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The Big Squeeze

The Big Squeeze: A Social and Political History of the Controversial Mammogram

Copyright Date: 2012
Edition: 1
Published by: Cornell University Press,
Pages: 128
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  • Book Info
    The Big Squeeze
    Book Description:

    In 2009, an influential panel of medical experts ignited a controversy when they recommended that most women should not begin routine mammograms to screen for breast cancer until the age of fifty, reversing guidelines they had issued just seven years before when they recommended forty as the optimal age to start getting mammograms. While some praised the new recommendation as sensible given the smaller benefit women under fifty derive from mammography, many women's groups, health care advocates, and individual women saw the guidelines as privileging financial considerations over women's health and a setback to decades-long efforts to reduce the mortality rate of breast cancer.

    In The Big Squeeze, Dr. Handel Reynolds, a practicing radiologist, notes that this episode was only the most recent controversy in the turbulent history of mammography since its introduction in the early 1970s. In a book written for the millions of women who face the decision about whether to get a mammogram, health professionals interested in cancer screening, and public health policymakers, Reynolds shows how pivotal decisions made during mammography's initial launch made it all but inevitable that the test would be contentious. He describes how, at several key points in its history, the emphasis on mammography screening as a fundamental aspect of women's preventive health care coincided with social and political developments, from the women's movement in the early 1970s to breast cancer activism in the 1980s and '90s.

    At the same time, aggressive promotion of mammography made the screening tool the cornerstone of a huge new industry. Taking a balanced approach to this much-disputed issue, Reynolds addresses both the benefits and risks of mammography, charting debates, for example, that have weighed the early detection of aggressively malignant tumors against unnecessary treatments resulting from the identification of slow-growing and non-life-threatening cancers. The Big Squeeze, ultimately, helps to evaluate the ongoing public health controversies surrounding mammography and provides a clear understanding of how mammography achieved its current primacy in cancer screening.

    eISBN: 978-0-8014-6600-7
    Subjects: Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-x)
  3. INTRODUCTION: The Mammography Story
    (pp. 1-4)

    The story cried out to be told. It cried out in the passion of the true believers, apologists for a beleaguered test. It cried out in the polemics of the skeptics, emphasizing possible risks and advising caution. It cried out in the posturing of political leaders who co-opted a scientific debate to satisfy the expediency of the moment. It cried out in the gratitude and calm resignation of those for whom mammography worked. And it cried out in the silent pain and anguish of those who did “everything right,” yet for whom mammography failed.

    Over the years, our national conversation...

    (pp. 5-14)

    Screening mammography burst onto the stage of national consciousness in 1973. When it did, it found an audience primed to receive it. Political, social, and health movements that had been occurring in the larger American society underwent a remarkable convergence in the late 1960s to mid-1970s. This was precisely the time when the results of the earliest medical research on mammography were becoming widely known. Though it is likely that this new screening test would have been successful on its own, this fortuitous alignment of external forces helped ensure that public acceptance would be rapid and durable. In this chapter...

    (pp. 15-27)

    In medicine, the introduction of new imaging technology is typically a three-phase process.¹ In the first phase, diffusion occurs slowly as early adopters—academics and other “technology leaders”— perform much of the initial clinical research that defines the capability of the new device. If these results are favorable, then as they are disseminated in medical journals and professional conferences, there comes a point when a rapid increase in the adoption of the new technology is observed. This second phase is often aided by media attention, which in turn drives consumer interest. Finally, as market saturation is achieved, the rate of...

    (pp. 28-35)

    Screening in the BCDDP was concluded in 1981, and the first results were published the following year.¹ Despite, or possibly because of, the controversy that had ensnared the program through much of its course, its sponsors proudly highlighted its accomplishments. Just over 280,000 participants had enrolled in the program, and about half (51.7 percent) completed all five screening rounds; 4,443 breast cancers were diagnosed. Of these, 3,557 diagnoses (80 percent) were directly attributable to screening (mammography or physical examination). The remaining 886 cases came to light either between annual screening visits or sometime after the participant completed the final round...

    (pp. 36-49)

    In June 1981 the U.S. Centers for Disease Control (CDC) published a brief report on five previously healthy gay men in Los Angeles who had been diagnosed with a rare form of pneumonia. Two of them had died.¹At the time, no one could have anticipated the public health cataclysm that was about to be unleashed upon the world. During the first two years of what would become known as the AIDS epidemic, cases increased exponentially. By September 1982, 593 cases had been reported, and 243 patients (41 percent) had died.² One year later the CDC reported 2,259 cases and 917...

    (pp. 50-61)

    It has been frequently observed that the United States is virtually alone among developed countries in its support for screening mammography in women under fifty. This support has wavered little since the technology was introduced. This apparent American consensus on screening, however, is only an illusion. Just beneath the veneer of unanimity lies a dispute that will not die. Since 1976, every time mammography has become embroiled in controversy, the question of screening women in their forties has been the central issue. In the 1970s this issue nearly aborted mammography’s debut during the Breast Cancer Detection Demonstration Project, and in...

    (pp. 62-71)

    The 1997 NIH-NCI episode had two far-reaching consequences. First, it established the primacy of politics over science in mammography disputes. No longer would science have the last word. If the conclusion based on scientific data was politically untenable, it would simply be overruled or circumvented by political leaders. This priority, evolving for about a decade, came to full fruition during this episode. Second, for the first time, a de facto U.S. government position on the screening of women under fifty was defined. Since that time the federal government has, despite the conclusions of its own scientific agencies, consistently been on...

    (pp. 72-83)

    With a little help from its friends, screening mammography has not merely survived its myriad controversies, it has thrived. Eighty-one percent of women over fifty and 65 percent of women forty to forty-nine undergo regular screening.¹ As mammography succeeded, a vast multifaceted collateral economy developed around it. In this screening-centric system, the various elements in the secondary economy are directly sustained by ongoing screening. This remarkable phenomenon, without ready parallel, is the subject of this chapter.

    Over the past few decades of widespread screening mammography, countless lives have been saved. But there is also a large population of women for...

    (pp. 84-94)

    In this final chapter I expand on a subject that was previously mentioned in passing. Mammography-induced breast cancer overdiagnosis represents the most significant detriment of screening. Yet until recently it has received almost no mention in the public education messages of government, advocacy, or professional entities. This deafening silence reflects the long-standing aversion of the pro-screening community to any public discussion of mammography’s limitations. We have been afraid of “confusing” women with “mixed messages” on screening. This fear has prevented us from having the frank, honest conversations that are absolutely essential for genuine patient-consumer education to occur.

    As noted by...

  12. NOTES
    (pp. 95-112)
  13. INDEX
    (pp. 113-122)