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The curse of awareness
DISSECTING ROOM
Doctoring the risk society The curse of awareness
It’s not the winning . . .
As breast awareness month comes around again in the UK, family doctors must prepare for this year’s influx of the victims of the cult of the pink ribbon. It is strange that in a society whose mammary fixation is proclaimed from every advertising hoarding, popular newspaper, and television screen, health authorities consider it necessary to raise public awareness of the breast. Yet the popularity of such campaigns reveals that beneath narcissistic obsessions with the body lurk morbid fears about its susceptibility to disease. Campaign propaganda offers as a “breast cancer fact” the statistic that “one in nine women in the UK will develop breast cancer at some time in their life”. But many of these cancers are diagnosed in elderly women who will die of some other cause. A more accurate—but less scary—estimate suggests that the lifetime risk of a woman dying of breast cancer is one in 26 (BMJ 1997; 317: 1307–09). Though 85% of cases of breast cancer occur in women who have passed the menopause, “breast awareness” tends to be greatest in women younger than 25 years, a population in which breast cancer is extremely rare. Although screening authorities now acknowledge that routine breast self-examination is ineffective, women’s magazines and health promotion leaflets are still offering earnest advice about how to detect lumps. The result is a steady flow of frightened women into doctors’ surgeries. After examination, some can be reassured; many increasingly demand hospital referral, leading inexorably to mammography (of controversial value) and more invasive investigation. Women who have had breast cancer are perhaps the greatest casualties of breast awareness. It is not only that they are reminded of their disease every time they see a pink ribbon or a campaign poster. The discussion of lifestyle factors compounds women’s worries about the future with guilty reflections on their past behaviour. The fairly strong influence of family history provides further scope for guilt and blame. During a previous breast awareness month, a patient who had survived mastectomy, radiotherapy, and chemotherapy came in to ask me what she had done to deserve breast cancer. I don’t know who benefits from breast awareness, but I know many of its victims.
Mike Fitzpatrick e-mail: [email protected]
1086
ne competitor in a longdistance race in the World Athletics Championships in Paris, France, was so out of touch she had fallen behind the “pack” even by the first bend of the opening lap, and the gap became greater as the contest progressed. She was chugging round the track long after the others had completed their course. Eventually, the runner forced herself across what she supposed to be the finish-line only to hear the bell ring—signifying that for her there was one more lap. By now she had little control over her legs and in the run-in staggered off the track onto the adjoining grass and then back into her lane. Would she be disqualified? No—the administrators showed sympathy in allowing her to finish the race to the generous applause of the spectators. Her name was flashed up on the public screen, then the time she had taken, and then the words—“Personal Best”. There could be no greater testimony to the saying that “it is not winning that matters, but taking part”. Cricket fast bowler Fred Tate took part in the Test Match for England against Australia at the Old Trafford ground, Manchester, in 1902—and in no other. He contributed directly to the destiny of The Ashes, but not in the way in which he could have foreseen or wished. Tate was asked to field in the deep, a position to which he was unaccustomed. He dropped the catch that enabled the Australian captain to play what proved to be the matchwinning innings. Fate had not finished with Fred. England fought back and came close to winning the match. Tate, the last batsman, came to the crease with just a few runs needed for victory. Then the rain fell, causing the players to leave the field. On resumption Tate needed only to keep the ball out of his wicket for a few minutes and his batting partner could hit the winning run, but he was bowled, giving Australia
O
victory by the narrow margin of three runs. Fred supposedly pointed to his 7-year-old son, Maurice, saying that he would make amends for his father’s failure. Apocryphal or not, Maurice did become one of England’s great bowlers of the next generation and contributed to several victories over Australia. Did Jack MacBryan actually take part in England’s test match against South Africa on the same ground at Manchester in 1924? He was selected and took the field. Yet he didn’t bowl and didn’t hold a catch. Then it rained so hard that the rest of the match was abandoned and he didn’t bat either. He was never chosen to play again. The saddest place in sport is probably the dressing-room of a losing boxer. Some boxers are deemed to be losers even before the contest starts. A few years ago I interviewed Tony, a journeyman heavyweight, while he was changing in a corridor of the venue in which he was engaged to fight the local hero. An old malfunctioning radiator provided the only heating in the extreme cold of the snowy winter day. At the tail-end of his career, Tony had been signed as fodder to build the reputation of a rising star. Even so he couldn’t seek an early release by “taking a dive” (faking defeat). The spectators wanted to see their hero give him a thrashing. He had to stand up for round after round as the younger man rained punishment on him. He didn’t need to be told, or induced, to do so. There are a lot of journeymen like Tony, and they know that if they “take the easy way out”—or even win the fight—they might never get another pay-day. Is it really the taking part that counts? I am happy enough to participate from the convenience of the press-box. Clayton Goodwin
THE LANCET • Vol 362 • September 27, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
Doctoring the risk society The curse of awareness
It’s not the winning . . .
As breast awareness month comes around again in the UK, family doctors must prepare for this year’s influx of the victims of the cult of the pink ribbon. It is strange that in a society whose mammary fixation is proclaimed from every advertising hoarding, popular newspaper, and television screen, health authorities consider it necessary to raise public awareness of the breast. Yet the popularity of such campaigns reveals that beneath narcissistic obsessions with the body lurk morbid fears about its susceptibility to disease. Campaign propaganda offers as a “breast cancer fact” the statistic that “one in nine women in the UK will develop breast cancer at some time in their life”. But many of these cancers are diagnosed in elderly women who will die of some other cause. A more accurate—but less scary—estimate suggests that the lifetime risk of a woman dying of breast cancer is one in 26 (BMJ 1997; 317: 1307–09). Though 85% of cases of breast cancer occur in women who have passed the menopause, “breast awareness” tends to be greatest in women younger than 25 years, a population in which breast cancer is extremely rare. Although screening authorities now acknowledge that routine breast self-examination is ineffective, women’s magazines and health promotion leaflets are still offering earnest advice about how to detect lumps. The result is a steady flow of frightened women into doctors’ surgeries. After examination, some can be reassured; many increasingly demand hospital referral, leading inexorably to mammography (of controversial value) and more invasive investigation. Women who have had breast cancer are perhaps the greatest casualties of breast awareness. It is not only that they are reminded of their disease every time they see a pink ribbon or a campaign poster. The discussion of lifestyle factors compounds women’s worries about the future with guilty reflections on their past behaviour. The fairly strong influence of family history provides further scope for guilt and blame. During a previous breast awareness month, a patient who had survived mastectomy, radiotherapy, and chemotherapy came in to ask me what she had done to deserve breast cancer. I don’t know who benefits from breast awareness, but I know many of its victims.
Mike Fitzpatrick e-mail: [email protected]
1086
ne competitor in a longdistance race in the World Athletics Championships in Paris, France, was so out of touch she had fallen behind the “pack” even by the first bend of the opening lap, and the gap became greater as the contest progressed. She was chugging round the track long after the others had completed their course. Eventually, the runner forced herself across what she supposed to be the finish-line only to hear the bell ring—signifying that for her there was one more lap. By now she had little control over her legs and in the run-in staggered off the track onto the adjoining grass and then back into her lane. Would she be disqualified? No—the administrators showed sympathy in allowing her to finish the race to the generous applause of the spectators. Her name was flashed up on the public screen, then the time she had taken, and then the words—“Personal Best”. There could be no greater testimony to the saying that “it is not winning that matters, but taking part”. Cricket fast bowler Fred Tate took part in the Test Match for England against Australia at the Old Trafford ground, Manchester, in 1902—and in no other. He contributed directly to the destiny of The Ashes, but not in the way in which he could have foreseen or wished. Tate was asked to field in the deep, a position to which he was unaccustomed. He dropped the catch that enabled the Australian captain to play what proved to be the matchwinning innings. Fate had not finished with Fred. England fought back and came close to winning the match. Tate, the last batsman, came to the crease with just a few runs needed for victory. Then the rain fell, causing the players to leave the field. On resumption Tate needed only to keep the ball out of his wicket for a few minutes and his batting partner could hit the winning run, but he was bowled, giving Australia
O
victory by the narrow margin of three runs. Fred supposedly pointed to his 7-year-old son, Maurice, saying that he would make amends for his father’s failure. Apocryphal or not, Maurice did become one of England’s great bowlers of the next generation and contributed to several victories over Australia. Did Jack MacBryan actually take part in England’s test match against South Africa on the same ground at Manchester in 1924? He was selected and took the field. Yet he didn’t bowl and didn’t hold a catch. Then it rained so hard that the rest of the match was abandoned and he didn’t bat either. He was never chosen to play again. The saddest place in sport is probably the dressing-room of a losing boxer. Some boxers are deemed to be losers even before the contest starts. A few years ago I interviewed Tony, a journeyman heavyweight, while he was changing in a corridor of the venue in which he was engaged to fight the local hero. An old malfunctioning radiator provided the only heating in the extreme cold of the snowy winter day. At the tail-end of his career, Tony had been signed as fodder to build the reputation of a rising star. Even so he couldn’t seek an early release by “taking a dive” (faking defeat). The spectators wanted to see their hero give him a thrashing. He had to stand up for round after round as the younger man rained punishment on him. He didn’t need to be told, or induced, to do so. There are a lot of journeymen like Tony, and they know that if they “take the easy way out”—or even win the fight—they might never get another pay-day. Is it really the taking part that counts? I am happy enough to participate from the convenience of the press-box. Clayton Goodwin
THE LANCET • Vol 362 • September 27, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.