Bottle Tops and Breast Cancer: Pushing Mammograms With Every Prescription

Overly simplified messages about early detection too often ends up blaming women for their cancers or gives them false assurances that the treatment they are enduring is ultimately all for the best. Medical advice on a complex issue.
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Why is breast cancer messaging appropriate for Walgreens prescription bottle caps during October?

Over the last few weeks, our beloved (and aged) family dog's health declined rapidly. As a final effort to improve his quality of life, we introduced some new medications to relieve his symptoms. The prescription from Walgreens arrived with a pink cap bearing a pink ribbon and the message "early detection saves lives."

It went without saying: Pink stands for breast cancer. But how big of a success is it that I am not only aware of breast cancer, I am aware of what the pink ribbon stands for?

Thirty years after the launch of an aggressive, pharma-driven breast cancer awareness campaign, awareness and screening remain the dominant message of the breast cancer movement. Why are we singling out breast cancer as the appropriate topic for all prescription bottle caps in the month of October? Breast cancer does not have a lock on disease diagnosis in the month known as "Pinktober." Is this the best public health message for all prescriptions -- human and canine -- filled at Walgreens during October? Catchy messaging like "early detection saves lives" oversimplifies the issues, overlooks the harms of screening and leads to persistent misconceptions and myths.

Mainstream breast cancer organizations continue to focus on screening as the primary tool to address the breast cancer epidemic, despite the fact that mammography screening programs have not produced a significant decline in death rates. Each year nearly 40,000 women in the United States die of breast cancer. The popular early detection mantra conceals some important truths about breast cancer screening.

Mammograms do not prevent breast cancer. They detect some cancers that already exist. They miss other cancers. And they detect tumors that will never become life threatening. At the final calculation, mammograms save fewer lives than commonly assumed. Evidence continues to grow that inherent limitations of mammography combined with the significant harms of aggressive screening are cause for caution rather than promotion of simplistic public health messages on pink prescription lids.

The more we learn about breast cancer, the more we understand this is not a single disease. The term "breast cancer" describes a complex set of diseases that occur in the breast. Unfortunately, we do not have effective treatments for some aggressive, fast-growing breast cancers and, tragically, no matter how early these cancers are found they will prove to be lethal. Other cancers and lesions are slow-growing and may never become life threatening. But because doctors do not know enough about which cancers may be life threatening, they end up treating these non-life threatening cancers with harsh, scarring, life-altering and bankrupting cancer treatments.

To be clear, improved treatments are leading to some better outcomes for some women. But all cancer treatments come with harms which should be avoided except when the benefit can be shown to outweigh those harms. Mammograms are implicated in the over-diagnosis and over-treatment of nearly one third of all newly diagnosed breast cancers. The result is that tens of thousands of women in the U.S. are over-diagnosed and over-treated each year.

The "early detection saves lives" message obscures a nuanced and balanced discussion of the benefits and harms of breast cancer screening by blindly insisting all women, of all ages, participate in aggressive screening, regardless of medical counsel and scientific evidence.

For those women who already have a breast cancer diagnosis, the message is no less complicated. What are those women who are picking up their prescription as part of their breast cancer treatment to think?

What are the tens of thousands of women with metastatic breast cancer -- 40,000 of whom will die this year -- to think? That if only they'd gotten a mammogram sooner they might not be facing this life threatening diagnosis? Such messages overlook the fact that approximately 30 percent of breast cancers, including early stage tumors, will metastasize, spreading to other parts of the body. Are the millions of Walgreens prescription lids bearing this screening message blaming the victim?

At the other end of the spectrum, is this early detection promise meant to reassure women that the treatment they are enduring is for the best? Not all breast cancers are or will become life-threatening. A Norwegian study that included nearly 40,000 women with invasive breast cancer found that up to a quarter of breast cancers were over-diagnosed, meaning that these women received biopsies and treatment for breast cancer that would have either grown very slowly or not at all, and never would become symptomatic or life threatening. For women who are undergoing treatment that has no medical benefit, is the early detection message on the cap of their prescription meant to placate them to overlook the physical, psychological and financial toll of over-diagnosis?

The pink ribbon and simplistic message on the Walgreens pill bottle is a stark reminder of the serious shortcomings of Breast Cancer Awareness Month and the accompanying overemphasis on screening. Too many pink ribbon awareness messages are doing more harm than good, spreading myths and misconceptions and blinding us to the need for primary prevention that stops cancer before it starts and more effective, less toxic treatments that save women's lives. Overly simplified messages about early detection too often ends up blaming women for their cancers or gives them false assurances that the treatment they are enduring is ultimately all for the best. Medical advice on a complex issue does not belong on the tops of prescription packaging. Let us not confuse bottle top awareness with accurate, science-based information that is useful and necessary to women making critical decisions about their health.

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