By Barbara Gottlieb, MD, MPHAssociate Professor, Harvard Medical School; Associate Professor, Harvard School of Public Health; Brookside Community Health Center and Associate Physician, Brigham and Women's Hospital, Boston, MA
Although my patients have very diverse backgrounds (ie, in class, age, ethnicity, race, education, language, health literacy), they are quite similar in what they fear and what they don’t fear. For my female patients, breast cancer is at the top of the list. Somewhere beneath that is diabetes, then heart disease, stroke, and others that you would expect. I’m pretty sure that for most of my patients, lung cancer doesn’t even make it on the list.
This isn’t the first time the possibility of lung cancer came up for a patient of mine whom I will call Mrs. B. Many years ago, when she still smoked heavily, a persistent pneumonia sparked fear of lung cancer on my part. Not hers. A few courses of antibiotics and a series of CT scans buried the threat, at least for the time being. It was another few years before she cut down on her smoking, and more years after that until she finally quit. Unusual chest x-ray findings came up now and again over the years, each time resolving in subsequent x-rays and scans. Again the monster hid. Unexplained weight loss—again I searched for lung cancer. Again not found. Each time my fears were allayed but never put aside. Mrs. B never feared lung cancer. She had no cough, no bloody sputum. She felt well. Her demons wore pink ribbons.
Last week, when I had to give her the bad news, she was, to my surprise, relieved. “At least it’s not breast cancer.”
Had we never discussed lung cancer? Had I not mentioned the fact that while breast cancer strikes twice as many women each year as lung cancer, lung cancer kills more women every year than breast, uterine, and ovarian cancers combined? Had I not mentioned that as a longtime, heavy smoker, she really did need to worry about lung cancer? Might she have quit smoking sooner if I had succeeded in communicating this to her? Would it have mattered, since 20% of women who get lung cancer have never smoked?
Coincidentally, I had been reading Promise Me, Nancy Brinker’s account of her sister Susan G Komen and the history of the foundation established in her name. Since 1982, activities in the name of Susan G. Komen have spawned an international grassroots movement dedicated to raising awareness of breast cancer, improving detection, all aspects of care and treatment, and ultimately to saving the lives of women. Breast cancer went from a closeted, stigmatized illness, spoken in hushed tones, to becoming a household word and a global movement.
The passion of many extraordinary people, including Nancy Brinker, excellent marketing, and hard work made breast cancer a leading target of the war on cancer. According to a New York Times review of federal funding for cancer, breast cancer receives the most funding per new case, $2,596, and per death, $13,452. In contrast, lung cancer, responsible for more deaths among both men and women, receives $1,518 for each new case and $1,630 for each death, the least amount of funding from the National Cancer Institute relative to cancer deaths.
Bringing breast cancer into prominence was an amazing feat, with collateral effects on the stature and prominence of women’s health more generally. The Susan G Komen success is a proud and enduring chapter of the history of medicine. There are many lessons to be learned about lung cancer. As a physician, I can only do so much one-on-one with a patient. Sometimes my fears can become my patient’s fears, and those fears can be used to catalyze behavior change. But my fears, my messages really do need to resonate with what people hear in the 99.9% of their lives that they spend outside of my office. The media, grassroots activities, friends, and neighbors need to have complete and accurate information about how to be healthy and what the threats are to their health and well being. Without reducing the attention to breast cancer, the application of society’s resources, particularly from the public sector, needs to be driven by the numbers, an accurate accounting of the risk and the threat.