Laura J. Esserman, MD, MBA
Which had to go, the nipple or the status quo? Laura J. Esserman, MD, MBA, was discussing an upcoming mastectomy with a patient when the woman asked a simple question: “Why do you have to take the nipple?”
“Because if you don’t, it wouldn’t survive,” Esserman explained.
“Really?” the patient persisted. “How many times have you tried it? How do you know?”
That stopped Esserman cold—not an everyday occurrence for a woman routinely described as a visionary…a revolutionary…a force of nature.
Esserman, a professor of surgery and radiology at the University of California, San Francisco, and director of the UCSF Carol Franc Buck Breast Care Center, is best known for shredding the standards about breast cancer screening and treatment— even the definition of breast cancer itself. But she’s willing to take on any conventional wisdom if she thinks there is promise in the unconventional.
After that conversation in the early 2000s, Esserman learned more about the challenging, time-consuming, and the then almost unheard-of technique of skin-sparing mastectomy: removing the breast tissue but preserving the skin envelope and the nipple-areola complex. She and her team tried a series of surgical approaches until they figured out what worked. By 2007, it was their standard procedure.
That is, it was as much of a standard procedure as Esserman’s driving philosophy of change allows. She is not a believer in the one-size-fits-all approach, be it surgical techniques, mammography screening, or treatment protocols. A breast cancer surgeon who routinely calls for less surgery in favor of active surveillance of low-risk patients, she is a standard-bearer in the field of personalized and individualized medicine—and she is willing to take the heat for it.
“You have to learn most from what does not work,” Esserman said. “First, you understand what went wrong and why and then move on. Keep trying.”
No Stranger to Controversy
Esserman has never been a stranger to controversy, from her passionate call for the Equal Rights Amendment in her high school graduation speech (“I got a lot of flak for that,” she said, laughing) to a 2009 JAMA
piece she coauthored with a prostate cancer specialist that argued that the benefit of breast and prostate screening came at the cost of overdiagnosis and overtreatment.
They did not propose an end to screening but pointed out that it increases detection of slow-growing tumors, many of which are not life-threatening, and misses more aggressive ones. They even suggested that the lowest-risk cancers not be labeled cancer at all, but rather indolent lesions of epithelial origin, or IDLES. Many ductal carcinoma in situ (DCIS), found in the milk ducts of the breast and classified as noninvasive, or stage 0 breast cancer, may never be destined to become cancer.
“DCIS is, in many ways, a disease we created because of screening,” Esserman said. “Cancer is a serious disease, but we have to redefine what cancer truly is.”
Try telling the 60,000 women diagnosed with DCIS in the United States each year, many of whom undergo lumpectomies, radiation, or even mastectomies, that they don’t actually have cancer. Initially, the hate mail—“scathing things,” according to Esserman—poured in from women who felt she had invalidated their experience, as well as from physicians against change. But now her inbox is full of messages from patients seeking less-intensive intervention and clinicians looking for better data and approaches.
Esserman showed that ultra low-risk cancers can be molecularly defined. Now she is taking it one step further with her WISDOM study, an adaptive, randomized clinical trial that looks at a woman’s individual risk factors—age, race, family history, breast density, genetics—and uses risk profiles to identify when women should receive annual or biennial mammograms, or no screening until age 50. Women found to be at the highest risk undergo an annual mammogram and magnetic resonance screening.
This personalized screening model could reduce the high rate of false positives (61% of women screened annually, according to a 2011 study of nearly 170,000 women in their 40s and 50s) and the anxiety and potentially unnecessary treatments they incur and, perhaps, promote prevention for those at highest risk.
“Some cancers are never destined to kill you, and some are rapidly growing and are destined to kill you,” Esserman said. “The WISDOM study is allowing us to ask who is at risk for what kind of tumor and how can we tailor screening to maximize benefit and minimize harm.”