Wednesday, May 1, 2013

Kudos to The New York Times Magazine for Examining the "Feel-Good War" on Breast Cancer!

In last week's The New York Times Magazine, Peggy Orenstein wrote an article called "Our Feel-Good War on Breast Cancer".  The piece is lengthy but well researched, insightful, and well worth the reading time.

Peggy, a breast cancer survivor herself, hits every key public health issue- cancer screenings, treatment options, "awareness" raising, message framing, funding, and research.  As someone who has been critical of "awareness" raising, I was happy to see the issue discussed front and center.  For me, her interview with Dr. Gayle Sulik (Sociologist and Founder of the Breast Cancer Consortium) was the most striking.  A key quote from Dr. Sulik (I added the bolding):

“You have to look at the agenda for each program involved.  If the goal is eradication of breast cancer, how close are we to that? Not very close at all. If the agenda is awareness, what is it making us aware of? That breast cancer exists? That it’s important? ‘Awareness’ has become narrowed until it just means ‘visibility.’ And that’s where the movement has failed. That’s where it’s lost its momentum to move further.”

Peggy also tackles the issue that is an ongoing challenge in public health and medicine:  screening.  Screenings are tests that look for diseases before you have symptoms.  Ideally, screening will identify diseases early when they are easier to treat and have better outcomes.  For breast cancer, the key screening test is a mammogram (x-ray of the breasts).  However (as Peggy points out), we seldom hear about the research that demonstrates limited effectiveness of mammograms for reducing cancer death.  This is not the research cited in the communication materials from advocacy organizations.  We also tend not to hear about the negative side effects of screening large segments of the population.  There can be false positive tests: which subject the patient to unnecessary medical intervention and emotional distress.  There can also be over-treatment for the detected cancer, even if it turns out to be a non-aggressive tumor.

When I was working in suicide prevention, one of the best articles I read was "Screening as an Approach for Adolescent Suicide Prevention" by Dr. Juan Pena and Dr. Eric Caine.  The authors dedicate a section of the paper to key decisions and tasks to resolve before implementing a screening program.  While the public health issue and screening tests are different, I believe many of their decision points are generalizable to almost any health issue.  The table presenting these decisions and tasks is a great reminder to public health professionals and clinicians that recommending and undertaking a screening program should be strategic and the decision should be re-visited regularly.  For example, the authors highlight:
  • Key Decision:  Population and Setting- Is the screening program consistent with the target population's community or cultural values?
  • Key Decision:  Screening Instrument- What will be the false positives and false negatives rates in the population to be screened?  Are these rates acceptable?
  • Key Decision:  Staffing and Referral Network- Are there effective treatments available for the types of conditions being screened for?
  • Key Decision:  Quality Assurance- How will the screening program be monitored to ensure that protocols are followed?
  • Key Decision:  Legal and Ethical Issues- Has sufficient informed consent been given to parents and youth about risks, benefits, and limits of screening?

Going back to the "Feel-Good War" article:  I like that Peggy did not just point out all the flaws in our current breast cancer screening and treatment systems.  Instead, she invited her interviewees to recommend potential improvements.  Some ideas were noted in two key areas:
  • Message Re-Framing:  Rather than offering blanket assurances that “mammograms save lives,” advocacy groups might try a more realistic campaign tag line. The researcher Gilbert Welch has suggested this message, “Mammography has both benefits and harms — that’s why it’s a personal decision.”
  • Funding Re-Distribution:  Peggy asked scientists and advocates how some of that "awareness" money could be spent differently. She highlights the February recommendations of a Congressional panel (made up of advocates, scientists and government officials) that called for increasing the share of resources spent studying environmental links to breast cancer. They defined the term liberally to include behaviors like alcohol consumption, exposure to chemicals, radiation and socioeconomic disparities. 

Tell Me What You Think:
  • What do you think about the "pink culture" or awareness raising around breast cancer?  Will it effectively lead us to our goal of prevention?
  • In addition to message re-framing and funding re-distribution, what else would you recommend to help improve the approach to breast cancer prevention, screening, and treatment?


  1. Hi Leah - Great post! After I read the NYTimes article yesterday, my mind was swirling. To preface my comments, I will say I am thankful for the mammogram that caught my mom's breast cancer 11 years ago; it was invasive and had started to spread. That being said, I was alarmed by two things in the article: 1) that the death rates from breast cancer have not budged in years, and 2)the shockingly small amount of funding that is going toward research. I think the "early detection" message tied to the awareness campaigns is based on outdated research and should be reframed. Even in the 11 years since my mom had cancer, we have seen tremendous progress in the "science" of breast cancer. But we need to do more. The visibility that the advocacy groups bring to breast cancer is great - but they need to put their money where it can have a real impact, and that is no longer in early detection and education. We need new solutions, not more awareness.

    1. I think the issues with breast cancer screening are interesting. Doctors are no longer supposed to recommend that patients perform self breast exams, because of the high rates of patients freaking out about nothing. If we change the message about mammography to "It's a personal choice," then what is the real message about breast cancer? There's nothing you can do? Perhaps we should be promoting the fact that diet, exercise, and weight reduction are still the most effective ways of reducing your risk for breast cancer (even though - sometimes - there's nothing you can do).