Shifting the Conversation Regarding Breast Cancer

Source: Liza Papautsky

By Liza Papautsky and Martha Carlson
*Judith Dawson, MD (1964-2024) co-conceptualized, co-wrote, reviewed, and edited earlier drafts.

A brief call to action from Novartis at the Super Bowl shamelessly showered us with a barrage of boobs. It’s no secret that breasts sell, so perhaps it makes sense that a pharmaceutical giant relied on them for this advertising event. Yet, for people who are watching the state of women’s healthcare in the United States decline, the Novartis ad is a reflection of what has harmed and continues to threaten it today.

The reality is that the public-facing conversation regarding breast cancer is grounded in historical gender bias and is an example of the healthcare disparities that women continue to face. Where breast cancer is the “good cancer,” we also find dismissal or downplaying of traumatic experiences of pregnancy and childbirth and immediate threats to women’s reproductive rights in the United States. The messaging is loud and clear: Women’s health is not prioritized, and their autonomy is not respected.

Gender Bias in Healthcare Is Pervasive

A sustained and widely implemented public awareness campaign could have a measurable effect on breast cancer outcomes. Historically, women and men have been treated differently in healthcare. Gender bias is well documented in the medical and social science literature. According to a 2020 United Nations report, 90 percent of people have some form of gender bias—a set of beliefs and generalizations associated with gender. Biases unconsciously influence clinical decision-making in a way that contributes to inequities that reflect in both patient experiences and clinical outcomes.

Sources of gender biases against women that are still alive and well today, abound. Historically, clinicians (the decision-makers) have been predominantly white males. White males have also dominated clinical trials and other health research as both investigators and participants, yielding findings that may not generalize to women’s bodies, experiences, or needs. Further, women have historically been considered too emotional, a belief that contributes to clinicians downplaying pain and other clinically relevant symptoms, compared to men, resulting in potentially consequential care delays. Additionally, women are too often not in control of their outcomes. Examples include waking up after a mastectomy with excess skin after explicitly communicating the decision to "go flat" to their surgeon.

What about other conditions that are specific to women? Pregnancy, birth, postpartum, maternal health issues, female sexual health, and female (or mostly female) cancers are all subject to the effects of gender bias. Only in recent years have numerous women’s health issues begun to receive attention, including increased rates of maternal mortality especially for Black women, experiences of traumatic births resulting in physical and psychological consequences, and standard practices associated with lack of pain management for procedures such as IUD (intrauterine device used for birth control) insertion. These advances are currently under threat by the new U.S. administration, where even the words “women” and “female” are discouraged and result in an outright rejection of grants to federal funding agencies. Further, with the overturning of Roe v. Wade, making abortion illegal in many U.S. states, women have limited agency over their bodies even in life-threatening situations. Despite the significant attention that these topics have received, progress will take a significant cultural and systemic shift that acknowledges how we have failed to treat women as complete and complex individuals.

As the leading cancer diagnosis in women and pregnancy-associated malignancy, breast cancer remains a significant public health problem. Devastatingly, recent findings highlight that breast cancer rates among young women are on the rise, with Black women continuing to be at significantly greater risk.

A Devastating Disease

Pinkwashing, pink ribbon campaigns, and Super Bowl ads do nothing to bring attention to the urgent research gaps and systemic issues that need action—advocacy, setting of research priorities, and funding. Breast cancer is a devastating, serious, and potentially fatal disease.

Yet, the implications of a breast cancer diagnosis are poorly understood by people who are not directly involved, even the well-meaning. Despite its consideration as the "good cancer," even an early-stage treatment plan can include the immense physical and emotional toll of surgeries, chemotherapy, and radiation. Further, there is a lack of awareness that breast cancer survivors often suffer from life-long invisible disabilities, ranging from the physical, such as sleep disturbances and chronic pain, to effects on mental and sexual health, finances, employment, and fertility. At best, a patient with a history of breast cancer takes on an ever-present fear of recurrence, sometimes with no awareness that most recurrence is metastatic and incurable.

Many don't think about breast cancer outside of October, when “awareness” is a massive marketing campaign, with little going to the causes that truly need attention. Thus, efforts throughout the year take on outsized importance. We need to make them count!

What Is Our Responsibility?

Almost 40 years since the pink ribbon entered public consciousness and became a marketing juggernaut, women generally have little awareness of their own risk factors. This is especially problematic for young women, who not only have to understand and follow up on the appropriate screening modalities but also often must insist on screening after a doctor has dismissed their concerns. Most vulnerable are women who are pregnant or postpartum from underserved and minority populations.

What we need is a truthful campaign that includes attention on:

1. Understanding risk: If women are not aware of modifiable risk factors, they—and their doctors—need to be educated. If family history is kept secret, they need to find ways to account for that when assessing risk. Online tools exist to support risk calculation, including the Tyrer-Cuzick risk model and the BWHS Breast Cancer Risk Calculator, created specifically for U.S. Black women. Further, women should be educated about screening modalities, counseled about resources, and encouraged to feel comfortable with health advocacy.
2. Reducing risk: A concerted public health advertising approach is needed to address alcohol consumption, physical activity, and healthy diets—without shaming—so that modifiable risks. evidenced by scientific research, receive sustained attention.
3. Getting treatment: Women—and their doctors—need to secure care that maintains quality of life rather than suffering silently because that is what “pink” demands. Integration of supportive/palliative care with oncology teams is needed to support ongoing conversations about side-effect management.
4. Improving survivorship following active treatment: Increasing awareness and access to services to support long-term impacts of breast cancer and associated treatment (such as physical therapy and occupational therapy, mental health, etc.) is needed for survivors with an early-stage diagnosis.

Gender Essential Reads

Motherhood and Achievement Amnesia

Why ChatGPT Thinks Professors Are Men—and So Do Our Kids

Wouldn’t Happen to Men…

The majority of breast cancer diagnoses (99 percent) are in women. Male breast cancer is a significant research and operational gap that is in desperate need of attention. Similarly, transgender and gender-diverse individuals have specific, poorly understood or addressed care needs. However, these populations are not the topic of this piece.

Women with breast cancer have long been expected to rally, be brave, fight a battle, and, most of all, to survive as though breast cancer made them better, stronger people. Anything different is not acceptable. Anything different makes us uncomfortable.

Can you imagine if prostate, testicular, or colorectal cancers were dressed up to be more profitable, consumable, and pleasant for the public? Hiding an ugly reality is not just harmful to patients who are more isolated and their experience invisible, but it also contributes to barriers to progress.

Empowering better management of breast cancer means normalizing and empowering dialogue and risk reduction. Awareness campaigns need honesty and a change in focus.