Do Americans, even in anxious times, prefer an optimistic leader or an angry one?
As luck would have it, I had my first mammogram right before the new federal guidelines appeared stating that women my age might as well skip the whole thing for another decade.
Like most women my age, I know too many people who have been diagnosed with breast cancer to be cavalier about the possibility. And while I didn't relish the idea of getting "squished," I felt like I was being good by overcoming my dread of the whole topic--not to mention the desire to avoid a misdiagnosis or, worse, bad news--and going in for my appointment.
I got a free nail file, and a lot of praise from the technician, who reinforced my sense that I was doing the right thing.
I particularly appreciated the heads-up that, as a first-time patient, I would likely be called back for follow-up pictures, but not to worry--this was standard protocol until a patient has a history of mammograms and the radiologists can identify normal lumps and distinguish these from abnormalities.
My mother, I found out late, spent my college graduation worrying about what finally turned out to be a benign lump, though she was left hanging by doctors who led her to suspect the worst but didn't give her more information for weeks.
Apparently, breast cancer screeners have become more sensitive to needless stress and are doing everything they can to make mammography more pleasant, overcome women's reluctance to get diagnosed, and promote early screening.
To little avail, as it turns out. The benefits of all that early screening--two-thirds of women in their 40s have received a mammogram in the last two years--turns out to be statistically very small.
The United States Preventive Service Task Force--a panel of medical experts appointed by the Department of Health and Human Services--has decided that, contrary to every bit of breast-cancer-awareness propaganda we've been bombarded with for the last seven years--there is real harm in overscreening, including extreme stress, unnecessary further tests, and overtreatment.
The report, released this week, prompted a lot of controversy right away. Everyone seems to know someone who has been diagnosed with breast cancer at a young age, and, thanks to early detection, been treated and recovered from the deadly disease.
According to the task force, cancer death is prevented for one in every 1,904 women in their forties who are screened for 10 years. But mathematical models of risk mean nothing next to the emotional impact of real-life stories of women we know. If you can do something to save your life, why wouldn't you?
As a society, much of what we do about breast cancer, as Barbara Ehrenriech points out in her new book Bright Sided, is more about shoring up women emotionally than actually attacking the disease in the most effective possible way.
The support groups and cancer runs and pink ribbons and, as Ehrenreich acidly observes, the teddy bears and other infantilizing breast-cancer-survivorship paraphernalia, seem to provide comfort mainly by reassuring women that we are good girls if we follow the prescribed regimens of screening and, if called for, treatments, and keep a cheerful, compliant attitude about it.
You can see the appeal of this approach. Cancer is a terrifying disease and the combination of solidarity and reassurance and the feeling that we are part of a team, led by competent, expert authorities, that is actively doing something to combat the threat, is a hell of a lot better than feeling helpless and afraid.
No wonder the new guidelines from the Preventive Service Task Force caused such and uproar.
The American Cancer Society has flat-out refused to accept them. And many women and doctors say they will plow right ahead with annual mammograms despite the panel's recommendations. The web is abuzz with rumors that cost-cutting is the real reason for the new federal guidelines, and women will die to save money on potentially life-saving screenings.
But overscreening and overtreatment are as much of a plague in the U.S. medical system as cost-cutting measures. And looking at breast cancer screening rationally, as the federal panel has done, makes a lot of sense.
Just because it gives people a feeling of psychological empowerment to do something does not mean promoting the hell out of dubiously effective screening is the right thing to do.
Aside from an irrational avoidance reflex, it turns out there are good reasons women might not be inclined to get mammograms.
"Routine screening mammograms are the major goal of 'awareness,'" Barbara Ehrenreich wrote in Harper's back in 2000. Yet the effect of all this early screening is "a vanishingly small impact on breast cancer mortality," Ehrenriech wrote. For every cancer detected, two to four biopsies turn out negative, putting a lot of women through a lot of needless stress. Despite what seems like widespread consensus that you'd have to be crazy not to get an annual mammogram starting at age 40, Ehrenreich quoted eminent doctors including David Plotkin, director of the Memorial Cancer Research Center of Southern California, and Alan Spievack of Harvard Medical School--saying the benefits of early screening were dubious if not, as Spievack and the British surgeon Dr. Michael Baum put it, "one of the greatest deceptions perpetrated on the women of the Western World." Damn.
The problem, at bottom, is that there is no cure.
This, more than denial and cowardliness, explains a lot of women's reluctance to get screened.
We know in our guts, despite the cheerful face of the early-screening crusade, that getting the news you have cancer does not mean you can do much about it.
Leaving aside the stress of proceeding with further screenings only to find out you don't have cancer, there is, it turns out, another problem with early screening: just because it detects tiny tumors, it is not necessarily "early." I always thought that if you catch breast cancer early on a mammogram, you have a much greater chance of survival. But the truth is murkier than that.
Some cancers are so slow-growing you never would have known you had them, and would have died of something else before the cancer killed you. The detection and treatment of these cancers, through early screening, turns out to be one reason for the federal panel's recent reversal. The treatment is literally worse than the disease in these cases, and finding a lot of these cancers and treating them is neither useful from a public health standpoint nor beneficial to individual women.
Other cancers are quite advanced though tiny on the mammogram. For patients with these types of cancers, "early" detection is actually too late.
Others--that one in 1,904--are early, treatable, and early detection is a lifesaver.
Whether or not to get a mammogram, given these statistics, is a question women will have to answer for themselves based on some combination of what their hearts and heads tell them.
The bigger problem with the emphasis on early screening, which Ehrenreich identified, to her credit, long before it was socially acceptable, is that it puts the emphasis in the wrong place. While we spend our time going to screenings and joining the corporate-sponsored cancer awareness drives that turn out to have little impact on breast cancer mortality, we are living in the middle of what looks like an environmental plague brought on, in part, by the same companies that produce pink-ribboned Cancer Awareness Month propaganda. In some cases the same companies that produce breast-cancer-treating drugs also produce carcinogenic pesticides and other products that have been linked to cancer in lab animals.
Looking at the cause, not just screening, would be a far more rational approach to doing something about breast cancer.