Effective Clinical Practice
LETTER TO THE EDITOR
I read with great alarm your article "Misleading Presentation of Breast Cancer in Popular Magazines." (1)
To suggest that the portrayal of young women being at risk for breast cancer is causing unnecessary and unrealistic fear is a rather worrisome position for the medical community to take and for a respected journal like ecp to report.
While it is indeed true that younger women are less at risk for breast cancer than older women, young women certainly can and do do get breast cancer. And when we do, it's usually a more aggressive and more fatal form of the disease than that of our older counterparts.
Why? Unfortunately, lack of knowledge and awareness play a major role in a young woman's later detection and diagnosis. Young women themselves "know" intuitively that breast cancer is an older woman's disease—something that only happens to Grandma—and assume that they are not at risk because they are too young.
Even worse, most doctors determine that younger women who present with a lump are also "too young," and tell their patients to wait a few months and come back if it hasn't gone away, rather than taking appropriate steps to diagnose the problem. Sending the patient away undiagnosed compromises her chances of early diagnosis and increases her chances of dying of the disease. An educated, aware young woman is less likely to be ignored by her doctor.
This deadly combination of misconceptions frequently results in a later-stage diagnosis for premenopausal women. Our role as a minority in the breast cancer world severely compromises our ability to be properly screened, diagnosed, and treated.
Another of the largest impediments for young women is that there is no available screening for the disease. The recommended age for mammography as an annual screening tool is 40, and the denser breast tissue in young women is not accurately penetrated by mammography, rendering it an ineffective tool for detection in young women.
The Washington Post's coverage of this study provided an unreferenced statistic (2): "In the United States, 16 percent of breast cancer cases occur in women under age 50, and only 3.6 percent occur in women under 40." But for the statistics to be accurate, young women would also need a screening tool. Postmenopausal women have mammography. We only have our fingers—if we are educated enough to do monthly breast self-examinations. Are the researchers sure that we are all being counted? And wouldn't we prefer to be counted as a stage 1 disease rather than a stage 4?
The truth is, there is a fine line between fear and caution. We fear car accidents, so we wear our seatbelts. We fear breast cancer, so we do a breast self-examination every month, and when we present to our primary care giver, we don't stop asking questions until we are properly diagnosed. In car accidents, we have found that children are less likely to survive an accident, so we did the research and created a special seat for them and increased their chances at survival. They are just a small portion of the population, but we considered them important enough to pay special attention to.
The media's efforts to bring awareness to the fact that young women can and do get breast cancer is helping more premenopausal women survive. While we can't condone the use of sensationalism to create fear in reader's minds, we commend the magazines for calling attention to the fact that every woman is at risk, and the best chance for beating this terrible disease comes from education and awareness of risk, signs, and symptoms and how to advocate for your own health care.
Our numbers may indeed be small, but we will certainly not continue to die "politely" as a continually overlooked and misdiagnosed minority. The YSC supports responsible depiction of the real women who are living with, and dying from, the disease they were not supposed to be at risk for.
Thank you for reminding us exactly how much work we still have to do to change perceptions within the medical community, the media, and the population at large.
Educational Programming and Medical Outreach Officer
Young Survival Coalition
New York, NY
The media today is increasingly bombarding the public with misleading and sensational information regarding diseases and their therapies, especially in light of direct-to-consumer advertising by the pharmaceutical companies. It is exactly this state of affairs that makes the article by Burke and colleagues' (1) examination of the issue of representation of breast cancer in popular magazines most relevant. However, I believe further limitations of this study other than those noted by the authors should be raised.
Besides the six journals cited in Table 1, the authors provided no further descriptive information regarding the remaining 46 journals that were reviewed. The hard truth is that magazines publish articles that appeal to the greatest number of their readers. Obviously, more details about the readership characteristics, specifically their median age, may have explained why age misrepresentation was a factor.
I also believe that there is inherent bias in two of the four themes that were chosen to assess these articles. How breast cancer affected mothers of small children and/or their experiences with dating or marriage is extremely subjective and open to a large degree of interpretation. Furthermore, the fact that these themes were common in the articles reviewed speaks to the notion that most of these magazines were geared toward a young female population. Again, the editors' decision to focus on these issues may have been motivated by the characteristics and interests of the magazine's readership.
Finally, there was no indication that these articles were evaluated for the presence of accurate screening information. I wholeheartedly agree that inaccurate representation of the frequency of breast cancer in younger women may lead to paranoia; however, a healthy fear of the catastrophic consequences of missed screening opportunities is crucial to women of all ages. If the importance of screening was in fact discussed in these articles, I believe we should extend to the editors of these magazines a certain degree of leniency.
Steven John Angelo, MD
Assistant Clinical Professor
Yale University School of Medicine
Hospital of Saint Raphael
New Haven, CT
1. Burke W, Olsen AH, Pinsky, LE, Reynolds SE, Press NA. Misleading presentation of breast cancer in popular magazines. Eff Clin Pract. 2001;4:58-64.
2. Boodman S. Too young to die. Washington Post. 2001; 1 May.
THE AUTHORS RESPOND
For those affected, early breast cancer is a potential tragedy. Thus, we share Ms. Rosenberg's concern about the lack of breast screening options for young women, and we agree that early breast cancer is an important health concern. However, we question her conclusion that the publication of our study, documenting a skewed presentation of breast cancer in popular magazines, is a cause for "great alarm." Ms. Rosenberg rightly notes that delayed diagnoses of breast cancer can occur as a result of misperceptions about risk on the part of both patients and doctors. Neither this concern nor the lack of effective screening measures for young women constitute a reason to promote or endorse inaccurate health messages in the popular media. Rather, we believe that women are best served by reliable health information that they can use to make reasoned judgments about their health care. Women need to know that breast cancer can occasionally occur at an early age, but they also need to understand the relationship between age and risk. The "unsourced" data to which Ms. Rosenberg refers are the National Cancer Institute statistics on breast cancer incidence that were quoted in our article. They demonstrate the rising incidence of breast cancer with age and thus the importance of continued breast cancer screening as women enter their 60s and 70s. Messages that emphasize breast cancer in women under 50 may convey inappropriate reassurance to older women.
We also agree with Dr. Angelo that the misrepresentation of breast cancer found in our sample of popular magazines may be explained by the demographics of magazine readership. Although published information on magazine readership is limited, the available data suggest that the average age of readers for the magazines we sampled ranges from the early 30s to the 40s. This is consistent with the mean age of diagnosis of 41 for the breast cancer vignettes we analyzed. While this similarity may help to explain the problem, it does not minimize the effect of the age misrepresentation. Dr. Angelo also notes the importance of evaluating media coverage of screening. Our sample was designed to bracket the two National Institutes of Health consensus conferences on mammography screening, held in 1993 and 1997, and an analysis of the coverage of mammography in this sample is under way.
Ms. Rosenberg states that "there is a fine line between fear and caution." We agree. Health messages intended to promote disease prevention may sometimes cause fear, but the goal should always be to instill caution without unnecessary worry. Messages that generate irrational fear—as may be the case for articles presenting breast cancer as a disease of young women—pose a health problem in their own right. We believe consumers should be able to count on accuracy in articles about health in the popular media. For this reason, instances in which health care topics are misrepresented should be documented.
Wylie Burke, MD, PhD
Departments of Medical Ethics and Medicine
Amy H. Olsen, MD
School of Medicine
Linda E. Pinsky MD
Departments of Medicine and Medical Education
Susan E. Reynolds
Department of Medical History and Ethics
University of Washington
Nancy A. Press PhD
Department of Public Health and Preventive Medicine
Oregon Health Sciences University