What good the pink ribbon?

The huge PR behind breast cancer awareness may raise the profile of a dread disease, but mislead wom

October has been Breast Cancer Awareness Month and a huge, well-meaning PR machine has lurched into action. Armies of eager celebrities were marshalled, trotting down catwalks and posing for posters. The glitterati have hobnobbed at charity balls. Magazines have launched "pink issues" devoted to the theme, and supermarkets showcased their caring, sharing natures by flogging specially commissioned pink products.

Breast cancer gets huge amounts of publicity because the campaign is well-organised and awash with celebrities, providing newspapers with a great excuse to print photos of lithe young women wearing promotional T-shirts. And it also has the advantage of not being a disease associated with poverty - in fact, it affects people from higher-income backgrounds more than the poor. It's not hard to see why, say, bowel cancer or boring old heart disease fail to match its media profile.

In the midst of the glitz, glamour and media hullabaloo, one rather important question goes unanswered: where does awareness of breast cancer actually get us? Talk to doctors about the effects of the awareness month and a complex picture emerges. Encouraging high level of disease awareness has some negatives for public health, which should be weighed against its benefits.

The first problem is that it is difficult to get media-based health campaigns to target the right people. Michael Fitzpatrick, an east London GP and author of a book on health awareness, says: "I get young women coming into the surgery on a regular basis who are worried about breast lumps. They are actually more likely to be hit by a bus on the way to the surgery than they are to have a breast tumour. But the message they get is that they are at risk, and that they should be constantly on the lookout for symptoms."

Age is the single most important factor in calculating the risk of breast cancer, but this simple fact is often obscured by media campaigns. Women below the age of 25 have a one in 15,000 chance of getting the disease, rising to one in ten by the time they are 85. "When the press picks up on breast cancer stories, it will always choose to feature young, sexy women, when in fact they are a tiny minority of the cases," says Diana Jupp of Breast Cancer Care. "In fact, this year we have chosen older women, such as [the actress] Honor Blackman, to front the campaign, and we're trying to target it carefully for an older audience."

The benefits of awareness are far from clear-cut. Nobody knows what causes breast cancer or how to prevent it. Advice offered to nervous women focuses on giving up alcohol, keeping their weight down and having a baby before 20. None of these, however, is foolproof. Indeed, in a recent article on the "breast cancer crisis", the Guardian concluded that the underlying cause of breast cancer was "the way we live in the rich, ambitious and sophisticated northern half of the globe".

We are often told that awareness will help women to detect the disease when it is still at an early stage. Yet recent research by the World Heath Organisation showed that women who regularly examine their own breasts for cancer almost always miss real tumours, and often raise the alarm unnecessarily. The WHO now says that doctors "should not recommend screening by self-examination and physical examinations of the breast". So with a terminological wriggle of which new Labour would be proud, women are now advised to be "breast aware". This is rather nebulously defined as "becoming familiar with your breasts and the changes they go through throughout your life". "We no longer tell women to sit down and formally examine themselves once a month," explains Jupp. "But they should still know what signs to be looking out for." Women might be forgiven for finding the messages a little confusing.

The debate over mammography, or breast-screening using X-rays, reveals further difficulties with early detection. At present, the NHS encourages women over 50 to have a mammogram every three years, and says it saves 300 lives per year as a result. Some doctors argue that this justifies the investment. Dr Sunita Shrotria, a breast disease specialist at Ashford and St Peter's Hospitals, told me: "We can't be too paranoid. I think women can handle anxiety, and it is always justified by those who are treated and cured."

But there are voices of dissent. Critics point out that, to save one life, you need to screen 1,250 women over ten years, at enormous cost and with all the attendant risks of misdiagnosis. Professor Michael Baum, a breast cancer specialist who helped set up the NHS screening programme, later criticised it fiercely for encouraging false alarms, overtreatment and needless mastectomies. He argues that investing in treatment has been 200 times more effective in saving lives than the screening programme. "It is galling how the political spin from government agencies suggests that the best way of reducing deaths from breast cancer lies in trawling through the asymptomatic population," Baum wrote in the British Medical Journal.

The truth is that screening, and disease awareness in general, serve some rather powerful interests. Health is one of the few issues that continue to engage voters. Getting people to worry about disease and attend health screenings creates a sense that the government is intervening positively in their lives.

"I see it as a two-sided thing," says Fitzpatrick. "There's a drive from above, from the government, which wants to make health a central feature of policy, and from the medical establishment, which wants publicity. On the other side, there's a popular resonance. People don't find screening and endless tests intrusive - they want to get involved."

Breast cancer is one in a huge number of similar health campaigns. By the end of October, we had had Lupus Awareness Month, Stroke Awareness Week, Babyloss Awareness Week, World Mental Health Day, International Herpes Week, BackCare Awareness Week and World Osteoporosis Day - and those happened in that month alone. Over the course of the year, similar campaigns will be organised for psoriasis, Alzheimer's, male cancer, cancer among children, ovarian cancer, eczema, and many other unpleasant and life-threatening ailments. "We rarely hear the term 'hypochondria' these days," Fitzpatrick observes. "People see it as a virtuous state of awareness of health problems."

The irony of all this is that, generally, it is the people who are least likely to die prematurely who worry most about disease. One GP remarks: "Poor people, who often have good reason to worry about their health, don't, no matter what you say. And the middle classes, who are basically very healthy, worry inordinately." This is borne out by research from the Nobel prizewinning economist Amartya Sen, who compared health and perception of health in America and India. He found that in areas of rural India where there is very short life expectancy, people considered themselves to be ill less often than people did in the United States. This tendency is only exacerbated by media campaigns, which encourage the chattering classes increasingly to corner more of their doctors' time and NHS resources.

It is difficult to accept that illness and death are inevitable for all of us, particularly at a time when we tend to live long and healthily. By buying into the media hype, however, we are compromising this quality of life with unnecessary worry.

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