Earlier this week I listened to a radio broadcast in which a woman in her 20s with breast cancer described how she examined her breast and found a lump. She is now being treated for breast cancer. The interviewer, an older woman, interviewed her gently with empathy. There was no challenge, as there would have been to a politician, and the result was misleading and probably harmful messages.
The peg for the interview was the death from breast cancer of Kris Hallenga, the founder of CoppaFeel!, a breast awareness campaign. Hallenga was clearly a remarkable woman full of pazazz and humour. As the website of CoppaFeel! says: “In 2009 Kris was diagnosed with secondary breast cancer at the age of 23, after being turned away from her GP for over a year. By the time she was diagnosed, it was terminal. Kris’ ambition was for no one else to find themselves in her position and so CoppaFeel! was born, to ensure breast cancers are diagnosed early and accurately.” https://coppafeel.org/
The broadcast wanted to pay tribute to Hallenga’s life and achievements in a sensitive way and interviewing a young woman with breast cancer naturally seemed a good way to do so. In the context of the death of one young woman from breast cancer and interviewing another young woman with breast cancer, how could the interviewer do anything but let the young woman tell her story and conclude with the message that all women, including women in their 20s, should examine their breasts regularly?
It seems self-evident that examining your breasts regularly is a good thing to do. How could it not be? But, as all doctors know, many things that seem obviously beneficial can actually be harmful, and evidence suggests that that is the case with breast self-examination, particularly in young women.
One obvious problem with the broadcast was that hearing about two women who developed breast cancer in their 20s inevitably gave the impression that this was common. In fact, it’s extremely rare. In the UK there are on average in a year two cases of invasive breast cancer in every 100 000 women aged 20-24 and 11 cases for every 100 000 in women aged 25-29. There were no cases of what Cancer Research UK calls “breast carcinoma in situ” among women aged 20-24 and one case per 100 000 women in women aged 25-29.
As I’ve blogged before, breast carcinoma in situ or ductal carcinoma in situ (DCIS) is a confusing condition that may or may not progress to invasive cancer. https://blogs.bmj.com/bmj/2011/09/07/richard-smith-communicating-with-patients-about-ductal-carcinoma-in-situ/ A graph of age-specific incidence looks very odd because it has a big spike at age 50-54 while invasive breast cancer incidence rises progressively to peak at age 65-70. Breast cancer, like most (but not all) cancers is a disease of older people (men get breast cancer as well). Breast carcinoma in situ peaks at age 50-54 because women in Britain are routinely offered mammography at age 50, and breast carcinoma in situ is diagnosed mostly by mammography. Very few women in their 20s will have a mammogram, explaining the almost non-existent cases of breast carcinoma in situ in women in their 20s.
Many, even most, people in Britain think that breast cancer is a disease of young women rather than old women, largely because of the great attention paid to young women, particularly celebrities, who develop breast cancer. This week’s broadcast would have strengthened that misperception and it wouldn’t have been insensitive of the broadcast to state that cancer in woman in their 20s is extremely rare.
But the bigger misperception was to encourage young women to regularly examine their breasts. This is the conclusion from the Cochrane Library systematic review of breast self-examination: “Data from two large trials do not suggest a beneficial effect of screening by breast self‐examination but do suggest increased harm in terms of increased numbers of benign lesions identified and an increased number of biopsies performed. At present, screening by breast self‐examination or physical examination cannot be recommended.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7387360/
In other words, lives are not saved by breast self-examination but a lot of women will have biopsies without benefit and naturally the finding of a lump will make women anxious, particularly as many people think that cancer leads to death. It’s a matter of false-positives, a signal (the examination) that something is wrong when it isn’t. False positives will be particularly common in women because true-positives, the signal (the examination) that something is wrong when it is are vanishingly rare because hardly any women in their 20s develop breast cancer.
How could the broadcast have avoided promoting these misperceptions? One option would have been not to have had the broadcast at all, and that probably would have been the best option. Another option would have been to interview after the young woman a doctor knowledgeable about breast cancer who could have corrected the misperceptions, but that would have cast a cloud over Hallenga’s work. Silence is often the best option.
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