A while back I wrote about really rethinking how we screen for breast cancer using mammography. Basically, the USPSTF, an independent panel of physicians and health experts that makes nonbinding recommendations for the government on various health issues, reevaluated the evidence for routine screening mammography and concluded that for women at normal risk for breast cancer, mammography before age 50 should not be recommended routinely and should be ordered on an individualized basis, and that routine formalized breast self-examination (BSE) should also not be routinely recommended. In addition, for women over 50, it was recommended that they undergo mammography every other year, rather than every year. These recommendations were based on a review of the literature, including newer studies.
To say that these new recommendations caused a firestorm in the breast cancer world is an understatement. The USPSTF was accused of misogyny; opponents of health care reform leapt on them as evidence that President Obama really is preparing "death panels" for your mom; and HHS secretary Kathleen Sebelius couldn't run away from the guidelines fast enough. Meanwhile, a society I belong to (the American Society of Breast Surgeons) issued a press release accusing the USPSTF of sending us back to the "pre-mammography" days when, presumably women only found breast cancer after it had grown to huge size (just like Europe and Canada, I guess, given that the recommendations for screening there closely mirrors those recommended by the USPSTF. Meanwhile, in the most blatant example of protecting its turf I've seen in a very long time, the American College of Radiology went full mental jacket with a press release that was as biased as it was insulting. Meanwhile some physicians even likened the recommendations to going back to being like Africa, Southeast Asia and China as far as breast screening goes in that he actually speculated that he'd now become very busy treating advanced, neglected breast cancers.
I had left the issue alone for a while, primarily because I was seeing a whole lot of heat and no light in the discussion. I had my problems with the new guidelines; indeed, I was surprised at how far they went and how fast. I had expected a rethinking of our recommendations on mammographic screening based on multiple new studies questioning the value of screening the way we have screened. If you want to know more before I move on to the meat of this post, I'll list my posts here:
- Early detection of cancer, part 1: More complex than you think
- The paradox of screening mammography and breast cancer
- The spontaneous regression of breast cancer?
- Overdiagnosis of breast cancer due to mammography
- Rethinking cancer screening?
- Really rethinking breast cancer screening (I discuss the new guideinles in this one.)
- Mammography and the risk of breast cancer from low dose radiation: Weighing the risks versus hysteria
Despite all the hysterical and disingenuous attacks on the new guidelines, there is one criticism that actually resonates with me because I work at a cancer center in a very urban environment with a large population of African American women. A couple of days ago I heard on NPR this story:
Many African-American women don't fit the profile of the average American woman who gets breast cancer. For them, putting off the first mammogram until 50 -- as recommended by a government task force -- could put their life in danger.
"One size doesn't fit all," says Lovell Jones, director of the Center for Research on Minority health at Houston's M.D. Anderson Cancer Center. Jones says the guidelines recently put out by the U.S. Preventive Services Task Force covered a broad segment of American women based on the data available. "Unfortunately," he says, "the data on African-Americans, Hispanics and to some extent Asian-Americans is limited."
So while the recommendations may be appropriate for the general population, he says, it could have a deleterious affect on African-American women who appear to have a higher risk of developing very deadly breast cancers at early in life.
And this is actually true. Some of the studies used to develop the latest mammographic guidelines were performed in Scandanavian countries, and in the others arguably African American women were underrepresented. As the article points out:
When you look at the death statistics for breast cancer in African-American women and compare them to white women, it's stunning. Beginning in their 20s, into their 50s, black women are twice as likely to die of breast cancer as white women who have breast cancer. In older black women, cases of breast cancer decline, but the high death rates persist.
Overall, breast cancer deaths have been declining for nearly a decade (by 2 percent annually), yet deaths of African-American women have been dropping at a much slower pace. In 2009, an estimated 40,170 women will die from breast cancer. Nearly 6,000 will be African-American women.
Why this disparity exists is unclear. One potential reason is that, for whatever reason, African American women tend to develop a more aggressive form of breast cancer known as "triple negative" cancer. What triple negative means is that the tumor is estrogen receptor negative [ER(-)], progesterone receptor negative [PR(-)], and HER2?neu negative [HER2/neu(-)]. The lack of estrogen receptor means that these tumors don't respond to antiestrogen drugs, while the lack of HER2/neu means that they don't respond to Herceptin. In other words, there are no targeted therapies for these tumors, only cytotoxic chemotherapy or nothing.
More importantly, there is something about the biology of these tumors that makes them more aggressive. They may respond well initially to chemotherapy but they tend to relapse rapidly and kill quickly. This subtype of tumor generally makes up around 15% of cancers among women who are not black, but among African-Americans it makes up nearly 40% of tumors. This is a striking difference, and five year survival for women with triple negative cancer is considerably lower than for other types of breast cancer, particularly for young, premenopausal African-American women.
With that background, it's not unreasonable to ask what "normal" risk for breast cancer is for purposes of recommending a program of screening mammography. On the one hand, if young African-American women are at a higher risk for breat cancer, then beginning their screening at an earlier age makes sense because it is the lower risk of breast cancer in women in their 40s that led the USPSTF to conclude that the risk-benefit ratio of mammography was less favorable in this age range. On the other hand, the more aggressive nature of breast cancer in young, premenopausal African-American women means that length bias becomes a consideration. Basically, length bias means that mammographic screening tends preferentially to pick up slower-growing, more indolent tumors. Faster-growing, more aggressive tumors tend to "pop up" between screening intervals. So, even if screening were started earlier for African-American women, it's not clear that the benefits would be as dramatic as we might hope. Indeed, the NPR story alludes to this:
Sheppard even wonders if the old guideline of routine screening every year beginning at age 40 is good enough. "The tumors are growing fast and the intervals that we prescribe may not work," she says. "How can we have better diagnostic tools, better screening tools that can capture the women that aren't the average woman?"
Still, fellow ScienceBlogger Isis brought up this very point the other day has a point when she wonders:
The other thing I wonder about is the effect these recommendations will have on the perception of health care equity. A black woman is more likely to develop aggressive cancer than a white woman before age 50, yet the USPSTF has recommended not to actively screen women less than. I wonder how this will be interpreted by that community? Black women experience a distrust of scientists performing clinical trials (second reference here), operate within a healthcare that is not always sensitive to their needs, and use mammography as a resource less frequently than white women. Will these new recommendations foster feelings of distrust and reinforce the notion that the current health care system does not adequately meet their needs?
There is a legitimate concern that the USPSTF guidelines may not be a good fit to African-American women because not only do they tend to have more aggressive disease at a younger age but they have been underrepresented in many of the large screening trials that have been used to formulate the recommended mammography guidelines. For that reason, upon further reflection I don't think that the USPSTF guidelines should be used to determine how and when African-American women should undergo screening, as I consider them to be at a high enough risk that screening beginning at 40 makes sense.
However, as much as she did raise a valid point when she questioned whether the current mammography guidelines should apply to African-American women, still I must remonstrate with Isis and point out that the article by Nicholas Kristof that she cited in support of her speculations is dubious at best and a load of grade-A woo at worst. For example, Kristof states:
Dr. Philip Landrigan, the chairman of the department of preventive medicine at Mount Sinai, said that the risk that a 50-year-old white woman will develop breast cancer has soared to 12 percent today, from 1 percent in 1975. (Some of that is probably a result of better detection.)
What's very important to realize is that 12% of women do not get invasive breast cancer as compared to 1% in the past. Moreover, "some of that" is not "probably" a result of better detection. Most of it is almost certainly a result of better detection of earlier breast cancer, including premalignant lesions, through widespread mammography screening programs. Indeed, as this report by the American Cancer Society shows, the incidence of invasive breast cancer per 100,000 women is not increasing nearly that fast, and, in fact, since 2002 breast cancer rates have plummeted, very likely due to the massive decrease in hormone replacement therapy use in the wake of the 2002 report from the Women's Health Initiative showing that HRT doesn't decrease cardiovascular risk but does increase the risk of breast cancer. Figure 1 in particular shows this trend, while Figure 2 shows what's really driving the apparent increase in breast cancer diagnoses, a massive increase in the amount of preinvasive ductal carcinoma in situ (DCIS).
We've known for quite some time that what's driving this increase is nearly all mammographic screening; indeed, the article speculates that we may have finally reached the plateau in the increase of DCIS cases with the widespread use of mammographic screening over the last 20 years. That 12% figure is not just invasive cancer; it includes DCIS. While invasive cancer diagnoses are more or less stable, diagnoses of DCIS skyrocketed due to mammography. Indeed, this dovetails nicely with my earlier discussions of overdiagnosis due to mammography, because this is exactly what I'm talking about. Mammography picks up early cancers that may or may not ever threaten the life of the woman; that's what overdiagnosis is. Moreover, overdiagnosis leads to overtreatment, as we don't have a good handle on what percentage of DCIS lesions would ever progress to life-threatening disease if left alone. So we treat them all with surger, nearly all of them with radiation, and most of them with Tamoxifen after surgery and radiation.
Unfortunately, in the article Kristof takes a somewhat reasonable suspicion and runs right off the dock with it into woo land, and Isis appears not to have been skeptical enough about his claims, given that she then used Kristof's article as the basis for speculation that maybe African American women, tending to be of lower socioeconomic status than Caucasian women, are exposed to more toxic chemicals and endocrine disruptors. Unfortunately, as Peter Lipson characterized his article, Kristof has clearly fallen for the "one true cause" fallacy so beloved of practitioners of woo, labeling endocrine disruptors such as BPA as a major environmental cause of the apparent increase in breast cancer diagnoses. Don't get me wrong, there may well be something there in that BPA and endocrine disruptors may contribute to breast cancer, but almost certainly not to the extent that Kristof claims, even given the evidence he cites. In addition, if there's one thing about breast cancer, it's that no single environmental exposure has been found to be strongly correlated with it; most of the correlations other than family history and exposure to hormone replacement therapy, including both positive and negative correlations, have been in general pretty weak. Indeed, I was recently peripherally involved in an effort to design a project to study environmental influences in breast cancer, and there are amazingly few validated environmental factors that increase the risk of breast cancer. Also, timing is very important; it may well be that it is exposure to these factors in adolescence or childhood in a "window" of susceptibility, not in adulthood, which is when they are normally studied. Right now, that's where the current research efforts seem to be focused. In addition, breast density, which is primarily genetically determined, is a known risk factor for breast cancer as well, and investigators are actually planning to study that at our institution. All in all, it's a hideously complicated business combining genetic and environmental factors that I am only beginning to wrap my brain around, while Kristof's article was simplistic and alarmist in the extreme. For better information, I recommend a report from the Endocrine Society for the more sober, balanced perspective, and a report from the Breast Cancer Fund for arguments more explicitly in favor of a link. More information, including the chemical industry's viewpoint (if you're interested), can be found here.
I firmly believe that the recommendations for how we screen for breast cancer were overdue for an overhaul. Badly. However, the USPSTF guidelines may have gone too far too fast, at least for public consumption in light of the years of urging by the government and private advocacy organizations for all women over 40 to be screened, recommendations that say that mammography before age 50 may not be particularly beneficial were a hard pill to swallow. As I think about it more, though, one big flaw in the guidelines is that there was little consideration of how changing screening recommendations would impact special populations that may be at higher risk, such young African American Women. Worst of all, the USPSTF recommendations are an example of some of the astoundingly worst science communication I've seen in a long time. No groundwork was laid to prepare the public; the guidelines were just announced; and the spokespeople for the USPSTF looked like deer in the headlights when they showed up in the media to defend the guidelines. Specialty groups protecting their interests such as the American Radiologial Society and its President Dr. Kopans ate them for lunch and then laughed at their discomfiture. Meanwhile high ranking government officials couldn't distance themselves fast enough, and lawmakers and ideologues had a field day playing politics with the guidelines.
In the end, while I still think that the new guidelines are reasonable for most non-black women, after thinking about it I doubt that they should be applied to African Americans. Finally, I'm now convinced more than ever that screening will only have limited effects in decreasing mortality from breast cancer, regardless of the test used, as long as we have so poor an understanding of the aspects of breast cancer biology that govern which early cancerous lesions will progress, which will not, and which will regress. Until we do, if there were developed a test to replace mammography, the same problems of overdiagnosis and overtreatment would remain. More than ever, we need to develop an understanding of the biology of breast cancer sufficiently advanced that it permits us to develop imaging tools and biological markers that can differentiate breast cancers that will progress and those that are not going to threaten the life of the woman. At the very least we need better indicators of risk. Until we have these things, screening will remain a highly imperfect tool that doesn't save as many lives as it has the potential to.
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Relax Orac, as we discussed in my graduate class seminar, race is a social construct designed by the man to keep us down. Thus, there is no basis for such fear and hand-wringing.
My first thought when reading this is that if you thought this was a firestorm, anyone reccomending a different screening processes for african-americans should be prepared for immolation. While there may be a good case scientifically for such an approach, politically, it seems disasterous, particularly in such an already emotionally charged area.
Un-related to that thought, I would like to ask you, Orac, what your approach would be. You have stated in this post and others that you feel our current screening process should be revamped, but that the USPSTF guidelines go "too far, too fast." What, in your opinion, would have been a reasonable reccomendation, in light of both the political atmosphere and the scientific literature?
I don't know what Orac will say, but one babystep could have been to recommend every other year screening after the age of 40, moving to every year screening at 50. After doing this for a while, you move to screening every other year after 50, too, and then you phase out the screenings in the 40s.
It's a lot longer process to get it done, admittedly, but probably more palatable.
Orac says: "Worst of all, the USPSTF recommendations are an example of some of the astoundingly worst science communication I've seen in a long time."
This is what I was saying over and over again in comments on your blog and Whitecoatunderground. finally you state it.
My favorite quote from these "idiots' on the committee (idiot refers to there inability to appreciate what the hell they were really doing) came from an article in the NY Times, where someone from the panel said that they were surprised by this firestorm because they viewed the work as just some mundane number crunching.
Correct me if I'm wrong, but African-American women seem to develop cancer at higher rates then white women and African women in Africa. If the cause isn't environmental, then what is it? It doesn't make sense that the cause is genetic.
Michael, the African American population, due to the ancestral bottlenecks of the slave trade, have narrower genetic diversity than Africans in general (especially since the continent of Africa has the largest genetic diversity in the world). African American ancestry originates predominantly from western African Niger-Kordofanian (~71 percent), European (~13 percent), and other African (~8 percent) populations (source). There has been some general speculation that the 'selective pressures' of brutal cross-ocean transits, the harsh slave life, and the meddling of slave owners in reproduction has resulted in some very important differences in allele frequencies that may underlie some of the known disease risks.
So...in short, African-Americans with slave ancestry are in many ways a genetically unique subpopulation when it comes to genetically-derived disease risk factors. This is certainly confounded by correlations with lower economic class, which carries multiple health risks, but it's likely there are many important genetic factors that remain to be elucidated.
Orac addresses the issue of screening for diverse populations very effectively with information backing up his concerns. This comment does not seek to detract from this very thoughtful post.
Question: Given the current lack of options for treating the triple negative cancers, how is screening going to improve prognosis? Is early detection more likely? Does it improve outcomes?
Given the marketing blitz regarding breast cancer, one would think that the ONLY health problem women need to worry about these days is breast cancer. The very predictable response to the new guidelines was to protest that the government was trying to kill women by reducing the recommended number of mammograms. It's very troubling that they have been convinced that the path to immortality lies in endless screening. There seems to be an exploitative element to the whole "breast cancer awareness" campaign.
IMHO, high-pressure tactics used to coerce women into yearly mammograms is misogyny, especially when they are used in place of actual care. As in, "No, we aren't really interested in treating your chronic upper respiratory infections, fatigue, and joint pain. But, be sure to schedule your mammogram on your way out!" It's easier to get a mammogram than it is to get real health care.
I think the whole mammogram controversy is just a diversionary tactic. And itâs working really well.
In addition, if there's one thing about breast cancer, it's that no single environmental exposure has been found to be strongly correlated with it
Sunlight? Breast Cancer Mortality Rates by State vs UVB DNA Spectral Exposure
It could explain why breast cancer occurs earlier in African American women. They have darker skin and hence lower vitamin D levels.
Nesby-O'Dell, S. et al. Hypovitaminosis d prevalence and determinants among african american and white women of reproductive age: third national health and nutrition examination survey, 1988-1994. The American journal of clinical nutrition 76, 187-192 (2002) - "The prevalence of hypovitaminosis D was 42.4 ± 3.1% (xâ ± SE) among African Americans and 4.2 ± 0.7% among white"
From Garland, C. F. et al. Vitamin d and prevention of breast cancer: pooled analysis. The Journal of steroid biochemistry and molecular biology 103, 708-711 (2007) - "individuals with serum 25(OH)D of approximately 52 ng/ml had 50% lower risk of breast cancer than those with serum [below] 13 ng/ml"
DayOwl: I don't think breast cancer awareness is a diversionary tactic; more a victim of its own success. It used to be something that people didn't talk about, and so despite how common it is, people really didn't have much awareness of it. But I think we have indeed come too far; breast cancer awareness overshadows other things. When you can buy breast cancer awareness toothbrushes, it has probably gone too far. ;-)
My biggest worry is the one you alluded to; that the fantastic success of breast cancer awareness campaigns may make people less aware of other, more pressing concerns. For instance, there is still a tendency to think of heart disease as a male problem, yet it kills more women than breast cancer does.
Orac, thanks for addressing this. Iâve read your previous posts on breast cancer and found them especially well-written and useful.
I was wondering if you could address a claim that popped up in the comments over at Isisâ place: should premenopausal women be screened with ultrasound instead of mammography? Iâd be interested to know what the sensitivity and specificity of those two modalities are in the 40-49 group, whether white or African American. Can you point me to reputable studies?
@Pablo: I canât speak for others, but Iâd be pretty angry to be told that I should get a mammogram every other year and then a few years later to hear that I shouldnât have bothered at all, based on no new evidence. I would like doctors to make recommendations about my health based on the best available scientific evidence and leave the PC bullshit out of it. Iâm a big girl â I can deal with controversy.
Michael, the difference could be epigenetic. Exposure to stress in utero does program adult physiology to cause more CHD and hypertension. African Americans are more susceptible to CHD and hypertension and some of that may be due to stress on their mothers while they were in utero. Hypertension is a risk factor for preeclampsia, which is very likely a risk factor for hypertension in adults exposed to preeclampsia in utero.
Many of the disorders that are observed at higher rates in the African American community in the US are exacerbated by stress. There is some very interesting work on lead levels and violence. That could be mediated through a stress response too, and lead exacerbates all the stress exacerbated diseases too.
It might take a few more generations to remove the epigenetic effects of the stress of racism.
Hope
Good for you, Hope. Unfortunately, you are not typical. The backlash against the recommendations has come at all levels, not just from immature women.
And who said anything about "no new evidence." This is something that can continue to be examined. You change the guidelines to every other year after 40, every year after 50. Then you see the effect - does prognosis get worse? If not, then you can say, "The last change in guidelines has not caused a problem in breast cancer detection or treatment; current data suggests that further modifications would be in order." Then do it again.
That is indeed "new data," the data that reducing the frequency of mammograms has not caused an upsurge in the number of untreated cancers.
Long time reader, first time poster.
I'm a current medical student and I love this blog. You guys (along with Science Based Medicine) are a huge asset whenever pseudoscience comes up with patients or class.
This may be a quibbling question about breast cancer, but in your post you say that being triple negative is extremely bad because you're not receptive to anti-hormonals or herceptin. However, I thought that being her2neu positive correlated with having a better prognosis?
Any clarification appreciated.
@Pablo: Iâm not convinced that the backlash is necessarily a bad thing, nor do I believe that âimmature womenâ had anything to do with it.
If, based on the current scientific data, doctors decide that the right thing to do would be to screen 40-49 year-olds every two years and those >50 every year, that is one thing. Of course these recommendations could be revisited when enough new data becomes available that it makes sense to re-evaluate them.
What you posted initially was something else. Basically, you were implying that we know now that the right thing to do is what was recommended by the USPSTF, but, for political reasons, it was best to implement the guidelines in two stages:
It's a lot longer process to get it done, admittedly, but probably more palatable.
Did I misunderstand you? If so, my apologies.
See, it's rather funny. My first assumption when I heard about the new guidelines was something along the lines of, say, "Hm, cancer screening not recommended for women under 50. I guess that means they're lower-risk than we initially estimated -- trying harder to look may be more useful than doubling our efforts to find unicorns in my sock drawer with a metal detector, but the basic principle is similar, that finding significant cancerous masses via screening is likely to be rarer for these middle-aged women."
I was surprised to find there was all this controversy.
The links in my previous post (No 9) don't appear to work , so here are the explicit URLs:
Breast Cancer Mortality Rates by State - http://www.sunarc.org/dna_exp2.gif
UVB DNA Spectral Exposure - http://www.sunarc.org/breastcancer.htm
Nesby-O'Dell, S. et al. - http://view.ncbi.nlm.nih.gov/pubmed/12081833
Garland, C. F. et al. - http://dx.doi.org/10.1016/j.jsbmb.2006.12.007
Does vitamin D deficiency account for increased breast cancer rates in African American women? Thoughts or comments?
"...I was wondering if you could address a claim that popped up in the comments over at Isisâ place: should premenopausal women be screened with ultrasound instead of mammography? I'd be interested to know what the sensitivity and specificity of those two modalities are in the 40-49 group, whether white or African American. Can you point me to reputable studies?"
Good question!
I'm also wondering about ultrasound instead of mammography, in my case because my breasts are so small and flat against my chest that I'm not sure they *can* be squeezed flat enough perpendicular to my chest for a mammogram when I'm old enough for one.
MuteKi:
Part of the reason is the abysmal timing with respect to the health care reform efforts plodding their way through Congress right now. They released these new guidelines just as the "death panel" nonsense was starting to settle.
The controversy is not unfounded, but at the same time seems overblown. A quick, albeit non-extensive, look at the cochran database shows that for many years now we have had no good evidence showing mammograms and self breast exams decrease mortality, and yet, the rate of mortality for breast cancer is trending down. So it is a sticky question whether or not we continue with the current guidelines. I do not envy their position, but I think it is ludicrous to accuse them of not caring about womens' health. I think we are all trying to do the best we can with limited and somewhat contradictory evidence.
I had a mammogram as a private patient (not through the public health system) in January 09 that indicated architectural distortion in 2 areas but was not advised to have further sonographic investigation. However, I opted to have an ultrasound (again as a private patient) and had a FNA but no pathology was done and I was diagnosed as having 2 benign cysts. As I was not confident with the diagnosis from the private clinic, I had a mammogram through the public health system in September, which also showed architectural distortion in the same areas as indicated in January. I was advised to have ultrasound followed by core biopsy. I had two invasive tumours. The doc advised I also have an MRI, which revealed a further larger invasive DC which had not been detected during the very lengthy and thorough US investigation. Several women at the same clinic had further tumours revealed after MRI. It would appear that although mammography is useful it is not as accurate as MRI, but given that MRI is costly to the government and time consuming it seems that mammography will remain the first course of screening for most women in the public health system not only in Australia but in most countries in the world.
More than ever, we need to develop an understanding of the biology of breast cancer sufficiently advanced that it permits us to develop imaging tools and biological markers that can differentiate breast cancers that will progress and those that are not going to threaten the life of the woman.
AMEN!
Thankyou, on going after the Kristof article, I knew that there was (probably) something seriously wrong with the numbers, but after not finding precisely what I was looking for quickly online, decided to see if someone else had explained why they were too high in the comments before spending an hour looking for statistics myself.
I'm late to this party, but I was wondering what you think of the idea that African-American women are exposed to estrogen in their hair products, and that that causes them to have higher rates of breast cancer.
Orac,
You could have done a better job refuting Kristof's Landrigen quote. Kristof stated
Your response was
It sounds like you're saying that 88% of women get invasive breast cancer, which is scary, (very) false, and confusing as a refutation of Kristof's Landrigen quote.
You could have said what you meant more carefully. For example:
Kristof confuses develop breast cancer with be diagnosed with either carcinoma in situ or breast cancer. The facts underlying the Landrigan quote go something like this:
@Bald Ape: I'm even later to the party than you, but if I'm reading what Orac said correctly, estrogens in hair products probably have nothing to do with it. Only certain breast cancers have any relationship to estrogen levels and the particular ones that African American women are prone to don't fall into that category.
@Mac:
And if you've got a triple negative tumor, you're not her2neu positive. That help?
To the people that donât think these âpink promotionsâ are doing any good for breast cancer: I agree with you that breast cancer is being employed as a cheap means of gaining sympathy and is used by most companies as nothing more than a marketing strategy for their other crap products (a lot like selling promotional items at a loss, except most places are actually making profits off of these âcharityâ promotions). I used to denounce these companies, too, but the reality is that most people have no interest/desire to care about breast cancer research unless they or someone close to them has suffered from it. Iâd probably be guilty of the same thing⦠the only reason I even found this page is because I was searching for info about complications I had from a removal of a malignant node (and yes, men can have breast cancer, too - you can see for yourself what happened⦠bad breast augmentation pics, but make sure you didnât just eat). As shady as these companies are, with most giving maybe a penny to actual breast cancer research off of every pink nic nac they sell, the reality is that their âcontribution,â as disingenuous as it is, is better than nothing at all. If it wasnât for greedy, shady corporations trying to exploit pplâs emotions, I donât see any other way that we can raise awareness and garner support for this cause. And letâs face it, interest groups donât work when the only money coming in is from the small group of ppl that are actually motivated enough to join. People just simply donât care unless itâs affecting them directlyâ¦