Challenging Dogma - Spring 2011

Monday, May 23, 2011

How routine mammography of women under 50 diverts attention from cancer prevention and environmental factors - Lynn Rosenbaum

Setting the stage
Breast cancer in the United States is a highly prevalent and dangerous disease for women. According to the Breast Cancer Fund, a woman has a one in eight chance of getting breast cancer in her lifetime, and more women between the ages of 20 and 59 die from breast cancer than from any other cancer. From the 1930’s to the end of the 1990’s, a woman’s risk of breast cancer continually increased, and between 1973 and 1998 alone, increased by 40%. [1] In the last decade, we have finally seen a decrease in both incidence and mortality for women; however, the research is unclear as to whether these positive results were only relevant to women over age 50 [1,2]. Many sources agree that the decline was probably due mainly to the decrease in post-menopausal hormone replacement therapy which, in 2002, was found to be associated with an increased risk for breast cancer[1].
So what is the most effective way to prevent breast cancer? And what exactly do we mean by prevention? One of the most prevalent public health strategies to address breast cancer is screening through the use of mammograms. According to The American Cancer Society “Getting a mammogram is one of the best things a woman can do to protect her health.” They recommend, “Women age 40 and older should have a mammogram every year and should continue to do so for as long as they are in good health. While mammograms can miss some cancers, they are still a very good way to find breast cancer.” [3]
But does screening mammography truly prevent breast cancer? In this paper I will argue that an emphasis on routine screening mammography among average risk women under 50 is neither safe nor effective; it directs attention and resources to secondary rather than primary prevention; and it results in minimizing the links between environmental toxins and breast cancer.

Mammograms can be unsafe and ineffective
Although regular mammograms have been shown to offer benefits to post menopausal women, mammograms carry associated risks, and are not proven to offer the same benefits to healthy women under age 50. The first risk of routine mammography screening in premenopausal women is unnecessarily exposing them to radiation, which is potentially dangerous. Although many experts believe that this low-dose exposure radiation is of low risk (perhaps causing 1 additional breast cancer death per 10,000 women) [4], other researchers have argued that the risk has been underestimated and cannot adequately be predicted by models based on higher doses or radiation [1]. It has also been found that “young women with the very mutations that lead them to begin mammography screenings at earlier ages are actually more vulnerable to the cancer-inducing effects of early and repeated exposures to mammograms.” [1]
The second risk of routine mammography is that it may lead to unnecessary medical interventions. Mammograms, particularly for younger women whose breast tissue tends to be more dense and less likely to yield accurate results, can lead to both false positives and false negatives. As a result of false positives, women may end up getting dangerous and unnecessary surgeries and radiation treatments. “It is estimated that a woman who has yearly mammograms between ages 40 and 49 has about a 30 percent chance of having a false-positive mammogram at some point in that decade and about a 7 percent to 8 percent chance of having a breast biopsy within the 10-year period.”[5]
In the 1980-1990’s, according to a study by Horner 2009, rates of diagnosis of the non-invasive condition ductal carcinoma in situ (DCIS) increased by 4 times, mostly due to the greater use of mammogram screenings. [1] Because, current medical science cannot tell us which cases of DCIS will end up actually leading to cancer and, in fact, most do not [4], many women have been unnecessarily subjected to the risks of subsequent surgical biopsies, radiation and Tamoxifen.
There is very minimal evidence of benefits to outweigh the above risks. Some research has shown that for women between 40-49, after a seven year follow-up, there was no effect on mortality, and in order to even extend one life, it is estimated that 2500 women would have to be screened regularly. [4]
In 2009, the U.S. Preventive Services Task Force (USPSTF) published a controversial revision to its policies. It weighed the potential benefits (reduced chance of dying from breast cancer) and potential harms (for example, false-positive results and unnecessary biopsies) and then concluded that “there is moderate evidence that the net benefit is small for women aged 40 to 49 years.”
It recommended biennial mammograms to women age 50 and over, rather than annual screenings to women 40 and over, and for women of average risk, age 40-49, it recommended against routine screening. [6]
Despite this report and the evidence cited above, The American Cancer Society, National Cancer Institute, Susan B. Komen and others continue to recommend regular screening mammography for younger women[7], although other organizations such as the Cancer Prevention Coalition and Breast Cancer Action are in accordance with the Task Force’s recommendations in discouraging healthy young women to be screened [8,9]. And then there are those organizations such as the Center for Disease Control which have backed off of any strict recommendations and instead encourage women to talk with their doctors to make an individual decision based on the research and their particular set of conditions [10].
Another problem with a policy of routine mammograms for women under 50 is that women may think that getting a mammogram is all they need to do to avoid getting breast cancer, at the expense of attending to important lifestyle and environmental factors. Women are subject to the “illusion of control,” which refers to the expectation that one has more control over a situation than is objectively warranted by probability. This illusion is enhanced when one is involved or takes action in the situation at hand. [11] So in this case, young healthy women who take a specific action by getting mammogram screenings may feel more in control of preventing the likelihood of their getting breast cancer, even though the mammogram is a tool to potentially detect existing cancer rather than to prevent it and, as argued above, has questionable benefits. In order to truly prevent cancer, that is, address its underlying causes, young women should be encouraged to focus on controllable lifestyle factors, such as diet, exercise and alcohol consumption and perhaps more importantly, on environmental factors, such as toxins which permeate our food, air, water, and consumer products.

Primary versus secondary prevention
An emphasis on mammogram screening directs focus and resources at secondary prevention, that is, researching and promoting how to detect cancer early enough to treat it, instead of at true primary prevention, which identifies and eliminates preventable causes of the disease. The way in which a problem is framed determines what is seen as important. “Elements left out of the story are outside the frame and are thought to be unimportant.” [12] The framing of a medical problem in this way is not limited to breast cancer. “The dominant focus in epidemiology and perhaps the American culture in general is on individually-based risk factors that lie relatively close to disease in a causal chain.” [13] Thus the medical establishment has framed the issue such that both doctors and patients tend to approach breast cancer prevention as an individual level problem – it’s up to individual women to make sure they get regular mammograms and to monitor their individual risk level and their behavior around diet, exercise, and alcohol consumption.
Framing is very important in determining what types of interventions are used to address the problem. The medical establishment tends to frame breast cancer in such a way that leads to “downstream” solutions rather than “upstream” solutions. The money, research, and attention focused on detection, treatment, and finding a cure, greatly outweigh addressing causal factors, such as environmental toxins, which are contributing to the development of the disease in the first place.
The predominant frame described above is reinforced by both public health campaigns and the media. According to Agenda Setting Theory [14], how much the news media covers a particular issue directly affects how important people think the issue is. The media not only reflects the news agenda, but shapes it as well. The media emphasizes mammogram screenings, and to a lesser degree, diet and lifestyle, and thus encourages women to value these same issues. One recent analysis by Michigan State University of news stories covering breast cancer found that 31% focused on treatment, while just 18% addressed prevention [15]. Newspapers, television and advertising offer widespread coverage and promotion of fundraising walks such as the Avon Walk for Breast Cancer and the Susan B. Komen Race for the Cure, which are corporate sponsored and raise money mostly for screening, treatment and finding a cure, while spending very little on primary prevention [7,16].

Environmental factors
One major consequence of the framing of breast cancer as a downstream rather than an upstream issue, is that environmental factors of breast cancer are minimized and under funded. According to researchers at Cornell University, “Because established risk factors for breast cancer account for less than half of all cases, scientists believe environment may play a role in this disease.” [17] And despite the fact that breast cancer research is the most funded of all cancers [18] over the last decade, only a small percentage is spent on environmental links to the disease.
When underlying environmental toxins are addressed, they often point to large corporations, which are responsible for producing harmful chemicals in almost every area of life. These corporations often have a vested interest in continuing to produce these chemicals because of the profits they bring in. The close financial and political ties between large pharmaceutical/chemical corporations and some cancer organizations influence the “anti-cancer” agenda that is promoted. Several progressive organizations such as the Cancer Prevention Coalition, have pointed out that Breast Cancer Awareness Month is completely controlled by Astra/Zeneca, a multimillion dollar donor to the American Cancer Society. Astra/Zeneca is one of the world’s top ten largest pharmaceutical companies, formerly a part of Imperial Chemical Industries, and the producer of Tamoxifen, a drug used in breast cancer treatment and prevention. AstraZeneca retains the right to oversee all of the promotional materials of the awareness campaign and heavily promotes mammograms and treatment – including Tamoxifen – while ignoring links between industrial toxins and breast cancer [19].
Despite the relative lack of funding for research on links between environmental toxins and breast cancer, there is still much that we do know and need to be concerned about. “There are over 85,000 synthetic chemicals on the market, and fewer then 10 percent have been tested for their effects on our health.” [20] The harmful effects of toxins are particularly relevant to breast cancer because many toxins are concentrated in fat and thus breast tissue. And according to the Center for Disease Control and the Environmental Working Group, over 200 chemicals have been found in our body fluids. Furthermore, studies reveal 216 chemicals associated with increased mammary gland tumors in animals [21].
Harmful chemicals reach into virtually every aspect of our lives including our food, air, water, and consumer products. We ingest pesticides and additives in the foods we eat, are exposed to chemicals used in food packaging and production, and are subject to synthetic hormones in milk and meat. For example, recombinant bovine growth hormone (rBGH ) which is given to cows to increase their milk production, has been shown in several studies to contribute to links to increased risk of breast cancer, and has been banned in Europe, Canada and elsewhere. [21]
Plastics, which are used extensively in household products, toys, and electronics, contain many chemicals of concern, such as styrene, bisphenol A (BPA), and phtalates. For example some baby products such as bottles are particularly concerning because they contain a combination of carcinogens, such as vinyl chloride, and several endocrine-disrupting compounds, namely, BPA and phtalates. Cosmetics, including makeup, soap, and sunscreen, are rife with harmful chemicals which may affect our hormonal systems and affect breast development. Some of the chemicals have already been banned in European nations, but are still permitted in the United States. [21]
In sum, young healthy women do not need to undergo routine mammograms and take on their associated risks and resulting unnecessary interventions, all in the name of prevention. Instead, we must address the underlying root causes of the disease, particularly environmental toxins in our daily lives. We need to fund more research on links between environmental toxins and breast cancer, persuade corporations to use more caution in putting untested chemicals into our lives, and demand that our government increase its testing and regulation of harmful chemicals.

An Alternative Approach
So what is a truly effective way to prevent breast cancer among young healthy women? We can focus on changing corporate and governmental practices to remove from our daily lives the environmental toxins that put people at risk for breast cancer. We need to involve and empower young women and others in the population to bring about these changes. It is not enough to recommend that people individually try to avoid toxic chemicals by buying certain consumer products; this is not always possible to do, especially for those with limited income and accessibility. Furthermore, we all deserve to live in a society where we are not exposed to toxins which are known or suspected to increase risk for cancer.
One organization that advocates for this approach is Breast Cancer Action (BCA), a small non-profit organization which often works as part of larger coalitions to make social change. Despite its limited size and budget, it has succeeded in several of its campaigns to change policies. For example, in 2008, BCA’s “Think Before you Pink” campaign, successfully persuaded Yoplait yogurt to change its practices. Yoplait, which is manufactured by General Mills and touted as a “pink” company because it donates money to breast cancer treatment and sponsors the Susan B. Komen Race for the Cure, was producing yogurt from cows treated with rGBH, a suspected cancer-causing hormone. Through an online campaign in which thousands of consumers contacted General Mills in protest, BCA was able to exert enough public pressure to convince the company to commit to sourcing its dairy products from cows not treated with rGBH. After this victory, Dannon yogurt, a competitor, followed suit [22].
Unlike mammography screening, a campaign such as this was safe and effective : there were no medical risks involved for women (though speaking out against the status quo often involves other types of political/social risks.) Women were empowered by taking action, and unlike with mammography, were exerting real control in taking a step to reduce breast cancer risk as opposed to just the illusion of control; the campaign resulted in the actual elimination of the suspected cancer causing hormone from the source of the dairy products.
The Yoplait campaign took a group level approach which enabled change to happen quickly on a large scale, affecting thousands of consumers simultaneously. The campaign also framed the issue as one of primary prevention – targeting the company producing the yogurt, rather than targeting individuals’ buying or eating habits. This is an example of an effective upstream approach.
Finally, by focusing on rGBH, the Yoplait campaign raised awareness of environmental toxins, which not only affected Yoplait, but Dannon as well. Given that these 2 companies represent two thirds of America’s dairy products, it is likely that their change will also affect the practices of farmers, since they will no longer be able to supply these companies with milk unless they stop injecting their cows with the harmful hormone.
We need to continue to launch and expand upon policy campaigns such as the Yoplait example. A current environmental campaign which is in the works and is supported by a coalition of nearly 300 environmental health organizations is the proposed reform of the Toxic Substances Control Act of 1976 [23]. One way to motivate people to join a campaign for changing policy is to emphasize the ways in which women’s freedoms are being threatened by corporations and governmental agencies. According to the theory of psychological reactance, developed by Jack W. Brehm in 1966, as human beings we all need to feel in control of influencing our own environment. When we feel that our ability to be in control is threatened, we will experience “reactance” and resist against whatever is threatening us [24].
We can use this understanding of human psychology to our advantage in crafting a public health campaign. For example, the “Think Before you Pink” campaign used a form of psychological reactance by highlighting the hypocrisy of Yoplait in its giving money to breast cancer organizations while at the same time manufacturing a product thought to increase breast cancer risk. When women learned that they were being used in this way, they likely felt a threat to their sense of control and fairness and were motivated to write to General Mills in protest.
We need to deliver promotional messages to women that show how corporations who market harmful products are taking advantage of the public by profiting off of the chemicals which they produce and similarly, how governmental agencies who design environmental policies are failing to enforce them. As women learn about the way their freedoms are being squashed, they are likely to be motivated to fight back and join a campaign to restore those freedoms. In other words, if women feel like they are being duped, they are likely to take action.
We can make campaigns most effective by using tools honed by the advertising industry, which include making large promises to meet the needs of our target population, supporting these promises and appealing to universal core values [25]. This approach was used very successfully in the late 1990’s by the anti-tobacco Truth Campaign, which significantly reduced smoking rates among Florida youth. The campaign designed commercials, among other tools, aimed at the core value of rebelliousness among youth. They showed young people how they were being manipulated and lied to by big tobacco companies. The campaign promised them the “truth” and opportunities to rebel against the tobacco industry. Youth responded by joining in community activities directed against the tobacco industry and ultimately deterring more young people from starting to smoke [26].
Simon Sinek, a leader from the advertising industry, explains how to create an effective message that will inspire people to action. He describes the “golden circle” of three rings in which the message should start in the center with “why,” your purpose or cause. The “why” relates to universal core values, such as freedom and fairness. (Unfortunately “health” is not as important a core value to most people.) The next outer ring in the golden circle is “how,” the specific actions to take. And the final ring is “what,” the actual results [27].
So, for example, these tools could be applied to the campaign to reform the Toxic Substances Control Act (TSCA). The messages should emphasize the ways in which we are being duped by the law – we have been lead to believe that products brought to market have been tested and are safe, when it fact this is not the case. Thousands of chemicals in the marketplace have never been tested. The message should first introduce the “why” - we want our control back! We don’t want to be manipulated – and joining this campaign will allow all of us to do that. The “how” is to take concrete steps such as contacting legislators, garnering media attention, and raising money. Finally, the “what” is the result that we will all have healthier lives and less risk of breast cancer and other diseases.
In conclusion, in order to prevent breast cancer among young healthy women, we must bring more attention and action to the production, distribution and regulation of environmental toxins in our daily lives. In order to do so we need to inspire the public to put pressure on corporations and governmental agencies which are responsible for the manufacturing and regulation of chemicals. By using lessons learned from the social sciences and advertising, we can effectively mobilize the public to participate in campaigns which are safe and effective and ultimately change policies.


1. Gray, Janet. State of the Evidence: The Connection Between Breast Cancer and the Environment, 6th Ed, Breast Cancer Fund, 2010.
2. American Cancer Society. Cancer Facts and Figures 2010. Atlanta: American Cancer Society, 2010.
3. American Cancer Society. “Mammograms Matter” 9/14/2010.
4. Love, Susan. Dr. Susan Love’s Breast Book, 4th Ed. Cambridge, MA: Da Capo Press, 2005.
5. Edison Imaging Associates. 2009.
6. U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2009;151:716-726.
7. Susan B. Komen for the Cure.
8. Cancer Prevention Coalition.
9. Breast Cancer Action.
10. Center for Disease Control.
11. Langer EJ. The illusion of control. Journal of Personality and Social Psychology 1975;32:311-328.
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13. Link,BG and Phelan, J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995;35(extra issue):80-94.
14. McCombs, Maxwell.The Agenda-Setting Function of the Press (Chapter 9). In: Overholser, Geneva and Jamieson, Kathleen Hall, eds. Institutions of American Democracy: The Press. Oxford: Oxford Press, 2006.
15. Michigan State University (2008, April 15). Media Coverage of Breast Cancer Focuses Too Little on Prevention, Study Suggest. Science Daily.
16. Avon Walk for Breast Cancer.
17. Program on Breast Cancer and environmental Risk Factors. Cornell University. 2010.
18. National Cancer Institute. Funded Research Portfolio;jsessionid=BC78DC94EFAEDA27F675478235BDB811?action=full&fy=PUB2009&type=site
19. Epstein, Samuel and Liza Gross, “The High Stakes of Cancer Prevention.” Tikkun Magazine, Nov/Dec 2000.
20. Breast Cancer Action;jsessionid=BC78DC94EFAEDA27F675478235BDB811?action=full&fy=PUB2009&type=site

21 Nudelman, Janet and Connie Engel. State of the Evidence: From Science to Action. Breast Cancer Fund, 2010
22. Breast Cancer Fund.
23. Safer Chemicals, Healthy Families.
24. Dillard, Price James and Michael Pfau. The Persuasion Handbook: Developments in Theory and Practice. Thousand Oaks, CA: Sage Publications, 2002.
25. Siegel, M. and Lotenberg, LD. Chapter 3 in Marketing Social Change: An Opportunity for the Public Health Practitioner, 2nd Ed . Sudbury, MA: Jones and Bartlett, 2007.
26. Bauer, U.E., Johnson, T.M., Hopkins, R.S., and Brooks, R.G. Changes in youth cigarette use and intentions following implementation of a tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA 2000; 284:723-728.
27. Simek, Simon.

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