Search Results

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 explores how the representation of statistical information affects the understanding of risks and uncertainties in medical contexts. Using mammography screening as a prime example, it is shown that problems in understanding and dealing with numbers are often due to poorly designed information environments, rather than to internal deficiencies of the human mind. For three types of statistical information that physicians and patients often encounter—conditional probabilities, single-event probabilities, and relative risks—a representation is proposed that facilitates understanding. These are compared to the representations actually used in published materials about mammography screening. Factors in the environment that can contribute to innumeracy are identified and the question of why risks are not always communicated in a transparent manner is addressed. Finally, recommendations are formulated for changes, in both the information environment and the institutional and legal environments, that could help foster statistical thinking and informed decisions about medical screening.

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.

Using a 2009 American debate on a federal public health recommendation on mammography screening for women younger than the age of 50 as a case study, it is argued that public acceptance of health technology assessment depends on the ethical acceptability of its recommendations. At the same time, that acceptability cannot be separated from the politics and values of the healthcare system of which it is part. In the United States, those values display a sharp ideological split between a conservative individual-based ethic and a liberal communitarian-oriented ethic. A clash of this kind cannot be solved by invocation of ethical principles when it is those principles themselves that are in conflict. Inevitably, acceptance of health technology assessment is threatened by this conflict as is the fate of healthcare reform. In a rather disturbing and paradoxical way, once ethical values become dominant in a political debate, compromise and nuanced dialogue seems to become harder not easier.

This chapter begins with a presentation of the basic principles for early disease detection, such as the disease should be of serious consequence and should have an accepted treatment. It then reviews various approaches to the evaluation of screening programs. These approaches range from descriptive comparisons between populations exposed to screening to randomized population based trials. The advantages of the case-control method for the evaluation of screening programs are presented, such as efficient use of resources and simultaneous evaluation of more than one technique of screening. The final part of the chapter discusses specific problems in the use of the case-control method in evaluating screening programs. It presents two classical case-control studies of evaluation of screening programs for colon cancer and breast cancer.

Evidence and politics intersect in the delineation of policy about prevention. Historically, prevention has played a prominent role in defining the evidence-based medicine movement and creating evidence-based recommendations. Changes in prevention over time make it likely that prevention recommendations and policies in the future will be subject to more heated attempts to politicize them. Evidence-based recommendations face a variety of challenges that affect their relative immunity to political attack. Important differences exist in the evidence standards applied to prevention compared with treatment and diagnostic services; those differences vary in their justifiability. The December 17, 2009, U.S. Preventive Services Task Force mammography screening recommendations provide an interesting case study of the intrusion of politics into prevention policy; in some respects this intrusion is particular to mammography, and in others it applies to prevention as a whole. Particular factors can be identified that tend to politicize health topics in general. There are specific ways, however, in which the corrupting influences of politics on evidence-based prevention recommendations and policies can be mitigated.

This chapter gives a deeper understanding of screening, and of the diverse consequences it brings. It illustrates the over-detection problem with reference to mammography breast screening, and explains the ‘popularity paradox’ that this leads to. In the early days, the simplistic notion that screening must automatically be beneficial meant that people only asked ‘why are we not doing it?’ Later scientific challenges brought a new question: ‘how do we tell if screening succeeds in reducing risk?’ This served well as a driving force for better evaluation, but it ignored the need to assess harmful consequences. Growing experience has revealed the need to ask: ‘what are all the consequences?’ Different observers see some consequences more starkly than others depending on their viewpoint. This chapter explains why it is important that everyone recognizes the complete overview.

This chapter shows how resources, values, beliefs, and commercial factors all influence screening policy, and gives clear insight into some of the ethical dilemmas involved. Case histories include celebrity selling of HPV testing, the USA ‘Mammography Wars’ incident, and genetic testing. The chapter strongly emphasises the value of following robust and explicit processes when making screening policy, and argues that this is best done at national level. The reasons why screening policy-making can be difficult are explored in detail, and clear lessons are drawn from the case examples. The chapter addresses the technical aspects of using evidence. It explains the power of the cultural belief that all screening must automatically be a good thing and of commercial and professional interests, often enacted through invisible lobbying using ‘third party’ techniques. The ethical conflicts inherent within screening are described and explored.

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 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.

Grid computing enables a global e-science infrastructure that has the potential to become a technically complex supercomputing infrastructure, distributed among geographically disparate locations and providing higher processing power and larger data storage. This chapter discusses the importance of a “soft” infrastructure of e-science by focusing on the electronic Diagnostic Mammography National Database (eDiaMoND) pilot project in the United Kingdom. The project was launched to create a database of digital mammography images using Grid technology. The chapter discusses the intellectual property rights and ownership issues concerning images in the eDiaMoND project and highlights the need for e-science collaborations to include, at their project design stage, plans for creating a functioning working culture.

This chapter sets out four ways that misinformation is communicated to women invited to breast cancer screening. These are as follows: tell women what to do without stating the benefits, report relative risks only, report five-year survival rates (which say nothing about mortality reduction), and report absolute risk reduction but use unrealistically high numbers. The chapter shows just how information is skewed to give a false impression of screening benefits and calls for all misinformation to stop. One recommendation is that all pamphlets show a “fact box” that explains benefits and harms in a transparent way. All women and women’s organizations should tear up the pink ribbons and campaign for honest information.

Contemporary U.S. health care is characterized by the under-use of services known to improve patients’ outcomes and the over-use of services beyond what can benefit patients. Large proportions of Americans are not receiving treatment that is in accordance with evidence showing what works best for their conditions. The situation is allowed to continue because of payment policies that reimburse physicians and hospitals for the services they deliver on the basis of volume rather than appropriateness, evidence of effectiveness, or value. Our outlays for health insurance premiums, deductibles, and co-payments are buying us suboptimal medical care. If more and better comparative effectiveness research is to increase the value of the dollars we spend on health care, patients, providers and third party payers must become better students of medical evidence, and payment policies and the organization of health services must be reconfigured to align medical care with evidence.

This chapter provides an overview of the public health significance of breast and cervical cancer. It discusses disparities in incidence and mortality rates according to race, ethnicity, urban versus rural residence, and geographic locality; the primary prevention of breast cancer; the primary prevention of cervical cancer; breast cancer screening through screening mammography; and cervical cancer screening. It highlights the important role of community-based participatory research (CBPR) in addressing breast cancer and cervical cancer in diverse communities, including faith-based interventions. Finally, it discusses lessons learned from CBPR studies on breast and cervical cancer screenings and makes recommendations for further research. Additional CBPR studies are needed to address breast and cervical cancer screening in population subgroups where screening rates are relatively low.