Elle Macpherson Made a Reasonable Choice, and Naturopathic Medicine Did Not Help

Declining adjuvant chemotherapy is fair, if you understand the risks

The lay media is abuzz with stories about Elle Macpherson, who admits in a new memoir to declining chemotherapy seven years ago. Although precise details are not provided, it sounds like Ms. Macpherson had localized or regional breast cancer and underwent surgery.

We learned something about the risks of commenting on the health of celebrities over a decade ago when an OpEd we published in Washington Post about former president George W. Bush caused a bit of a firestorm. We still feel like you can learn something from the care, and coverage of the care, of the rich and famous.

Chemotherapy is sometimes offered to a woman after surgery for localized breast cancer. This is referred to as adjuvant therapy. The goal of adjuvant therapy is to reduce the risk of breast cancer recurrence and improve survival. Without knowing the precise details, the magnitude of the benefit is typically 2-7%. To give some rough (and plausible numbers), 16 women out of 20 might be cured by surgery alone, but 17 women out of 20 would be cured with surgery and chemotherapy. Put another way, 20 women have to take chemotherapy so that 1 more is cured. And, sadly, 3 will have recurrence no matter what they do.

Elle Macpherson didn’t want chemotherapy and declined it. That is a personal choice. Some people might not want the toxicity or side effects and be willing to risk a higher chance of recurrent cancer. Alex Honnold gets to decide he wants to rock climb, Elle Macpherson can choose not to get chemotherapy. The media meanwhile barely understands this, and is generally critical of Elle saying she ‘refused’ or ‘disregarded doctors advice.’ That’s paternalistic and incorrect.

Our guiding principle in medicine today is shared decision making. A doctor provides what is known about the expected harms and benefits of therapy. The patients weighs these facts with her values and makes an informed decision about her health care. The strongest stand a doctor should take is, “you’re accepting a higher risk if you choose this strategy but that is your decision to make.”

Everyday, patients choose more aggressive therapy that lowers their risk of harm from their disease or less aggressive therapy that raises the risk. Sometime for the former end up being unlucky, sometimes the latter end up lucky. Often, their choice does not matter.

Ms. Macpherson was lucky. She made a personal choice to take a little extra risk with her breast cancer to avoid the toxicity of therapy. We celebrate her good health.

However, she credits her favorable outcome to a holistic approach, and that she found “a solution that worked for me”. We do think this sends the wrong message. It was not holistic therapy that saved her. She was among the 16 or so women out of 20 cured with surgery. Rather than pitching her wellness strategy, we wish she had used this opportunity to talk about informed decision making.

What the story of Elle Macpherson reveals most is that the media (both social and traditional) is nearly incapable of covering celebrity health with nuance and tact. Celebrities are either complete morons, dedicated to wheatgrass or acai berries, or heroes who stood up to the evils of modern medicine. Can we just be a little sensible?