I abhor the pinkification of our culture.
I have nothing against the color pink (for a brief time in my childhood, after wearing a princess-like peach bridesmaid dress at my aunt’s wedding, peach was actually my favorite color), but I do have a deep dislike of the culture of cancer that has grabbed pink ribbons (or pink cookware, clothes, and even garbage barrels) to raise awareness *cough* money *cough* for foundations that make a big deal out of breast cancer.
I don’t want to downplay breast cancer. According to The American Cancer Society, breast cancer is the most common cancer among American Women after skin cancer. It is estimated that around 40,000 women will die from breast cancer this year. But breast cancer awareness is also a BIG money maker- turning over many million dollars per year.
I’ve yet to see this movie, but the trailer raises some interesting points.
All the pinkification and fanfare would be tolerable if the breast cancer awareness campaigning, and most importantly the mammography that it promotes, reduced the toll of breast cancer, but the reality, according to a November 2012 New England Journal of Medicine article [1], is not such a pretty picture.
Let’s cover some of the basics…
To be an effective screening tool, a modality must detect life-threatening disease at an early treatable stage. It follows that an effective screening tool then decreases the prevalence of late stage disease.
While screening mammograms have certainly led to an increased detection of breast lesions (it has effectively doubled the rate of diagnosis), the reality is that this increase in detection has not led to a significant decrease in advanced disease. [The NEJM abstract is here, and certainly worth a read]. Furthermore, it appears that increased detection has had, at best, only a small effect on the rate of death from breast cancer.
What the NEJM of article doesn’t cover is the psychological toll that the pinkification of our culture has had. Women feel like they are failing themselves if they don’t start getting annual mammograms at the age of 40. Teenage girls are being brought up to believe that their breasts are two pre-cancerous lesions… ticking time bombs.
Yes- breast cancer kills, but there are also plenty of breast lesions that women have that they would live and die with, not from, if it weren’t for aggressive screening recommendations. I’m not a psychiatrist (and I’m not going to be), but I do wonder what the increased diagnosis (and then “survival”) of otherwise slow-growing and relatively benign cancers does to the psyche – the survivor effect. These factors raise a number of concerns, without even bringing up any monetary issues…
Apparently the prostate cancer ribbon is blue, but men (and our culture) seem to have avoided a tidal wave of “bluification”. Perhaps, as the gender that tends to utilize the healthcare system less, [2], men have been seen as a less lucrative target. Nonetheless, prostate cancer has fallen victim to some of the same pitfalls (abuses?) as breast cancer.
Prostate cancer is the most common non-skin malignancy and the second leading cause of cancer death in men. Prostate specific antigen [PSA] is a protein that can be detected in the blood, and until fairly recently it had been recommended that men undergo regular PSA testing as a screening for prostate malignancy.
The problem with PSA testing however, much like mammography, is that it catches many lesions that a man would die with, not from. As with mammography, increased detection leads to increased treatment, increased surgery, increased patient stress, and increased financial burden for the patient and the system. And for what?
Many of the lesions that PSA screening catches do not negatively impact the life expectancy of the patient. In fact, a paper published yesterday in the Annals of Internal Medicine [3] shows the opposite- that treating these lesions (instead of observing them), actually leads to a decrease in quality-adjusted life expectancy (and increased medical costs).
What does this all mean? Should we give up on screening tests for the two big sex-specific cancers?
No- I’m not a nihilist when it comes to screening, but I do think that screening should be done with full patient awareness of the risks, benefits, and consequences.
I think the American Urological Association (AUA) is on the right track, with their 2013 guidelines that greatly limit the recommendations for PSA testing (these came after the 2012 US Preventative Taskforce recommendations, which advised against the use of all PSA screening). While the AUA made general recommendations for some populations that PSA screening is unnecessary (those with a low-risk who are young, those who are old, and those with less than a 10-15 year life expectancy), for a large group the recommendation is that men should talk to their doctors about the relative risks and benefits, and from that discussion make a decision based on their personal values and preferences.
Having a patient weigh in with his personal values doesn’t seem like a particularly groundbreaking recommendation, but in many ways it is. A patient’s medical care should be in his hands as much as possible, and when the risks and benefits of a screening tool are unclear it is appropriate that the patient and doctor discuss the risks and benefits. Looking back at the data on mammography over the last few years, I think it is only right that doctors start to have similar discussions with women about their personal values and preferences when it comes to mammography. [The elephant in the room, however, is that if screening tests are deemed “optional”, will insurance companies cover them?]
So where does that leave us.
Screening MAY catch an early cancer, but it may also catch a lesion that you would die with not from. It can lead to extensive testing, stress, expenses, and surgery. I’m not saying we shouldn’t screen, but I’m saying that the medical community (and the organizations that profit from cancer-awareness) need to be honest about the reality of our testing modalities.
I also think this is a call to arms for scientists. The screening tests we have are not meeting our needs. While the tests above can tell us about potential lesions, they tell us little about the malignancy of the lesions. We need tests that can more accurately tell us what is going on in our bodies. Those tests are coming- in the forms of mRNA and protein assays, but until they get here I think we ought to have more informed discussions about what screening tests are really doing today.
1. Bleyer, A. and H.G. Welch, Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med, 2012. 367(21): p. 1998-2005.
2. Bertakis, K.D., R. Azari, L.J. Helms, E.J. Callahan, and J.A. Robbins, Gender differences in the utilization of health care services. J Fam Pract, 2000. 49(2): p. 147-52.
3. Hayes, J.A., D.A. Ollendorf, S.D. Pearson, M.J. Barry, P.W. Kantoff, P.A. Lee, and P.M. McMahon, Observation Versus Initial Tretment for Men with Localized, Low-Risk Prostate Cancer: A Cost-effectiveness analysis. Annals of Internal Medicine, 2013. 158(12): p. 853-860.
principleintopractice 
The medical profession has repeatedly dismissed the link between bras and breast cancer, ever since it was first proposed in 1995. They usually attack the credentials of its proponents and criticize the methodology of their study. The critics dishonestly conclude that a poorly designed study is evidence that the theory is “false,” rather than “unproven.”
I am personally convinced that the theory is true. Asian and African women never got breast cancer until they adopted western customs (see http://www.voanews.com/content/breast-cancer-on-the-rise-among-african-women-say-experts–142962875/181109.html ) despite the fact that their genetic makup hasn’t changed. Bras constrict the tissues, depriving the cells of oxygen and trapping the toxic waste products of cellular metabolism. The theory is discussed in more detail at http://www.isisboston.com/assets/PDF-Files/Bras-and-Breast-Cancer.pdf . Victoria, I hope you’ll consider this theory with the same commendable openness you’ve shown toward other challenges to medical orthodoxy.
Thanks Jonathan
I certainly appreciate that it’s important to know the difference between something that is unproven and something that is false!
There is a lot to consider when we think about the many factors of our modern lifestyle that can contribute to our alarming rates of breast cancer. Delayed pregnancy, reduced rates of breast feeding, other fertility issues, environmental exposure, vitamin D deficiency, various nutritional considerations… the list could go on and on. As we know, our body’s evolutionary expectations are incredibly important when understanding many of our modern conditions- certainly bras are not an evolutionary expectation, though they have certainly become a cultural one. I remember seeing a recent flurry of press over a study that came out of France showing that women’s breasts aren’t kept “perkier” by bras, and on the contrary they actually do better without- I doubt that’s the only benefit of going braless! http://www.cbsnews.com/8301-204_162-57579077/french-study-suggests-younger-women-should-stop-wearing-bras/
I’m open to the possibility that bras could be a factor in breast cancer, though I am very cynical. One only needs to look at what other factors would have been introduced to indigenous non-bra wearing cultures at the time bras themselves were introduced. I can think of the usual white poisons of sugar and flour that would have accompanied Missionaries and the influence they had on cultural dress.
Jamie- I’ll admit that I’m a bit skeptical about the bra factor (though it’s worth noting that skepticism is my initial response to most things!). It is something to consider, but like you, I wonder about what other factors came along with the culture of bras (nutritional changes, xenoestrogens, lifestyle changes that led to vitamin D deficiencies, etc). Worth thinking about, and like everything- worth making an informed decision!
Pink is diluted scarlet.
Here is Jim Reeves.
I’m sure there are some pink ribbon songs on youtube, but I don’t dare look!
The thing I thoroughly object to is these screening procedures being referred to as “prevention”. They “prevent” nothing. They require, for the detection of a cancerous lesion, the cancer to already be there.
We actually do have some very good prevention strategies – all lifestyle based. But on the various New Zealand cancer society sites, you would be hard pressed to find ANY of those strategies on any of the main pages.
Cancer is a disgusting money-grabbing industry.
The “prevention” issue is exactly the problem with mammography. It prevents nothing (including advanced disease), and actually increases the diagnosis of cancer. There is also some terrible misconceptions in the population that mammograms are protective- again, a lack of communication between patient and practitioner.
I agree that where we SHOULD be focussing much of the effort is on prevention, both education people about what they can do to lower their risks and researching the pathophysiology. Alas, here too our culture seems to be “keep doing what you’re doing, and we’ll try and fix you when you’re broken” instead of “lets keep everyone healthy”.
Thanks for the comment!
There is an interesting statistical effect here: if a disease is rare in the population, then even what seems like a low risk of false positive diagnosis will result in a problematic number of these if enough people are tested.
False positives are certainly an issue, and are the reason why almost all guidelines now recommend AGAINST starting mammography screening at 40 (though many practitioners still start screening in that age group). The reality of any lesion being *real* in that group is quite low, yet we image on…
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I can’t believe how little alcohol is brought into the breast cancer issue. It is a carcinogen of the same ilk as asbestos.
I discovered belatedly it likely contributed to my own breast cancer, which I had removed via lumpectomy. I have since given up alcohol completely.
I have refused further therapy including radiation and hormonal and am quite happy with my decision – as it turned out, for my particular kind of cancer (tubular, a rare and least aggressive known breast cancer) radiotherapy only offered me about 5% improvement in recurrence rates, yet assured me lung scarring and much more. My biggest concern was the lack of interest the medical people showed in informing me about my particular case i.e. none at all, just the one size fits all recommendation.
I advise all women diagnosed with breast with do a LOT of research about their particular situation and not just take everything into your body, that is recommended.
I believe the medical profession should inform a LOT more and communicate a lot more with the patient, and allow the patient to make informed decisions without a giant guilt trip – which is what I got, as well as “if I had known you would be like this, we would have given you a mastectomy”.
Is the “pink” so large in culture that it is overwhelming women who are diagnosed and makes them extremely pliant to all suggestions from the medical community. In my experience, yes, I think so. Its evident the radiation oncologist I was dealing with, and the nurse, were not used to being questioned about anything.
I wish the CDC would update its YPLL lists – ‘Years of potential life lost’ to a particular disease. It is obvious that if one diagnoses a disease and treats it, there will be a ‘survival rate’ associated with the disease and treatment. Diagnosing it 5 years earlier, with no improvement in treatment, will show an increased survival rate from diagnosis (which will be trumpeted by certain interest groups), with NO impact on YPLL. So YPLL is the obvious metric we should use, and yet the CDC declines to keep it current. Personally I suspect dirty work at the crossroads! The best thing we could do for public health is have a reliable YPLL metric to judge our interventions.