“The problem with women today is they reach puberty at twelve or thirteen and don’t have a baby until they’re thirty-five,” said Pike. “That’s extraordinary! It’s incredibly non-evolutionary!” He’s right; anthropologists have studied the cycling histories of contemporary hunter-gatherer cultures, believing they provide some insight into how early humans lived. Dogon women in Mali don’t reach puberty until the age of sixteen, and soon after, they marry. They spend much of their adult lives either pregnant or nursing (they breast-feed each child an average of two years). They ovulate approximately one hundred times during their life. Women in Western nations ovulate, on average, four hundred times. Today in America, nearly 20 percent of women between the ages of forty and forty-four have never borne a child, a figure that has doubled just since 1976.
Pike scribbled down some charts and pictures for me on scrap paper and printed out articles on his printer. At seventy-four, he is tall and lean and generously bearded, like Santa after a crash diet. When I first Googled him, the top document was a marketing article from the University of Southern California calling him “the dashing Malcolm Pike,” and it stuck in my mind. He speaks in a strong, lilting South African accent and enjoys asking Socratic questions. Having grown up in Johannesburg under apartheid, Pike is an arch proponent of tolerance and open debate. He clearly enjoys taking conventional wisdom apart.
“The pill,” he continued enthusiastically, “gives you hormone levels every day that look like the levels after you’ve ovulated. It was a brilliant pathologist in Scotland who showed us that there’s more cell proliferation in the breasts in the second half of the cycle.”
“I could have told you breast cells are more active after ovulation,” I said, thinking the genius in Scotland was a bit overrated.
The dashing Malcolm Pike raised his eyebrows. “How do you know?”
“Because they hurt! They get bigger. They’re inflamed,” I said.
“Ah!” said Pike. “But how do you know?” he repeated. “How do you know that’s not just water? You can’t feel cell proliferation! We had to see it in a dish!”
Well, I thought, if that’s the way scientists need to do it, fine.
The reason breasts become bigger and more tender after ovulation illustrates how strongly these organs are geared to procreation. Every time an egg pops out of the ovary, the body is preparing for the big event, whether fertilization actually takes place or not. Progesterone courses through our cells to help prepare the uterine wall and to begin growing the dairy machinery in our breasts. It may seem overzealous to do this nine-plus months ahead of time, but in fact the breast needs every possible minute to get up to speed.
In any case, by the mid-1980s, Pike was publishing papers showing that women who began taking the pill as teens, before bearing children, doubled their risk of breast cancer before age forty-five. If they took the pill for eight years before becoming pregnant, they nearly tripled their risk. Captive tigers and lions also suffer from mammary and uterine cancers after taking oral contraceptives.
Between 1986 and 1989, a handful of studies in Europe and New Zealand confirmed Pike’s human data, although other studies showed the pill added a smaller risk of breast cancer. I told Pike I took the pill starting when I was eighteen. By then, in the mid-1980s, manufacturers had introduced lower-dose pills, despite insisting all along that the original formulation was perfectly safe. Today’s oral contraceptives contain one-fifth the hormone levels of the original.
“So has the pill transformed your breast?” he asked, anticipating my question. “We don’t know. How would you ever find out? You have to stick needles in people to look at breast tissue. We’ve been extremely reluctant. If we could look at 180,000 women, we’d understand.”
Just when I was starting to feel the dread of past mistakes, he asked, “How long did you take the pill?”
I shrugged. “About four years,” I said.
“We think the risk of breast cancer goes up for about ten years after you stop,” he explained. “So there’s probably no more risk for you. Now, whether it did you any good, we don’t know.”
Pike was untwisting a green paper clip, working it into a rough quadrangle. “We know it’s protecting you from ovarian cancer.”
I told him that after I stopped the pill, it took me six months to start ovulating again. He looked elated. “That four years you were on the pill was like having four babies when you were young!” he said. As far as my ovaries are concerned, that’s a good thing.
But before breaking out the cigars, Pike turned again to breast cancer. If the pill gave him epidemiological heebie-jeebies, so did hormone replacement therapy, or HRT. Like the pill, this therapy supplied extra daily doses of menstrual hormones, estrogen and later estrogen-plus-progesterone, but to women whose ovaries were no longer making them. As early as 1982, Pike was worried about HRT. He published papers, but, as he tells it, they met with thunderous silence. By 1992, Premarin (the name stands for pregnant mare urine) was one of the most widely prescribed drugs in America, given to 11 million menopausal women and earning its happy makers nearly $2 billion a year. To create the unprecedented demand, drug companies and physicians appealed to women’s vanity and reason, essentially inventing a new pathology called menopause in the same way the surgeons had invented one called micromastia, for small breasts.
As one physician told the New York Times in 1975, “I think of the menopause as a deficiency disease, like diabetes. Most women develop some symptoms, whether they are aware of them or not, so I prescribe estrogens for virtually all menopausal women for an infinite period.”
He had good company. In 1966, the prominent gynecologist Robert Wilson wrote an influential bestseller, Feminine Forever, in which he called menopause a state of “living decay” that makes women fat, moody, and saggy. He wrote that women “rich in estrogen,” by contrast, “tend to have a certain mental vigor that gives them self-confidence, a sense of mastery over their destiny … and emotional self-control.” Estrogen therapy, he wrote, “makes women adorable, even-tempered, and generally easy to live with.”
Not unlike the anthropologists who believe that women’s breasts exist for men, many mid-century doctors thought that women’s moods, sexuality, and general perkiness should be engineered, artificially if need be, to suit male preferences.
By now there has been much debate about whether menopause is evolutionarily adaptive—in other words, is there something useful about it?—or whether we’re really designed by nature to just wither up and die after our ovaries wear out. A common refrain is that we’re more or less supposed to get cancer simply because we live so unnaturally long. I won’t go much into the fray, but one of my favorite rejoinders, the “grandmother hypothesis,” is well defended by anthropologist Sarah Blaffer Hrdy. In her book Mothers and Others, she explains that our ancestors often lived past the age of reproduction, and those grannies were in fact critical to the survival of their progeny for most of human history. Far from being a medical malady, menopause is a highly adaptive mechanism to free up older females to help feed and care for their grandchildren. No creature on the planet is more costly than the human child, who needs a ridiculous amount of time to grow up; without extra hands to supply the thirteen million calories needed until maturity, our species would not have made it this far. Women are supposed to outlive their ovaries after all, concludes Hrdy, with breasts happily intact.
Still, given the choice, who wouldn’t want to have smooth skin and be adorable forever? Estrogen, miracle hormone that it is, does indeed relieve such symptoms as hot flashes, night sweats, and depression, which are experienced to a serious degree by 5 to 15 percent of menopausal women. This is the group that probably should have been targeted for risky drugs, but that wasn’t nearly as profitable as targeting the entire sex.
When uterine cancer was linked to estrogen therapy in 1980, drug makers responded by adding progesterone to the formulations. Then numerous studies in the 1980s and 1990s linked other comp
lications to HRT. In 1991, researchers launched the fifteenyear, $100 million Women’s Health Initiative Study, but they abruptly halted part of it in 2002 when they discovered that the women taking HRT (as opposed to a placebo) had a 26 percent increase in the incidence of breast cancers, a 41 percent increase in the incidence of strokes, and a 29 percent increase in the incidence of heart attacks.
Britain was also conducting studies. Its Million Women Study, the largest study of HRT, yielded data in 2003. Results showed that women who were taking both estrogen and progesterone had a 100 percent increase, or a doubling, in their risk of breast cancer. The main culprit appeared to be progesterone, just as Pike had shown years earlier. Estrogen alone created a smaller breast cancer risk, and more recent studies suggest it might actually protect against breast cancer, but, alas, not against uterine cancer. Typical of the unpredictable ways hormones work their magic (and harm), HRT’s added progesterone helped minimize one cancer (uterine) but exacerbated another—breast cancer. Overall, hormone therapy in Britain caused an additional twenty thousand cases of breast cancer during the decade of the study, which is still a relatively small added risk, but enough to give many women pause.
Although researchers had known for years that synthetic hormones were linked to breast and other cancers, it really wasn’t until these two huge studies in 2002 and 2003 that the knowledge finally stuck. To the dashing Malcolm Pike, that time lag was nothing short of tragedy. “People say, ‘Aren’t you proud? You spotted the danger early,’ and I say, ‘No, because our work didn’t stop it,’ “ he said. “Why?” He shrugged. “Doctors are not particularly nervous, and they like prescribing things,” he said.
But the answer also lies upstream, with the pharmaceutical industry, which has a zeal for profit and a masterful command of the regulatory landscape. These are traits it shares with the chemical industry. Both came of age in America at the same moment in time, often using very similar molecules.
It all adds up to a new ecology of the breast. Here’s the basic cheat sheet for how the risk of breast cancer has changed over the ages. Old days: We did not have so much exposure to cycling estrogens and progesterones (we were thinner, hit puberty later, had more children, dropped dead earlier). Modern times: We’re awash in steroidal hormones. We’re fat and sexually precocious, but have babies late if it all. We take the pill and “bio-identicals,” slather novel, untested chemicals on our bodies, and consume them through food and water. We’re pretty much marinating in hormones and toxins.
Just as our long environmental legacy as synapsids, mammals, and primates shaped our cellular past, our modern environment— in the largest sense of the term—is determining our cellular destiny.
But you don’t have to be in the sway of synthetic or natural hormones to get breast cancer. You don’t even have to be a woman.
• 12 •
THE FEW. THE PROUD. THE
AFFLICTED: CAN MARINES SOLVE
THE PUZZLE OF BREAST CANCER?
Do unto those downstream as you would have those upstream do unto you.
—WENDELL BERRY,
Citizenship Papers
EVEN ITS NAME SOUNDS JAUNTY: CAMP LEJEUNE. SIGNS posted along the Marine Corps base in coastal North Carolina pointed the way to archery and bowling. The Burger King on Holcomb Boulevard advertised frozen fruit drinks. I half expected to see a pickup game of Capture the Flag. For a moment, I thought it looked like summer camp, until I realized it’s the other way around. The traditional American summer camp model is based on the military. Think about it: the uniforms, mess hall, reveille, all those games of conquest.
People don’t live at Camp Lejeune, they live “aboard” it. Home to some 150,000 marines and sailors and their families, the base covers 236 square miles. In its outer reaches lies evidence of the more serious pursuits of the Second Marine Corps Division. There is, for example, the (former) Live Hand Grenade Course, the Fortified Beach Assault Area, and, of course, the Flame Tank and Flame Thrower Range. (Don’t think that one will be coming to Camp Wigwam any time soon.) These sites may have helped keep America strong, but they have also helped keep it sodden with volatile organic compounds. All of these zones, plus dozens of others on the base, are currently marked on the Environmental Protection Agency’s National Priority List—otherwise known as Superfund.
Unfortunately, the base’s worst historic contamination overlay much of its drinking water supply for at least three decades, from the mid-1950s to the mid-1980s. Nicknamed “camp sloppy,” the base is made up of a big series of linked wetlands, aquifers, and the lazy New River flowing down the middle of it, all tilted toward the ocean. In one industrial area of the base known as Hadnot Point, fuel tanks silently dribbled or poured close to two million gallons of gasoline into the groundwater, forming a plume of petroleum now believed to be fifteen feet thick and half a mile wide. Atop it all sat well number 602, which in 1984 helped supply water to eight thousand people and yielded a reading of 380 parts per billion of benzene. This is seventy-six times the legal limit for benzene, a known human carcinogen.
Hadnot Point was known as a “fuel farm”—essentially the base’s gasoline depot—and it’s also where the Second Maintenance Battalion fixed tanks, jeeps, and other fleet vehicles. Beginning in the 1940s, it also held, in addition to gasoline, leaking storage tanks of industrial chlorinated solvents, notably trichloroethylene (TCE) and perchloroethylene (PCE) used for degreasing machinery. Up the road sat the base’s disposal yard, where these solvents and others were dumped or buried. Some wells were more contaminated than others, but water from many wells was routinely mixed and then distributed to numerous houses and barracks from central water treatment plants.
The legal drinking water level for TCE and PCE, long considered probable carcinogens, is 5 parts per billion. That level, though, wasn’t established until 1989. Although the military knew there was a potentially hazardous contamination problem by 1982, it did not routinely check the levels here until late in 1984. At that time, analysis from one well revealed 1,600 parts per billion of TCE. Tap water at the elementary school contained 1,184 parts per billion. That is five times the levels recorded in the poster-child-city of water pollution, Woburn, Massachusetts, site of the book and film A Civil Action.
Camp Lejeune, in addition to being the “home of the Marine expeditionary forces in readiness,” now enjoys distinction as having had the most contaminated public drinking water supply ever discovered in the United States. Over the decades, 750,000 people drank it, bathed and swam in it, and inhaled its vapors.
The base also happens to form the center of the largest cluster of male breast cancers ever identified. We know this thanks not to the U.S. Marine Corps or even the Agency for Toxic Substances and Disease Registry (ATSDR), an arm of the Centers for Disease Control and Prevention that is tasked with assessing the health effects of the contamination. We know this because of one man with the disease and an Internet connection, Michael Partain. He calls himself Number One.
Partain, a father of four and an insurance claims adjuster in Tallahassee, Florida, was diagnosed with cancer in his left breast in 2007, at the age of thirty-nine. He underwent a partial mastectomy and eight rounds of chemotherapy, and then developed “gonadal failure,” or an inability to produce testosterone. This was tough business for the son of a marine. “I never even knew men could get breast cancer,” said Partain. “I kept thinking, what did I do to win this lottery? I never drank or smoked. I liked backpacking and Boy Scouts. There is no history of breast cancer in my family.”
Not long after Partain was diagnosed, his father called him and told him to turn on the TV. There was a news report about the pollution at Camp Lejeune and its possible links to leukemia and other diseases. It was the first either man had heard of the contamination. Partain had been conceived and born on the base. “I knew right away I’d been exposed. I figured if this was the cause of my cancer, I wouldn’t be the only one,” he said. Partain went public with his diagnosis in the local
media. Soon after, he got a call from a preacher in Alabama. He’d lived as a child in the same neighborhood as Partain, and at the same time. The preacher became Number Two.
Partain started Googling around for male breast cancer, and soon he found a photo of another man with the disease in Michigan. “His chest was half gone,” recalled Partain, “and his Marines uniform was draped over his arm. I was like, holy shit.” Before long, he’d found twenty men with breast cancer and ties to Camp Lejeune. CNN ran a story on them and their conviction that their disease was linked to contaminated drinking water on the base. Overnight, twenty more men contacted Partain. Soon there were fifty.
As of this writing there are seventy-one of them, and the number goes up virtually every month. (There are also plenty of women around who lived on the base and have breast cancer, but what else is new?) Is there really a link between the men’s cancers and the drinking water at Lejeune? Although some two hundred chemicals have been found to make mammary tumors grow in lab animals, it’s been extremely difficult to link chemicals to the disease in humans. Many experts say there is only one proven environmental cause of breast cancer, and that’s radiation. If new insight emerges from studying men like Partain, it could profoundly alter the way we view environmental health, and breast cancer in particular.
In the Western world, the incidence of breast cancer has grown in both men and women between 1 and 2 percent a year since 1960 (with the exception of a short-lived dip in women’s rates in the last decade), although it is still very rare in men. For every one hundred women who get breast cancer, only one man does. But ironically, it may be the men who help solve the puzzle of this disease. In looking for a link between breast cancer and chemicals, it’s much simpler to study men than women. Men’s risk factors aren’t complicated by such things as age at puberty, reproductive life history, and hormone replacement therapy. They’re just guys with a very rare disease, and rare diseases are easier to trace to environmental exposures. This cluster, unlike so many others, could prove statistically significant.
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