no concern, and for which they do not need to be exposed to the overzealous therapies routinely offered. As I read the breast-cancer mortality statistics for the past sixty years and conclude that we are not making much progress, I feel obliged to present the facts rather than to gloss over the harsh reality.

I am in substantial agreement with Charles Goldman, but his idea that at least three quarters of his patients have cancers driven by their biology is a more conservative position than mine. Is evidence available that any percentage of breast cancers are not biology-driven? The increased five-year disease-free survival rate of heavily node-positive patients treated with ultra-high-dose chemotherapy is quite predictable. If all the cytoreductive effect of ordinary serially employed chemotherapy regimens is put into one huge attack, the five-year disease-free rate will inevitably be higher than that seen in conventionally treated patients. This does not mean that long-term survival will be improved. Indeed, no such claim is made even by the proponents of the risky very aggressive therapy. The irony is that the burden of proof seems to have shifted from the advocate to the community -- in other words, here is an experimental treatment that should be regarded as standard until it is shown to be no more effective than the conventional approach.

M. A. Lewis appears to have missed a key point of my article -- that the higher-protein and higher-fat diet of modern Western women has caused the age of menarche to drop by several years. This fact, coupled with first pregnancies at a greater age, in my view plays a big role in the increased incidence of breast cancer. On the other hand, women several thousand years ago, with little or none of the rich foodstuffs at hand today, were considerably shorter, had fewer years of fecundity, and died young, the victims of pestilence, starvation, or carnivorous predation.

As Thomas Shapiro suggests, the oncology establishment, along with segments of the public, will likely continue to politicize this disease. Its agenda seems to lead its members to reject unpleasant conclusions even if they are credible.

Kaminer's piece would be more convincing if she offered a shred of evidence for her position. A simple declaration of her personal belief is not enough. I've studied religion and human spirituality quite seriously over the years, and I've also studied science and technology. I've encountered books with a New Age label that were less than inspiring in their depth of thought. I've also read many books that were thoughtful, logically presented, and quite clear and precise in the presentation of their sources and methodologies. Some of the best, in fact, dealt with the near-death phenomenon, and dealt with it as soundly as any other book directed at a popular audience. Kaminer tars with too wide a brush.

In all my reading and experience so far, I have found nothing presented by science and technology that precludes there being a spiritual element to the human being. In fact, quantum physics holds special promise in opening up the universe to other worlds -- some of which, as more-speculative physicists have pointed out in their own popular books, might resemble the afterlife described in religion.

The bottom line is this: Maybe there are no angels, afterlife, UFOs, or even a God. Certainly their existence has not yet been scientifically proved. But just as certainly, their nonexistence remains unproved. Any reasonable person would therefore have to reserve judgment. Kaminer does not. Therefore, her argument -- actually, it is merely a wandering diatribe -- has no credibility.

Robert Allan Stewart
Nepean, Ont.

Wendy Kaminer appears to practice a double standard in her attack on many forms of modern spirituality. She argues against a belief in angels, immortality, the inner child, and even movements promoting "a good attitude" because they refuse to deal with evil, they criticize rational thinking and then flip-flop by citing scientific studies, they argue by simple declaration, and so on. Yet Kaminer herself feels free to ignore all historical precedents for contemporary spirituality -- from Plato's mystical theories to the long-standing belief in celestial beings in virtually all religions, from Christianity to Buddhism. Furthermore, she uses rhetorical sleights-of-hand to denigrate spiritual teachings, including misrepresentation (if a spiritual book encourages a childlike innocence, for instance, it becomes "childlike passivity") and ridicule ("Descending from heaven, or wherever"). Incredibly, she even links contemporary spiritual teachings with violent militia movements, using as her proof a single individual ("I know a convert . . ."). Kaminer might take a lesson from the nineteenth-century skeptic philosopher David Hume, who argued brilliantly against all "proofs" of God, yet dealt with the thorny issue of mysticism by simply admitting to no personal experience of it -- and leaving it at that.

Paul Angiolillo
Waltham, Mass.

Wendy Kaminer replies:

I'm accused of advancing fallacious arguments against the existence of God, angels, and UFOs, but I presented no arguments, fallacious or compelling, either denying or confirming supernatural realities. Of course I have my doubts, but I don't presume to harbor any particular insights into the nature of the universe and gave up wondering about the meaning of life years ago. My own religious beliefs are pretty simple: maybe God exists and maybe not.

What's interesting is that a critique of popular spirituality books is read as a dismissal of spiritual teachings through the ages and of the mere possibility of transcendence. My article was not about God, angels, the prospect of immortality, or the complicated, variable effect of religion on behavior. It was about one way in which spiritual yearnings, fears of death and disorder, and antagonism toward rationalism are expressed in contemporary American culture. It speculated about the relationship between spiritual and political beliefs. I did not, as Robert Allan Stewart hyperbolically asserts, suggest that billions of believers are potential terrorists. I simply pointed out that the denial of coincidence at the heart of many popular spirituality books also gives rise to conspiracy theories. Why is that a controversial point? It is one of the obvious lessons of history that fears of randomness and cravings for order are not always benignly expressed.

In Singapore public-health inspectors, not police officers, visit households to follow up on complaints of mosquito breeding. But we have no record of any complaint against Mr. Wrage. No health inspectors or police officers visited him, during the day or at night. I therefore wrote to ask Mr. Wrage for the date and time of the alleged visit, and the names of the officers who visited him, in order to investigate the matter. Unfortunately, he declined to substantiate his story.

Why should the police be interested in him, when he was never under any criminal investigation? It would be as much a waste of time as lunging at a lone irritating mosquito in the dark.

S. R. Nathan
Ambassador of the Republica of Singapore
Washington, D.C.

Stephen Wrage replies:

My little story was meant to be an amusing, perhaps indicative anecdote of life in Singapore. If Ambassador Nathan finds so much that is sinister in it, perhaps I should rethink my experience in that vigorously governed little country.

For the record: my protagonist, Will Savage, is a self-destructive music producer who comes from a wealthy southern dynasty and spends a third of the novel at a New England prep school. I'm told that the Huey Long-like character in All the King's Men comes from poor white stock and that the book follows his political "rise to power" -- a phrase Thompson inappropriately applies to the development of my own hippie protagonist. Thompson's astonishment at discovering duck-hunting scenes and Civil War diaries in both books -- and for the moment I have to take his word, compromised as it is, on this -- suggests that he hasn't spent much time in this part of the South, and hasn't encountered many of its other literary artifacts. My own annual hunting trips with my in-laws to Reelfoot Lake, in Samburg, Tennessee, provide all the inspiration I need duck-hunting-wise, while the diaries were inspired by -- among other sources -- letters and diaries in my wife's family archives.

Thompson achieves a deadpan comic pitch of hysteria when he claims to find it especially sinister that my novel contains no mention of Penn Warren or All the King's Men. Neither do I mention Eudora Welty, Flannery O'Connor, Carson McCullers, John Crowe Ransom, Peter Taylor, or Leadbelly. By Thompson's logic, I would seem to be secretly indebted to all of the above by virtue of leaving them out of the book. (And why is it so significant that Penn Warren attended college in Nashville, when my novel is set in Memphis?)

Finally, it's curious to me that neither my editor, who has read All the King's Men, nor any of dozens of reviewers commented on these "improbable" resemblances between the two novels. Among the meager credentials in the Contributors note for Thompson is a previous assignment for Spy magazine; his "review" might have been amusing in that particular context. In a publication as reputable as The Atlantic Monthly it is alarming.

Jay McInerney
Franklin, Tenn.

Some of my friends at The Atlantic asked for my reaction to the review by Charles Thompson of Jay McInerney's The Last of the Savages. I believe that Thompson does an injustice to McInerney by suggesting that his book was unduly influenced by Robert Penn Warren's All the King's Men. I've read both novels carefully, and I find no compelling evidence of a direct line of literary descent in McInerney's plot, characters, prose style, or general artistic tone and intent. Indeed, the novels offer reading experiences so utterly unlike -- in terms of signature preoccupations, narrative voice, and dramatic approach -- that I wondered what had possessed Thompson to bring something close to a conspiracy theorist's zeal to bear on this issue.

The two novels do share a few circumstantial similarities, as Thompson claims, most of which are either trivial (the titular hero hires an armed bodyguard) or literarily commonplace (the narrator's "story" merges with the story of the titular hero). But a couple of them -- a Civil War-era diary that becomes the basis for an academic thesis by the narrator, and the titular hero's becoming the benefactor of a large hospital -- do seem, on their face and completely out of context, possibly deliberate. Unfortunately, many readers of Thompson's review will never experience the context, and may unfairly conclude that McInerney has done something wrong.

Trying to prove the "influence" of one writer on another is a common critical exercise, but sometimes critics forget that writers use their imaginations to invent things, and their inventions can resemble those of other writers because we're all human and some of our experience is universal. Some of our experience is regional, too, and the literary importance of "sense of place" is well known. Given that the South is probably the most idiosyncratic and literarily worked-over region of our country, I'm surprised that Thompson didn't accord the influence of the South (where Savages's dust-jacket copy says McInerney lives part-time) at least as much weight as the possible influence of Robert Penn Warren.

For the record, I have never met or communicated with Jay McInerney.

Ralph Lombreglia
Arlington, Mass.