Awareness makes you sick
It may be a symbol of wider political trends that 1998 was the year in which the pink ribbon of breast cancer awareness finally eclipsed the red ribbon of the AIDS campaigners. But now that every week of the year is devoted to raising public awareness of some condition or other - a trend universally regarded in a positive light - it is worth looking at the negative consequences of the heightened public consciousness of disease.
Though the benefits of awareness are contentious, its dangers are ignored. While everybody assumes that greater awareness leads to earlier diagnosis and more effective treatment, mortality from breast cancer has remained constant in the USA for the past 50 years - and in cancer survival rates Britain lags behind America. Meanwhile, in my surgery I see many women who do not have breast cancer but are terrified that they have, and a few women who have the disease, for whom the high public-profile of their condition is distressing.
One of the main effects of the promotion of breast cancer awareness is that it generates an exaggerated sense of risk. The Cancer Research Campaign has promoted the estimate that 'one in 12' women will develop breast cancer, which featured in a recent poster campaign. According to an authoritative review in the British Medical Journal, this is 'correct only for women who have escaped a number of equally serious but more likely threats to life at an earlier age' ('Putting the risk of breast cancer in perspective', 7 November 1998). The authors conclude that 'for most women, the lifetime risk of dying of breast cancer is only one in 26; the other 25 will die of something else'.
Most of the women who come into the surgery worried about breast lumps are under 50 - though the vast majority of deaths from breast cancer are in women over 65. Only one woman in 136 in Britain dies of breast cancer before the age of 50. Though the risk of dying from breast cancer increases with age, it appears to progress more slowly in older women, so that they often live long enough to die from some other cause. One of the ironies of discussing the risks of breast cancer is that, if the woman smokes, she has a greater risk of dying from lung cancer; even if she is a non-smoker, she is far more likely to die of heart disease.
Public awareness of breast cancer has intensified the demand for screening tests which promise early diagnosis. The most basic is the technique of breast self-examination, generally recognised to be much more effective in generating anxiety than it is at detecting tumours. Yet when this was publicly acknowledged by the government's chief medical officer a couple of years ago he was forced to back down by the disease awareness lobby. Women's magazines and health promotion leaflets are still offering detailed diagrams and earnest advice about how to detect lumps - resulting in a steady flow into the surgery of frightened women, some scarcely out of their teens, who are more likely to win the national lottery than to have breast cancer.
For women over 50 the key screening test is the mammogram. Though this has been shown to be effective in detecting tumours, it does so at the cost of finding many lumps which subsequently turn out to be benign. The technique of aspirating cells from a suspicious lump with a fine needle and examining them under a microscope has greatly enhanced the process of diagnosis. However, whereas the mammogram is uncomfortable, fine needle aspiration is quite painful - and the vast majority turn out to be negative.
An inevitable consequence of greater breast cancer awareness is the demand to extend mammography to women in their 40s. According to one commentator this has provoked a debate in the USA 'out of proportion to its potential impact on public health' ('Mammography and the politics of randomised controlled trials', BMJ, 31 October 1998). Although numerous trials have failed to confirm the efficacy of this technique in younger women - and despite concerns that it might do greater harm - political pressures from disease awareness campaigns have resulted in younger women having mammograms.
Women who have had breast cancer are perhaps the greatest casualties of breast awareness. It is not only that they are reminded of their disease every time they turn on the television or open a newspaper or magazine - and every time they see a pink ribbon on the bus or train.
The popular discussion of the role of lifestyle factors in predisposing women to breast cancer compounds women's worries about their future with guilty reflections on their past behaviour. This is encouraged by epidemiological surveys which report the loosest of associations as causal influences. The risk of breast cancer appears to be increased in women who have no children or who have them after the age of 30; in women who have taken the oral contraceptive pill or hormone replacement therapy; in women who drink alcohol and have a high-fat diet. The relatively strong influence of family history on chances of getting breast cancer provides further scope for recriminations and fatalistic preoccupations - 'it's my genetic destiny to die a premature and disfiguring death'.
During last year's breast awareness week a patient who has survived mastectomy, radiotherapy and chemotherapy and now has a good prognosis, came in to ask me what she had done to deserve breast cancer. I don't know who benefits from breast aware- ness, but I know many of its victims.
Dr Michael Fitzpatrick
Reproduced from LM issue 116, December 1998/January 1999