Breast cancer awareness

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Breast cancer awareness is an effort to raise awareness and reduce the stigma of breast cancer through education on symptoms and treatment. Supporters hope that greater knowledge will lead to earlier detection of breast cancer, which is associated with higher long-term survival rates, and that money raised for breast cancer will produce a reliable, permanent cure.

Breast cancer advocacy and awareness efforts are a type of health advocacy. Breast cancer advocates raise funds and lobby for better care, more knowledge, and more patient empowerment. They may conduct educational campaigns or provide free or low-cost services. Breast cancer culture, sometimes called pink ribbon culture, is the cultural outgrowth of breast cancer advocacy, the social movement that supports it, and the larger women's health movement.

The pink ribbon is the most prominent symbol of breast cancer awareness, and in most countries, the month of October is National Breast Cancer Awareness Month. National breast cancer organizations receive substantial financial support from corporate sponsorships (King 2006, page 2).

Marketing approaches

The goal of breast cancer awareness campaigns is to raise the public's "brand awareness" for breast cancer, its detection, its treatment, and the need for a reliable, permanent cure. Increased awareness has increased the number of women receiving mammograms, the number of breast cancers detected, and the number of women receiving biopsies (Sulik 2010, pages 157–210). Overall, as a result of awareness, breast cancers are being detected at an earlier, more treatable stage. Awareness efforts have successfully utilized marketing approaches to reduced the stigma associated with the disease.

Generally speaking, breast cancer awareness campaigns have been highly effective in getting attention for the disease. Breast cancer receives significantly more media coverage than other prevalent cancers, such as prostate cancer (Arnst 2007).

Events

Main article: National Breast Cancer Awareness Month

Each year, the month of October is recognized as National Breast Cancer Awareness Month by most governments, the media, and cancer survivors. The month-long campaign has been called Pinktober because of the proliferation of pink goods for sale, and National Breast Cancer Industry Month by critics like Breast Cancer Action (Sulik 2010, pages 48, 370). NBCAM was begun in 1985 by the American Cancer Society (ACS) and pharmaceutical company AstraZeneca. The organization that runs the official NBCAM aims to promote mammography and other forms of early detection as the most effective means of saving lives (King 2006, page xxi).

Typical NCBAM events include fundraising-based foot races, walk-a-thons, and bicycle rides (Ehrenreich 2001). Participants solicit donations to a breast cancer-related charity, in return for their promise to run, walk, or ride in the event. Through mass-participation events, breast cancer survivors form a single, united group that speaks and acts consistently and shares a coherent set of beliefs. There are little significant discrepancies among individuals (Sulik 2010, page 56). They also reinforce the cultural connection between each individual's physical fitness and moral fitness (King 2006, pages 46–49). Typically, one-quarter to one-third of the money donated is spent on advertising and organizing the event itself (Ehrenreich 2001).

Various landmarks are illuminated in pink lights as a visible reminder of breast cancer, and public events, such as American football games, may use pink equipment or supplies. In 2010, all King Features Syndicate comic strips on one Sunday were printed in shades of red and pink, with a pink ribbon logo appearing prominently in one panel.

Private companies may arrange a "pink day", in which employees wear pink clothes in support of breast cancer patients, or pay for the privilege of a relaxed dress code, such as Lee National Denim Day (Ehrenreich 2001).

Some events are directed at people in specific communities, such as the Global Pink Hijab Day, which was started in America to encourage appropriate medical care and reduce the stigma of breast cancer among Muslim women, and Male Breast Cancer Awareness Week, which some organizations highlight during the third week of October.

Most events are well-received, but some, like the unauthorized painting of the Pink Bridge in Huntington, West Virginia, are controversial.

Facebook campaigns have encouraged users to use sexual innuendo and double entendres in their status updates to remind readers about breast cancer. In 2009, a campaign asked women to post the color of their brassieres, and in 2010, a campaign asked women to post where they keep their purses, resulting in status messages such as "I like it on the floor" (Kingston 2010). These campaigns have been criticized as sexualizing the disease (Kingston 2010).

Mere symbolism itself does not prevent cancer, improve treatments, or save lives. However, it is an effective form of promoting the pink ribbon culture: fear of breast cancer, the hope for a scientific breakthrough, and the goodness of the people who support the cause. These supporters may feel socially compelled to participate, in a type of "obligatory voluntarism" that critics say is "exploitative" (Sulik 2010, page 250, 308).

Pink ribbon

Main article: Pink ribbon

A pink ribbon is a symbol of breast cancer awareness. It may be worn to honor those who have been diagnosed with breast cancer, or to identify products that a manufacturer would like to sell to consumers that are interested in breast cancer. Pink ribbons are sometimes sold as fundraisers, much like poppies on Remembrance Day.

The pink ribbon is associated with individual generosity, faith in scientific progress, and an optimistic "can-do" attitude. It encourages individuals to focus on the emotionally appealing ultimate vision of a cure for breast cancer, rather than the true possibility of a timely future cure considering current progress (Sulik 2010, pages 359–361). Despite these positive associations, the simple act of wearing a pink ribbon alone and promoting it as a symbol for breast cancer has not been credited with saving any lives. The practice of blindly wearing or displaying a pink ribbon without making other, more concrete efforts to cure breast cancer has been described as a kind of slacktivism due to its lack of real effects (Landman 2008), and compared to equally simple yet ineffective "awareness" practices like the drive for women to post the colors of their bras on Facebook (Borrelli, 2010). Critics say that the feel-good nature of pink ribbons and "pink consumption" distracts society from the lack of progress in curing breast cancer (Sulik 2010, pages 365–366). It is also criticized for reinforcing gender stereotypes and objectifying women and their breasts (Sulik 2010, pages 372–374).

Shopping for the cure

Thousands of breast cancer-themed products are developed and sold each year (Ave 2006). Some of these, like pink ribbons and awareness bracelets, have no purpose other than as a type of status symbol that displays the wearer's interest in breast cancer. Others are everyday products that have been repackaged or repositioned to take advantage of cause-related marketing, such as teddy bears, clothing, jewelry, candles, and coffee mugs (Ehrenreich 2001). These blended value objects offer consumers an opportunity to simultaneously buy an object and make a donation to a breast cancer organization (Ehrenreich 2001). Some of these products are produced and/or sold by breast cancer survivors or charities for fundraising purposes, while others are for profits in addition to fundraising. Manufacturers also produce products with pink labels or pink ribbon logos to donate a sum of money to support the cause (Levine 2005). The donation is typically capped so that it is reached after a fixed level of sales, although in some cases the company is providing only free advertising for a selected charity. Although advertising costs are rarely disclosed, some companies have been found to spend far more money advertising "pink products" and tie-ins than they donate to charitable organizations supporting research or patients. For example, in 2005, 3M spent US $500,000 advertising post-it notes printed with a pink ribbon logo. Sales were nearly double what the company expected, but the campaign resulted in a $300,000 donation (Levine 2005).

Pink products have also been condemned as promoting consumerism, materialism, and environmental degradation. Critics are also concerned that the ubiquity of pink products may mislead people into thinking that significant progress has been made, and that small, individual actions, like buying a breast cancer-themed product, are sufficient (Stukin 2006).

The first breast cancer awareness stamp in the U.S., featuring a pink ribbon, was issued in 1996. As it did not sell well, a semi-postal stamp without a pink ribbon, the breast cancer research stamp, was designed in 1998. Products like these emphasize the relationship between being a consumer and supporting women with breast cancer (King 2006, pages 61–79).

In Canada, the Royal Canadian Mint produced 30 million 25-cent coins with pink ribbons during 2006 for normal circulation (Royal Canadian Mint 2006). Designed by the mint's director of engraving, Cosme Saffioti (reverse), and Susanna Blunt (obverse), this colored coin is the second in history to be put into regular circulation (Royal Canadian Mint 2006).

Business marketing campaigns, particularly sales promotions for products that increase pollution or contribute to breast cancer, such as alcohol, high-fat foods, some pesticides, or the parabens and phthalates used by most cosmetic companies, have been condemned as pinkwashing (a portmanteau of pink ribbon and whitewash) (Mulholland 2010). Such promotions generally result in a token donation to a breast cancer-related charity by taking advantage of the consumers' fear of cancer and grief for people who have died to drive sales (Landman 2008). Critics say that these promotions, which net more than US $30 million each year just for fundraising powerhouse Susan G. Komen for the Cure, do little more than support the marketing machines that produce them (Stukin 2006).

Two significant campaigns against pink consumption are the National Breast Cancer Coalition's "Not Just Ribbons" campaign, and Breast Cancer Action's "Think Before You Pink" campaign. NBCC's "Not Just Ribbons" which opposed the hypocrisy of people and businesses who use pink ribbons to promote their products or themselves, but ignore or oppose substantive issues, such as genetic discrimination, access to medical care, patient rights, and anti-pollution legislation (Sulik 2010, pages 366–368). "Think Before You Pink" encouraged consumers to ask questions about pink products (e.g., to find out how much of a donation was being made) (Sulik 2010, pages 369–372).

Many corporate and charitable organizations run advertisements related to breast cancer, especially during National Breast Cancer Awareness Month, in the hope of increasing sales by aligning themselves with a positive, helpful message (King 2006). In addition to selling pink products, corporate advertisements may promote the company's progressive policies, or may provide free advertising for a chosen charity. Medical institutions may run advertisements for mammogram or other breast-related services. Non-profit organizations often benefit from public service announcements, which are free advertisements provided by newspapers, radio and television stations, and other media.

Some marketing blurs the line between advertisements and events, such as flash mobs as a form of guerrilla marketing.

The typical participant in the breast cancer movement, and therefore the advertisers' target audience, is a white, middle-aged, middle-class, well-educated woman (King 2006, pages 110–111).

Some corporate sponsors are criticized for having a conflict of interest. For example, some of the prominent sponsors of these advertisements include businesses that sell the expensive equipment needed to perform screening mammography; an increase in the number of women seeking mammograms means an increase in their sales. Their sponsorship is thus not a voluntary act of charity, but an effort to increase their sales (King 2006, page 37). The regulated drug and medical device industry uses the color pink, positive images, and other themes of the pink ribbon culture in direct-to-consumer advertising to associate their breast cancer products with the fear, hope, and wholesome goodness of the breast cancer movement (Sulik 2010, page 206–208). This is particularly evident in advertisements designed to sell screening mammograms.

Despite having been determined to be ineffective in low-risk and average-risk women, many charities still advertise breast self-examinations as a means of simultaneously raising awareness, encouraging early detection, and increasing the visibility of their organizations. Other organizations' advertisements now advocate breast awareness, which is paying attention to any changes in the breast that may require medical attention.

Media

Although more women die from lung cancer, breast cancer receives far more attention in women's magazines than any other cancer. Until the mid-1990s, nearly all of these stories were written from the perspective of the expert, who gave advice. Since then, the illness narrative, describing the personal experiences of individual patients, has become more prominent. (Sulik 2010, page 133).

Embedded marketing, branded content and frequent feature stories amount to free advertising for the brand and for the organizations that support it.

Breast cancer as a brand

Breast cancer advocacy uses a the pink ribbon and the color pink as a concept brand to raise money and increase screening. The breast cancer brand is strong: people who support the "pink brand" are members of the socially aware niche market, who are in favor of improved lives for women, trust biomedical science and believe in a future without breast cancer (Sulik 2010, page 22).

The brand ties together fear of cancer, hope for early identification and successful treatment, and the moral goodness of women with breast cancer and anyone who visibly identifies themselves with breast cancer patients. This brand permits and even encourages people to substitute conscientious consumption and individual symbolic actions, like buying or wearing a pink ribbon, for concrete, practical results, such as collective political action aimed at discovering non-genetic causes of breast cancer (Sulik 2010, pages 133–146).

The establishment of the brand and the entrenchment of the breast cancer movement has been uniquely successful, because no countermovement opposes the breast cancer movement or believes breast cancer to be desirable (King 2006, page 111).

Social role of the woman with breast cancer

The marketing of breast cancer awareness allows people to choose support for awareness as a personal identity or lifestyle. Socially aware, pro-woman individuals, businesses, politicians, and organizations use pink ribbons and other trappings of breast cancer awareness to signal their support for women, health, and mainstream medicine.

The she-ro

Sociologist Gayle Sulik uses the term "she-ro", derived from hero, to describe the social role expected of a woman with breast cancer. The term is used in breast cancer circles, describing an "idealized" patient who combines assertiveness, optimism, femininity and sexuality, despite the effects of treatment, and as a "paragon uses a diagnosis of breast cancer as a catalyst for a personal transformation" (Zuger, 2010). The qualities Sulik attributes to a she-ro include an educated medical consumer with a brave, pleasant and optimistic public appearance and demeanor who aggressively fights breast cancer through compliance with mainstream medical advice. In America the she-ro is diagnosed early due to rigid adherence to early screening recommendations, and survives her diagnosis (Sulik 2010, page 158, 243). The role emphasizes the femininity and female gender role of the she-ro, offsetting the masculine characteristics of assertiveness, selfishness and "fighting" cancer by cultivating a feminine appearance and concern for others (Sulik 2010, pages 78–89). After treatment, the she-ro regains her femininity by using breast reconstruction, prosthetic devices, wigs, cosmetics, and clothing to present an aesthetically appealing, upper-class, heterosexual feminine appearance and by maintaining relationships in which she can nurture other people (Sulik 2010, page 42, 374). Programs such as Reach to Recovery and Look Good, Feel Better educate breast cancer patients of this cultural standard and help them conform to it (Olson 2002, page 120; Sulik 2010, pages 37–38). Ensuring of the proper feeling rules of the breast cancer culture is encouraged, including remaining optimistic of a full cure, rationalizing the selfishness of treatment as a temporary measure and feeling guilty that it forces her to put her needs momentarily above the needs of others or due to her perceived inadequacy in caring her family or other women with cancer (Sulik 2010, pages 225–272, 277). Also included in the role is a form of have-it-all superwoman, cultivating a normal appearance and activity level and minimizing the disruption that breast cancer causes to people around her (Sulik 2010, pages 279–301).

Consequences

The effort of maintaining the role of a she-ro can be stressful. The role encourages women to care for others rather than themselves, which the patient may find comforting, but this may lead to the reluctance or inability to ask for help they need or want which can lead to bitterness that their friends and family did not offer these services unbidden (Sulik 2010, pages 279–301). The success of their normalization efforts may paradoxically increase their dissatisfaction, as their apparent ability to handle it all discourages people from offering help (Sulik 2010, page 283, 286). While the she-ro model may reduce the social stigma of breast cancer overall, it also increases the stigma of being overwhelmed, depressed, anxious, abrasive, or unattractive while undergoing treatment (Sulik 2010, page 45). The culture celebrates women who display the attitude deemed correct, and declares that their continued survival is due to this positive attitude and fighting spirit, even though cheerfulness, hope, and displaying a cosmetically enhanced appearance do not kill cancer cells (Sulik 2010, page 243–244). Women who reject the she-ro model may find themselves socially isolated by the breast cancer support groups that are nominally supposed to help them. Support from "the sisterhood" is reserved for the "passionately pink", rather than those whose response is deemed inappropriate because it is angry, unhappy, or afraid (Sulik 2010, page 274–277). The breast cancer culture is also ill-equipped to deal with women who are dying or who have died (Sulik 2010, page 4). Despite occasional efforts at memorials, such as displaying the names of women who have died, these women's experiences are not validated and represented. They are, instead, ignored and shunned as failures and as hope-destroying examples of reality. Similarly, the culture is ill-equipped to deal with the news that a previously hyped treatment or screening procedure has been determined to be ineffective, with women demanding acceptance and promotion of useless activities and harmful drugs (Ehrenreich 2001; Olson 2002, pages 204–205; Sulik 2010, pages 200–203).

Breast cancer culture

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Breast cancer culture, or pink ribbon culture, is the set of activities, attitudes, and values that surround and shape breast cancer in public. The dominant values are selflessness, cheerfulness, unity, and optimism. The she-ro uses the emotional trauma of being diagnosed with breast cancer and the suffering of extended treatment to transform herself into a stronger, happier and more sensitive person who is grateful for the opportunity to become a better person. In particular, she sees breast cancer as an opportunity to give herself permission for necessary personal growth—permission that she felt unable to give herself before, because of the restraints of her gender role (Sulik 2010, page 236). Breast cancer thereby becomes a rite of passage rather than a disease (Ehrenreich 2001; Sulik 2010, page 3).

The emphasis on cheerfulness allows society to blame women for developing breast cancer and to the limit their responses to culturally approved scripts. The requirement of cheerful optimism arises from a now-discredited idea that people who were diagnosed with cancer had a "cancer personality" that was depressed, repressed, and self-loathing. The cure for cancer was therefore psychotherapy to produce a cheerful, self-affirming identity (Olson 2002, pages 460–469; Sulik 2010, page 342).

Pink ribbon culture is pro-doctor, pro-medicine, and pro-mammogram. Health care professionals are sources of information, but the rightness of their advice is not to be seriously questioned. Patients are not encouraged to notice the absence of any meaningful method of prevention or treatments that are non-mutilating, non-debilitating, or noticeably more successful than what existed in the 1930s (Sulik 2010, pages 365–366).

Breast cancer culture values and honors suffering, selecting its she-roes by a "misery quotient" (Sulik 2010, page 319). Elizabeth Edwards, for example, personifies the breast cancer she-ro. Women whose treatment requires less suffering feel excluded and devalued. The suffering, particularly the extended suffering of months of chemotherapy and radiation treatment, forms a type of ordeal that initiates women into the inner circle of the breast cancer culture (Ehrenreich 2001).

Mainstream pink ribbon culture is also trivializing, silencing, and infantilizing (Sulik 2010, page 98). Women who choose not to conform to the culture feel excluded and isolated; those who cannot conform to the prescribed triumphant storyline feel unable to share their stories honestly. Anger, negativity and fatalism transgress the feeling rules, and women with breast cancer who express anger or negativity are corrected and disciplined by other women with breast cancer and members of the breast cancer support organizations (Ehrenreich 2001; Sulik 2010, page 240–242). Appearing unattractive—such as going out in public with a bare, bald head if treatment causes temporary hair loss—transgresses the approved, upper-class style of pink femininity and provokes shaming comments from strangers. Women with breast cancer are surrounded by sentimental kitsch and baby toys, such as pink teddy bears, when the equivalent for men, like a blue toy car, is unthinkable (Ehrenreich 2001).

Since the beginning of the 21st century, breast cancer culture has become more sexualized, and many awareness campaigns now reflect the old advertising truism that sex sells. The "booby campaigns", such as "Save the Tatas" and the "I ♥ Boobies" gel bracelets, rely on a cultural obsession with breasts and a market that is already highly aware of breast cancer (Kingston 2010). This message reflects a belief that breast cancer is important not because it kills women prematurely, but because cancer and its treatment makes women feel less sexually desirable and interferes with men's sexual access to women's breasts (Sulik 2010, page 347). These campaigns tend to attract a younger audience than traditional campaigns (Kingston 2010).

Breast cancer culture tends to overlook men with breast cancer and women who do not fit the white, middle-class archetype. African-Americans involved with breast cancer organizations often feel like their role is to be the token minority (Sulik 2010, pages 308–309).

The primary purposes or goals of breast cancer culture are to maintain breast cancer's dominance as the preëminent women's health issue, to promote the appearance that society is "doing something" effective about breast cancer, and to sustain and expand the social, political, and financial power of breast cancer activists (Sulik 2010, page 57).

The breast cancer culture tells women with breast cancer that their participation in fundraising, social support other women with breast cancer, and appearance at public events are critical activities that promote their own emotional recovery. Women begin to believe that refusing to raise money for breast cancer organizations or to become mentors for newly diagnosed women with breast cancer is an unhealthy response to breast cancer (Sulik 2010, pages 305–311).

Feminism and the breast cancer wars

Advocates have said that breast cancer is special because society's response to it is an ongoing proof of the status of women and the existence of sexism (Olson 2002, pages 195–202; Soffa 1994, page 208). Before the feminist movement, women with breast cancer were often treated as passive, dependent objects, incapable of making appropriate choices, whose role was to accept whatever treatment was decreed by the physicians, surgeons, or husbands, who held all of the power (Ehrenreich 2001). Because of sexism in education, few women were trained to be surgeons, and until the 1990s, when Susan Love of the UCLA Breast Center published Dr. Susan Love's Breast Book, the physicians who provided breast cancer treatments were generally men. Love said that some male physicians tended to impose their own values on women, such as recommending mastectomy to older women because, being past the age of child bearing and breastfeeding, they no longer "needed" their breasts (Olson 2002, page 198). The women's health movement promoted mutual aid, self-help, networking, and an active, informed role in the patient's health care (Ehrenreich 2001).

The breast cancer wars were a series of conflicts between advocates and others about the causes, treatments, and societal responses to breast cancer (Olson 2002, pages 192–220). Women in the late 1980s and 1990s followed the successful approach used by ACT-UP and other AIDS awareness groups, of staging media-friendly protests to increase political pressure. Prominent women who made the "wrong" choice were publicly excoriated, as when Nancy Reagan chose mastectomy over lumpectomy followed by six weeks of radiation therapy. The abortion–breast cancer hypothesis was formulated when an early study showed a connection between voluntary abortions and the development of breast cancer in premenopausal women, which pitted breast cancer advocates against abortion rights advocates (Olson 2002, pages 192–220).

Since the end of the breast cancer wars, feminists have again objected to the breast cancer culture's treatment of women with breast cancer as little girls who need to be obedient to authority figures, cooperative, pleasant and pretty (Ehrenreich 2001).

Achievements of the breast cancer movement

Breast cancer has been known to educated women and caregivers throughout history, but modesty and horror at the consequences of a largely untreatable disease made it a taboo subject. The breast cancer movement, which developed in the 1980s and 1990s out of 20th century feminist movements and the women's health movement, has mostly remove those taboos through its modern advocacy and awareness campaigns (Sulik 2010, page 4).

Educated, empowered patients

At the beginning and middle of the 20th century, breast cancer was usually discussed in hushed tones, as if it were shameful (Sulik 2010, page 113). Later, however, several celebrities publicly disclosed their own health challenges, and the resulting publicity reduced the stigma (Olson 2002, pages 124–144). One of the first was Shirley Temple Black, the former child star, who announced her diagnosis in 1972. In October 1974, Betty Ford, the wife of the then-President of the United States, openly discussed her breast cancer diagnosis and mastectomy. Two weeks later, the wife of the then-Vice President also had a mastectomy for breast cancer. The next year, journalist Rose Kushner published her book, Breast Cancer: A Personal History and Investigative Report, which she had written while recovering from a modified radical mastectomy. The media reported these women's health and their treatment choices, and even invited some to appear on talk shows to discuss breast cancer frankly (Olson 2002, pages 124–144).

The breast cancer movement has resulted in widespread acceptance of second opinions, the development of less invasive surgical procedures, the spread of support groups, and other advances in patient care (Olson 2002, pages 121, 171–220). The movement successfully separated diagnostic biopsy from mastectomy surgery; before about 1980, it was common to perform the biopsy and, if a quick review of tissues indicated a probable need, a mastectomy in the same surgery (Ehrenreich 2001; Olson 2002, pages 168–191). The one-step surgery prevented women from seeking different opinions about their treatment, and sent them into the surgery without knowing whether their breasts would be removed that day. In response to women's concerns over lymphedema after routine removal of lymph nodes during mastectomy, the more limited approach of sentinel node biopsy was developed. Advocacy efforts also led to the formal recommendation against the routine use of the Halsted radical mastectomy in favor of simple mastectomies and lumpectomies (Olson 2002, pages 176, 185–186, 250).

The breast cancer movement has supported practical, educational, emotional, and financial care for women with breast cancer. Support groups, individual counseling opportunities, and other resources are made available to patients.

Increased resources for treatment and research

Supporting breast cancer was seen as a distinctively pro-woman stance for public officials to take, without any of the political risks associated with supporting other feminist goals, such as abortion rights or lesbian rights (Olson 2002, page 202). This has resulted in better access to care. For example, in much of the United States, low-income women with breast cancer may qualify for taxpayer-funded health care benefits, such as screening mammography, biopsies, or treatment, while women with the same income, but another form of cancer or a medical condition other than cancer, do not.

Breast cancer advocates have successfully increased the amount of public money being spent on cancer research and shifted the research focus away from other diseases and towards breast cancer. Most breast cancer research is funded by government agencies (Mulholland 2010). Breast cancer advocates also raise millions of dollars for research into cures each year, although most of the funds they raise is spent on screening programs, education and treatment (Ave 2006).

The high level of awareness and organized political lobbying has resulted in a disproportionate level of funding and resources given to breast cancer research and care. Favoring breast cancer with disproportionate research may have the unintended consequence of costing lives elsewhere (Browne 2001). In 2001 UK MP Ian Gibson said, "The treatment has been skewed by the lobbying, there is no doubt about that. Breast cancer sufferers get better treatment in terms of bed spaces, facilities and doctors and nurses" (Browne 2001).

Risks of too much awareness

Women are far more likely to die from heart disease or stroke than from breast cancer

Deaths from breast cancer (2%) Deaths from heart disease or stroke (32%) Deaths from other cancers (10%) Deaths from lung diseases (7%) Deaths from injuries (6%) Deaths from digestive diseases (3%) Deaths from neuropsychiatric disorders (5%) Other (35%)

Because breast cancer is a highly visible disease, most women significantly overestimate their personal risk of dying from it. Misleading statistics, such as the claim that one in eight women will be diagnosed with breast cancer during their lives—a claim that depends on the patently unrealistic assumption that no woman will die of any other disease before the age of 95 (Olson 2002, pages 199–200)—obscure the reality, which is that about ten times as many women will die from heart disease or stroke than from breast cancer (Ave 2006).

Awareness has also led to increased anxiety for women. Early detection efforts result in overdiagnosis of precancerous and cancerous tumors that would never risk the woman's life (about one-third of breast cancers), and result in her being subjected to invasive and sometimes dangerous radiological and surgical procedures (Aschwanden 2009).

The breast cancer culture has also promoted an expansive definition of breast cancer, which includes non-invasive, non-cancerous conditions like lobular carcinoma in situ (LCIS) and pre-cancerous or "stage 0" conditions like ductal carcinoma in situ (DCIS). Despite the now-regretted decision to use the word carcinoma in these relatively common conditions (almost a quarter of "breast cancer" diagnoses in the USA), they are not life-threatening cancers (Sulik 2010, page 165–171). Women with these conditions are promoted as breast cancer survivors due to the fear they experienced before they became educated about their condition, rather than in respect of any real threat to their lives. This effectively increases the market size for breast cancer organizations, medical establishments, pharmaceutical manufacturers, and the makers of mammography equipment (Sulik 2010, page 170–171).

An emphasis on educating women about lifestyle changes that may have a small impact on preventing breast cancer often makes women feel guilty if they do develop breast cancer. Some women decide that their own cancer resulted from poor diet, lack of exercise, or other modifiable lifestyle factor, even though most cases of breast cancer are due to non-controllable factors, like genetics or naturally occurring background radiation. Adopting such a belief may increase their sense of being in control of their fate. Increased awareness inadvertently increases victim blaming (Olson 2002, pages 240–242, Sulik 2010, page 74, 263). Women who resist screening mammography or breast self-exams are subjected to social pressure, scare tactics, guilt, and threats from some physicians to terminate the relationship with the patient (Welch 2010). Similarly, the emphasis on early detection results in women blaming themselves if their cancer is not detected at an early stage.

The promotion of research to make screening programs find ever more cancers is also criticized. One-third of diagnosed breast cancers might recede on their own (Aschwanden 2009). Screening mammography efficiently finds non-life-threatening, asymptomatic breast cancers and pre-cancers, even while overlooking serious cancers. According to H. Gilbert Welch of the Dartmouth Institute for Health Policy and Clinical Practice, research on screening mammography has taken the "brain-dead approach that says the best test is the one that finds the most cancers" rather than the one that finds dangerous cancers (Aschwanden 2009).

Independence of breast cancer organizations

Some critics say that breast cancer awareness has transformed the disease into a market-driven industry of survivorship and corporate sales pitches (Ave 2006; King 2006). Corporate marketing machines promote early detection of breast cancer, while also opposing public health efforts, such as stricter environmental legislation, that might prevent the disease entirely. These critics believe that some of the breast cancer organizations, particularly the highly visible Susan G. Komen for the Cure, have become captive companies that support and provide social capital to the breast cancer industry, including big pharma, mammography equipment manufacturers, and pollution-causing industries, as well as large corporations, creating or exacerbating other problems.

For example, Ford Motor Company ran a "Warriors in Pink" promotion on their Ford Mustang sports car, which critics say was intended to sell cars and counter the bad publicity the company received by reducing its workforce by tens of thousands of people, causing many of them to lose their health insurance, rather than to prevent or cure breast cancer (Sulik 2010, page 130-135).

However, the primary sponsors are part of the breast cancer industry, particularly cancer drug makers like AstraZeneca, Bristol-Myers Squibb, and Novartis. Because the national breast cancer organizations are dependent on corporate sponsorships for survival, this situation may represent a conflict of interest that prevents these organizations from representing the needs of current and future people with breast cancer when those needs conflict with the profit-making motives of the corporate sponsors. To avoid offending sponsors or to woo new ones, breast cancer organizations may self-censor their message and oversell options like screening mammography and new chemotherapeutic agents (Sulik 2010, page 209–210).

The structure of the breast cancer movement may allow large organizations to claim to be the voice of women with breast cancer, while simultaneously ignoring their desires (Sulik 2010, page 376).

Some breast cancer organizations, such as Breast Cancer Action, refuse to accept funds from medical or other companies they disapprove of.

Environmental breast cancer movement

Most of the money raised by advocates is spent on advertising, increased awareness, cancer screening, and existing treatments (Ave 2006). Only a small fraction of the funds is spent on research, and most of that funding is spent on research to improve diagnosis and treatment of breast cancer. To the dismay of advocates like Breast Cancer Action and women's health issues scholar Samantha King, relatively little money or attention is devoted to identifying the non-genetic causes of breast cancer or taking steps to prevent breast cancer from occurring (Ave 2006). The mainstream breast cancer culture is focused on a cure for existing breast cancer cases, rather than on preventing future cases.

As a result, screening mammography is promoted by the breast cancer industry as the sole possible approach to public health for breast cancer (Sulik 2010, page 204). Alternatives, such as pollution prevention, are largely ignored.

As the majority of women with breast cancer have no risk factors other than sex and age, the environmental breast cancer movement suspects pollution as a significant cause, possibly from pesticides, plastics, or petroleum products (Ehrenreich 2001). The largest organizations, particularly Susan G. Komen for the Cure and the American Cancer Society, are not part of the environmental breast cancer movement (Ehrenreich 2001). These organizations benefit the most from corporate sponsorships that critics deride as pinkwashing, e.g., polluting industries trying to buy public goodwill by publishing advertisements emblazoned with pink ribbons, rather than stopping their pollution under the precautionary principle (King 2006, pages 1–2).

Samantha King says that prevention research is minimized by the breast cancer industry because there is no way to make money off of cases of breast cancer that do not happen, whereas a mammography imaging system that finds more possible cancers, or a "magic bullet" that kills confirmed cancers, would be highly profitable (King 2006, page 38). This prejudice applies equally to breast cancer organizations, because a reliable form of prevention would deplete their future supply of dedicated volunteers.

Dissent through art

While the pink ribbon culture is dominant, cracks in the façade of unity show through. The environmental breast cancer movement is one type of dissent. Another is the rejection of compliant optimism, aesthetic normalization, and social pleasingness that the pink ribbon culture promotes (Sulik 2010, pages 229–377).

In 1998, the Art.Rage.Us art collective published a book that collected some of the art work from their traveling collection. This included art that was shocking, painful and realistic rather than beautiful, such as several self-portraits that showed mastectomy scars (Sulik 2010, pages 326–332).

Another art form has a wider range: the illness narrative has become a staple of breast cancer literature. This may take the form of a restitution or cure narrative (the protagonist seeks a physical or spiritual return to a pre-diagnosis life), a quest narrative (the protagonist must meet a goal before dying), or a chaos narrative (the situation inexorably goes from bad to worse). The cure and quest narratives fit neatly with the breast cancer culture. Chaos narratives, rarer with breast cancer, oppose it (Sulik 2010, pages 321–326).

History

Breast cancer has been known and feared since ancient times. With no reliable treatments, and with surgical outcomes often fatal, women tended to conceal the possibility of breast cancer as long as possible. With the dramatic improvement in survival rates at the end of the 19th century—the radical mastectomy promoted by William Stewart Halsted raised long-term survival rates from 10% to 50%—efforts to educate women about the importance of early detection and prompt action were begun (Olson 2002, page 1; King 2006, page xix).

Early campaigns included the "Women's Field Army", run by the American Society for the Control of Cancer (the forerunner of the American Cancer Society) during the 1930s and 1940s. Explicitly using a military metaphor, they promoted early detection and prompt medical intervention as every woman's duty in the war on cancer. In 1952, the first peer-to-peer support group, called Reach to Recovery, was formed. Later taken over by the American Cancer Society, it provided post-mastectomy, in-hospital visits from women who had survived breast cancer, who shared their own experiences, practical advice, and emotional support, but never medical information. This was the first program designed to promote restoration of a feminine appearance, e.g., through providing breast prostheses, as a goal (Sulik 2010, pages 37–38).

Organizations

A wide variety of charitable organizations are involved in breast cancer awareness and support. These organizations do everything from providing practical support, to educating the public, to dispensing millions of dollars for research and treatment. Thousands of small breast cancer organizations exist. The most largest and prominent are:

Susan G. Komen for the Cure: Komen is the largest and best funded organization, with highly visible fundraisers. They represent the good, hopeful, happy, unified survivors who have embraced pink ribbon culture.
National Breast Cancer Coalition: This large umbrella organization played key roles in several prominent pieces of American legislation, such as the creation of the United States Department of Defense's Breast Cancer Research Program, genetic non-discrimination laws, and the patients' bill of rights. They are committed to evidence-based medicine.
Breast Cancer Action: Famous for its "Think Before You Pink" campaign against pinkwashing, BCA emphasizes the need for research into pollution as a cause of breast cancer. Like the National Women's Health Network, they refuse funding from any group that may have a conflict of interest, such as pharmaceutical companies, medical imaging companies, or pollution-causing industries.
National Breast Cancer Organization: Closed in 2004. A dissenter to the notion of mandatory public unity, it provided case management and other services.
New York State Breast Cancer Support and Education Network (US): An association of groups in New York that are not affiliated with Komen, they are committed to evidence-based medicine rather than conventional wisdom.
Breast Cancer Fund: Like Breast Cancer Action, they are a key player in the environmental breast cancer movement.

While the large organizations dominate the media, most of the practical, day-to-day support for women with breast cancer is provided by small, local groups. While providing the bulk of unglamorous, practical assistance, like driving women to and from medical appointments, these organizations typically struggle for funding in the shadow of the large groups (Sulik 2010, page 53).

Notes

As an example, the State of Texas pays for breast cancer treatment in women whose income is 200% of the Federal Poverty Income Guideline, but to be screened or treated for hypertension, diabetes mellitus, or lung cancer, the income limit is 185% of FPIG.

References

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