The not so rosy side of breast cancer pink ribbons

National Breast Cancer Awareness month celebrates its 26th anniversary this year, and pink seems to be everywhere. Even football players are wearing pink. Have you ever wondered how this campaign began and what impact it is actually having on the prevention of breast cancer? Personally, I didn't give it much thought, that is until I was diagnosed with breast cancer. Before then, I rather naively assumed that anything pink was linked to a benevolent organization that was supporting the critical research needed to prevent the disease. That's why it came as a total surprise to realize that when it comes to the pink movement it seems there's a whole lot of gray.

Before I get to the gray, here's a brief history of the pink. Back in 1985, National Breast Cancer Awareness Month (NBCAM) was organized through the sponsorship of Astra Zeneca, a pharmaceutical company, the American Academy of Family Physicians, a medical society, and CancerCare, Inc., a non-profit. More on this later, suffice to say for now that their purpose in forming NBCAM was to "promote breast cancer awareness, share information on the disease and provide greater access to screening services." NBCAM's initial week long event spawned what is now an internationally recognized month devoted to breast cancer awareness.

On to the story of how breast cancer awareness became wrapped up in a pink ribbon. In the early 1990's, activist Charlotte Haley was inspired by the yellow ribbons tied on trees to honor American soldiers. She decided to make peach ribbons in her home and distribute them in an effort to raise public awareness about the National Cancer Institute's small percentage (5%) of their then $1.8 billion budget going towards cancer prevention.  Her efforts caught the attention of Estee Lauder and Self Magazine executives. They contacted Charlotte about joining her efforts.  She refused saying they were "too commercial". The attorneys at Self Magazine suggested that the color of the ribbon be changed in order for Self to use the concept. That's when the pink ribbon began to be associated with breast cancer, and shortly after Avon began their breast cancer cause related marketing campaign. 

Now, there is absolutely nothing wrong with pink ribbons, or raising money for cancer research, or providing greater access to mammography for the under or uninsured. When done altruistically, these are extraordinary  things. What is disconcerting is when pink ribbons are used to boost a company's profits or image under the guise of philanthropy. Unfortunately, it seems that breast cancer has become big business. It's because of those seeking to profit from breast cancer that some critics of NBCAM are now referring to it as "BCAM SCAM", or Breast Cancer Industry Awareness Month.  But how is it that such a noble and worthy cause has come to be viewed by some as a scam? To answer this question, a little research, along with some open minded consideration, is required.

When it comes to the public's health, the primary goals of health officials are prevention, intervention and eradication of disease, with prevention being preferable to intervention (McKenzie). For example, "immunizing to prevent a disease is preferable to taking an antibiotic to cure one" (McKenzie). Case in point, the human papillomavirus (HPV) vaccine and cervical cancer. Yet, when we look at the pink ribbon message, it focuses not on prevention, but detection and cure. Wait a minute. If prevention is preferable, why is the push for detection and cure? Because the detection and treatment of breast cancer has become a multi-billion dollar industry. Simply stated, prevention just isn't as profitable.

Skeptical? Perhaps a closer look at NBCAM might provide additional insight. Their organization was formed by Imperial Chemical Industries, the creator of Tamoxifen, a breast cancer treatment drug. In the 90's, Imperial Chemical Industries spun off Zeneca Group. Then Zeneca merged with Astra and became Astra Zeneca, which formed a non profit arm that is known today as AstraZeneca Healthcare Foundation, one of the largest financial contributors to NBCAM.  Astra Zeneca also created and markets Arimidex, another breast cancer treatment drug. CancerCares was also involved in the formation of NBCAM. A look at their donors reveals several pharmaceutical companies as well. So, what message would you want to spread if you were a drug manufacturer financially invested in breast cancer treatment medications? Probably not prevention. Might this explain NBCAM's focus on awareness and detection? To be clear, I'm in no way suggesting that awareness, screening and early detection of breast cancer is negative. The point is non-profit organizations accepting donations from companies that stand to gain from their philanthropy seems to represent a conflict of interest.

The pink campaign isn't only effected by conflicts of interest. There are also the companies that profit from linking their products to the breast cancer cause. At first glance this may seem altruistic, but sometimes things aren't always as transparent as they seem. For example, 12 years ago Yoplait began a pink ribbon campaign called Save Lids to Save Lives. A portion of the proceeds from the sale of their yogurt are donated for breast cancer research. The conflict resulted from their yogurt being made with milk from cows that were given a synthetic growth hormone, called rBGH. This chemical has been linked to breast cancer and is banned from use in many countries. You can read more about the topic here, and Oregon Physicians for Social Responsibility has an interesting video discussing rBGH and milk found here or click on the Videos tab in this blog.

The term "pinkwasher" has been used to describe a company "that purports to care about breast cancer by promoting a pink-ribboned product, but manufactures products that are linked to the disease" (Breast Cancer Action). When you consider that Yoplait was both contributing to and profiting from breast cancer, one could say they were successful at "pinkwashing." Thankfully, because of pressure brought about by health activist groups, like Breast Cancer Action and their "Put a Lid on It" campaign, as well as concerned consumers, to their credit as of 2008 Yoplait has stopped using rBGH milk in their yogurt.

The above is just one example of pink ribbon profiteering. Breast Cancer Action has some great information on their Think Before You Pink site to help guide consumers when purchasing "pink" products. They suggest asking the following questions:

1. How much money from your purchase actually goes toward breast cancer?
2. What is the maximum amount that will be donated? Sometimes contributions are capped at a certain amount. 
3. How are the funds being raised? 
4. To what breast cancer organization does the money go, and what types of programs does it support?
5. What is the company doing to assure that its products are not actually contributing to the breast cancer epidemic? 

You can find a more detailed discussion of these points here.

In a recent post I mentioned my support of the Love/Army of Women, a non-profit foundation dedicated to stopping breast cancer before it starts.  At first inspection I felt this group represented something that I feel is of critical importance - the need for more research into the prevention of breast cancer. However, after closer scrutiny I realized that this group is funded through a grant from Avon. This cosmetics company uses a number of chemicals in their products that have been linked to cancer through standard laboratory feeding tests done on mice and rats by the National Toxicology Program. Their study results have been published and accepted by the International Agency for Research on Cancer. A perfect example of the importance of the need to "think before I pink."

A final thought. On my last visit to the doctor she mentioned that Tamoxifen is now being recommended as a breast cancer prevention treatment for women who are considered to be at high risk for developing the disease. I was hoping that more breast cancer prevention research would be focused on how to reduce our exposure to cancer causing agents, such as the above-mentioned chemicals. Sadly, this doesn't appear to be a research priority, but it's not that surprising.  All things considered, I suppose drugs would be the first line of defense offered for prevention, if the pharmaceutical and chemical companies are underwriting a great deal of the research being conducted in the area of cancer prevention. Evidently there isn't anything completely transparent when it comes to this issue. One thing is for certain, pink looked a whole lot rosier before I took off my rose-colored glasses.

Sources
McKenzie, J., et.al., An Introduction to Community Health, 5th Ed., Jones & Bartlett, MA, 2005
http://www.nbcam.org/newsroom_nbcam_facts.cfm
http://bcaction.org/index.php?page=newsletter-88d
http://www.safe2use.com/drsherman/life/15.htm
http://www.cancercare.org/about_us/
http://www.cancercare.org/about_us/annual_reports/2009/donors.php
http://globalrace.info-komen.org/site/PageNavigator/hq_gr_learn_FAQ_2010
http://en.wikipedia.org/wiki/Imperial_Chemical_Industries#History
http://www.cancer.gov/cancertopics/factsheet/Risk/HPV
http://www.ajcn.org/cgi/content/full/86/3/878S
Lancet - Circulating concentrations of insulin like growth factor 1 and risk of breast cancer -  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2897%2910384-1/abstract
Potential public health impacts of the use of recombinant bovine somatotropin in dairy production - http://www.consumersunion.org/food/bgh-codex.htm
Breast Cancer Action - http://thinkbeforeyoupink.org/?page_id=10
http://ntp.niehs.nih.gov/

Breast cancer risk indicators

Wouldn't it be great if doctors had a way to determine our individual risk factors for breast cancer? Then armed with this knowledge we could take specific steps or treatments to prevent the disease? Now you might be thinking, well, there's the mammogram, which has become the gold standard for breast cancer screening. There's also the breast MRI and ultrasound, and let's not forget the clinical or self breast exam. As important and useful as these tools are, they are not about the prevention of breast cancer. The focus of these tests is on detection not prevention, and these are two totally different things.

The National Cancer Institute (NCI) defines cancer prevention as an "action taken to lower the chance of getting cancer". When it comes to disease, prevention really is the best cure. Yet, compared to screening information, not much discussion about prevention is offered to women. 

There are three approaches to disease prevention one can take: reducing risk factors, increasing protective factors or doing both.  Risk factors are defined as anything that increases the chances of getting a disease. Protective factors are anything that helps to reduce the chances of getting a disease. Some risk factors for disease can be avoided and others cannot. For example, tobacco smoking, poor nutrition or lack of exercise can be changed, but a genetic tendency toward cancer cannot. Reducing risk factors and increasing protective factors can help lower the risk of getting cancer, but this doesn't guarantee you won't ever get it either. 

What are the risk factors for breast cancer? According to the NCI, studies have shown the following risk factors:

• Age
• Personal history of breast cancer
• Family history of breast cancer
• Certain breast changes
• Genetic alterations
• Menstrual history
• Race/ethnicity
• Radiation therapy to the chest
• Breast density
• DES (diethylstilbestrol) exposure
• Reproductive history
• Hormone use
• Obesity after menopause
• Physical inactivity
• Alcoholic beverage intake

The good news is that "most women who have these risk factors do not get breast cancer" (NCI). If you're interested in learning more about each of the risk factors listed above you can view more detailed information here. The National Cancer Institute also has an excellent resource called the Breast Cancer Risk Assessment Tool which you can access here. This tool helps estimate a woman's individual risk of developing invasive breast cancer. The NCI points out that no risk assessment tool is 100% accurate and that the tool does have limitations, but it is useful for providing insight into the factors that increase each individual woman's risk for breast cancer. Armed with this knowledge, it can then provide a jumping off point for discussion of an action plan for breast cancer prevention with a health care provider.

If you're considering a breast cancer prevention action plan, experts suggest beginning with specific lifestyle changes to increase the protective factors against developing breast cancer. There are several nutrition and exercise steps you can take, such as limiting alcohol, staying physically active, maintaining a healthy weight, watching the type of fat consumed in your diet (see previous post on understanding the omegas) and eating a diet that is rich in fruits and vegetables. Also, other lifestyle changes like limiting chemical exposure and avoiding antibiotics and hormones found in food can be protective as well (Mayo Clinic and Linus Pauling Institute).

Many of the posts in this blog are focused on providing more information about each of these protective factors against cancer. I believe that when it comes to our health, knowledge is power. It's easy for medical misinformation to result. For example, a news story might have misinterpreted the findings from a research study, or the story that is reported may be a small portion of the bigger picture. In addition to confusing information, medical terminology, data and statistics can often seem overwhelming and frightening.

Rather than living in the shadow of fear that can be created by misinformation and technicality, we can attempt to become empowered by educating ourselves. We can learn more about our own health, beginning with knowing our own realistic level of breast cancer risk. Armed with this knowledge, we can then talk to our medical professional about ways to reduce the risk factors and increase the protective factors that are within our control.  That old saying really is true - an ounce of prevention is worth a pound of cure.



Sources
National Cancer Institute -
Breast Cancer Risk Assessment: http://www.cancer.gov/bcrisktool/
Mammogram: http://www.cancer.gov/cancertopics/factsheet/Detection/mammograms
MRI and ultrasound: http://www.cancer.gov/cancertopics/factsheet/Detection/breast-cancer
Risk factors: http://understandingrisk.cancer.gov/a_breast/01.cfm
Science Daily - http://www.sciencedaily.com/releases/2010/04/100421102338.htm
http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-detection

More on Breast Thermography

When my doctor suggested a breast thermogram he also mentioned that I should check with my insurance company to see if they covered it.  My insurance informed me that this screening test is considered experimental and unproven. I was surprised by this because from what I understand breast thermography has been approved by the FDA since 1983. So what's up?

Well, unfortunately it seems that thermography has become a victim of ethics and politics. According to Dr. William Cockburn, some less than ethical providers aren't adhering to testing protocol, or aren't qualified to interpret the thermograms.  These should always be read by doctors trained in thermography, just as doctors trained in radiology read mammograms. Politically, thermography is seen as competition with mammography. The American College of Clinical Thermography states that thermography  is a supplement to mammography, not a competitor. "In fact, thermography has the ability to identify patients at the highest risk and actually increase the effective usage of mammography."

I found several studies that underscore the effectiveness of thermography in detecting breast cancer. Research reported in the International Cancer Journal suggests that it shows considerable predictive value.  It's important to note that thermography and mammography do not diagnosis breast cancer.  This can only be done by pathology, but both screening tools do aid in detection.  Where thermography shines is in its ability to find abnormalities before they can be seen with mammography. This is especially important for young women who typically have denser breast tissue, which makes detection of irregularities more challenging with mammography. 

Another benefit of thermograms is their cost. Screening mammograms aren't routinely offered to women under the age of 40. Electing to monitor breast health with an annual screening thermogram is a more cost effective option than paying for a mammogram. With the recent advances in digital technology, current research in breast cancer screening is showing that "for breast cancer care, it has become possible to use thermography as a powerful adjunct and biomarker tool, together with mammography for diagnosis purposes." I think a thermogram is worth it.  What do you think?

By the way, if you're interested in finding a qualified thermography clinic in the US, this link lists them by state: http://www.thermologyonline.org/Breast/breast_thermography_clinics.htm
 



Sources:
http://www.breastthermography.org/paradigmshift.html
http://www.thermologyonline.org/Breast/breast_thermography_what.htm
http://www.biomedcentral.com/content/pdf/1471-2407-4-17.pdf
http://informahealthcare.com/doi/abs/10.1080/03091900600562040

Breast thermography?

Isn't technology incredible? Especially when it works. My most recent remarkable medical technology moment occurred the other day when I had a digital infrared thermal imaging (DITI) test. DITI, or thermography, is a no contact, non-invasive screening tool. When I took the test all I had to do was stand in front of the scanner. There is no risk of radiation, no needles and no nuclear dyes.  Ladies, imagine no cold, glass plates clamping down on your sensitive body parts! A screening test with NO side effects.  Like I said, remarkable.


No side effects sounded great, but I wondered how does thermography work? From what I understand, we all radiate infra-red heat (think night vision goggles). Each of us has our own unique heat signature and usually these are fairly symmetrical. Symmetry is important in heat signatures, but more on that later.

Anyway, the thermography technician explained to me that as I stand in front of the scanner it converts the infrared heat radiating from my body into electrical impulses. As the image from Meditherm shows, these impulses are then computer mapped using different colors. A photo is taken of these colored heat patterns. This is called a thermogram. Each color on the thermogram indicates more or less heat coming off the body.

Of course, being the wondering type of person I am,  I questioned why I needed a thermogram when I've already had digital mammograms, a contrast MRI and a sonogram of my breasts. My doctor explained that a thermogram is about looking at physiology, which is the study of the function of the body's systems.  Whereas, a mammogram, MRI and sonogram are all about anatomy, which is the study of the body's physical structures. He went on to say that because of this they can be complementary tests. 

So what is significant about temperature imbalances in the body showing up on a thermogram?  Well, remember I mentioned that symmetry or balance of heat signatures in the body is important. My doctor explained that he compares the heat signatures from one breast with the other.  If an imbalance between them is noted he considers it a "thermal signal." A thermal signal may be the result of "increased vascularity". What's that? Well, it may indicate disease and in some cases cancer. According to the American Cancer Society (ACS), when cancer cells begin to grow they start out by using nearby blood vessels. But the tumor soon outgrows this blood supply and it begins angiogenesis - the growth of new blood vessels.  As a result, increased vascularity, or blood flow, occurs in the area of the tumor. This additional blood supply increases metabolic heat which shows up as a thermal signal on the thermogram.
 
Interestingly, "without new blood vessels, a tumor can't grow larger than about the size of a pin head (about 1 to 2 cubic millimeters)(ACS)." Cancerquest states that "a mammogram can detect tumors at very early stages, when they are around the size of a pencil eraser." So what about the period of growth between pin head and pencil eraser stage? This is where breast thermography is particularly useful. It has the potential to detect problems earlier than mammography and this allows for earlier intervention and treatment.

So you may be wondering, like I was, why thermography isn't offered as a standard screening tool for breast cancer? Why isn't it used in conjunction with mammography? Why doesn't my insurance company cover this test? I'll get into this in my next post.  



Sources:
http://degreedirectory.org/articles/What_is_Anatomy_and_Physiology.htmlhttp://www.meditherm.com/thermography.htm
http://www.acsevents.org/docroot/ETO/content/ETO_1_4X_Why_Do_Tumors_Need_Their_Own_Blood_Supply.asp
http://www.cancerquest.org/index.cfm?page=3223#Q19
http://www.radiologyinfo.org/en/info.cfm?pg=bodymr