Early Detection: Women, Cancer, and Awareness Campaigns in the Twentieth-Century United States

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Prostate cancer screening recommendations have been influenced by the conflicting results from 2 large, prospective RCTs of prostate cancer screening that were published in Tsodikov et al sought to reconcile the differences in the observed mortality reductions between the 2 studies in terms of their implementation and practice settings and the intensity of screening.

However, the novel methodology of the study was to estimate the intensity of screening in each study group by estimating the mean lead time MLT gained in each arm of the 2 trials. The MLT is the average time that diagnosis is advanced by screening. However, it is obvious that treating men in the PLCO control group as if they did not undergo screening introduces considerable measurement error in the analysis of outcomes.

To overcome this bias, the investigators treated the MLT as a covariate to capture the level of screening in both arms of both studies. In a study with no contamination, the MLT will be zero in the control group, because their cancers will be detected after symptoms appear ie, no lead time , whereas a control group that has high rates of contamination will have MLTs that approach those of the intervention group, because screening is taking place in both study arms.

After adjustment for the MLT in modeling the risk of prostate cancer death on each arm of the study, the investigators observed similar reductions per year of MLT in the risk of prostate cancer death. By using data from both trials and a novel analysis, the authors concluded that screening in the 2 studies had a similar and significant effect on reducing the risk of prostate cancer death, but they also acknowledged that this benefit must be weighed against the potential harms associated with screening.

The ACS estimates that 63, women will be diagnosed with endometrial cancer, and 11, women will die from this disease in The evaluation of endometrial histology with the endometrial biopsy is still the standard for determining the status of the endometrium. Lung cancer is the most common cancer affecting both men and women, accounting for an estimated , new cases in Core elements of this discussion should include the following benefits, uncertainties, and harms of screening.

Most organizations that recommend lung cancer screening do so directly and may or may not stress the importance of informed or shared decision making. Although the guideline publication stated that there was sufficient evidence of an overall benefit to support a recommendation for screening, the recommendation wording about initiation of a discussion suggests that the balance of benefits and harms was judged to be uncertain or at least highly subject to individual patient preferences.

Typically, a recommendation for shared decision making is reserved for cancer screening tests in which there is uncertainty over whether benefits exceed harms and where patients are expected to differ in the value they place on those potential outcomes as is the case with the current prostate cancer screening guideline issued by the ACS and most other organizations.

Smoking cessation counseling constitutes a high priority for clinical attention for patients who are currently smoking. Current smokers should be informed of their continuing risk of lung cancer, and referred to smoking cessation programs. Screening should not be viewed as an alternative to smoking cessation. This clarification properly places the emphasis as intended on a positive recommendation for screening based on randomized trial evidence of screening efficacy in reducing lung cancer mortality and a judgment that the balance between potential benefits and harms is favorable.

In late , the ACS established the National Lung Cancer Roundtable NLCRT , a national coalition of public, private, and voluntary organizations, and invited individuals, dedicated to reducing the incidence of and mortality from lung cancer in the US through coordinated leadership, strategic planning, and advocacy. The NLCRT's focus is on promoting increased lung cancer awareness, prevention, early detection, and assurance of optimal therapy through public education, provider education, targeted research, and health policy initiatives. This roundtable is similar to other ACS supported roundtables, such as the National Colorectal Cancer Roundtable NCCRT in that it is intended to serve as a catalyst to stimulate greater levels of collaborative engagement among member organizations' efforts to address key lung cancer issues, or to take on challenges that are not likely to be addressed by any one organization.

The work of the Roundtable is guided by its strategic plan with direction and input from its Steering Committee. Although the annual incidence of ovarian cancer is low compared with that of breast cancer and precursor lesions of the cervix, it is the most lethal of the gynecologic cancers. Screening and diagnostic methods for ovarian cancer include pelvic examination, cancer antigen CA as a tumor marker, transvaginal ultrasound TVU , and potentially multimarker panels and bioinformatic analysis of proteomic patterns. Figure 1 displays cancer screening prevalence for colorectal, breast, and cervical cancer between and , when CRC screening increased from In , CT colonography use was uncommon, and the inclusion of this test did not alter overall CRC screening prevalence estimates.

Cervical cancer screening prevalence declined slightly between and , from In , CRC screening prevalence ranged from The proportion of women receiving mammographic screening in the past year ranged from Cervical cancer screening rates ranged from It is important to note that, while the NHIS is nationally representative and is a useful tool for measuring progress toward cancer screening, there are several limitations to sample surveys, which include respondents' recall bias and tendency to overestimate screening practices as well as nonresponse bias, which may be accounted for in part but not in full by the survey weighting procedures.

Additional information on cancer screening surveillance, including rates of screening by state and other sociodemographic factors, can be found in the periodically updated ACS Cancer Prevention and Early Detection Facts and Figures and Interactive Cancer Statistics Center. The most recent data on cancer screening rates are an ongoing cause for concern. As noted above, although CRC screening rates have steadily risen, screening rates for cervical cancer have declined since ; breast cancer screening rates have remained stable at an unacceptable level; and, 5 years after publication of the National Lung Screening Trial findings indicating a benefit of lung cancer screening, little lung cancer screening is taking place.

The potential to significantly raise the number of adults with access to preventive care was enhanced by the increase in individuals with health care insurance resulting from the Affordable Care Act. However, the Supreme Court decision that the federal government could not force states to expand their Medicaid programs blunted the beneficial impact of the ACA. In the current political climate, there is little evidence of a commitment to expand access to health care and there continue to be attempts to repeal or weaken the ACA. Thus, increasing screening rates in those with newly acquired health insurance takes on a particular urgency.

But overall, cancer screening rates are unacceptably low and, for the most part, not increasing. What factors chiefly account for the stagnation in screening rates? One persistent barrier to increasing screening rates is the lack of uniform appreciation of the value of cancer screening. Other barriers to screening have been known for years.

While social determinants of health, such as income, insurance status, and educational achievement, are paramount factors, numerous individuals confronting relatively few barriers to screening are not up to date. Requiring individuals to bear out of pocket expenses in the form of copays or deductibles is a barrier to screening.

Without a national program, the uptake of cancer screening relies on the combination of highly variable modes of health care delivery, varying from highly organized approaches as seen in some integrated delivery systems to completely nonsystematic and opportunistic delivery models. Adults who report recent cancer screening tend to have a usual source of care and receive a recommendation to undergo screening from a health care professional, and there is a higher probability that this will happen if the patient has undergone an office visit dedicated to preventive care, such as a wellness visit or checkup.

Given the limited time available to patients and providers during acute and chronic care visits, it is not surprising that referrals to cancer screening and other preventive care do not consistently take place. The nation has an unequivocal opportunity to reduce mortality from cancer by increasing the cancer screening rates in those most likely to benefit.

It also would provide a more dependable foundation for interventions focused on raising rates of regular screening. With greater uptake of regular screening, there would be a significant reduction in avoidable cancer deaths in the United States. Volume 68 , Issue 4. The full text of this article hosted at iucr. If you do not receive an email within 10 minutes, your email address may not be registered, and you may need to create a new Wiley Online Library account. If the address matches an existing account you will receive an email with instructions to retrieve your username.

Article Free Access. Robert A. Kimberly S. Stacey A. Otis W. Richard C. Search for more papers by this author. Tools Request permission Export citation Add to favorites Track citation.


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Share Give access Share full text access. Share full text access. Please review our Terms and Conditions of Use and check box below to share full-text version of article. Abstract Each year, the American Cancer Society publishes a summary of its guidelines for early cancer detection, data and trends in cancer screening rates from the National Health Interview Survey, and select issues related to cancer screening.

Introduction The American Cancer Society ACS provides an annual report for health care professionals and the public that summarizes the current ACS cancer screening guidelines, including current recommendations, updates, and guidance related to early cancer detection when a direct recommendation for screening cannot be made.

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Adults in good health with a life expectancy of greater than 10 y should continue screening through the age of 75 y. Using records of individual physicians and women, women's groups, cancer organizations, popular literature and film, Gardner persuades the reader that it is our memory, not the work of countless women, that is at fault in our misguided perception that health activism for, by or about women did not exist prior to the late s.

Gardner moves through the twentieth century, highlighting people, funds, organizations, and strategies employed to educate women about female cancers, by which she means breast, uterine, ovarian and cervical. The first chapter, "Look cancer straight in the face," traces the involvement of women in the founding and development of the American Society for the Control of Cancer ASCC. Messages about cancer emphasized early detection -- "if you find it, we can cure it.

Progressive-era women's organizations disseminated information to members, and those whom they aimed to help; their message promoted attention to warning signs and the value of early cancer treatment. In the s and s, women's networks grew, and these networks received and reinforced, rather than challenged, medical authority.

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The former, based in Baltimore and named after a woman who believed in cancer prevention and early detection, encouraged women to have periodic pelvic examinations. The messages of the WFA were consistent with that of the ASCC: cancer could be cured; early detection worked; and necessity of periodic medical examinations. During the war years, Edith Nourse Rogers introduced or earmarked congressional funding for cancer research. Lasker, with a background in advertising, knew the value of, and how to get, publicity. Lasker pushed ACS to put 25 percent of their budget into research, enabling ACS to sponsor clinical trials of vaginal smears in the early s.

As Gardner writes, "Lasker demonstrated that women could orchestrate changes in male-dominated medical societies.

Early Detection

Moreover, she effectively established that the public could influence government appropriations for medical research by employing public relations tools" They also searched for a technological solution to the problem of early detection but, by the end of the century, it was clear that no viable means of mass screening had emerged. Ovarian cancer, while a relatively rare condition compared with breast or uterine cancers, was certainly not unknown to nineteenth-century physicians.

They considered it to be an invariably fatal disease, but found it was often impossible to distinguish from non-cancerous growths unless it was very advanced. While the suspicion of breast or uterine cancer was commonly aroused by the presence of a breast lump or unexplained bleeding, the vague symptoms of ovarian cancer were usually recognized in retrospect and were only occasionally mentioned in medical literature. Despite the poor prognosis for ovarian cancer patients, ovarian growths of all sorts were of great interest to nineteenth-century physicians.

In good part, this was because the more common, non-cancerous cysts could become debilitating and even deadly if they grew large enough, and there was good reason to seek new means of treatment. Other surgeons attempted similar operations, and the first ovariotomy in Britain was performed in The dangers involved in abdominal surgery, however, brought the procedure into disrepute.

Not only was there a very high death rate, estimated at close to 50 per cent at mid-century, but surgeries were performed on women who turned out not to have ovarian disease at all or had cancerous tumours adhering to other abdominal structures, which made effective surgery impossible. Could we know beforehand that the circumstances would admit of such treatment? The difficulty was in the diagnosis.

There was a thick surgical darkness over the abdomen, and it gave out only uncertain sounds. Although surgery was in disfavour at mid-century, within a few years the ovariotomy would become an established, if still controversial, procedure. Wells worked to perfect his technique by performing hundreds of ovariotomies at charity hospitals such as the Samaritan Hospital for Women during the s and s, and he claimed to have reduced the fatality rate in his cases from 50 per cent to 11 per cent.

Rising confidence in the safety of surgery, combined with a growing awareness of the changeability of ovarian growths, caused some physicians to believe that the development of life-threateningly large and even cancerous ovarian growths might be prevented if surgery was undertaken sooner rather than later—that the risk of delay might outweigh the risk of surgery. But the call for immediate action should not be taken to mean that surgeons expected to save the lives of women in whom malignant ovarian growths had already developed.

As one London surgeon explained, it was more a matter that one should not assume a tumour to be cancerous and therefore hopeless when surgery might prove that the diagnosis was mistaken. Throughout the early decades of the twentieth century, the fatalism surrounding ovarian cancer stood in contrast to the rhetoric of optimism applied to some of the more common cancers in women. Cancer awareness campaigns, which emphasized the promise of early detection, portrayed both breast and uterine cancers as enemies which could be conquered through due vigilance on the part of patients and their physicians.

One factor which may have enhanced the image of ovarian cancer as a particularly deceptive disease was the growing fascination with the hormone-producing granulosa cell tumour, even though it was a much less common form of the disease. However, this cruel deception is not kept up for long, the disease soon destroying both this tragic illusion and the body itself. In the inter-war period and beyond, medical literature increasingly framed ovarian cancer of all types as a cruel trick of nature, a disease which grew stealthily until it was too late.

In spite of their general pessimism about treating ovarian cancer and the still very real dangers of surgery, many surgeons during the inter-war years continued to advise an aggressive approach to dealing with all ovarian masses in the hope of reducing the risk of cancerous changes developing in benign cysts.


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  7. Although there was a great variation in opinion regarding the percentage of growths which would prove to be malignant, there was a growing consensus by the s that all were potentially deadly and that all must be investigated as soon as they were detected. Because ovarian cancer was so difficult to detect and treat, some surgeons advocated prophylactic oophorectomy as a means of reducing the risk of ovarian cancer in post-menopausal women. The removal of healthy ovaries was still a controversial procedure and, as the frequency of hysterectomy increased during the early twentieth century, the practice of performing oophorectomy at the same time caused divisions within the medical profession.

    Crossen advocated the removal of the ovaries when abdominal surgery was done for any reason in women past their childbearing years, which he set at forty-two. He cited several cases from his own experience of women for whom he had performed hysterectomies who later developed ovarian cancer. As a second front in the struggle for ovarian cancer control, some gynaecologists also advocated increased surveillance of middle-aged patients through regular pelvic examinations.

    The growing acceptance of this procedure as a normal part of health care was a side effect of the campaign to control uterine cancer, which encouraged apparently healthy women to seek regular checkups.

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    They noted, however, that the procedure, including a rectal examination, must be conducted by physicians with considerable expertise, and they acknowledged that this level of surveillance was impossible to establish and maintain in entire populations. Thus, as concern over ovarian cancer grew, emphasis was placed upon preventive surgery and on signs which could be detected by the physician, rather than on sensations which might be reported by the patient. Given its neglect in medical literature, it not surprising that ovarian cancer symptomatology was seldom discussed in cancer awareness campaigns aimed at the wider public.

    Even though the rhetoric of early detection seemed not to apply to ovarian cancer, an interest in pursuing a more nuanced understanding of its non-specific symptoms did emerge within a very small minority of medical researchers on both sides of the Atlantic. Relying, as had others, on case histories of cancer patients to illustrate the problem, he recounted the death of a year-old woman who succumbed shortly after exploratory surgery was performed.

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    The illness attracted growing attention, however, partly because its incidence appeared to be on the rise. In the face of such discouraging facts, researchers sought new means of gaining control over the disease. Important advances in surgery and chemotherapy were made, but their long-term impact was limited by the fact that a majority of cases were not diagnosed until metastasis had occurred. The first risk factor to be systematically examined was low parity, although there was much disagreement over why it might predispose women to ovarian cancer.

    The ovary is like a cam running off center. The U. As women became more vocal about their right to know about potential risks associated with drugs and medical treatments, some cancer patients would charge that fertility clinics were negligent in not providing this information. The question of a hereditary factor was also given serious consideration in s. Instances of individual families with a high incidence of the disease had been mentioned in the late nineteenth century, and, from the s onwards, studies of affected families grew slowly in number.

    At the time, Liber was a lone voice calling for radical action based on his assumption of a genetic link.

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