Angelina Jolie's "Medical Choice" Dominates the Internet

I woke up this morning to the quintessential Pop Health story.  Angelina Jolie published an op-ed called "My Medical Choice" in the New York Times.  She talks about undergoing a preventative double mastectomy in February 2013 after genetic testing revealed that she carried the BRCA1 gene.

As I inventoried her column and the online chatter today, I worried that I missed the boat!  Dozens of bloggers and news outlets wrote about her op-ed within hours of its posting...what else could I add to the conversation?

With so many posts for readers to sift through- many of which focus on very specific issues (e.g., the efficacy of preventative mastectomies)- I decided to add to the conversation by cataloging the public health implications being discussed:

Angelina as a "champion" for breast cancer prevention: will her celebrity status help or hurt the cause?:  Most of the articles and comments that I read in response to her op-ed were overwhelmingly positive.  This is exemplified by an open letter on KevinMD.com written by Dr. James Salwitz.  He praises Angelina for her bravery and leadership in the battle against breast cancer.  He goes on to state, "Your action will save more lives than all the patients I could help, even if I were to practice oncology for hundreds of years".  On the flip side, a few writers/commenters raised the concern that Angelina's influential status in conjunction with her decision to have surgery could cause women to panic about their own breast cancer risks.  For example, David Kroll writes for Forbes, "For all the bravery of Ms. Jolie and the positive groundswell that her op-ed generates, I also want to be sure that women with breast cancer - women who are already scared - do not feel the extra burden that they’re not doing enough if they don’t consider a double mastectomy".

I thought that Linda Holmes (of NPR's pop culture blog) did a really nice job of reconciling Angelina's role as both "celebrity" and "champion" in her post called "Why Angelina Jolie's Op-Ed Matters".

Legal and Policy Issues:  BRCA Genetic Testing:  On April 15, 2013, the Supreme Court heard oral arguments challenging Myriad Genetics' patents on "the breast cancer genes".  As a side note: I do not remember hearing about this story last month- perhaps because the Boston Marathon bombings also took place on April 15th?  The concern is that such patents inhibit scientific advancements, keep testing costs high- and therefore limit access to the testing.  Angelina alludes to this in her op-ed when she reveals that the BRCA1 and BRCA2 testing costs approximately $3,000 in the U.S.  Sarah Kliff from The Washington Post notes that this testing "is about to get significantly less expensive: The Affordable Care Act included the genetic test among the preventive services that insurers are required to cover without any cost sharing".

Health Communication- Risk Perception:  Nancy Shute wrote an interesting piece for NPR entitled, "Angelina Jolie and the Rise of Preventative Mastectomies".  She interviews Dr. Todd Tuttle, who raises concerns about women overestimating their risk of breast cancer (in the other breast after being diagnosed on one side) and choosing more invasive treatment like mastectomy when not medically necessary.  Shute also discusses some potential contributors to the increases in risk perception and preventative mastectomy. For example, she mentions advancements in breast surgeries/reconstructions and the "hyper-awareness" of breast cancer resulting from ubiquitous pink ribbon campaigns.  Many of these contributors were discussed two weeks ago in the must-read The New York Times Magazine article "Our Feel Good War on Breast Cancer" by Peggy Orenstein.

Reviewing the Evidence Base for Recommending BRCA Testing or Preventative Mastectomies:  Many articles focused on reviewing what we know about the effectiveness of (1) BRCA testing for predicting cancer and (2) mastectomies for preventing cancer death.  Several articles linked to the CDC feature, "When is BRCA Genetic Testing for Breast and Ovarian Cancer Appropriate"?  Sarah Kliff discusses why "Most Women Probably Shouldn't Get the Cancer Screening Angelina Jolie Did".  NPR linked to a 2010 Journal of the American Medical Association (JAMA) article that provided the "clearest evidence yet that women carrying the BRCA1 and BRCA2 genes should consider preventive surgery because they are at a very high risk for breast and ovarian cancers."

With so many articles and blogs to sift through, I could probably keep going.  But I'd like to stop and hear from you:

• What other public health implications could result from Angelina Jolie's disclosure in today's New York Times?
• How do you think her disclosure could impact the issues I've raised above- risk perception, policy decisions, etc?
• I've linked to some of the articles that I read today- are there others that you would recommend to me and Pop Health readers?

Kudos to The New York Times Magazine for Examining the "Feel-Good War" on Breast Cancer!

In last week's The New York Times Magazine, Peggy Orenstein wrote an article called "Our Feel-Good War on Breast Cancer".  The piece is lengthy but well researched, insightful, and well worth the reading time.

Peggy, a breast cancer survivor herself, hits every key public health issue- cancer screenings, treatment options, "awareness" raising, message framing, funding, and research.  As someone who has been critical of "awareness" raising, I was happy to see the issue discussed front and center.  For me, her interview with Dr. Gayle Sulik (Sociologist and Founder of the Breast Cancer Consortium) was the most striking.  A key quote from Dr. Sulik (I added the bolding):

“You have to look at the agenda for each program involved.  If the goal is eradication of breast cancer, how close are we to that? Not very close at all. If the agenda is awareness, what is it making us aware of? That breast cancer exists? That it’s important? ‘Awareness’ has become narrowed until it just means ‘visibility.’ And that’s where the movement has failed. That’s where it’s lost its momentum to move further.”

Peggy also tackles the issue that is an ongoing challenge in public health and medicine:  screening.  Screenings are tests that look for diseases before you have symptoms.  Ideally, screening will identify diseases early when they are easier to treat and have better outcomes.  For breast cancer, the key screening test is a mammogram (x-ray of the breasts).  However (as Peggy points out), we seldom hear about the research that demonstrates limited effectiveness of mammograms for reducing cancer death.  This is not the research cited in the communication materials from advocacy organizations.  We also tend not to hear about the negative side effects of screening large segments of the population.  There can be false positive tests: which subject the patient to unnecessary medical intervention and emotional distress.  There can also be over-treatment for the detected cancer, even if it turns out to be a non-aggressive tumor.

When I was working in suicide prevention, one of the best articles I read was "Screening as an Approach for Adolescent Suicide Prevention" by Dr. Juan Pena and Dr. Eric Caine.  The authors dedicate a section of the paper to key decisions and tasks to resolve before implementing a screening program.  While the public health issue and screening tests are different, I believe many of their decision points are generalizable to almost any health issue.  The table presenting these decisions and tasks is a great reminder to public health professionals and clinicians that recommending and undertaking a screening program should be strategic and the decision should be re-visited regularly.  For example, the authors highlight:

• Key Decision:  Population and Setting- Is the screening program consistent with the target population's community or cultural values?
• Key Decision:  Screening Instrument- What will be the false positives and false negatives rates in the population to be screened?  Are these rates acceptable?
• Key Decision:  Staffing and Referral Network- Are there effective treatments available for the types of conditions being screened for?
• Key Decision:  Quality Assurance- How will the screening program be monitored to ensure that protocols are followed?
• Key Decision:  Legal and Ethical Issues- Has sufficient informed consent been given to parents and youth about risks, benefits, and limits of screening?

Going back to the "Feel-Good War" article:  I like that Peggy did not just point out all the flaws in our current breast cancer screening and treatment systems.  Instead, she invited her interviewees to recommend potential improvements.  Some ideas were noted in two key areas:

• Message Re-Framing:  Rather than offering blanket assurances that “mammograms save lives,” advocacy groups might try a more realistic campaign tag line. The researcher Gilbert Welch has suggested this message, “Mammography has both benefits and harms — that’s why it’s a personal decision.”

• Funding Re-Distribution:  Peggy asked scientists and advocates how some of that "awareness" money could be spent differently. She highlights the February recommendations of a Congressional panel (made up of advocates, scientists and government officials) that called for increasing the share of resources spent studying environmental links to breast cancer. They defined the term liberally to include behaviors like alcohol consumption, exposure to chemicals, radiation and socioeconomic disparities. 

Tell Me What You Think:

• What do you think about the "pink culture" or awareness raising around breast cancer?  Will it effectively lead us to our goal of prevention?
• In addition to message re-framing and funding re-distribution, what else would you recommend to help improve the approach to breast cancer prevention, screening, and treatment?

How Is Breast Cancer Diagnosed

Are you looking for more information on how breast cancer is diagnosed?
If so, this information should help. Breast cancer is an extremely common type of cancer, especially among females. It is therefore extremely important that, as women, we take the time to get ourselves regular breast exams. If you are interested in learning more about checkups and breast cancer diagnosis, continue reading this article. Throughout the article we will discuss what breast cancer is and how it is diagnosed.
Let's begin by learning what this disease is. Breast cancer is, next to skin cancer, the leading cancer among women. While it is most commonly diagnosed among females, it can also effect the lives of men. Breast cancer is a group of cancerous cells, known as a malignant tumor, that begins in the cells of the breast and can potentially spread into other areas of the body.
While there are some signs that point to breast cancer (swelling of breast, skin irritation, pain, redness, nipple discharge, etc.), most women in the beginning stages of the cancer experience no symptoms at all. It is therefore extremely important that all women have a clinical breast exam performed at least once a year by a medical physician. If this exam is performed, and anything abnormal is found, other tests will be performed to determine if any of the irregularities could be from breast cancer.
What types of tests will be performed?
One of the most common tests used to diagnose this type of cancer is the mammogram. A mammogram is generally used for early detection of the cancer as they can detect anywhere from 85 to 90 percent of all breast cancers. Mammograms can help to detect breast cancer before a lump can even be felt or seen.
Another test commonly used to diagnose cancer of the breast is an ultrasound. Ultrasounds are usually used after a mammogram has already been conducted to help target a specific area of concern (as found by the mammogram). Ultrasounds also help to tell the difference between cysts and solid masses, as well as benign and cancerous tumors.
If a lump is found on your breast, a sample of tissue and fluid will be taken by your doctor and will be sent to be tested by a pathologist. Once you get the results back, your doctor will summarize your diagnosis. If you are diagnosed with cancer, you will be informed of which stage you are at. The stage you are at will determine which course of treatment you will need to seek.
Because this type of cancer is so common, it is very important that you have an annual breast exam completed by your health care professional. It is also suggested that you ask your doctor how to perform a regular breast exam on your own so that you can do regular checks on yourself.

Learn how to get all of the healthy advantages of a well balanced diet, a fun and effective exercise program and a healthier and move active lifestyle go to Health Tips For Women you will get health and beauty tips for today's strong and active women and discover how to live longer and live stronger!!

Breast Cancer and Breast Health

For fifteen years I have worked as a professional educator. For 5 of those years I have worked in a healthcare organization. One of the most talked about topics is breast cancer and breast health. The bottom line is that although breast cancer is not preventable, it is usually easily detectable.
Note: Breast cancer is not race specific - all races get breast cancer!
Note: Breast cancer is not gender specific - men get breast cancer too!
When breast cancer is caught in the early stages the chances of survival are very high. Please don't add yourself or a friend or loved one to the growing list of statistics. Take action today! Here is a simple three part action step plan to help you with the early detection of breast cancer.
Part One: Regular Mammograms
Ladies, this is the most important part of maintaining good breast health: regular mammograms. Mammograms are fast, simple x-rays similar to the x-rays you get at a dentist's office visit. In fact, mammograms actually use less radiation than a dental x-ray!
Mammograms put you light years ahead when it comes to cancer treatment because they can detect breast lumps long before you or your doctor could physically feel a breast lump. Because early detection is a key to survival, you need to put regular mammograms on your schedule.
The American Cancer Society recommends regular mammograms for all women starting at age 40. If you have a family history of breast cancer, your physician may want you to start a regular mammogram schedule much earlier.
The older you get, the higher your chances of breast cancer. Over 75% of all breast cancers occur in women who are 50 or older. Over 50% of all breast cancers occur in women who are 65 or older.
Ladies - listen to me! Get a regular mammogram! Please! For the sake of your friends and family who love you so much, schedule a yearly mammogram if you are 40 or older or have a family history of breast cancer.
Part Two: Clinical Breast Exam
Only your physician or nurse will do a clinical breast exam for you. All women in their 20's and 30's should have a clinical breast exam as part of their annual health checkups at least every 3 years. After the age of 40, this should be done every year without fail.
What Will Happen In A Clinical Breast Exam?
The physician or nurse will take your personal health history by asking you a series of health history questions. This will include asking about family history. Next the physician or nurse will look at your breasts while you stand in front of a mirror with your hands on your hips. Finally the physician or nurse will physically exam your entire breast up to the neck, in your armpit, the center of your chest and to the bottom of your rib cage. Finally they will discuss proper breast health with you as well as show you how to perform breast self-exams. The entire process can take up to 10 minutes. It should rarely be under 5 minutes.
Part Three: Breast Self-Exams
You need to become familiar with how your breasts look and feel regularly so that you are aware of any changes from normal. If you notice changes, report these to your physician immediately.
One of the most important steps you can take is to do monthly breast self-exams. An easy way to remember to do this is to check while you take a shower. Some organizations even have a shower card you can hang from your shower head with punch out holes for each month, so you can easily track when you have done your exams.
Remember that you need to physically exam your breasts by hand as well as look in the mirror for any visible changes. If you think you've found a lump or noticeable change, notify your doctor immediately.

Anti-vaccine ads on Delta planes; Magic and Ellen as celebrity champions for HIV/AIDS prevention...and more- What Am I Reading This Week?

New pop culture and public health stories to check out this week:

1. Darrell Hammond of Saturday Night Live fame reveals that child abuse led to alcohol/drug use and cutting. He details the horrific abuse in a new memoir, "God, If You're Not Up There, I'm F*cked".

2. Fellow Boston University School of Public Health alum Elizabeth Cohen reports on the 20th anniversary of Magic Johnson's announcement that he is HIV positive. His announcement had an incredible impact on the public's health- both in terms of reducing stigma of those diagnosed and proving that the diagnosis is not always a death sentence.

3. Delta airlines is seeing backlash from public health organizations and other flu vaccine advocates after airing a 3-minute PSA from the National Vaccine Information Center that describes alternate ways to avoid the flu (besides getting the flu shot).

4. Ellen DeGeneres is named global envoy for AIDS awareness. The hope is that Ellen's enormous platform (from both her TV show and social media channels) will allow her to reach millions of people with the prevention message. Ellen is a partner in other important public health issues, for example- bullying prevention.

5. This week, Evelyn Lauder passed away from Ovarian Cancer. Evelyn was one of the powers behind the creation of the pink ribbon campaign for breast cancer awareness.

How about you? What are you reading this week?

Pink Fatigue? JCPenney's Sexist Merchandise. Smoking and its Box Office Impact. What Am I Reading This Week?

Here are the top 5 stories I'm following this week:

1. Amid breast cancer month- Is there pink fatigue? A very important public health story. "Awareness" does not equal behavior change (e.g., increased screenings or access to medical care). A related story appeared last week in Upstream: A forum on interdisciplinary health communication.

2. JCPenney CEO responds to petition to stop selling sexist clothing marketed to young girls like "I'm too pretty to do homework". The company is using this incident as a "teachable moment".

3. The use of social media in street protests can be effective for both protesters and police. A story in ScienceDaily.

4. Smoking is a drag at the box office. An analysis of top-grossing movies from the past decade shows that films with smoking make less money.

5. Video game can reduce fatigue in African American women with lupus. A pilot study to explore using Wii Fit to reduce fatigue.

What are you reading this week?