By Gayle Sulik
One might assume that anything involving breast cancer awareness would be based on the best available evidence. Unfortunately, this assumption would be wrong. I’ve evaluated hundreds of campaigns, advertisements, websites, educational brochures, and other sundry materials related to breast cancer awareness only to find information that is inaccurate, incomplete, irrelevant, or out of context. We could spend the whole year analyzing them. For now, consider a print advertisement for mammograms by CENTRA Mammography Services. [Note: I previously shared this ad back in July in an essay called Mammogram Mania.]
The full-page ad was published last October in a special issue magazine devoted to breast cancer awareness. Such special issues are now a common feature in magazines and other media outlets during National Breast Cancer Awareness Month. They include personal stories, information, interviews with experts, fund-raising events, pink ribbon promotions, and of course a slew of product placements that come with their own versions of “helpful” health information.
Awareness advertorials tend to include factoids and impressions, and the impressions come first.
Color matching. The reader’s eye moves between a pink foreground and a matching pink sweatshirt. Pink, we already know, signifies breast cancer awareness.
Joy, nature, sisterhood, and health. A group of smiling women, friends in fact, of varied ages and ethnic backgrounds walk outside, arm in arm, wearing sneakers and sweatshirts. The sunshine, trees, and “just do it” attitude nearly walk off the page.
The hook. After the impressions are set, they are reinforced and followed with a directive. A large caption: “All your friends are doing it,” is followed by a sheepish, “Shouldn’t you?” Peer pressure directed toward adult women to sell mammography services. CENTRA follows up its peer pressure with a finger-pointing guilt grip.
With early detection, diagnosis and improved treatment, women are beating breast cancer. But still, many of you aren’t doing the one thing that may help prevent and diagnose it in the first place, a mammogram.
The “shame on you” accusations are reminiscent of the bad old days of paternalistic medicine, in which doctors used fear of physical and/or social mutilation to promote breast examination and medical intervention. In the 1940s and 1950s physicians and popular health magazines used imagery of women “blowing their brains out” to represent the seriousness of their responsibility to examine their breasts. At the same time, the words are misleading and/or inaccurate.
Early detection is a common and overused phrase that gives the impression that mammograms unequivocally find cancers early, so early in fact that if they are found on a mammogram and then treated, you will not die from breast cancer. Not true.
• Some breast cancers are slow growing and unlikely to spread.
• Other breast cancers grow and spread quickly.
• The most important factor related to whether a person’s breast cancer is likely to cause death is related to tumor biology.
• Stage zero breast conditions such as DCIS are not in themselves life threatening. They are called precancers or risk factors for invasive breast cancer.
• People found to have stage zero conditions may develop an invasive breast cancer later in their lives, but most won’t.
• People diagnosed across stages I, II or III have a recurrence in 20 to 30 percent of cases. The longer someone lives without having a recurrence, the greater the chance that there won’t be one.
• Clinical trials show that population screening reduces the mortality rate by 15 to 30 percent.
In reality, the detection of a cancer on a mammogram before it has become symptomatic has been translated into the phrase early detection. Although routine screening sometimes leads to a reduction in mortality from breast cancer, as stated above, improved treatment for breast cancer is more likely to account for known reductions in mortality. Still, somewhere around 40 to 41 thousand women and men die each year from metastatic breast cancer regardless of whether or not their cancer was detected on a mammogram.
The ad does not include any of this information. Instead it states that mammograms the “one thing” that matters to “prevent and diagnose” breast cancer in the first place. Mammograms do not prevent breast cancer, and they identify (with varied degrees of accuracy) cancers that are already there. The National Cancer Institute reports that screening mammograms “miss up to 20 percent of breast cancers that are present at the time of screening.”
To show how much their mammography services are needed, the ad provides a 2010 incidence statistic of 207,090, and claims that “a mammogram detects 90 percent of all breast cancers.” I don’t know where that statistic comes from. The ad includes no information about how many results are inconclusive, false-positives, or false-negatives. It does not give the number of deaths.
Beneath the hours of operation and contact information for CENTRA’s mammography centers, the box reads: “Why risk it? Be proactive!” Playing on both the fear and uncertainty of breast cancer as well as the general social expectation that individuals should be responsible and proactive medical consumers, the ad reinforces its earlier message that preventing breast cancer is completely within women’s power. Should a woman learn at some point in her life that she has breast cancer but did not take the action recommended in the ad, the outcome must be due to her failure to act as warned. The exclamation point emphasizes the importance of the directive.
If the ad were just an ad it could be taken at face value, but it is not just an ad. It is yet another cultural message within a sea of messages in the name of breast cancer awareness that plays on fear of breast cancer, hope for the future, and the goodness of jumping on a pink bandwagon. At the same time, these types of ads and campaigns are almost always accompanied with some type of “legitimizing” evidence. The information sounds right. It rings true to the reader but without telling the whole story. Of course, the ultimate appeal is to get consumers to buy the product.
Should women get screened for breast cancer? It’s clearly not a simple answer. It requires deep thought about the strengths, limitations, risks, and benefits of this diagnostic tool. Some women will benefit from it. Others will not. The conditions vary. Yet the “just do it” tide in breast cancer awareness floods advertisements, campaigns, and product placements.
Thank you, CENTRA Mammography Services, for telling me what to do for my own good, but I can think for myself! [That's an exclamation point to indicate strong feeling.]
P.S. I just got this E-card from a friend!
Gayle A. Sulik, Ph.D. is a medical sociologist and was a 2008 Fellow of the National Endowment for the Humanities for her research on breast cancer culture. She is author of Pink Ribbon Blues: How Breast Cancer Culture Undermines Women’s Health. You can read her previous OUPblog posts here and learn more on her website, where this article originally appeared. For more consciousness raising essays, check out “30 Days of Breast Cancer Awareness.”