Breast cancer awareness

A pink ribbon, an international symbol of breast cancer awareness.

Breast cancer advocacy uses the pink ribbon and the color pink as a concept brand to raise money and increase screening. The breast cancer brand is strong: people who support the "pink brand" are members of the socially aware niche market, who are in favor of improved lives for women, believe in positive thinking, trust biomedical science to be able to solve any problem if given enough money, and prefer curative treatments to prevention.[4]

The brand ties together fear of cancer, hope for early identification and successful treatment, and the moral goodness of women with breast cancer and anyone who visibly identifies themselves with breast cancer patients. This brand permits and even encourages people to substitute conscientious consumption and individual symbolic actions, like buying or wearing a pink ribbon, for concrete, practical results, such as collective political action aimed at discovering non-genetic causes of breast cancer.[5]

The establishment of the brand and the entrenchment of the breast cancer movement has been uniquely successful, because no countermovement opposes the breast cancer movement or believes that breast cancer is desirable.[6]

A pink ribbon is a symbol of breast cancer awareness. It may be worn to honor those who have been diagnosed with breast cancer, or to identify products that a manufacturer would like to sell to consumers that are interested in breast cancer. Pink ribbons are sometimes sold as fundraisers, much like poppies on Remembrance Day.

The pink ribbon is associated with individual generosity, faith in scientific progress, and an optimistic "can-do" attitude. It encourages individuals to focus on the emotionally appealing ultimate vision of a cure for breast cancer, rather than the reality that there is no certain cure for breast cancer, and no guarantee there will ever be such a cure.[7] The practice of blindly wearing or displaying a pink ribbon without making other, more concrete efforts to cure breast cancer has been described as a kind of slacktivism due to its lack of real effects,[8] and has been compared to equally simple yet ineffective "awareness" practices like the drive for women to post the colors of their bras on Facebook.[9] Critics say that the feel-good nature of pink ribbons and "pink consumption" distracts society from the lack of progress in curing breast cancer.[10] It is also criticized for reinforcing gender stereotypes and objectifying women and their breasts.[11]

Large events, such as walkathons, promote breast cancer awareness.

Each year, the month of October is recognized as Breast Cancer Awareness Month by many governments, the media, and cancer survivors. The month-long campaign has been called Pinktober because of the increased production of pink goods for sale, and National Breast Cancer Industry Month by critics like Breast Cancer Action.[12] BCAM was begun in 1985 by the American Cancer Society and pharmaceutical company AstraZeneca. The organization that runs the official BCAM aims to promote mammography and other forms of early detection as the most effective means of fighting breast cancer.[13]

Typical BCAM events include fundraising-based foot races, walk-a-thons, and bicycle rides.[14] Participants solicit donations to a breast cancer-related charity in return for running, walking, or riding in the event. Through mass-participation events, breast cancer survivors form a single, united group that speaks and acts consistently and shares a coherent set of beliefs.[15] They also reinforce the cultural connection between each individual's physical fitness and moral fitness.[16] Events organized by Avon or Komen are known to allocate around 25%-33% of donations to the funds needed to organize the event and advertise it.[17]

A breast cancer awareness program is presented in India to Muslim women in 2013.

Various landmarks are illuminated in pink lights as a visible reminder of breast cancer, and public events, such as American football games, may use pink equipment or supplies. In 2010, all King Features Syndicate comic strips on one Sunday were printed in shades of red and pink, with a pink ribbon logo appearing prominently in one panel.

Private companies may arrange a "pink day", in which employees wear pink clothes in support of breast cancer patients, or pay for the privilege of a relaxed dress code, such as Lee National Denim Day.[18] Some events are directed at people in specific communities, such as the Global Pink Hijab Day, which was started in America to encourage appropriate medical care and reduce the stigma of breast cancer among Muslim women, and Male Breast Cancer Awareness Week, which some organizations highlight during the third week of October. Most events are well-received, but some, like the unauthorized painting of the Pink Bridge in Huntington, West Virginia, are controversial.

Many cancer survivors find that BCAM is an emotionally difficult time, as it reminds them of a distressing time and because the cheerful marketing images do not match their experiences.[19]

The basket contains an assortment of pink ribbon-branded promotional merchandise, including awareness bracelets, ink pens, candy, and emery boards.

Thousands of breast cancer-themed products are developed and sold each year.[20] Some of these items are everyday products that have been repackaged or repositioned to take advantage of cause-related marketing, such as teddy bears, clothing, jewelry, candles, and coffee mugs.[21] These blended value objects offer consumers an opportunity to simultaneously buy an object and make a donation to a breast cancer organization.[22] Some of these products are produced and/or sold by breast cancer survivors or charities for fundraising purposes, while others are for profits in addition to fundraising. Manufacturers also produce products with pink labels or pink ribbon logos to donate a sum of money to support the cause.[23] The donation is typically capped so that it is reached after a fixed level of sales, although in some cases the company is providing only free advertising for a selected charity. Although advertising costs are rarely disclosed, some companies have been found to spend far more money advertising "pink products" and tie-ins than they donate to charitable organizations supporting research or patients. For example, in 2005, 3M spent US$500,000 advertising post-it notes printed with a pink ribbon logo. Sales were nearly double what the company expected, but the campaign resulted in a $300,000 donation.[24]

Advertisers and retail consultants have said that because of consumer cynicism, a company can benefit from marketing its support for a cause such as breast cancer awareness only when the company treats that support as "a commitment and not a marketing opportunity". Andrew Benett, an executive at Euro RSCG said that because consumers "have become more mindful, more thoughtful, about how they consume, where they consume, why they consume", companies cannot succeed by "just slapping a pink ribbon on a product and [expecting that] people will buy more".[25] Pink products have also been condemned as promoting consumerism, materialism, and environmental degradation. Critics are also concerned that the ubiquity of pink products may mislead people into thinking that significant progress has been made, and that small, individual actions, like buying a breast cancer-themed product, are sufficient.[26] Responding to criticism, Komen CEO Nancy G. Brinker said that corporate promotions enabled the organization to reach new audiences and that "America is built on consumerism. To say we shouldn't use it to solve the social ills that confront us doesn't make sense to me".[27]

The first breast cancer awareness stamp in the U.S., featuring a pink ribbon, was issued in 1996. As it did not sell well, a semi-postal stamp without a pink ribbon, the breast cancer research stamp, was designed in 1998. Products like these emphasize the relationship between being a consumer and supporting women with breast cancer.[28] In Canada, the Royal Canadian Mint produced 30 million 25-cent coins with pink ribbons during 2006 for normal circulation.[29] Designed by the mint's director of engraving, Cosme Saffioti (reverse), and Susanna Blunt (obverse), this colored coin is the second in history to be put into regular circulation.[30]

Pink Ribbon chocolates

Business marketing campaigns, particularly sales promotions for products that increase pollution or have been linked to the development of breast cancer, such as alcohol, high-fat foods, some pesticides, or the parabens and phthalates used by most cosmetic companies, have been condemned as pinkwashing (a portmanteau of pink ribbon and whitewash).[31] Such promotions generally result in a token donation to a breast cancer-related charity by taking advantage of the consumers' fear of cancer and grief for people who have died to drive sales.[32] Critics say that these promotions, which net more than US$30 million each year just for fundraising powerhouse Susan G. Komen for the Cure, do little more than support the marketing machines that produce them.[33] Komen says that corporate sponsorships are necessary to pay for the organization's efforts: in the 2010 fiscal year it spent $175 million on public health education and awareness campaigns, $75 million on medical research and about $67 million on treatment and screenings for patients.[34]

Two significant campaigns against pink consumption are the National Breast Cancer Coalition's "Not Just Ribbons" campaign, and Breast Cancer Action's "Think Before You Pink" campaign. NBCC's "Not Just Ribbons" campaign sought to focus awareness efforts onto substantive issues such as genetic discrimination, access to cancer treatment, patient rights, and environmental breast cancer research.[35] "Think Before You Pink" encouraged consumers to ask questions about pink products (e.g., to find out how much of a donation was being made).[36]

This trolley advertisement promotes cosmetics company Avon Products, Inc. and breast cancer awareness. Because of the pink ribbon brand's strength, the advertisement is easily recognized as a promotion for breast cancer awareness, even among people who cannot read the Japanese text.

Many corporate and charitable organizations run advertisements related to breast cancer, especially during National Breast Cancer Awareness Month, in the hope of increasing sales by aligning themselves with a positive, helpful message.[37] In addition to selling pink products, corporate advertisements may promote the company's progressive policies, or may provide free advertising for a chosen charity. Medical institutions may run advertisements for mammogram or other breast-related services. Non-profit organizations often benefit from public service announcements, which are free advertisements provided by newspapers, radio and television stations, and other media. Some marketing blurs the line between advertisements and events, such as flash mobs as a form of guerrilla marketing. The typical participant in the breast cancer movement, and therefore the advertisers' target audience, is a white, middle-aged, middle-class, well-educated woman.[38]

Some corporate sponsors are criticized for having a conflict of interest. For example, some of the prominent sponsors of these advertisements include businesses that sell the expensive equipment needed to perform screening mammography; an increase in the number of women seeking mammograms means an increase in their sales, which has led critics to say that their sponsorship is not a voluntary act of charity, but an effort to increase sales.[39] The regulated drug and medical device industry uses the color pink, positive images, and other themes of the pink ribbon culture in direct-to-consumer advertising to associate their breast cancer products with the fear, hope, and wholesome goodness of the breast cancer movement. This is particularly evident in advertisements designed to sell screening mammograms.[40]

The term she-ro, derived from hero, is used in discussions of breast cancer to refer to women who have been diagnosed with breast cancer, and sometimes to those who have survived breast cancer. The term describes an "idealized" patient who combines assertiveness, optimism, femininity and sexuality, despite the effects of treatment, and as a "paragon [who] uses a diagnosis of breast cancer as a catalyst for a personal transformation".[41]

Sociologist Gayle Sulik analyzed the she-ro's social role and ascribes it qualities that include being an educated medical consumer with a brave, pleasant and optimistic public appearance and demeanor, who aggressively fights breast cancer through compliance with screening guidelines and "disciplined practice of 'breast health'". In America the she-ro is diagnosed early due to adherence to early screening recommendations, and, by definition, she survives her diagnosis and treatment.[42] The role emphasizes the femininity and female gender role of the she-ro, offsetting the masculine characteristics of assertiveness, selfishness and "fighting" cancer by cultivating a feminine appearance and concern for others.[43] During and after treatment, the she-ro regains her femininity by using breast reconstruction, prosthetic devices, wigs, cosmetics, and clothing to present an aesthetically appealing, upper-class, heterosexual feminine appearance and by maintaining relationships in which she can nurture other people.[44] Following the proper feeling rules of the breast cancer culture is encouraged, including remaining optimistic of a full cure, rationalizing the selfishness of treatment as a temporary measure, and feeling guilty that it forces her to put her needs momentarily above the needs of others or due to her perceived inadequacy in caring for her family or other women with cancer.[45] Also included in the role is a form of the have-it-all superwoman, cultivating a normal appearance and activity level and minimizing the disruption that breast cancer causes to people around her.[46]

The effort of maintaining the role of a she-ro can be stressful. The role encourages women with breast cancer to care for others rather than themselves. Some of them find this comforting, but it may lead to them feeling reluctant or unable to ask for the help they need or want, and this can lead to bitterness that their friends and family did not offer these services unbidden.[47] The success of their efforts to look and act normally may paradoxically increase their dissatisfaction, as their apparent ability to handle it all discourages people from offering help.[48]

The breast cancer culture celebrates women who display the attitude deemed correct, which implies that their continued survival is due to this positive attitude and fighting spirit. While cheerfulness, hope, and good social support can be advantageous to health outcomes, it cannot determine survival rates.[49] Women who reject the she-ro model may find themselves socially isolated by the breast cancer support groups that are nominally supposed to help them. Support from "the sisterhood" favors the "passionately pink", and tends to overlook women whose response to being diagnosed with breast cancer is incompatible with the pink ribbon culture, because they feel angry, unhappy, or afraid.[50]

The breast cancer culture is ill-equipped to deal with women who are dying or who have died,[51] and their experiences may not be memorialized, validated or represented as part of the movement, instead being ignored or shunned as failures and as hope-destroying examples of reality. They may feel like treatment failure is a "dirty little secret" that others want to make invisible.[52] Similarly, the culture is also ill-equipped to deal with the news that a previously hyped treatment or screening procedure has been determined to be ineffective, with women advocating for the acceptance and promotion of inexpedient activities and inefficient or even sometimes harmful drugs.[53]

Breast cancer culture, or pink ribbon culture, is the set of activities, attitudes, and values that surround and shape breast cancer in public. The dominant values are selflessness, cheerfulness, unity, and optimism. It is pro-doctor, pro-medicine, and pro-mammogram. Health care professionals are sources of information, but the rightness of their advice is not to be seriously questioned by women with breast cancer. Patients are not encouraged to ask where research money is going or if the research industry is making progress in finding the "cure".[54] The emphasis on cheerfulness allows society to blame women for developing breast cancer and limits their responses to certain culturally determined scripts. The requirement of cheerful optimism arose from the then-popular theory that cancer had a psychosomatic origin and that people who were diagnosed with cancer had a "cancer personality" that was depressed, repressed, and self-loathing. Psychotherapy was therefore considered an adjunct treatment used to produce a cheerful, self-affirming identity. This theory was predominant among psychiatrists through the 1970s, but has since been discredited.[55] In a process called benefit finding, the she-ro uses the emotional trauma of being diagnosed with breast cancer and the suffering of extended treatment to transform herself into a stronger, happier and more sensitive person who is grateful for the opportunity to become a better person. In particular, she sees breast cancer as an opportunity to give herself permission for necessary personal growth that she felt she was prohibited from or unable to make before.[56] Breast cancer thereby becomes a rite of passage rather than a disease,[57] with pink ribbon culture honoring the suffering of its she-roes by selecting them based on the amount of misery they have experienced,[58] and leading women whose treatment is less painful or debilitating to feel excluded and devalued. The suffering, particularly the extended suffering of months of chemotherapy and radiation treatment, forms a metaphorical type of ordeal or rite of passage that initiates women into the inner circle of breast cancer culture. Barbara Ehrenreich describes it this way:

Understood as a rite of passage, breast cancer resembles the initiation rites so exhaustively studied by Mircea Eliade: First there is the selection of the initiates—by age in the tribal situation, by mammogram or palpation here. Then come the requisite ordeals—scarification or circumcision within traditional cultures, surgery and chemotherapy for the cancer patient. Finally, the initiate emerges into a new and higher status—an adult and a warrior—or in the case of breast cancer, a "survivor".[59]

Mainstream pink ribbon culture has aspects that are trivializing, silencing, and infantilizing.[60] Women with breast cancer are surrounded by childish kitsch such as pink teddy bears and crayons, but there is no equivalent gift of toy cars for men diagnosed with prostate cancer.[61] Women who choose not to conform to the culture may feel excluded and isolated; those who cannot conform to the prescribed triumphant script report feeling unable to share their stories honestly. Anger, negativity and fatalism transgress the feeling rules, and women with breast cancer who express anger or negativity are corrected by other women with breast cancer and members of the breast cancer support organizations.[62] Appearing unattractive—such as going out in public with a bare, bald head if treatment causes temporary hair loss—transgresses the approved, upper-class style of pink femininity and provokes shaming comments from strangers.[63] Programs such as Reach to Recovery and Look Good, Feel Better inform breast cancer patients of this cultural standard and help them conform to it.[64] This standard is not universally adhered to in every detail. Ehrenreich says that "[t]he question of wigs versus baldness ... defines one of the few real disagreements in breast-cancer culture." Some women have avant garde aesthetic tastes: "One decorates her scalp with temporary tattoos of peace signs, panthers, and frogs; another expresses herself with a shocking purple wig; a third reports that unadorned baldness makes her feel 'sensual, powerful, able to recreate myself with every new day'".[65] Regardless of whether the transformation is towards a radical, natural or cosmetically enhanced appearance, treatment is always "a makeover opportunity".[66]

Since the beginning of the 21st century, breast cancer culture has become more sexualized, and many awareness campaigns now reflect the old advertising truism that sex sells. The "booby campaigns", such as "Save the Tatas" and the "I ♥ Boobies" gel bracelets, rely on a cultural obsession with breasts and a market that is already highly aware of breast cancer.[67] This message trivializes women and reflects a belief that breast cancer is important because cancer and its treatment makes women feel less sexually desirable and interferes with men's sexual access to women's breasts, instead of because cancer and its treatment kill and disable women.[68] These sexualized campaigns tend to attract a younger audience than traditional campaigns.[69]

At the same time, breast cancer culture tends to overlook men with breast cancer and women who do not fit the white, middle-class archetype. African-Americans involved with breast cancer organizations often feel like their role is to be the token minority.[70]

The primary purposes or goals of the breast cancer culture itself are to maintain breast cancer's dominance as the preëminent women's health issue, to promote the appearance that society is "doing something" effective about breast cancer, and to sustain and expand the social, political, and financial power of breast cancer activists.[71]

The breast cancer culture tells women with breast cancer that their participation in fundraising, social support of other women with breast cancer, and appearance at public events are critical activities that promote their own emotional recovery. Because of this message, some women begin to believe that refusing to raise money for breast cancer organizations or to become mentors for newly diagnosed women with breast cancer is an unhealthy response to breast cancer.[72]

The breast cancer wars were a series of conflicts between advocates and others about the causes, treatments, and societal responses to breast cancer.[73] Women in the late 1980s and 1990s followed the successful approach used by ACT-UP and other AIDS awareness groups, of staging media-friendly protests to increase political pressure. Prominent women who made the "wrong" choice were publicly excoriated, as when Nancy Reagan chose mastectomy over lumpectomy followed by six weeks of radiation therapy. The abortion–breast cancer hypothesis was formulated when an early study showed a connection between voluntary abortions and the development of breast cancer in premenopausal women, which pitted breast cancer advocates against abortion rights advocates.[74]

Advocates for women's issues have said that breast cancer is special because of its status as a largely female disease, society's response to it is an ongoing indication of the status of women and the existence of sexism.[75] Breast cancer activist Virginia Soffa wrote that "[a]s long as it is not a national priority, the breast cancer epidemic will remain a metaphor for how society treats women".[76] Barbara Ehrenreich writes that, before the feminist movement "medicine was a solid patriarchy", and women with breast cancer were often treated as passive, dependent objects, incapable of making appropriate choices, whose role was to accept whatever treatment was decreed by the physicians and surgeons, who held all of the power.[77] Because of sexism in education, female surgeons were far outnumbered by their male counterparts, and until the 1990s, when Susan Love of the University of California, Los Angeles Breast Center published Dr. Susan Love's Breast Book, the physicians who provided breast cancer treatments were generally men. Love said that some male physicians tended to impose their own values on women, such as recommending mastectomy to older women because, being past the age of child bearing and breastfeeding, they no longer "needed" their breasts.[78] The women's health movement promoted mutual aid, self-help, networking, and an active, informed role in the patient's health care.[79] Since the end of the breast cancer wars, feminists have again objected to the breast cancer culture's treatment of women with breast cancer as little girls who need to be obedient to authority figures, cooperative, pleasant and pretty.[80]

Breast cancer has been known to educated women and caregivers throughout history, but modesty and horror at the consequences of a largely untreatable disease made it a taboo subject. The breast cancer movement, which developed in the 1980s and 1990s out of 20th century feminist movements and the women's health movement, has mostly removed those taboos through its modern advocacy and awareness campaigns.[81]

At the beginning and middle of the 20th century, breast cancer was usually discussed in hushed tones, as if it were shameful. As an example, The New York Times refused to publish an advertisement for a breast cancer support group in the early 1950s, stating that it would not print either the word breast or the word cancer.[82] Later, however, several celebrities publicly disclosed their own health challenges, and the resulting publicity reduced the stigma.[83] One of the first was Shirley Temple Black, the former child star, who announced her diagnosis in 1972. In October 1974, Betty Ford, the wife of the then-President of the United States, openly discussed her breast cancer diagnosis and mastectomy. Two weeks later, the wife of the then-Vice President also had a mastectomy for breast cancer. The next year, journalist Rose Kushner published her book, Breast Cancer: A Personal History and Investigative Report, which she had written while recovering from a modified radical mastectomy. More recently, Angelina Jolie has also come forward publicly regarding her experience surrounding her diagnosis and treatment, which managed to raise public awareness of the issue significantly. In one study, when a survey of women was taken following Jolie's announcement, awareness rose by 4% among those women surveyed.[84] The media reported these women's health and their treatment choices, and even invited some to appear on talk shows to discuss breast cancer frankly.[85]

The breast cancer movement has resulted in widespread acceptance of second opinions, the development of less invasive surgical procedures, the spread of support groups, and other advances in patient care.[86] The movement successfully separated diagnostic biopsy from mastectomy surgery; before about 1980, it was common to perform the biopsy and, if a quick review of tissues indicated a probable need, a mastectomy in the same surgery.[87] The one-step surgery prevented women from seeking different opinions about their treatment, and sent them into the surgery without knowing whether their breasts would be removed that day. In response to women's concerns over lymphedema after routine removal of lymph nodes during mastectomy, the more limited approach of sentinel node biopsy was developed. Advocacy efforts also led to the formal recommendation against the routine use of the Halsted radical mastectomy in favor of simple mastectomies and lumpectomies.[88]

The breast cancer movement has supported practical, educational, emotional, and financial care for women with breast cancer. Support groups, individual counseling opportunities, and other resources are made available to patients.

Educational interventions using written material and brief one-to-one interaction about breast checking behaviour, breast cancer symptoms and age-related risk have the potential to increase breast cancer awareness in older women, over a sustained period of time.[89]

Supporting breast cancer was seen as a distinctively pro-woman stance popular among public official. This has resulted in better access to care. For example, in much of the United States, low-income women with breast cancer may qualify for taxpayer-funded health care benefits, such as screening mammography, biopsies, or treatment, while women with the same income, but another form of cancer or a medical condition other than cancer, do not.[lower-roman 1]

Breast cancer advocates have successfully increased the amount of public money being spent on cancer research and shifted the research focus away from other diseases and towards breast cancer.[90] Breast cancer advocates also raise millions of dollars for research into cures each year, although most of the funds they raise is spent on screening programs, education and treatment.[91] Most breast cancer research is funded by government agencies.[92]

The high level of awareness and organized political lobbying has resulted in a disproportionate level of funding and resources given to breast cancer research and care. Favoring breast cancer with disproportionate research may have the unintended consequence of costing lives elsewhere.[93] In 2001 UK MP Ian Gibson said, "The treatment has been skewed by the lobbying, there is no doubt about that. Breast cancer sufferers get better treatment in terms of bed spaces, facilities and doctors and nurses".[94]

Breast Cancer Action is an American grassroots education and advocacy organization that promotes breast cancer awareness and public health issues relating to breast cancer, and advocates for system-wide change based on prevention. Breast Cancer Action is also known for its Think Before You Pink campaign, launched in 2002, which encourages consumers to ask critical questions before buying pink ribbon products.[126]