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This introductory chapter sets out the book's purpose, which is to chronicle the often turbulent history of screening mammography since its introduction in the early 1970s. The book makes five key points. First, it shows how pivotal decisions during the initial roll-out of mammography made it all but inevitable that the test would never be far from controversy. Second, the book describes how, at several key points in its history, the establishment of a culture of mammography screening was greatly aided by concurrent social and political forces and movements. Third, the book illustrates how politics came to dominate the debate, eventually achieving primacy over science itself. Fourth, it describes the collateral economy that developed around screening.

This chapter examines three principal movements that set the stage for the auspicious debut of the process of mammography screening. First, the passage of the National Cancer Act of 1971 provided massive new federal funding for the United States's anticancer effort and significantly elevated the status of the National Cancer Institute (NCI). Of all its provisions, the allocation of $90 million to fund cooperative cancer control programs with state or private agencies would prove pivotal in the establishment of mammographic screening. Second, the women's health movement of the 1960s and 1970s, which was intertwined with the feminist movement of the same period, was motivated by a viewpoint that women did not have ultimate control over their own bodies and their own health. Third, the American Cancer Society's (ACS) efforts against cervical cancer that began in the 1950s would come to define its approach to screening mammography some decades later.

This chapter details the American Cancer Society's massive Breast Cancer Detection Demonstration Project (BCDDP) launched in 1973, when most Americans had never heard of mammography. The BCDDP completed the initial round of screening on 270,000 women in the first two years of the program. The new screening test rapidly achieved widespread public acceptance and there was a fresh sense of optimism about the potential of modern medical technology to conquer breast cancer. However, mammography's growing reputation was marred by the controversy over the risk of radiation-induced breast cancer posed by screening, particularly to younger women. In January 1976, Dr. John C. Bailar III, National Cancer Institute (NCI) deputy associate director for cancer control, published “Mammography: A Contrary View” in the Annals of Internal Medicine. In it he detailed his analysis of the radiation hazards associated with screening mammography.

This chapter discusses the legacy of the Breast Cancer Detection Demonstration Project (BCDDP), which was concluded in 1981. According to sociologist Maren Klawiter, the BCDDP represented a shift of the “mammographic gaze” into asymptomatic populations. Prior to this time, mammography was a diagnostic (as opposed to a screening) test, used to evaluate women with signs or symptoms of breast cancer. As the mammographic gaze became fixed on the population of women without symptoms, the message of early detection changed. Another important consequence of the BCDDP was the rapid diffusion and adoption of a new breast cancer screening paradigm. The concept that perfectly healthy women exhibiting no signs of disease should be regularly screened with mammography had become widely accepted by the public. Screening mammography joined breast self-examination and clinical breast examination to form a new screening triumvirate that still stands today. The BCDDP also spurred major improvements in mammographic quality.

This chapter first details the emergence of the AIDS epidemic in the 1980s and the events that galvanized AIDs activism and led to important victories on both the legislative and the scientific fronts. It then describes the emergence of the modern breast cancer activist movement during the period from 1987 through 1992. Though it began slowly, it quickly gained steam and became a formidable social and political force in a very short space of time. Taking note of the successes of militant AIDS activism, breast cancer survivors started forming their own organizations and adopted the direct political action model of AIDS activists. It wasn't long, however, before tensions arose between the two activist communities. In 1990, U.S. government research expenditures were $1.1 billion for AIDS and $77 million for breast cancer. Breast cancer activists condemned this funding discrepancy, given that breast cancer had claimed six times as many lives in the past decade as had AIDS.

This chapter details the re-emergence of a controversy in the 1990s, which nearly brought the ascendancy of mammography to a complete halt. The controversy stemmed from the results of a major mammography screening trial performed in Canada, which showed that after eight years of follow-up, routine mammography did not reduce the death rate from breast cancer among women forty to forty-nine. In fact there were 36 percent more breast cancer deaths in the group that received annual mammography and physical examination of the breasts, than in the usual care group had one initial physical examination of the breasts but no subsequent examinations and no mammography. Almost immediately, the Canadian Trial came under a barrage of withering criticism. In lay and professional publications, the backers of screening for women under fifty, led by the American Cancer Society and the American College of Radiology, denounced the study as so deeply flawed that its results were untrustworthy and should be ignored.

This chapter begins by detailing another controversy that mammography became embroiled in the fall of 2009. In October 2009, the American Cancer Society's chief medical officer Dr. Otis Brawley admitted in a New York Times interview that American medicine has overpromised when it comes to screening and that the advantages to screening have been exaggerated. This article, widely reported on in the lay press, drew renewed attention to one of the potential downsides (harms) of screening and forced the American Cancer Society (ACS) to acknowledge that its “one simple message (just do it!)” approach to mammography promotion may have done American women a disservice. The chapter then argues that this may be the last time there is a heated national debate on mammography screening for a number of reasons. First, the underlying science is not likely to change. After many large scientific trials and real-life experience spanning the past forty years and more, we know that screening mammography reduces deaths from breast cancer. Second, the fight over screening women under fifty has always been about access. At both the federal and state levels, political leaders have made the decision that American women have a right to screening mammography starting at age forty.

This chapter details the advent of breast cancer cause-related marketing. Cause-related marketing is a strategy whereby a company enhances its public image and drives consumers to its products by affiliating itself with a favored cause or issue. Breast cancer cause-related marketing has benefited from mammography screening in three principal ways. First, it was the mammography-induced breast cancer “epidemic” of 1987–1991 that led to the emergence of a new wave of activism which drew the attention of the nation and its political leaders to this disease. Second, for every woman diagnosed with breast cancer, there are at least an additional twenty people—family, close friends, co-workers, and others—who are “touched” by the diagnosis. These are the individuals who are most likely to be influenced by pink marketing. Finally, the frequent, well-publicized mammography controversies over the past twenty years and more have kept breast cancer a “hot topic” in the public square.

This chapter discusses mammography-induced breast cancer overdiagnosis, which represents the most significant detrimental consequences of screening. Until recently the issue has received almost no mention in the public education messages of government, advocacy, or professional entities. This deafening silence reflects the long-standing aversion of the proscreening community to any public discussion of mammography's limitations. They have been fearful of “confusing” women with “mixed messages” on screening. The chapter argues mammography-induced overdiagnosis, particularly of ductal carcinoma in situ (DCIS), is the most significant risk of screening. While the subject is complex, the proponents of screening must do a better job of educating the public about this issue. Despite the myriad controversies in its more than forty-year history, mammography remains an indispensable tool in the fight against breast cancer.