Can New Breast Cancer Screening Recommendations Help Reduce the Harm of Cancer Phobia?

Research finds that some early screening for breast cancer may do more harm than good. But that’s what the numbers say. How will women feel?

For decades, cancer has been the disease people fear most. Understandably. Study of the psychology of risk perception has established that we worry more about risks over which we have no control, and “You have cancer” has always seemed like an inescapable, can’t-do-anything-about-it death sentence. We are more afraid of threats that involve greater pain and suffering — what the academics call "dread" — and many of the more than 150 types of cancer certainly involve great suffering. We are more afraid of risks that seem like they are imposed on us, caused by something done to us by others, and decades of advocacy campaigns have created a widespread belief that cancer is caused by external environmental triggers far more than is the case.

Against all this fear of cancer we are only beginning to realize that the fear itself may cause serious harm, in some cases more than the disease itself. The American Cancer Society’s new recommendations on breast cancer screening (spelled out in far more detail here) imply precisely that. They recommend that:

+ women not otherwise at high risk not begin screening until age 45, the average age at which breast cancer really begins to spike (previously they recommended starting at age 40),

+ that women screen less frequently after age 55 (once every other year instead of annually, because breast cancers grow more slowly after menopause),

+ and that breast exams no longer need be part of regular visits to the doctor.

It recommends all these changes, it says, because the evidence shows that earlier screening, more frequent post-menopausal screening, and regular exams by doctors don’t save any lives.

It’s going to be really hard for women who have always believed that earlier and more frequent screening gives them something they can do to reduce their risk, to let go of that reassuring sense of control, and screen less.

What it also says, bravely, is that those earlier and more frequent screenings appear to do more harm than good. They turn up all sorts of false positive or equivocal results that scare women into biopsies, follow-up tests, mastectomies, and cause chronic worry and stress, all of which do real physical harm, even though the evidence finds that, across the whole population, screenings earlier and more frequently than these recommendations do not save lives. Many early screening tests turn up Ductal Carcinoma In Situ (DCIS), which in many cases never grows or spreads, and frequently just disappears on its own. Yet many DCIS cases get treated like full-blown life-threatening disease because, let’s face it, when a woman hears she has a lump or a shadow in her breast, and its description has the word carcinoma in it, what’s she going to do? Wait and see what happens?

These new recommendations will be surely controversial. Experts will debate the epidemiological evidence of whether early and more frequent screening save lives. But the real controversy won’t be among those experts and it won't be about the facts. It will be among the women who face these difficult scary choices, and who will view these objective recommendations and the factual evidence through the subjective emotional lens of how the threat of breast cancer feels.

It’s one thing for experts to warn what our fears might cause, as Dr. Nancy Keating essentially did in the Journal of the American Medical Association:

For many years, we convinced everybody, including doctors, that mammograms are the best tests and everyone has to have one. But now we're acknowledging that the benefits are modest and the harms are real.

It’s another for 42-year-old Eunice, who has always been told that screening should start at 40 that now, "Don’t worry, Eunice. It’s okay to wait." It’s another thing to tell 59-year-old Amy, who has always believed that she can reduce her chance of breast cancer with yearly exams that, "Don’t worry, Amy. Every other year is enough." It’s another thing to tell middle-aged Mei Lee that having her doctor — a trusted medical expert — do a reassuring breast exam whenever she visits, is reassurance that has no value.

[T]he real controversy won’t be among those experts and it won't be about the facts. It will be among the women who face these difficult scary choices...

That may be what the facts and the experts say about risks for the average women population-wide, but the deep fear of cancer is going to make it really hard for individual women to consider such expert advice objectively and change how they feel. It’s going to be really hard for women who have always believed that earlier and more frequent screening gives them something they can do to reduce their risk, to let go of that reassuring sense of control, and screen less. Even though that may actually be what’s best for their health.

This isn’t just about breast cancer, or gender. Men make these choices with prostate cancer, screening earlier and more frequently than evidence-based guidelines suggest, doing themselves harm with procedures or surgeries their conditions don’t require. This is also not about what’s right or wrong. Who is to say that a woman who removes a DCIS lump, or a 40-year-old man who risks impotence to remove a slow growing prostate tumor that would probably never harm him, are wrong? Not me. Indeed the fear of cancer is so real it can do lots of serious harm all by itself, from the myriad profound effects of chronic stress, which, among other things, weakens the immune system and makes it more likely you’ll get sick — including develop cancer. Getting rid of the stress from persistent fear is good for health too.

This is about how these new breast cancer screening recommendations are an important step as we enter a new era in our relationship to our most feared disease. Not only are we learning that we are not powerless against cancer — more and more forms of the disease are being successfully treated — but we are just beginning to recognize that fear of cancer can be a risk too, and sometimes that fear can do more harm than the disease itself. For bravely sending that message to women, despite the controversy these new breast cancer screening recommendations will spark, the American Cancer Society is to be applauded.


(Image: Lilli Day, Getty Images)

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A map of America’s most famous – and infamous

The 'People Map of the United States' zooms in on America's obsession with celebrity

Image: The Pudding
Strange Maps
  • Replace city names with those of their most famous residents
  • And you get a peculiar map of America's obsession with celebrity
  • If you seek fame, become an actor, musician or athlete rather than a politician, entrepreneur or scientist

Chicagoland is Obamaland

Image: The Pudding

Chicagoland's celebrity constellation: dominated by Barack, but with plenty of room for the Belushis, Brandos and Capones of this world.

Seen from among the satellites, this map of the United States is populated by a remarkably diverse bunch of athletes, entertainers, entrepreneurs and other persons of repute (and disrepute).

The multitalented Dwayne Johnson, boxing legend Muhammad Ali and Apple co-founder Steve Jobs dominate the West Coast. Right down the middle, we find actors Chris Pratt and Jason Momoa, singer Elvis Presley and basketball player Shaquille O'Neal. The East Coast crew include wrestler John Cena, whistle-blower Edward Snowden, mass murderer Ted Bundy… and Dwayne Johnson, again.

The Rock pops up in both Hayward, CA and Southwest Ranches, FL, but he's not the only one to appear twice on the map. Wild West legend Wyatt Earp makes an appearance in both Deadwood, SD and Dodge City, KS.

How is that? This 'People's Map of the United States' replaces the names of cities with those of "their most Wikipedia'ed resident: people born in, lived in, or connected to a place."

‘Cincinnati, Birthplace of Charles Manson'

Image: The Pudding

Keys to the city, or lock 'em up and throw away the key? A city's most famous sons and daughters of a city aren't always the most favoured ones.

That definition allows people to appear in more than one locality. Dwayne Johnson was born in Hayward, has one of his houses in Southwest Ranches, and is famous enough to be the 'most Wikipedia'ed resident' for both localities.

Wyatt Earp was born in Monmouth, IL, but his reputation is closely associated with both Deadwood and Dodge City – although he's most famous for the Gunfight at the O.K. Corral, which took place in Tombstone, AZ. And yes, if you zoom in on that town in southern Arizona, there's Mr Earp again.

The data for this map was collected via the Wikipedia API (application programming interface) from the English-language Wikipedia for the period from July 2015 to May 2019.

The thousands of 'Notable People' sections in Wikipedia entries for cities and other places in the U.S. were scrubbed for the person with the most pageviews. No distinction was made between places of birth, residence or death. As the developers note, "people can 'be from' multiple places".

Pageviews are an impartial indicator of interest – it doesn't matter whether your claim to fame is horrific or honorific. As a result, this map provides a non-judgmental overview of America's obsession with celebrity.

Royals and (other) mortals

Image: The Pudding

There's also a UK version of the People Map – filled with last names like Neeson, Sheeran, Darwin and Churchill – and a few first names of monarchs.

Celebrity, it is often argued, is our age's version of the Greek pantheon, populated by dozens of major gods and thousands of minor ones, each an example of behaviours to emulate or avoid. This constellation of stars, famous and infamous, is more than a map of names. It's a window into America's soul.

But don't let that put you off. Zooming in on the map is entertaining enough: celebrities floating around in the ether are suddenly tied down to a pedestrian level, and to real geography. And it's fun to see the famous and the infamous rub shoulders, as it were.

Barack Obama owns Chicago, but the suburbs to the west of the city are dotted with a panoply of personalities, ranging from the criminal (Al Capone, Cicero) and the musical (John Prine, Maywood) to figures literary (Jonathan Franzen, Western Springs) and painterly (Ivan Albright, Warrenville), actorial (Harrison Ford, Park Ridge) and political (Eugene V. Debs, Elmhurst).

Freaks and angels

Image: Dorothy

The People Map of the U.S. was inspired by the U.S.A. Song Map, substituting song titles for place names.

It would be interesting to compare 'the most Wikipedia'ed' sons and daughters of America's cities with the ones advertised at the city limits. When you're entering Aberdeen, WA, a sign invites you to 'come as you are', in homage to its most famous son, Kurt Cobain. It's a safe bet that Indian Hill, OH will make sure you know Neil Armstrong, first man on the moon, was one of theirs. But it's highly unlikely that Cincinnati, a bit further south, will make any noise about Charles Manson, local boy done bad.

Inevitably, the map also reveals some bitterly ironic neighbours, such as Ishi, the last of the Yahi tribe, captured near Oroville, CA. He died in 1916 as "the last wild Indian in North America". The most 'pageviewed' resident of nearby Colusa, CA is Byron de la Beckwith, Jr., the white supremacist convicted for the murder of Civil Rights activist Medgar Evers.

As a sampling of America's interests, this map teaches that those aiming for fame would do better to become actors, musicians or athletes rather than politicians, entrepreneurs or scientists. But also that celebrity is not limited to the big city lights of LA or New York. Even in deepest Dakota or flattest Kansas, the footlights of fame will find you. Whether that's good or bad? The pageviews don't judge...

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Image: Abel Suyok
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