Be aware - but don't panic

With the best of intentions, the media is over-emphasising the bad news about breast cancer. Markie Robson-Scott reports

IF YOU ARE a woman and you read glossy magazines, you may already have noticed that October is Breast Cancer Awareness Month. If you have digested the facts and figures on breast cancer, put out by the breast cancer charities and pressure groups, you are probably feeling rather worried: one in 12 women develops it during her lifetime, it's the most common cause of death in women aged 35 to 54, and the UK has the highest mortality rate from this disease in the world.

If you've been reading some of the magazine articles on breast cancer, it's easy to feel that there's little hope for any woman, young or old. The October issue of Elle says that if you're too thin, or too fat, or if you've got a thick waist, or have been on the Pill for more than a decade,or drink more than two glasses of wine a day, you're entering the high-risk category. "Be Aware, Be Very Aware", quips the headline to the piece, which goes on to relate heart-rending personal stories from breast cancer sufferers - all of them diagnosed when under 40, one when she was only 23.

Yet, the actual risk of breast cancer for the average Elle reader, a woman in her twenties, is less than one in a thousand. The one in 12 statistic applies to women who live to the age of 85, and as we know, the risk of breast cancer increases greatly after the age of 50. A third of all breast cancers are in women aged between 70 and 85. So, that one in 12 is a cumulative risk, not an across-the-board one. The actual risk is one per thousand per year for a woman in the 35 to 50 age group, and two per thousand in the 50 to 65 age group. Is breast cancer awareness becoming breast cancer alarmism?

"The incidence of breast cancer under the age of 30 is extremely rare," writes Michael Baum, Professor of Surgery at University College and Middlesex Hospitals, in a recent article in the British Journal of Radiology. "Yet it is these women who are constantly bombarded by breast cancer awareness campaigns and who, as a result, grossly over-estimate their risk." Marie O'Riordan, editor of Elle, argues that heightened awareness is better than a lack of it, and that any piece focusing on the need for more funding for research must be helpful.

That can't be denied. Increased politicisation around the issue of breast cancer has brought about important advances. Activism in the USA has forced Congress to increase funding dramatically, and the Government has invested pounds 10 million this year in order to improve women's access to specialist care. But while spreading alarm among politicians may be useful, causing panic among young women is certainly not. "My clinics are flooded with frightened young women who shouldn't be there at all," says Professor Baum. "What we need is breast cancer unawareness month - we need to desensitise the public to panic and hysteria." As far as breast cancer is concerned, he says, there are lies, damn lies and relative risks.

In these PC days of pink ribbons, that almost amounts to heresy. No one wants to deny the value of the work done by the UK Breast Cancer Coalition and the National Cancer Alliance. But what Baum and many of his colleagues say should help us to sleep better at night. It certainly puts those extra risk factors in context. Consider, for example, those extra glasses of wine mentioned in the Elle article. Dr Ian Smith, head of medicine at the Royal Marsden and a consultant at its breast unit, says that, assuming excessive drinking increases your risk by 50 per cent, the increased risk here would result in a one and half, rather than a one, per thousand chance. Accumulating fat around the waist may be of significance, though no one knows exactly how or why and it's not enough to constitute a "risk". And losing the fat will make no difference - it's a question of having that kind of physique to begin with, so implying that one should watch one's shape is unhelpful.

What about other well publicised, high-risk factors, such as genetic predisposition, early menstruation and late motherhood? Apart from carrying the inheritable mutated BRCA1 and 2 genes, very few indisputably increase one's risk. Having two "first degree" relatives (mother or sister) who had the disease pre-menopause makes the greatest difference: it's increased to five in a thousand more than the average woman's. Menstruating early gives you a 1.3 in a thousand more of a risk, late menopause a 1.5, and having a child after 30 a 1.9. (One possible cause of the increase in breast cancer may be repeated menstruation - we have at least 15 times more periods than our ancestors, and oestrogen and progesterone cause cell multiplication in the breasts). So, if you find that you're at a risk which is twice that of the normal population, you might well panic and think you had a one in six chance of getting breast cancer. But if you're in your thirties and forties, your risk is still only two per thousand - which might, as Baum says, "seem insignificant against the other risks of living in a modern urban society".

Dr Ian Smith agrees that there's "inappropriate anxiety" and he's constantly telling his own daughters that they're over-reacting to media hype and that it's a relatively rare disease. "It's an important, devastating disease, of course, and anything we can do to reduce the risk is worth doing, but we're going over the top." It's easy to hit the headlines, he says, with "Pill increases risk of breast cancer by 20 per cent", but no one mentions that in your thirties, as a Pill user, your risk is then just 1.2 per thousand - and if you're under 30, much less than that - or that the risk returns to normal after 10 years anyway. Does this really outweigh the advantages of the Pill?

It is true there is an increased incidence of breast cancer, but this is partly because there are more older women, and, because of the baby boom, an unprecedented number of women approaching 50. As Margaret Spittle, clinical oncologist at the Middlesex Hospital and medical advisor to the charity Breakthrough, says, "There aren't many other diseases to die of between the ages of 35 and 54. The greatest risk in breast cancer is age - the older you are, the greater the risk."

In the US, where mammography screening is far more widespread for women under 50 (screening pre-menopausal women doesn't work well because their breast tissue is dense and hard to read, quite apart from the danger of increased exposure to radiation and the trauma of false alarms), the sense of panic among women is possibly even greater, and breast cancer is seen as an epidemic. This is misleading, says David Plotkin MD, the director of the Memorial Cancer Research Foundation of Southern California. Writing in the Atlantic Monthly, Plotkin says that women are "needlessly terrified" about breast cancer. In fact, taking demographic shifts into account, the proportion of women who are killed every year by breast cancer has remained more or less the same since the Thirties. There is a real increase - growing at one per cent a year for decades, he reckons - and the incidence has increased because mammograms pick up slow-growing, non-invasive tumours, called ductal carcinoma in situ, that would never have been noticed before. Some of these may well not have needed treatment - one reason why widespread screening has its detractors. (In 1995, the Journal of the National Cancer Institute found that well-educated women in New York State over-estimated their risk of dying of breast cancer 22 fold, and, as a result, over-estimated the benefits of screening 127 fold.)

Of course, it's the tragic, rare cases of fast-growing, terminal cancers in young women that no one can forget, rather than the stories of those who survive. But Jan Tibble, a benign breast-care nurse at the North Middlesex Hospital, is also in favour of a breast normality awareness month. While she agrees that it is important for young women to be diagnosed quickly, she says that clinics are over-crowded because people don't know that most breast changes aren't likely to be cancer. Ninety per cent of women referred by their GPs to a breast clinic don't have cancer. Dr Eleanor Clarke, a GP, agrees that too many women are being sent to specialist centres, partly because their GPs want to protect themselves, partly because women demand it. "Clinics get bunged up with worried women, and their worries are not relieved, because the time and energy go to the few who do have cancer and the others are told to go away. And because of the numbers, it can take longer for those with malignant lumps to be seen." Tibble, at least, can give information and reassurance to women who have the many different kinds of non-sinister lumps, bumps or pain.

Have treatments advanced? Baum says, since 1985, the mortality rate has been falling; tamoxifen, chemotherapy and ovarian suppression have all led to 1,500 lives saved a year. Many women whose cancers have spread live for many years (Action against Breast Cancer has just started a five- year project on why some survive so much longer than others). In response to a Department of Health report in 1995, which revealed that standards were very patchy - women in the north of Britain were getting inferior treatment to those in the south, and urban woman were better served than rural ones - the Government has invested pounds 10 million in breast cancer this year for better access to care for all. And, in spite of myriad unknowns about the causes of breast cancer - What part do environmental factors play? Why do women in southern Italy survive longer with breast cancer than those in the north? Why are breast cancers so aggressive in young women in India? - that is good news.

For information, send an sae to Breast Care Campaign, Blythe Hill, 100 Blythe Road, London W14 0HB.