Breast cancer gets the hard sell

Abstract

The US congress is on its way to approving an unusual method of raising money for medical research. The House of Representatives has passed, by an overwhelming majority (422 to three), a bill allowing the US Post Office to add a surcharge of eight cents to the price of a 32-cent stamp, with the extra revenue earmarked for research into breast cancer. The Senate has already passed a similar bill, but only allowing a surcharge of one cent per stamp. Legislators will have to reconcile these two bills. An advocate of this measure, Senator Dianne Feinstein, predicted it would yield $60 million per year if 10% of stamps were bought at the higher rate. It may seem churlish to criticise this initiative, but we share the reservations expressed by the US Post Office, which opposed the plan, arguing that any money so raised should not go to only one cause. The size of the House of Representatives' majority is likely to be a testament to the campaigning skills of the measure's proponents and widespread fear of this high-profile cancer rather than a reflection of any dispassionate assessment of how best $60 million could be spent on cancer research. Dedication to research alone also neglects an opportunity to improve standards of care for women with breast cancer. Those aware of the miserable side-effects of surgical, chemotherapeutic, and radiotherapeutic treatments, or of the dreadful ways death comes to women with breast cancer, might well be more inclined to opt for the higher priced stamp if they knew the extra cost was going towards making patients comfortable, rather than on unspecified research projects. Breast cancer is undoubtedly a major health problem in the USA; the American Cancer Society reports that in 1996 there were 185 700 new cases and 44 560 deaths. Yet the assumption that spending vast amounts of money on research into any cause of illness will necessarily lead to a cure is unreasonable. If a committee of medical scientists with representatives of nursing, hospice, and patients' groups were to choose the best way to spend $60 million per year, would it be on research into breast cancer alone? The answer is likely to be no. Despite generous funding in the USA for research into breast cancer (according to the National Cancer Institute, the National Institutes of Health have budgeted $401 million and the Department of Defense $112·5 million for 1997), the incidence of this disease in the USA has remained static for 10 years, and 5-year relative survival rates have improved only marginally from 74·3 to 80·4. Similarly, large sums of money have been spent in Europe and in the rest of the developed world, and with the same negligible effects. In terms of lives saved and pain eased, other projects might have a better case. Surcharged stamps introduce competitive hard-sell marketing techniques into the funding of medical research. Breast cancer activists, competing with fundraisers for other charities, got their bills passed first and there is little doubt that money will pour in. How many people, when given the choice at the Post Office counter of spending 32 cents or 33 cents on a stamp that is going to cure breast cancer will risk being seen as mean-spirited by going for the cheaper option? Is the US legislature going to make similar opportunities available to competing charities by permitting voluntary surcharges for other medical-research purposes on, for example, income-tax assessments? The idea of voluntary taxes to pay for medical research has been around for a long time, but not been implemented because of concerns that such monies would be misappropriated or worthy causes denied government funding if there are facilities for voluntary donation. It remains to be seen whether the postage-stamp initiative escapes either pitfall. There is room for improvement in the way nations fund medical research; a hasty and thoughtless voluntary tax on postage stamps to provide funds for a single cancer is not one of them.