Raising a stink over getting Pinked

Will “Boob Bombing” really prevent breast cancer?

DRUG BUST by Alan Cassels

• The people’s briefing note on prescription drugs
Portrait of columnist Alan Cassels
Rarely, if ever, has a disease colonized a colour, but that’s precisely what you can say about the corporate fundraising behemoth around breast cancer. It’s audacious, sometimes crass and very hard to miss. And did I say, it’s very, very pink?

The Canadian Breast Cancer Foundation’s Get Pink Campaign kicks things off on March 12, urging you to “recruit your co-workers or classmates to join your Get Pink’d! team…” You could go one step further and “Shop for the Cure,” choosing from 35 corporate or community partners to spend money or to raise money for the cause. Or you could send a “Boob Bomb,” touted as “a fun and cheeky way to help remind your friends that they should check their breasts regularly.” While you’re at it, download the free Don’t Forget to Check app so you can learn how your breasts look and feel.

Ok, go ahead, call me a curmudgeon, but is all this saucy pinkification of our lives and all the touchy feely – literally speaking – stuff about breasts likely to make any difference?

I can understand how people get infected with the urge to jump aboard the breast cancer bandwagon. Those who’ve had a close brush with breast cancer or lost a loved one to the disease are likely to find great comfort in a likeminded community that somehow wants to contribute back.

The foundation’s Don’t Forget to Check program sounds benign and fun, but like many aspects of breast cancer advocacy, there is the obvious gap between the research around what they’re promoting and the marketing hype. One message – that women should carry out routine breast self examinations – is the opposite of what you hear from evidence-based sources, such as the United States Preventive Services Task Force (USPSTF), which says breast self-examination shouldn’t be done – probably because there is no evidence it helps and may even cause harm.

In the two trials where it’s been studied, it led to more imaging procedures and biopsies than for control patients without changing the length or quality of those women’s lives. You should definitely talk to your doctor about any suspicious changes to your breasts, but the push to carry out routine breast self examination is not endorsed by the World Health Organization, the American Academy of Family Physicians or the Canadian Task Force on Preventive Health Care (CTFPHC).

As for full-blown mammography, there is also a contrast between the advocates and the cautious experts. Those who review screening as part of Canada’s Task Force on Preventive Health Care don’t recommend that women start mammography in their 40’s, but recommend doing it every two to three years starting at age 50. The USPSTF agrees with this and says women should only do it every two years until age 74. By contrast, the American Cancer Society says women should be getting a mammogram every year starting at 40, “continuing as long as a woman is in good health.” The American College of Radiology has the most zealous pro-screening position, claiming, “By not getting annual mammograms starting at age 40, you increase your chances of dying from breast cancer and the likelihood that you will experience more extensive treatment for any cancers found.” (See mammographysaveslives.org)

So who is right? Why do some groups recommend having mammograms twice as often as another group? Does this have anything to do with the science-based orientation of some groups (like the USPSTF or the CTFPHC) versus the advocacy, fundraising and professional goals of other groups?

I agree there are legitimate differences of opinion around breast cancer screening because of the problems of overdiagnosis. Any screening involves false positive and false negative findings, unnecessary biopsies, surgeries and radiation, all of which are capable of inflicting psychological and physical harm. All the pink you see this time of year tends to camouflage the fierce debates within medical circles around how frequently breast cancers are overtreated.

One of the world’s major breast screening researchers, Danish physician Peter Gotzsche said, “Healthy women are getting unnecessary diagnoses of pre-cancerous conditions that are unlikely to develop during their lifetime.” This sentiment is echoed by Dr. Gilbert Welch, author of Overdiagnosed, who wrote that, in the US alone, “Seventy thousand women a year are overdiagnosed and treated unnecessarily for breast cancer.” How common is overdiagnosis in breast cancer screening?

One meta-analysis – a study of many large studies – of breast cancer screening was summarized by the Public Health Agency of Canada in an excellent online guide. It says if you gave mammograms to 1,000 women aged 40 years and older every year for 10 years, here’s what you’d find: 1) 981 women will not have breast cancer. 2) 451 women will have normal results every year. 3) 549 women will be told they have an abnormal result at some point during the 10 years. 4) 533 of the abnormal results will be false alarms, which turn out to be normal after further testing.

After a decade of annual mammograms, this means 97% of the women who are told they have an abnormality on a mammogram do not have breast cancer. Furthermore, of those 1,000 screened women: 1) 16 women will have their breast cancer diagnosed through a screening test. 2) Three women will develop breast cancer that is diagnosed and treated without screening. 3) One death from breast cancer will be prevented. 4) 12 women will die from some cause other than breast cancer. 5) Two women will die of breast cancer despite breast cancer screening.

The “mammography saves lives” rhetoric that underlies the pink fundraising activities is only true for the one in 1,000 women who is screened every year for a decade. Independent groups, such as the USPSTF, are more restrictive in their assessment of screening because they are only interested in assessing screening on its medical value. Other countries recommend women not start screening till age 50 and some have even severely curtailed it. Some experts in Switzerland, widely considered to have one of the best healthcare systems in the world, have suggested that mammography be banned in that country.

Thankfully, there is a tide flowing in the other direction from all the pink surrounding us this time of year. The 2012 film, Pink Ribbons, Inc., is a powerful documentary, calling breast cancer “the poster child of corporate cause-related marketing campaigns.”

The activists at the US group Breast Cancer Action (BCaction.org) based in San Francisco is not financially tied to the breast cancer industry and they deconstruct it at every opportunity. Their Think Before You Pink campaign asks if we should really allow companies to “pinkwash” themselves, i.e.: wrapping themselves in the feel-good vibe of pink ribbons and pink marketing while they sell products containing chemicals linked to breast cancer? Anyone up for a big ole pink bucket of fried chicken?

What would make me trust the fundraising campaigns run by groups like the Canadian Breast Cancer Foundation? To start, I would need it to come clean about the facts around preventing breast cancer and that means some unvarnished facts about the downsides of mammography. As much as we might like to wear pink sunglasses and have fun with this disease, the harm and unnecessary treatment caused by encouraging more and more women into the mammography juggernaut should have us all seeing not pink, but red.

Alan Cassels wrote Seeking Sickness: Medical Screening and the Misguided Hunt for Disease where he discussed, among other things, mammography. www.alancassels.com

2 thoughts on “Raising a stink over getting Pinked”

  1. I’m one of the women the Get Pink campaign advocates rarely mention: after a mammogram revealed a “suspicious mass” in my right breast, I underwent a disfiguring surgical procedure called a Quadrant Resection which revealed – surprise! – a perfectly harmless benign mass. I suffered that “psychological and physical harm” you mentioned here (not the least of which was the frightening wait between the time a grim-faced doctor first recommended this “life-saving” surgery and the time I finally heard the dismissive “Oh! Never mind!” truth.

    Many of my friends in the breast cancer patient community are asking the hard questions (for example, about metastatic breast cancer) that fans of Get Pink won’t. Many of these patients are just as dismayed by all of this PINK, suggesting we don’t need more corporate “awareness” marketing schtick (pink Kentucky Fried Chicken buckets, pink-handled Smith & Wesson handguns (no kidding!), or those famous 1,000 pink drill bits from oilfields giant Baker Hughes.

    As the late Lisa Adams, who died recently of metastatic breast cancer, once warned in The Stream: “Awareness should be about education. We need to teach accurate facts about breast cancer. You can have early detection of breast cancer and still have it metastasize. You can get metastatic breast cancer which is incurable and which is what I have. You can do everything right and cellular biology is more powerful than that.”

    Yet the celebratory pinkification led by groups like Komen in the U.S. essentially ignore any mention of metastatic breast cancer. Nor do they explain using misleading statistics to persuade women to undergo mammography, as noted by Steven Woloshin & Lisa Schwartz in the British Medical Journal – http://www.bmj.com/content/345/bmj.e5132

    Thank you, Alan, for a refreshingly honest reminder that is shared by a growing number of concerned parties, albeit one that’s often hard to hear above the pinkification din.

  2. Mr. Cassels, a pharmaceutical policy researcher, has weighed in on mammography screening again, and criticizes the Canadian Breast Cancer Foundation in the process. He does women a disservice by implying that there is agreement that screening mammography is ineffective at saving lives. He quotes selective anti-screening authors, and ignores the 2014 paper by Coldman and colleagues, who showed that among Canadian screening mammography programs, women who had mammograms were 40% less likely to die from breast cancer, than women who did not.

    Mr. Cassels, whose conflict of interest is in selling his anti-screening book, says that promoting mammography is possibly dangerous, citing Dr. Peter Gotschze and the Cochrane review, which have been roundly criticized by authorities in public health, epidemiology and statistics from Cambridge, Harvard, UC Berkeley, Denmark, Sweden and Pasadena because of their manipulation of data. Gotschze cherry-picked studies that supported his hypothesis, and disregarded favourable studies, based on his misunderstanding of the methodology of cluster randomization in screening trials.

    Mammography is not perfect. It doesn’t find all cancers, and when we find something on a mammogram that needs more testing, there is unavoidable anxiety. In pursuit of small, curable cancer, most women can tolerate transient worry better than tolerating a delayed diagnosis of cancer, and most would choose to have the test rather than let a patronizing administration decide that they should be spared the anxiety.

    Canadians deserve to hear the truth, not Mr. Cassels slagging the Canadian Breast Cancer Foundation. They appear to have a better understanding of the science than he does. Perhaps he should stick to his area of expertise.

    Paula Gordon, OBC, MD, FRCPC, FSBI
    Clinical Professor, University of British Columbia

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