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Sunday, February 16, 2014

Women's health: Cancer, Heart Disease and Misfearing

This blog is based largely on a recent paper in the Perspective series of the prestigious New England Journal of Medicine by US cardiologist Lisa Rosenbaum, entitled:” ‘Misfearing’ – Culture, Identity and Our Perceptions of Health Risks”[1]. First let me explain the term “misfearing”.  It is characterised by two attributes. It describes the widespread human tendency to base fear on emotive reasons and not on fact. It is also characterised by fear of dreadful events, which catch headlines and which are quite often rare (plane crashes, nuclear accidents, severe weather, HIV-AIDS etc.) rather than by fear of the familiar such as heart disease, obesity, smoking which are common and which occupy a great % of the health budget. Rosenbaum discusses this concept of misfear in relation to women’s health and specifically female cancer and female heart disease.

The majority of women would say that breast cancer is a bigger threat to women’s health than heart disease. However, the facts are the reverse, hence the concept of misfearing. In the US, over the period 2006 to 2010, the number of cases of all cancers in women was 2.8 million. The comparable figure for heart disease was 12.7 million, 4.5 times greater. The data skeptics will immediately argue that the heart disease data are flooded by statistics on high blood pressure, high blood cholesterol as well as actual cases of heart attack.  So let us consider deaths from cancer and heart disease in women. During this same period, 40,000 US women died from all forms of cancer. The comparable figure for deaths from heart disease was 410,000. Now, as regards mortality, the difference between all causes of female cancer and female heart disease is 10 fold.  Ten times as many graves of women who died of heart disease compared to all forms of cancer combined.

Why therefore is female health to a considerable health dominated by cancer, specifically breast cancer? The answer is largely sociological. But first consider the power and emotion behind the misfear of breast cancer. Rosenbaum points out that in 2009, the US Preventative Services Task Force recommended that the frequency of mammography in younger women should be reduced noting “…the potential harms outweighed the benefits”. The reaction among women was powerful. USA today conducted a poll of women aged 35 to 49 years and 84% intended to ignore the recommendations. So powerful was the backlash that the Affordable Care Act ignored the task force’s recommendations requiring insurers to base coverage on previous screenings. This perpetuated in law, a policy that the experts deemed did more harm than good. Rosenbaum writes: “Have pink ribbons and Races for the Cure so permeated our culture that the resulting female solidarity lends mammography a scared status? Is it the issue that breast cancer attacks a part of the body that is so fundamental to female identity that, to be a woman, one must join the war on this disease?”

I Googled the term “Famous women who have had breast cancer” and from the 20 listed, here are the ones whose names I recognise: Singers Kylie Minogue, Olivia Newton John, Sheryl Crow, and Carly Simon, actresses Cynthia Dixon of Sex and the City, Dame Maggie Smith, and Angelina Jolie. I did the same for “Famous women who have had heart disease” which oddly was dominated by men but I found one female name I recognised, Nancy Reagan. To me, it is understandable why women care more about breast cancer than heart disease. It is a disease that is unique to women and to womanhood. It is thus an extremely emotional thing. Heart disease is for all humanity. However emotional the issue of breast cancer may be, the census of the dead shows that female heart disease is ten times that of all female cancers combined. Men also have their emotional links with a cancer that has an incidence rate way below that of heart disease, namely prostate and testicular cancer. Indeed it’s a man thing to grow a moustache for a man’s cancer charity in “Mowvember”.

Rosenbaum explores her explanation in our commitment to cultural groups. It is a distinctive mark of human society that we alone cooperate beyond families and into groups and societies. What we lose as individual or selfish rights, we gain as communal rights[2]. Group identity is central to human society. For a group to thrive, it needs to support and reinforce the very reasons why it is a group. Misfearing is based not on fact but on emotions. It is what keeps opponents of pylons, fracking, intensive agriculture, fast food and the like together. She ends her article thus: ”Certainly, understanding of one’s risk for any disease must be anchored in facts. But if we want to translate into better health, we may need to start talking more about our feelings”.

Years ago during my two decades as a member of the EU Scientific Committee for Food, I learned the difference between fear based on facts and fear based on emotions. The social groups opposed to food additives and pesticides share this common misfear theme and pouring facts into this group is a waste of time. However I might see their “facts” as nonsense or unfounded or disproved, they see them as central and moreover, they see mine as threatening to the central belief of their group.

So how does public health and in my case, public health nutrition, tackle the misfearing among women who wrongly, if facts are the basis of truth, put breast cancer well ahead of heart disease as a threat to their health. Imagine if a mammography test required a prior blood lipid profile test and an ambulatory test? Would that not capture the problems of heart disease in women? Maybe so but the majority of cases of heart disease in women are among the poorer and the more socially disadvantaged. And thus the answer is not so obvious. Diet and lifestyle changes have a far greater link to the reduction in risk of heart disease than they do of most cancers. We need to advertise the fact that for every female death that arises from any cancer, ten times more women will die of heart disease. Simple measures such as blood lipid screening and blood pressure monitoring must be promoted among women.  And the promotion of healthy eating for heart disease prevention needs to gain as much print and social media as that which links diet and cancer, where, like it or not, the strength of evidence is much weaker.

[1] Rosenbaum, L (2014) New Eng J Med, 370, 595-597
[2] Wired for Culture – the natural history of human cooperation” Mark Pagel, 2012, Allen Lane, London