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I don’t think very highly of Dr. Oz.

Yes, yes, I realize that saying that is akin to saying that water is wet, the sun rises in the east, and that it gets damned cold here in the upper Midwest in December, but there you go. This year, I’ve been mostly avoiding the now un-esteemed Dr. Mehmet Oz, a.k.a. “America’s doctor,” even though his show could, if I paid much attention to it anymore, provide me with copious blogging material, because I’ve come to the conclusion that he is beyond redemption. He’s gone over to the Dark Side and is profiting handsomely from it. There’s little I can do about it except for, from time to time, writing about some of Dr. Oz’s more egregious offenses against medical science and reason, putting our tens of thousands of readers per day against his millions of viewers per day. It’s an asymmetric battle that we don’t have much of a shot at winning. However, at least from time to time I can correct misinformation that Oz promotes, particularly when it impacts my speciality. Consider it doing something pre-emptively to help myself. When one of my patients ask about something that’s been on Oz’s show, I can simply point her to specific blog posts, as I did the last time around when Oz arguably flouted the human subjects protection regulations of his own university and of the Department of Health and Human Services by running in essence a poorly-designed clinical trial to show that green coffee bean extract can promote weight loss. Of course, it showed nothing of the sort.

This time around, Dr. Oz caught my attention about a week and a half ago. I had planned on blogging about it last week, but the case of the Amish girl with cancer whose parents stopped her chemotherapy after less than two full courses, thus endangering her life, intervened. (It also didn’t help that I hadn’t recorded the show and the segment hadn’t shown up on Dr. Oz’s website by Sunday night last week.) I figured that I probably wouldn’t get back to Oz, but—wouldn’t you know it?—a week later I’m still annoyed at this story. So better late than never.

The story aired on December 6 and was entitled Why You Should Keep Your Cell Phone Out of Your Bra. The entire segment, lasting ten minutes or so, is one blatant piece of fear mongering. Even by the usual low standards of a typical Dr. Oz segment, this one was bad. How bad? I’ll give you a taste. Let me start just by asking what you might expect in a segment claiming a link between an environmental exposure of some sort and a specific cancer? You’d expect some actual scientific evidence, wouldn’t you? Some epidemiology, perhaps, showing that women who hold their cell phones in their bras have a higher risk of breast cancer, perhaps with some relative risks that were at least statistically significant. You might expect some scientific evidence suggesting why the proposed mechanism is plausible. You might even expect that there would be convincing (or at least suggestive) evidence that women who put their cell phones in their bras, when they develop breast cancer, develop it more frequently on the side where they stick their cell phone. These would be reasonable things to expect that, even though they wouldn’t be convincing proof, would at least raise concerns.

There was none of that at all. Zero. Nada. Zip. In fact, I was shocked at how evidence-free this whole segment was. Usually Oz at least tries to slather a patina of scientific evidence on his pseudoscience. OK, maybe not usually, but he does at least sometimes try when he’s not doing a story on alternative medicine, “complementary and alternative medicine,” or “integrative medicine,” anyway. Not here. It’s as if Dr. Oz’s producers weren’t even trying for this one.

So what evidence do we get? It starts out with Dr. Oz saying how he understands how easy and convenient it is for women to stick their cell phones into their bras because it leaves their hands free. A prerecorded segment shows several women listing all the things they keep in their bras these days and why, things that include money, keys, and credit cards, among other things—and, of course, cell phones. One woman even keeps her son’s pacifier in her bra, which sounds kind of disgusting to me. I suppose if she’s still breast feeding, what’s a little more spit? In any case, we get the message. Bras hold more than breasts these days.

Dr. Oz then points to an image on a screen in the studio, repeating how he understands how convenient bras are to carry things, but then goes on to warn that he never wants you to do this again. A breast surgeon like myself can recognize the image immediately as a breast ultrasound, with a mass in it. The mass is darker than the surrounding tissue (hypoechoic, as we call it) and irregular. It looks suspicious, and it is suspicious, because Oz tells us that it’s breast cancer, which is never convenient. (No kidding, doc. No one knows that better than a breast surgeon like myself, except for breast cancer patients, of course!)

Here’s where Dr. Oz introduces a young woman named Tiffany Frantz, who believes that carrying her cell phone in her bra caused her cancer because it was on the same side and in the same area where her phone came into contact with her skin. Tiffany tells the audience that she kept her cell phone there for four years and that her cancer was right where the phone used to sit, helpfully demonstrating at Dr. Oz’s request how she would carry it in her bra. I noted immediately that she happened to carry it in such a way that it covered (mostly) her upper outer quadrant, which is the most common location for breast cancers to appear because anatomically there is more breast tissue there. Right away, I was sure that this was almost certainly a coincidence.

It’s also an idea planted in her head by her mother, Traci Frantz, who apparently didn’t like the way that her daughter used to carry her cell phone in her bra, particularly the way it stuck out. Once her daughter got breast cancer at age 21, her mother latched on to the cell phone as the cause, after, of course, doing her “research” on the Internet. She emphasized that Tiffany was young and healthy, that there was no family history of breast cancer, and that she didn’t have any genetic mutations known to predispose women to cancer, sometimes at a very young age. She also mentioned that she had been contacted by a “half a dozen” women who were convinced that their cell phones caused their breast cancer. It all sounds very convincing if you don’t know much about breast cancer.

Naturally, those nasty doctors didn’t believe her and produced, as Dr. Oz put it, “pushback,” as though their skepticism was unreasonable. When Dr. Oz asked Mrs. Frantz about this, her response was very telling. She didn’t say that she was trying to figure out whether cell phones cause breast cancer. Instead, she said:

My objective now is to collect the data necessary in order to validate a possible link between cell phones and breast cancer.

In other words, she’s looking for evidence to confirm what she already believes to be true. I know this from other news stories about Tiffany in which her mother has weighed in, such as this one, in which Mrs. Frantz is quoted as saying, “I absolutely believe that storing her cell phone in her bra gave her cancer. No doubt.” If you absolutely “believe” something, there’s no room to change your mind, at least not easily. Don’t get me wrong. I can completely understand the shock Mrs. Frantz felt when her daughter felt a lump in her breast and it turned out to be cancer. Breast cancer is rare in women under 30. But how rare? Stay tuned.

In the meantime, I can’t help but note that Tiffany Frantz and her mother have been appearing all over the media over the last couple of years, for example, here:

And here:

Note how the doctor interviewed in this segment says that breast cancer at this young age is “unheard of.” Let me tell you that it is not. Uncommon, even rare? Yes. “Unheard of”? No. Not really. Let’s just put it this way: I’ve seen a case in a woman even younger than 21. So let’s look at the medical expert brought in for the second half of the segment. It’s a breast surgeon named Dr. John West, who is based in Los Angeles. A quick bit of Googling on his name revealed rather quickly that Dr. West also strongly believes that carrying cell phones in the bra can cause breast cancer. His explanation as to why, both on Dr. Oz’s show and elsewhere, is less than convincing. He starts out with the story of a 39-year-old patient of his who developed breast cancer. Now, I’ve seen plenty of 39 year olds (and younger) with breast cancer; so this patient’s age doesn’t raise any suspicions of an environmental cause. To his credit Dr. West acknowledged this. However, unfortunately he also related how this woman was totally convinced that her cancer had been caused by carrying her cell phone in her bra. Dr. West also said that she had multiple tumors that corresponded “basically” to where the cell phone used to rest. He even presented the case to a conference of breast surgeons (hmmm, I wonder if it was an American Society of Breast Surgeons Meeting that I attended—probably not, as I would have remembered) and that he “got laughed off the stage.”

An appropriate reaction, I would say. I’m relieved that my fellow breast surgeons understand at least that much.

The rest of Dr. West’s evidence consists of three more patients with breast cancer, one of whom was Tiffany. Interestingly, he mentions one of these patients as having come to his attention six months ago, although from articles from 2012 it’s clear that he’s believed in this link for a while. This was another 21-year-old with breast cancer. Dr. Oz intones gravely how he “wasn’t convinced” (of course not!) until he saw these images. A breast MRI is shown with a typical ductal pattern of enhancement, where the “bright spot” follows a ductal distribution. Dr. Oz acts as though this were some sort of major surprise, but it’s not. Breast cancer most commonly arises from the milk ducts, so it’s not surprising to see this sort of pattern. In this particular case, however, because the pattern involved ducts on the lateral side of the breast, which is where this woman held her cell phone, obviously it must have been the cell phone. The funny thing is that the “phone” drawing that is superimposed on the MRI image only matches up with one-half to two-thirds of the distribution of abnormal enhancement. In other words, even the “correlation” is not that convincing. This is even more true when you consider that only a small part of the phone, the antenna and radio, is actually responsible for generating the radio waves, not the whole phone. So it’s almost completely irrelevant whether the phone matches where the tumors were. What matters is whether the antenna and radio match where the tumors were. The same goes for all these cases.

Be that as it may, how common is breast cancer in young women? It turns out that the median age at diagnosis for breast cancer in this country is 61. Dr. West brags that he’s been practicing for 40 years and has personally treated 10,000 women. That’s about 250 women a year, which is not an unbelievable number for a busy breast surgeon. What I find rather hard to believe is Dr. West’s claim that he’s only seen three women with breast cancer who were under 30. Let’s just put it this way. I’ve only been practicing less than 15 years, and, because I run a lab, I haven’t even been practicing full time. I’ve treated far fewer women with breast cancer than Dr. West says that he has, but I’ve already seen at least five patients under 30 with breast cancer. My youngest patient ever was 19 years old when she was diagnosed. I know of a patient treated at my institution before I arrived who was 14 at the time of diagnosis. I do realize that I’ve spent all my career at two different NCI-designated comprehensive cancer centers. These are the best of the best, and there are only 41 such centers in the country, which means that we probably see more young patients than the average private practice breast surgeon. Even so, it strains credulity that Dr. West has seen so few young patients in his 40 years of practice.

I’ll try to show you what I mean. Dr. West goes on to state that only 3 out of the 10,000 patients he’s treated over the course of his career were under 30 at the time of diagnosis. If you go to the SEER Registry, which tracks cancer cases in the US, you’ll see that 1.8% of new cases of breast cancer occur in women under 34. That means, by random chance alone, if his patient population were a representative sample of the breast cancer population at large, Dr. West would expect to see somewhat less than 180 patients under 30. Because of the difference between age 30 and 34, let’s take a conservative estimate, which would be that he should probably have seen at least 100 patients under the age of 30. (In fact, I operated on a 33-year-old with breast cancer in the last month.) That’s a little more than two per year. Yes, that’s rare, but not that rare. Either Dr. West’s memory is faulty, or his patient population does not correspond to the normal age distribution of breast cancer cases. I’m assuming the latter, in which case no wonder he’s so amazed at having seen 21 year old with breast cancer and is so susceptible to leaping to the conclusion that it must be due to an environmental exposure! Moreover, if a large percentage of young women keep their cell phones in their bras at least part of the time, you can assume that by random chance alone most women under the age of 34 who develop breast cancer will have carried their phone in their bra. Half of those women by random chance alone will have a breast cancer on the same side as they usually carry their cell phone, and a significant number of those women, again by random chance alone, will have a tumor near where they carry their phone.

That’s why careful epidemiological studies are so important. Word to Dr. Oz and Dr. West: The plural of “anecdote” is not “data.” In fact, your anecdotes aren’t even all that suggestive; that is, if you look at them without the lens of a pre-existing belief that there is a cause-and-effect relationship.

I would also be remiss if I didn’t cover the issue that was mentioned multiple times, namely that Tiffany didn’t have a “gene” predisposing to breast cancer. I hate to be blunt (well, actually, no I don’t), but that means very little. The vast majority of breast cancer cases, including breast cancer in young women, are not linked to genetic predisposition. Indeed, only 5-10% of cases are inherited, and less than 20% are associated with a genetic predisposition. That means that over 80% of cases are sporadic, which basically means “we don’t know what caused them.” They are not linked to a strong family history or mutations in a gene known to predispose to breast cancer. It means almost nothing that these women didn’t have a family history or other evidence of a genetic predisposition. As for women under 40, it is hardly impressive to have found four women under 40 with breast cancer who might have been keeping their cell phones in their bras. To put it into more perspective, there are approximately 232,000 new cases of breast cancer a year. If 1.8% of those cases are in women aged 34 and under, that means that there are approximately 4,200 new cases of breast cancer in women under 35 every year.

Finally, besides pointing out the utter lack of evidence linking cell phone radio waves and breast cancer, we at SBM have written many times about both the scientific implausibility of the concept that radio waves cause cancer and the lack of any sort of compelling clinical evidence supporting a link. There just isn’t any biological plausibility. Radio wave energy at the power level used by most cell phones is not ionizing. It’s not even close, being several orders of magnitude too weak to break chemical bonds. Our understanding of cancer is that, in general, ionizing radiation is what is required to cause or contribute to cancer. That does not mean that there might not be a potential mechanism, as yet undiscovered, by which non-ionizing radiation might cause cancer, but simple physics and chemistry make the hypothesis that cell phone radiation causes or contributes to cancer not particularly plausible on the basis of currently-understood biology. On a basic science basis, at present there doesn’t appear to be strong evidence (or much of any evidence at all) supporting plausible mechanism by which cell phone radiofrequency radiation might cause cancer or an actual effect in which they do.

Add to this that the stories presented as evidence that cell phones cause cancer (i.e., the anecdotes) aren’t even that convincing, including Tiffany Frantz’s story, based on the lack of a plausible biological mechanism and a time frame between four and six years during which Tiffany Frantz said she was carrying her cell phone in her bra. (I note that she said four years in the Dr. Oz segment but her mother said six years in another segment.) I can understand why her being diagnosed with breast cancer was such a shock, given her young age, but it’s not unheard of. Certainly if I’ve taken care of a 19 year old with breast cancer, it’s not so unbelievable that a couple of 21 year olds could have breast cancer. I feel bad for the Frantzs, as no one should have to face a diagnosis like breast cancer at such a young age. It’s even worse, given that apparently Tiffany Frantz has bone metastases now, a horrible thing at such a young age. However, just because I feel bad for these patients does not mean I must accept their belief that cell phone radiation caused the breast cancer.

On the other hand, I can blame Dr. Oz for fear mongering not supported by science, and I do. I can also blame Dr. John West, and another surgeon, Dr. Lisa Bailey, for a depressing lack of critical thinking skills that led them to promote this concept. Truly, they embody the human trait of craving settling on a causative explanation. It’s very understandable why a patient like Tiffany and her mother might leap to confuse correlation with causation (except that it’s not even clear that there’s a correlation here). It’s the same need for causality that leads parents to become antivaccinationists. However, physicians and surgeons should know better. Unfortunately, they often do not. Indeed, Dr. Bailey and Dr. West have even been featured on that font of all things quackery, NaturalNews.com:

A new study raises concerns of a possible association between cell phone radiation exposure and breast cancer in young women. The research team, led by Dr. Lisa Bailey, a former president of the American Cancer Society’s California Division and one of California’s top breast surgeons, studied four young women – aged from 21 to 39 years old – with multifocal invasive breast cancer. The researchers observed that all the patients developed tumors in areas of their breasts next to where they carried their cell phones, often for up to 10 hours per day, for several years. None of the patients had a family history of breast cancer. They all tested negative for BRCA1 and BRCA2 – breast cancer genes linked to about one-half of breast cancer cases – and they had no other known breast cancer risks. Imaging of the young girls’ breasts revealed a clustering of multiple tumor foci in the part of the breast directly under where their cell phones touched their body.

Here’s the study, and a less convincing collection of four anecdotes is hard to imagine. Case 1, for instance, is particularly unconvincing, given that the cancer takes up the whole side of the breast, with an area of pleomorphic calcifications measuring 12 cm, the description being too vague to make any correlations. (Maybe this woman’s cell phone was a Samsung S4 or something even bigger.) Particularly hilarious is the claim that having invasive cancer intermixed with extensive ductal carcinoma in situ (malignant-appearing cells that haven’t invaded through the basement membrane) is unusual. It’s not. All in all, it’s a pretty sad attempt to link a biologically-implausible carcinogen to breast cancer. There’s nothing unusual about the locations or the histology of the cancers; yet Drs. West and Bailey try to claim that these cases are incredibly worrisome based on nothing but confusing correlation with causation. Is it possible that cell phone radiation can increase the risk of breast cancer? Sure, but it’s incredibly unlikely. There’s no currently known biological mechanism by which it could happen, although I won’t bore you with more than a brief one of usual swipes at people with a simplistic, “Cancer Biology 101”-level understanding of cancer declaring piously that it is absolutely physically impossible because radio waves can’t break chemical bonds and thus can’t cause mutations. Carcinogenesis is more complex than that. Even so, at least the people claiming cell phones cause brain cancer try to present epidemiological evidence to support their case. It’s almost uniformly negative and unconvincing evidence, but at least it rises above the level of anecdotes. Drs. West and Bailey (and, of course, Dr. Oz) have nothing.

As I said, I’ve given up on Dr. Oz’s ever seeing the light again. Money and fame have corrupted a man who was once a promising academic cardiovascular surgeon, combined, of course, with a propensity for woo. All I can do anymore is to try to counter his misinformation when I can, which is not that often. After all, I could easily devote a whole blog to trying to refute the medical misinformation that Dr. Oz dishes up every day on his show. Instead, I choose to comment only when his misinformation impacts my area of expertise or for whatever reason catches my interest. It’s all I can do anymore.