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Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
001. folder
Women's Voices '92 (134 pages)
Sep. 1992
Personal Misfile
002. fax
From: Rutgers Center for the American Woman and Politics, To:
10/7/92
Personal Misfile
Missy Darwin (20 pages)
003. report
Research Stories (16 pages)
1992
Personal Misfile
004. memo
From: Kim, To: Melanne and Maggie (9 pages)
n.d.
Personal Misfile
COLLECTION:
Clinton Presidential Records
First Lady's Office
Liz Bowyer
OA/Box Number: 3988
FOLDER TITLE:
Women
2014-0483-S
sb504
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)]
Freedom of Information Act - 15 U.S.C. 552(b)]
P1 National Security Classified Information [(a)(1) of the PRA]
b(1) National security classified information [(b)(1) of the FOIA]
P2 Relating to the appointment to Federal office [(a)(2) of the PRAJ
b(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute |(a)(3) of the PRA]
an agency |(b)(2) of the FOIA]
P4 Release would disclose trade secrets or confidential commercial or
b(3) Release would violate a Federal statute [(b)(3) of the FOIA]
financial information |(a)(4) of the PRA]
h(4) Release would disclose trade secrets or confidential or financial
P5 Release would disclose confidential advice between the President
information |(b)(4) of the FOIA]
and his advisors, or between such advisors |a)(5) of the PRA]
b(6) Release would constitute a clearly unwarranted invasion of
P6 Release would constitute a clearly unwarranted invasion of
personal privacy |(b)(6) of the FOIA]
personal privacy [(a)(6) of the PRA]
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
b(8) Release would disclose information concerning the regulation of
of gift.
financial institutions [(b)(8) of the FOIA]
PRM. Personal record misfile defined in accordance with 44 U.S.C.
b(9) Release would disclose geological or geophysical information
2201(3).
concerning wells |(b)(9) of the FOIA]
RR. Document will be reviewed upon request.
WOMEN
PHOTOCOPY
PRESERVATION
Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
001. folder
Women's Voices '92 (134 pages)
Sep. 1992
Personal Misfile
COLLECTION:
Clinton Presidential Records
First Lady's Office
Liz Bowyer
OA/Box Number: 3988
FOLDER TITLE:
Women
2014-0483-S
sb504
RESTRICTION CODES
Presidential Records Act |44 U.S.C. 2204(a)]
Freedom of Information Act [5 U.S.C. 552(b)]
P1 National Security Classified Information |(a)(1) of the PRA]
b(1) National security classified information [(b)(1) of the FOIA]
P2 Relating to the appointment to Federal office [(a)(2) of the PRA|
h(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute |(a)(3) of the PRA]
an agency [(b)(2) of the FOIA]
P4 Release would disclose trade secrets or confidential commercial or
b(3) Release would violate a Federal statute [(b)(3) of the FOIA]
financial information [(a)(4) of the PRA|
b(4) Release would disclose trade secrets or confidential or financial
P5 Release would disclose confidential advice between the President
information |(b)(4) of the FOIA]
and his advisors, or between such advisors [a)(5) of the PRA]
b(6) Release would constitute a clearly unwarranted invasion of
P6 Release would constitute a clearly unwarranted invasion of
personal privacy |(b)(6) of the FOIA]
personal privacy [(a)(6) of the PRA]
b(7) Release would disclose information compiled for law enforcement
purposes |(b)(7) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
b(8) Release would disclose information concerning the regulation of
of gift.
financial institutions [(b)(8) of the FOIA]
PRM. Personal record misfile defined in accordance with 44 U.S.C.
b(9) Release would disclose geological or geophysical information
2201(3).
concerning wells |(b)(9) of the FOIA]
RR. Document will be reviewed upon request.
Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
002. fax
From: Rutgers Center for the American Woman and Politics, To:
10/7/92
Personal Misfile
Missy Darwin (20 pages)
COLLECTION:
Clinton Presidential Records
First Lady's Office
Liz Bowyer
OA/Box Number: 3988
FOLDER TITLE:
Women
2014-0483-S
sb504
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)]
Freedom of Information Act - [5 U.S.C. 552(b)]
P1 National Security Classified Information [(a)(1) of the PRA]
b(1) National security classified information [(b)(1) of the FOIA]
P2 Relating to the appointment to Federal office [(a)(2) of the PRA]
b(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute |(a)(3) of the PRA]
an agency [(b)(2) of the FOIA]
P4 Release would disclose trade secrets or confidential commercial or
b(3) Release would violate a Federal statute [(b)(3) of the FOIA]
financial information |(a)(4) of the PRAJ
b(4) Release would disclose trade secrets or confidential or financial
P5 Release would disclose confidential advice between the President
information [(b)(4) of the FOIA]
and his advisors, or between such advisors [a)(5) of the PRA|
b(6) Release would constitute a clearly unwarranted invasion of
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) of the FOIA]
personal privacy |(a)(6) of the PRAJ
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
b(8) Release would disclose information concerning the regulation of
of gift.
financial institutions [(b)(8) of the FOIA]
PRM. Personal record misfile defined in accordance with 44 U.S.C.
b(9) Release would disclose geological or geophysical information
2201(3).
concerning wells |(b)(9) of the FOIA]
RR. Document will be reviewed upon request.
Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
003. report
Research Stories (16 pages)
1992
Personal Misfile
COLLECTION:
Clinton Presidential Records
First Lady's Office
Liz Bowyer
OA/Box Number: 3988
FOLDER TITLE:
Women
2014-0483-S
sb504
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)]
Freedom of Information Act - 15 U.S.C. 552(b)]
P1 National Security Classified Information |(a)(1) of the PRA]
b(1) National security classified information |(b)(1) of the FOIA]
P2 Relating to the appointment to Federal office |(a)(2) of the PRA]
b(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute |(a)(3) of the PRA]
an agency [(b)(2) of the FOIA]
P4 Release would disclose trade secrets or confidential commercial or
b(3) Release would violate a Federal statute [(b)(3) of the FOIA]
financial information |(a)(4) of the PRA]
b(4) Release would disclose trade secrets or confidential or financial
P5 Release would disclose confidential advice between the President
information |(b)(4) of the FOIA]
and his advisors, or between such advisors [a)(5) of the PRA]
b(6) Release would constitute a clearly unwarranted invasion of
P6 Release would constitute a clearly unwarranted invasion of
personal privacy |(b)(6) of the FOIA]
personal privacy [(a)(6) of the PRA]
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
b(8) Release would disclose information concerning the regulation of
of gift.
financial institutions [(b)(8) of the FOIA|
PRM. Personal record misfile defined in accordance with 44 U.S.C.
b(9) Release would disclose geological or geophysical information
2201(3).
concerning wells |(b)(9) of the FOIA]
RR. Document will be reviewed upon request.
WHEN WILL WOMEN
GET TO THE TOP?
Not for a long time yet, according to a new FORTUNE CEO poll. But a few pioneers are already
there, and a growing crowd of others are doing all the right stuff.
by Anne B. Fisher
ALK FOR A WHILE with any
whacked a golf ball that flickered
T
woman who has worked her way to
cerily across the airless surface of
How likely is it that your company
the top of a sizable U.S. corpora-
the moon. Exhilarated, isolated,
will have a female CEO
tion. You'll get a strong sense that
keenly aware of the world's atten-
In next
In next
she feels a bit like Apollo 14 astronaut Alan
tion ("Houston, can you see me
A
10 years?
20 years?
Shepard when he improvised a six iron out
now?'), female high executives
of a piece of lunar equipment and, onc-
are cager to colonize this unaccus-
Very
handed in his cumbersome space suit,
tomed terrain with more of their
likely
2%
18%
own. But like astronauts, they
Somewhat
know 100 much about the rigors of
likely
14%
63%
the journey to believe that it can
happen by next Wednesday, or
Not very
even by next year. Says Carol
likely
42%
15%
Bartz, 44, recently named chair-
man and CEO of Autodesk, a
Not likely
leading maker of software for cn-
at all
40%
2%
gineers and architects in Sausalito,
California: "I think that women in
Not sure/
2%
2%
corporate America are still a gen-
no answer
cration away from real success."
Alas, the top men in corporate
America appear to agree. A poll of 201
ny, agrees: "The problem with women ad
chief executives of the nation's largest com-
vancing has more to do with men than wit.
panies, conducted exclusively for FORTUNE
women. Men have dragged their feet."
by the opinion research firm Clark Martire
Thanks for the honesty, guys, but that
& Bartolomco, reveals that only 16% be-
pretty discouraging news. And coming du:
lieve it is "very likely" or "somewhat likely"
ing an election year in which, incredible
that they could be succeeded by a female
some conservative politicians and leader
CEO within the next decade. And only
of the religious right are openly or implicit
18% think it's "very likely" that even after
ly condemning the very notion that wome
20 years a woman would be picked to run
should work outside the home, it's enoug
their companies.
to make even the most optimistic femal
Why? The CEOs in our survey cite a host
executive despair. That would be wron
of reasons, but the biggest barrier, as a few
however, because better days are coming.
of them admit, is an irrational one-plain
True, progress has been painfully slow
and simple discrimination. Notes John H.
and there has even been some backsliding
Bryan, 56, CEO of Sara Lee: "I'm not sure
Susan Lowance, director of senior exect
there's a lot that women can do about it.
tive programs at MIT's Sloan School
They're already working hard and are very
Management, points out that the executive
qualified. It shouldn't be this way, but too
training seminars run by U.S. busine:
many senior managers, and particularly
schools-an indispensable credential f
CEOs, tend to want to pass their jobs along
future CEOs in many companies-are a
IRENE ROSENFELD, 39, executive vice
to someone who's the image and likeness of
most as exclusively a male preserve as B
president, Kraft-General Foods: "Do your job
themselves." John Nelson, 48, who heads
hemian Grove. Enrollment in thes
brilliantly, and the cream will rise to the top."
Norwest Colorado, a bank holding compa-
REPORTER ASSOCIATE Therese Eiben
RECEIVED FROM 2125994763
10.07.1992
2
FORTUNE
What's frustrating is that at the same lev-
el of management, the typical woman's pay
is lower than her male colleague's-even
when she has the exact same qualifications,
works just as many years, relocates just as
often, provides the main financial support
for her family, takes no time off for person-
al reasons, and wins the same number of
promotions to comparable jobs. That dis-
couraging conclusion comes from a new
study of 1,029 managers at 20 FORTUNE 500
companies across cight industries. Over
five years ending in 1989, women manag-
crs' pay increased 54%, their male counter-
parts' 65%.
Says Linda Stroh, 44, one of the study's
co-authors, who teaches in the Institute of
Industrial Relations at Loyola University in
Chicago: "The disparity probably comes
partly from the lingering and often uncon-
scious perception that women are going to
leave to have babies. But the women man-
agers we studied were in the work force to
stay and had done all the right stuff. It still
wasn't enough."
Even so, most of the available data sup-
port the notion that, on balance, women in
the workplace undeniably are advancing. To
a man-and that's what they all are-the
CEOs polled by FORTUNE say over the past
five years the number of female middle man-
agers at their companies has either in-
creased (92%) or stayed about the same
(8%). As for female officers, 62% of chief
executives say their number rose as well. In-
CAROL BARTZ, 44, chairman and CEO of California software maker Autodesk: "You have to be willing
sists Richard Deihl, 64, chairman of H.F.
to sitep out of the pack and take risks, even jump completely out of your element if that's what it takes."
Ahmanson & Co., a big California mortgage
lender: "Women are already moving up into
programs nationwide is just 5% female, af-
cized wage gap between the sexes keeps
higher and higher positions. We should at
ter peaking at 8% in the late 1980s. "Com-
shrinking. On average, a woman now carns
least see a woman chief operating officer
parnics were trying a little harder, for a
about 74 cents for every dollar a man brings
here well before 20 years from now."
whille, to develop senior women managers,"
home, up from 65 cents a decade ago.
Labor Department statistics support this
Lawance explains. "But the recession
Those relative gains reflect the fact that
upbcat forccast. Using a broad-gauge defi-
sequened that. In tough times, top manage-
women are better educated and hold more
nition of "manager" that includes every-
ment prefers to entrust the risks that ac-
highly skilled positions than ever before.
body from the head of a fast food
company decision-making at the highest
restaurant to a CEO, Labor rc-
levels to a known quantity-meaning some-
How has the number of female
ports that about 41% of U.S. man-
one like themselves. A man."
executives in your company
agers were female as of mid-1991,
Herc's more bad news: The Department
changed over the past five years?
up from 32% in 1983.
of Labor's latest report on the limits to pro-
FORTUNE'S own research sug-
mention of women at 94 major government
A
Middle
Officers
gests that a similar though smaller
comtractors finds that few are being
managers
increase occurred in the number
granomed for senior-level jobs. "The glass
of top female managers. To see if
ceiling in most companies is a lot lower
Increased
92%
62%
America's business leaders were
than we thought it was," says Labor Secre-
tary Lynn Martin. "And too few women are
Decreased
o
really walking their talk on this
subject, we commissioned Direc-
getzing the training they need to move up."
About the
torship, a research and consulting
Nor have women managers achieved
same
8%
36%
firm in Westport, Connecticut, to
paycheck parity with men. Among all fc-
comb the 1986 and 1991 annual
mailes with full-time jobs, the much publi-
reports of the companies whose
SEPTEMBER 21, 1992 FORTUNE 45
RECEIVED FROM 2125994763
10.07.1992 16:05
P. 3
MANAGING
bosses had answered our CEO poll. Its
that a valued manager choose, in
task: to tally the number of women who
How widespread a problem is
effect, between a child and a pro-
held senior positions in those two base
discrimination against women?
motion. Jill Elikann Barad, 41,
years. We defined "senior" as a job within
A
Middle
Top executives/
who in July was named president
three levels of management of the chief ex-
management
officer level
and chief operating officer of
ecutive's office. In the case of staff, that
Mattel, the $1.6-billion-a-year toy-
would encompass a chief financial officer
Very
widespread
6%
20%
maker. shares that faith in genera-
or his equal, n company comptroller and his
tional change. When told the
counterparts, and finally, say, someone like
Somewhat
results of FORTUNE'S CEO poll.
the head of the accounting staff. Among
widespread
52%
44%
she dismissed as "ridiculous" the
line officers, the three tiers might stretch
notion that women must expect to
from president to a division head.
Not really
wait 20 more years to become
or this select group, 4.8% in 1991 turned
a problem
chief executives. She says: "I don't
out to be women. Think that's small? Go
anymore
38%
31%
know how these guys can say that.
back five years, to 1986: Only 2.9% of se-
Maybe they won't be the ones
nior managers were then female. Gazers at
making the decision."
the half-empty part of glasses will quickly
since they know firsthand what it's like to
Finally, there's the "pipeline" argument.
complain that roughly 5% is still a scant
have no full-time help tending the home
For at least ten years we've all been hearing
one-tenth the number of female managers
fires. They quite often say to mc, "These
that while there aren't yet enough qualified
we would have if women's presence in the
guys upstairs who are running things just
women, as their number and experience in-
executive suite matched their representa-
don't understand."
crease, more will reach the top. Fully 64%
:ion in the rest of the workplace. (Women
Galinsky believes that as the current crop
of CEOs in FORTUNE'S poll attribute wom-
now account for nearly half all full-time
of thirtysomethings ascend to positions of
en's absence from the executive suites in
U.S. workers.) An optimist, of course,
power, companies' cultures are bound to
large part to lack of experience. "We've al-
would applaud a rise of nearly 60% in just
become more flexible-and less insistent
ways joked that it takes 30 years to be al-
five years.
D. J. HULET, 36, regional marketing manager, Pacific Bell: "I'm very candid and speak my mind. Other
OST IMPORTANT, evidence
M
managers have told me, 'If you did the same things you're doing and you were a guy, you'd be OK.'
abounds that women's second-
class citizenship in corporate
America is finally about to be
upgraded. Sex discrimination is already less
of an obstacle in some industries than in
others. High-tech and service companies,
for example, are generally more inclined to
promote women than old-line manufactur-
ers in businesses like steel and autos.
One important agent of change will bc de-
mographics. Restructurings and layoffs
have produced a surplus of skilled, experi-
enced managers of both sexes. But rock-bot-
tom birth rates in the carly and midddle
1970s guarantee that later in this decade and
well into the next one, not enough boy baby-
busters will be there to fill the new manage-
rial jobs that the economy will generate. Any
business that wants to stay competitive will
have to hire, train, and reward women.
Another demographic factor is the in-
creasing prevalence of two-career mar-
riages. Ellen Galinsky, co-president of a
nonprofit New York City research and
consulting group, the Families and Work
Institute, often conducts focus groups with
men in their 20s and 30s. "These men are
almost all in dual-career households, and
they have a totally different perspective
from their fathers' generation," she notes.
"They empathize far more with conflicts
between family and work responsibilities,
46 FORTUNE SEPTEMBER 21. 1992
P.
4
RECEIVED FROM 2125994763
10.07.1992 16:06
lowed 10 empty the wastebaskets around
herre." says Charles A. Corry, 60, chairman
of USX Corp. "It took me 21 years and 12
jobrchanges to become a vice president. It's
the:same for women. It takes time." Robert
C. Winters, 60, CEO of Prudential, agrees:
"Women should persist, endure, hang in.
The wave is really crest high now. Women
are making a mark, but they have to keep
up the good work."
It's been a wearisome slog, but a light is
now glimmering at the end of the pipeline.
The Bureau of Labor Statistics reports that
there are 6.1 million female managers in
the U.S., up from about 3.5 million in 1983.
These women, many of whom are in their
eartly 30s to mid-40s, are the first genera-
tiom to accumulate the same education, ex-
perfence, and expectations as their male
counterparts, and to find strength in their
comsiderable numbers. Says MIT's Susan
Lowance: "If many women are ever to
reach the top of corporations, it's the ones
in that big middle-management group who
are going to do it." Labor Secretary Martin
expects those middle managers to push
hard for recognition. "A lot of us thought
KERI BAUCH-SPARKS, 37, Information systems manager at a Monsanto plant in Illinois: "Some mon's
our pioneering days were over," she says,
Initial reaction to diversity training Is defensive. They think it's going to be a lot of finger pointing."
"trust they aren't."
That's why the smartest companies are
responsibility to prepare women for broad-
pays-its managers partly on the basis of
dewating ever more time and resources to
based roles."
how carefully they identify, train, and pro-
broadening and developing the talented fe-
Toward that end, dozens of corporate CO-
mote women.
maile middle managers they have already
lossi, from AT&T to Johnson & Johnson to
Accounting behemoth Arthur Andersen
hired. Hardly any of the CEOs polled by
Xcrox, have hired full-time "diversity man-
recruited Joseph Stokes, a psychology pro-
FORTUNE-only 8%-think women lack
agers," charged by top management to
fessor at the University of Illinois at Chica-
the aggressiveness or determination to
make the workplace more hospitable to tal-
go, to help it work out a diversity program.
scule the corporate heights. And just 5%
cnt of either SCX and all colors. In some cases
Stokes says that to ensure that women get
said that women should bc more willing
this is pure tinsel and tokenism, but for
more of the broad experience required to
than they are to relocate for a promotion,
many companies it's a hard-nosed business
rise to officer status, companies must stop
amtissue that some studies have suggested is
strategy. Says Actna Life & Casualty CEO
assuming that men arc automatically more
keeping good female managers down. But
Ronald Compton, 59, who is largely respon-
willing than women to leap across division-
ne:arly half insisted that the reason it will
sible for the fact that roughly half his com-
at boundaries for new assignments. "More
talke two decades for a female to rise to the
pany's managers are now women: "I'm not
companies need to ask both women and
torp of their companies is that women man-
doing this out of the goodness of my heart.
mcn what their long-term career goals are,
agens are still too concentrated in fields
I'm scifish. 1 want the very best people I can
what kinds of jobs would interest them
such as communications and human IC-
gct. A lot of them happen to be women." No
most, whether they'd consider an overseas
scurrees, which rarcly if ever lead upward.
diversity campaign will succeed without that
transfer, and so on," says he. "And then use
"It really isn't a question of what else
kind of blessing from the top.
that laundry list-which is a kind of blue-
women should be doing. It's a question of
Alarmed that turnover among female en-
print of a person's ambitions-and develop
what companies should be doing to ensure
gineers and salespeople was twice as high as
everyone accordingly."
that women are getting the opportunities
among men, chemical giant Monsanto
mean get," says William Ruckelshaus, 60,
hired a consultant to do exit interviews with
EYOND ALLOWING qualified
clhairman of Browning-Ferris Industries.
departing women. Most said they'd had
Even in relatively nonscxist industries like
B
women an equal chance at the
better offers from competitors or planned
same jobs men get, diversity-
remailing, some CEOs think there's much to
to start their own firms. "There is a glass
minded companies are trying to
be done. "We have to step up our commit-
ceiling at Monsanto," admits vicc president
recast their cultures so that old attitudinal
ment to exposing women to different di.
of administration Michael Miller. "We're
hurdles don't trip up women who might
mensions of the business," says Allen
trying to break it." How? Like many anoth-
otherwise be gold medalists. Nancy Ham-
Questrom, 51, chairman of Federated Dc-
cr company with a formal diversity pro-
lin, president of consulting firm Hamlin
partment Stores. "Management has'a clear
gram, Monsanto now evaluates-and
Fox in Marblehead, Massachusetts, has
SEPTEMBER 21. 1992 FORTUNE 47
-
RECEIVED FROM 2125994763
10.07.1992 16:07
P. 5
MANAGING
ception among men, which comes up rc-
peatedly. is that women make lousy
candidates for promotion because they al-
ways put their personal lives, particularly
their children, ahead of work. "When you
see this stuff up on flip charts around the
room, it gets people thinking," says Bauch-
Sparks. "Society has been telling us these
things for years, but do we necessarily be-
lieve they're true?" Slowly but certainly,
perceptions at Monsanto are changing, and
that seems to be encouraging ambitious
women to stick around. Turnover is down,
and a second round of exit interviews this
summer uncarthed far fewer responses
marked by frustration and bitterness.
Rare is the company intent on keeping
its best female employees and managers
that doesn't have some kind of work-fam-
ily program-a bit of jargon that encom-
passes everything from day care centers to
programs that counsel employees on how
to cope with the problems of ciderly par-
ents. All share the same purpose: to bol-
HAZEL O'LEARY, 55, executive vice president, Northern States Power in Minneapolis, Is learning how to
ster employee productivity by eliminating
pilay golf; "Without losing your personality, It's Important to be part of the prevailing corporate culture."
some of the distractions that family life in-
evitably imposes on single parents and
spent 25 years as an adviser on gender is-
typical. The company holds workshops, run
two-income couples.
RUCS to General Electric, Hewlett-Packard,
by consultants Pope & Associates, designed
Since 1971 the number of large U.S. cm-
Digital Equipment Corp., Fleet Bank, and
to expose and dismantle workers' preju-
ployers that provide some kind of day care
the U.S. Coast Guard. She says that even in
dices. About 5,000 Monsanto employees
assistance has grown from 11 to nearly
the best-intentioned and most progressive
have attended the six-day sessions, and
4,000. Now many companies are going
companies, women are usually kept out of
more are signed up to
the informal channels of information,
do so.
What should female executives be doing
where important decisions sometimes cry-
Kcri Bauch-Sparks,
to get to the top? (Choose one or more answers.)
stallize. Female managers, for example, are
37, an information sys-
lleft behind when their male peers go out to
tems manager at a Mon-
A Develop broad base of
lunch, or to a sporting event, or on a good
santo chemical plant in
experience
30%
bld-fashioned pub crawl. "Men don't do
Sauget, Illinois, has
this on purpose," Hamlin says. "They just
been through this drill
Go Into nontraditional positions,
don't think about it."
twice in the past four
such as operations,
She and other diversity experts add that,
years. "Some men's ini-
engineering, manufacturing
14%
since the Anita Hill-Clarence Thomas de.
tial reaction to it is dc-
bacle, fear and confusion have multiplied.
fensive. They think it's
Don't change; already doing what
As she says, "Male executives will think,
going to bc a lot of fin-
they need to.do to excel
13%
"Hmmm. wouldn't it be easier, and safer, to
gcr pointing," she says.
take this business trip, or go to that client
"But the idea is to im-
Make career a higher priority
dinner, with another guy?'" But the most
prove communications
than family life
12%
pervasive problem, and perhaps the most
for everybody. Once
Be more visible/assertive
12%
intractable one, is that a lifetime of social
people sce that, they're
conditioning has trained many men to
generally enthusiastic."
pand.network of contacts
9%
think of women as sweethearts, wives,
In one exercise, the
daughters, secretaries-not as equal col-
moderator asks group
It's a matter of time
10%
leagues. Muses Hamlin: "It's hard to com-
members to write down
pletely re-socialize people."
every stercotypical no-
It' per ormance, not gender
6%
Hard, but not impossible. Short of wait-
tion about women they
Get mar JIne (vs. staff) work
6%
ing for the dichard chauvinists to retire or
can think of, and the an-
threatening to fire them if they can't get
swers are posted on the
Bewilling to.relocate
5%
with the program, what can top manage-
walls for discussion.
ment do? Monsanto's diversity effort is
One widespread per-
RECEIVED FROM 2125994763
1992 16:09
6
MANAGING
much further. Kraft-General Foods offers
plc in a way that doesn't create enemies."
is something I didn't have when I was
the 2.000 employees at its headquarters in
Seymour coached her on how to influence
starting out in business," says Duckworth.
White Plains, New York, a smorgashord of
people without alienating them, manifestly
"It's an 'old-girls' network,' in an embry-
work-family benefits, including nearby
a valuable skill: Hulet was promoted in
onic stage."
company-subsidized day care centers, ex-
mid-1991 to regional marketing manager
"Women do need to do more network-
tended parental leaves, and vacation time
for Los Angeles.
ing," declares Autodesk Chairman Carol
available by the half-day.
As more women attain high positions,
Bartz. As a stellar senior executive at Sun
Ircne Rosenfeld, 39, is executive vice
they are reaching out to guide their youn-
Microsystems before taking her current
president in charge of the $1-billion-a-year
ger counterparts-sometimes those still in
job, Bartz met often with groups of women
Severage division that makes Kool-Aid and
school. A University of Pennsylvania alum-
in the company for brown-bag lunches and
Country Time lemonade. She's also the
nac group called the Trustees' Council of
tried to make herself available to advise
mother of two young daughters, and she
Penn Women, currently headed by First
anyone who sought her insights. "At some
calls the work-family program
point I realized, 'Hey, these pco-
"terrific." These new policies
Q
Why is a woman not likely to
plc are looking up to me,' and
and services are not for women
be a CEO sooner?
my first reaction was, 'I don't
only. Says Rosenfeld: "Women's
have time for this,' she recalls.
issues are rapidly becoming work
A
Women long enough
"But I decided I had to take the
force issues, and companies that
experience
64%
responsibility to help pave the
best address them will win in the
way for others-including my
marketplace." Her own division
Are too rated:In
daughter, who's 4."
is winning handily, with double-
of the company that
What advice docs she give
Eligit earnings increases in each
lead such a
women who aspire to the top
of the past five years.
commun
50%.
job? Like the chief executives in
About one-third of chief exec-
enough experience
FORTUNE'S poll, Bartz believes
urives in FORTUNE'S survey say
that women often don't get a
they've noticed that women's ca-
recrs often stall out for lack of the
bullt up olid
wide enough range of experi-
networks of connections
ence. "You have to step out of
kind of informal advice and spon-
and support
the pack and take risks, even be
sorship men get from one anoth-
willing to jump completely out of
= Some companies are trying
Personalives and ration
your element if that's what it
TO remedy that with mentoring
to families get in the
takes," she says. It helps, she
programs that pair promising
way of careers
29%
adds, to start as carly as possible.
women, nominated by their de-
Bartz knows whereof she speaks.
partment heads, with senior exec-
Not enough In male fominated
Seventeen years ago, while still
tutives who proffer one-on-one
indust ineering,
7%
in her 20s. she quit a comfortable
mareer counseling. San Francis-
manu acturing
job as a systems analyst at 3M in
no-based Pacific Bell started its
mentoring drive in late 1989, so
It's a,matter of time
Atlanta after a marketing execu-
tive at headquarters told her the
the second batch of about 35 fc-
Current CEO will be In position
company would never let a wom-
male protégées are now nearing
for a while
an sell computers.
the end of their two-year pro-
That fellow is probably kicking
gram. What exactly does a men-
Are not aggressive or determined
himself now, In 1987, with some
for do? Consider the experience
enough o make it to the
8%
trepidation, Bartz took over
of D.J. Hulet, 36. She started out
im sales 15 years ago, moved up
It's a matter of.numbers (more 6%
Sun's federal government sales
division, an area of the business
sucadily, and in 1990 was assigned
that was not only entirely alien to
mentor John Seymour, 48, vice
her but was populated largely,
president and general manager of Pacific
Interstate Bancorp senior vice president
she says, with "cigar-chomping ex-defense
Bell's Orange-Riverside division.
Pamela Reis, gives female seniors and
contractors." In just two years under her
Perhaps not surprisingly, she and he view
business school students a list of about 70
management, the unit's revenues jumped
her strengths and weaknesses somewhat
distinguished women they can call for Cit-
from $21 million to $124 million.
differently. "I'm very candid, and I speak
reer advice or information. The council
"There's still a lot of fulklore out there
my mind," says Hulet. "Other managers
also runs a "shadowing" program that lets
about what women can and can't do," ob-
have told mc, 'You know, if you did the
students spend a workday with a woman
serves Kraft-General Foods' Irene Rosen-
same things you're doing and you were a
executive for a close-up peck at the real
feld. "But don't ever believe you can't do
guy, you'd bc OK.'" Really? Seymour ex-
world. Constance Duckworth, 37, a part-
something until you've tried it." In an apt
plains: "Some people here saw her as very
ner in fixed-income securities at Goldman
metaphor, given her position, she adds:
bright but too aggressive. In my opinion
Sachs in Chicago, spent time this summer
"Just do your job brilliantly, and sooner or
there's no such thing as too aggressive. But
with a 21-year-old Wharton finance stu-
later the cream will rise to the top."
you do have to learn how to approach pco-
dent. The two plan to stay in touch. "This
Over and over again, female-and
RECEIVED FROM 2125994763
10.07.1992
16:10
P. 7
MANAGING
male-managers urge women to set ca-
and ask for feedback every step of the way,"
who aren't getting anywhere at all." (See
recr goals and work out a specific plan
But while you're pushing, keep a stiff
following story.)
for achieving them. Hugh McColl Jr., 57,
upper lip. Mary Herbert. 41, vice presi-
The surest way to ascend, of course, is to
is CEO of NationsBank, the holding com-
dent and director of quality for interna-
be SO good they can't overlook you. Jill
pany in Charlotte, North Carolina,
tional operations at Motorola, has talked
Barad won the No. 2 spot at Mattel largely
formed by the recent merger of NCNB
extensively with her female colleagues
because as head of the girls' toy division she
and C&S/Sovran. McColl told FORTUNE'S
about their careers. "You do have to go
had overseen a doubling of worldwide sales
pollsters: "Women have to push harder.
to management and say. 'Here's what I
of Barbic dolls in under four years, to near-
They often feel that things will be done
think I can do: here's why; let me try it,' "
ly $1 billion (see box). She dismisses the no-
fairly, whereas men don't believe that,
she says. "But from what I've seen. wom-
tion that women are at any special
and in reality it's often not the case. So
en who have had a chip on their shoul-
disadvantage in business-at least, not if
women must ask their bosses what's needed
der-who basically said, 'I should get this
they're smart, hard working, and imagina-
to get 10 the next level. They then need to
job because there are no women at this
tive. "One day soon, it isn't going to matter
make sure they get those opportunities,
level of the company'-those are the ones
anymore what SCX anyone is," she says.
"It'll come down to a question of who deliv-
ers the goods. Performance is what
counts."
FIVE MAGIC WORDS:
Hazel O'Leary, 55, an executive vice
'GIVE ME A BIGGER
president at Northern States Power in Min-
neapolis, agrees: "Whatever you're asked
CHALLENGE'
to do, make sure you do a better job of it
than the man next to you." But while you're
Ten years ago Jill Barad, then a
at it, don't neglect to form friendships.
junior manager in the boys' toys
"Without losing your own personality, it's
division at Mattel, went to Tom Ka-
important to be part of the prevailing cor-
linske, the senior vice president who
porate culture," she says. "At this compa-
had hired her, and said, "Okay, I'm
ny, it's golf. I've resisted learning to play
ready now. Give me a bigger chal-
golf all my life, but I finally had to admit I
lenge." His reply: "I was waiting for you
was missing something that way." O'Leary
to say that." He assigned her to Barbic
has bought a set of clubs and tees up with
dolls. In 1988, the year Barad took over
an instructor on weekends.
that business, sales hovered around
$485 million. The figure has since more
HE BEST REASON for believing
than doubled to nearly $1 billion. Mat-
T
that more women will bc in charge
tel's earnings over that time proved as
before long is that in a ferociously
resilient as Barbie's curls, springing
Mattel's Jill Barad is the diva of toydom.
competitive global economy, no
from a $113 million loss in 1987 to a
company can afford to waste valuable
$113 million profit last year.
think everyone thought 1 managed out
brainpower simply because it's wearing a
President and chief operating officer
of that well," says Barad. Ten promo-
skirt. That isn't casy for some folks to ac-
since mid-July, Barad never expected to
tions later, she runs a staff of more
cept. "Dealing with change is always pain-
end up the reigning divn of toydom.
than 1,000 worldwide but relies too on
ful," notes William Boyle, a Monsanto
Raised in New York City, she graduat-
the judgment of sons Alexander, 12,
plant manager who is a big believer in the
cd from Queens College and, perhaps
and Justin, 9-with now and then a
company's diversity-training programs.
because her father was television direc-
comment from husband Thomas
"But the days when any U.S. company
for Lawrence Elikann (Falcon Crest,
Barad, an independent film producer.
could stand pat, do things the same old
Knots Landing), aspired to be an ac-
Pleasing little customers can yield big
way, and say, 'Gosh, look how good we
tress. A single day in front of the cam-
moncy. When Barad signed on with
are-those days are gone."
cras in a 1973 Dino De Laurentiis film
Mattel in 1981, she earned $38,000 a
Happily for women in corporate Ameri-
called Cruzy Joe changed her mind. She
year. In 1991, as head of operations for
ca, radical change has'a way of favoring the
moved to California and worked for a
North America, she had a pay package
underdog. Says Jane White, author of the
cosmetics maker and an ad agency be-
that came to $711,539. Not too shabby a
forthcoming book A Few Good Women:
fore joining Mattel.
decade. "Wc all have to get the best peo-
Breaking the Barriers to Top Management: "I
Among her first projects at the com-
plc we can get," she says. "And you
think we're living in a fantastic time. The
pany: an icky toy called A Bad Case of
won't get the best people if they don't
ferment that is happening now will push the
Worms. Designed to be slammed
feel they'll have a chance to rise." Some
barricades down." For that to occur, it's
against a wall, whence it would slither
of the best people won't ever know the
crucial that the brightest and best women
slimily to the floor, the thing was aptly
chance is there or not-unless, as Barad
not become discouraged. As White puts it,
named-and has since disappeared. "I
did, they ask for it.
"If you're going to be in the forefront of a
revolution, you have to keep taking the flak
until it's won,"
F
% FORTUNE SEPTEMBER 21, 1992
P. 8
10.07.1992
16:12
RECEIVED FROM 2125994763
"A President's wife who undertakes a specific job in the government faces double jeopardy;
she is without real authority, yet she is expected to perform miracles. When she dares to
assert leadership, it is resented and resisted and if she does not, officials try to anticipate
what she wants done." Eleanor Roosevelt Washington Post 1/20/77
"The capacity for accomplishment is great, but an activist First Lady is assured of not only
rewards and heady personal power, but criticism and frustration as well.
If done right, it can be one of the toughest unpaid jobs in the world."
Washington Post 1/20/77
"But she comes into a job description that is pretty firmly set: A first lady is supposed to
be the supportive help-mate. She's not supposed to be an outspoken public figure. She's
not supposed to have separate, visible employment - although she is supposed to have
interests." Kathy Kleeman - Center for the American Women in Politics - Newsweek
1/22/89
"No other woman in our country is automatically elevated to international prominence
through marriage as is the First Lady."
Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
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From: Kim, To: Melanne and Maggie (9 pages)
n.d.
Personal Misfile
COLLECTION:
Clinton Presidential Records
First Lady's Office
Liz Bowyer
OA/Box Number: 3988
FOLDER TITLE:
Women
2014-0483-S
sb504
RESTRICTION CODES
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P2 Relating to the appointment to Federal office [(a)(2) of the PRA
b(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute |(a)(3) of the PRAJ
an agency [(b)(2) of the FOIA]
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RR. Document will be reviewed upon request.
The President's Cancer Panel
Special Commission on Breast Cancer
NATIONAL INSTITUTES OF HEALTH
National Cancer Institute
A REPORT TO THE NATION
The President's Cancer Panel
Special Commission on Breast Cancer
NATIONAL INSTITUTES OF HEALTH
National Cancer Institute
A NATIONAL STRATEGY
TABLE OF CONTENTS
Executive Summary 1
Introduction 5
Breast Cancer Etiology and Prevention 9
Findings 9
Genetics and Tumor Markers 9
Hormones 9
Diet 9
Physical Activity 10
Environment 10
Recommendations 11
Etiology 11
Genetics and Tumor Markers 11
Hormones 11
Diet 11
Environment
12
Prevention 12
Screening and Early Detection and the
Development of New Technologies for
Detection and Diagnosis
Findings 13
Recommendations 13
Practice and Outreach 13
Screening Research 14
New Technologies Research 14
Improving the Outcome for Breast Cancer
Patients: Treatment and Quality-of-Life
Effects
Findings 15
Recommendations 15
Treatment 15
Quality of Life
16
Infrastructure, Education, and Training
Findings 17
Recommendations 17
Public Communication
Findings 19
Recommendations 19
Special Commission on Breast Cancer
Patient Advocacy
Findings 21
Recommendations 21
Public Policy
Findings 23
National and State Legislation 23
Payment Policies 23
Recommendations 24
National Legislation 24
State Legislation 24
Payment Policies 24
Special Issues for Minority and
Underserved Women
Findings 25
Recommendations 25
Appendices
A. President's Cancer Panel Special
Commission on Breast Cancer
Membership Roster 27
B. Meetings Held 29
C. President's Cancer Panel
Membership Roster 30
The President's Cancer Panel
EXECUTIVE SUMMARY
Overview
Breast cancer is a large and growing public health problem in the United States.
During the decade of the 1990s, it is estimated that nearly 2 million women will have
been diagnosed with the disease and that 460,000 women will have died of it.
Between 1950 and 1989, the incidence of breast cancer increased by 53 percent.
The magnitude of this problem and its constant increase over time understandably
result in considerable anxiety among all women.
Some improvements in breast cancer detection and treatment have occurred over
the past few decades. Yet even these modest improvements are not uniformly
applied throughout the population. Most current therapies (surgery, radiation therapy,
and chemotherapy) are non-specific in their effects and frequently diminish quality of
life. Although women diagnosed with early-stage breast cancer have a 5-year
survival rate of 93 percent, there is no period of time after which a woman who has
been treated for breast cancer can be assured that it will not recur. At this time, there
are no proven methods of preventing breast cancer.
Advances in basic science have raised the realistic hope that more specific methods
can be developed to treat or prevent breast cancer.
Breast cancer advocates - women with breast cancer, their families, friends, and
supporters - demand that breast cancer become a national priority. There is a wide-
spread sense of urgency that more can and must be done to address the problem of
breast cancer in this country. There is growing public demand for even greater levels
of funding of a national breast cancer program and an outcry for the development of
cure and prevention.
Recommendations
The goals of the President's Cancer Panel Special Commission on Breast Cancer
recommended breast cancer program are:
1.
To make substantial progress in developing effective methods to cure and to
prevent breast cancer, and
2.
To make current and future proven methods of early detection, treatment,
and prevention universally available.
The National Institutes of Health and other involved federal agencies must receive
research funding of no less than $500 million per year for this program until these
goals are achieved.
Specific recommendations made by the commission are outlined below.
1
Special Commission on Breast Cancer
Causes and Prevention
Research into breast cancer causes and prevention must receive high priority.
Investigator-initiated inquiry should remain the mainstay of research funding.
Genetic, hormonal, environmental, dietary, and other causes of breast cancer
must be identified through basic and epidemiologic research; this knowledge is
the foundation needed to develop effective preventive strategies.
Knowledge gained through research must be translated into clinically effective
methods of prevention, early detection, and treatment.
Earlier Detection and Diagnosis
Early detection should be improved by further refining x-ray mammography,
developing newer imaging methods using non-ionizing radiation, and identify-
ing breast cancer biomarkers that can be detected in a blood test.
Improved access to early detection must include prompt diagnostic work-up
and treatment referral for patients in whom breast abnormalities are identified.
Treatment Strategies
Women must be empowered to be active participants in their decisions about
breast cancer screening and, if diagnosed with the disease, about their treat-
ment options.
Patients, their families, and breast cancer experts want and deserve less
invasive, disfiguring, and toxic treatments than surgery, radiation, and
chemotherapy.
High priorities for new and more specific treatments include: therapy directed
at hormones and hormone receptors, tumor growth factors or growth
factor receptors; inhibitors of angiogenesis and metastasis; immunologic
therapy; and gene therapy.
Methods should be developed to overcome resistance to hormonal and
chemotherapeutic agents.
Diagnostic decisions, treatment options, and recommendations should be
provided in an interdisciplinary setting.
Psychosocial Effects
Current methods of psychosocial support should be available to all breast can-
cer patients and their families.
More effective supportive care interventions for breast cancer patients and
their families must be developed.
Access
Current and future methods of early detection, treatment, and prevention
should be universally available as soon as their efficacy is demonstrated.
United States health care delivery system reforms must ensure the removal of
financial barriers to access.
2
The President's Cancer Panel
Research is required to understand and remove the non-financial barriers to
universal use of effective means of combating breast cancer.
Public Policy
Federal regulations should limit the proliferation and use of unproven treat-
ments, prognostic markers, prevention methods, and technologies, except
within the confines of a well-defined clinical trial.
Clinical testing of new detection, treatment, and prevention methods should
be supported cooperatively by third-party payors, industry, academic centers,
and the National Cancer Institute.
Research costs for clinical trials should be carefully delineated and paid by
industry or the National Cancer Institute, while patient care costs should be
covered by third-party payors.
The 1992 Mammography Quality Standards Act should be implemented
immediately.
Federal agencies should coordinate their breast cancer programs through an
interagency breast cancer task force.
A Partnership of Breast Cancer Advocates and Breast Cancer Scientists
This partnership must continue in a way that promotes the shared objective
of finding effective prevention and cure of breast cancer.
Breast cancer advocates should be integrated into decision-making regard-
ing the optimal use of breast cancer research funding.
Information and Empowerment
Women in the United States should be provided with accurate, up-to-date,
and culturally sensitive information about the risks of breast cancer and how
it is best detected.
Women diagnosed with breast cancer should be provided with accurate, up-
to-date, and culturally sensitive information about their treatment options.
The National Cancer Institute should provide leadership in the development
and distribution of culturally sensitive breast cancer educational materials
and special materials for women with low levels of literacy.
Women should be empowered both psychologically and financially to take
responsibility for their own breast health, including adopting healthy lifestyles,
practicing breast self-examination, following recommended guidelines for
breast cancer screening, and immediately obtaining diagnostic and treatment
services when breast abnormalities are observed.
Past investments in basic science and breast cancer research have brought us to a
point where numerous opportunities exist to advance our ability to prevent and treat
breast cancer. The enormity of the impact of breast cancer on the mental and physical
well-being of women in the United States and their families requires that we as a soci-
ety devote the resources needed to achieve the most rapid progress possible.
3
Special Commission on Breast Cancer
INTRODUCTION
Over the last decade, patients and their
most of their lives. It is estimated that
families have directed increasing national
during the 1990s nearly 2 million women
attention to breast cancer. Their input
in the United States will be diagnosed
has stimulated breast cancer research,
with the disease and that 460,000
focusing on the need for prevention and
women will die of it. Between 1950 and
cure. During the 1970s and 1980s,
1989, the incidence of breast cancer
breast cancer incidence rose by 21 per-
increased by 53 percent. Expanded use
cent among women of all ages in the
of screening mammography explains
United States, and increased by 49 per-
part of the recent rise in incidence, but
cent among women 65 and older. Even
the causes of the long-term increase are
among women least likely to experience
largely not known. The increasing mag-
breast cancer-those under 50-inci-
nitude of this problem has understand-
dence rose by 13 percent. National
ably resulted in considerable anxiety in
Cancer Institute funding for breast can-
the population, particularly among young
cer has increased from $92.7 million in
women and especially regarding future
1991 to $196.6 million in 1993. In addi-
generations of females.
tion, Congress appropriated $210 million
to the Department of Defense in Fiscal
Specific points about breast cancer
Year 1993 for a multi-year breast cancer
should be recognized. The incidence of
research program. There is wide public
breast cancer rises continuously as
demand for even greater levels of fund-
women age: At age 30-34, the rate is 27
ing of a national breast cancer program
per 100,000; at 40-44, it is 127 per
and an outcry for effective prevention
100,000; at 50-54, it is 222 per 100,000;
and cure.
at 60-64, it is 343 per 100,000; and at
70-74, it is 434 per 100,000 women.
In response to a request from the Vice
Also, the natural history of the disease is
President of the United States to the
prolonged. The time from the inception
Chairman of the President's Cancer
of breast cancer to its detection using
Panel, the President's Cancer Panel
current methods is estimated to be at
Special Commission on Breast Cancer
least several years. The time following
was appointed by the Director of the
initial diagnosis and treatment to the
National Cancer Institute in 1992. Its 19
development of recurrence and death is
members held 11 meetings over 14
measured in years. Furthermore, there is
months, hearing testimony from more
no time period beyond which recurrence
than 190 scientists, clinicians, patient
and death may not occur. If a cure is
advocates, and experts in all aspects of
defined as elimination of any chance of
breast cancer. This report contains the
recurrence and metastases, it is not cor-
findings and recommendations of the
rect at present to describe a "cure" of the
Commission based on this comprehen-
disease. Nevertheless, most patients
sive review.
diagnosed with breast cancer live out the
remainder of their lives without recur-
Breast cancer is a large and growing
rence. As reported by the National
public health problem in the United
Cancer Institute's Surveillance,
States. All women are at considerable
Epidemiology, and End Results program,
risk for developing breast cancer during
women diagnosed with early-stage
5
Special Commission on Breast Cancer
breast cancer have a 5-year survival rate
effectiveness of screening women aged
of 93 percent, in contrast to 70 percent
70 and older, despite their high risk.
and 17 percent for those diagnosed with
regional and distant metastases, respec-
Breast-conserving treatment (consisting
tively. Finally, the clinical course of breast
of excision of the cancer-commonly
cancer varies greatly among patients,
referred to as "lumpectomy" combined
suggesting that there is heterogeneity in
with breast irradiation) results in survival
the factors that affect both the occurrence
rates equivalent to those following
and the natural history of the disease.
mastectomy and provides important
quality-of-life gains for many patients. In
Breast cancer is now believed to result
addition, new surgical techniques facili-
from a series of alterations (mutations) in
tate breast reconstruction in patients
the genes of the breast cells. Some such
treated with mastectomy. Drug treatment,
genetic changes may be inherited, but
such as chemotherapy and Tamoxifen,
most are not. These alterations can re-
given at the time of local therapy can
sult in an increased likelihood of addition-
decrease breast cancer mortality. While
al genetic changes (genomic instability),
these improvements are important, the
uncontrolled cell growth (proliferation),
survival benefit of about 26 percent is
invasion into adjacent tissues, and
relatively modest given the magnitude of
spread to other sites in the body (metas-
the problem, and is achieved at a sub-
tases). The causes of these genetic
stantial cost in toxicity. Most current ther-
alterations are largely unknown. Ovarian
apies (surgery, radiation therapy, and
hormones (estrogen and progesterone)
chemotherapy) are toxic to normal tis-
clearly play an important role in the
sues and organs and thus frequently
development of breast cancer. It appears
impact negatively on quality-of-life.
likely that influences beginning very
Moreover, although the last decade has
early in life and continuing throughout
brought refinements in the available
adulthood are important. At this time,
treatment modalities, no major treatment
there are no proven methods of prevent-
advances have been introduced, and the
ing breast cancer.
mortality rate has remained constant.
Some improvements in breast cancer
Even these modest improvements are
diagnosis and treatment have occurred
not uniformly provided for all women. For
over the past few decades. A major
many women, optimal early detection,
advance has been achieved through
diagnosis, and treatment measures are
screening with mammography and clini-
unavailable for financial reasons-they
cal breast examination. Screening mam-
are unable to pay and have inadequate
mography can detect many cancers
or no health insurance. These women
before they are clinically evident and can
represent a large and growing percent-
lead to a breast cancer mortality reduc-
age of the population. Access is a partic-
tion of about 25 percent. However, the
ular problem for women who are low-
mortality benefit from mammography
income, minority, young, old, and living
has been unequivocally demonstrated
in rural areas. The inequities of this situ-
only in women aged 50-69. Possibly
ation have become painfully manifest.
due to limitations in study design and
Even well-insured women with adequate
implementation, the data for women
resources often do not receive the best
aged 40-49 are inconclusive, and there
of care, indicating the presence of signif-
is a paucity of information regarding the
icant non-financial barriers to optimal
health services delivery.
6
The President's Cancer Panel
The past decade has seen a major
$210 million to spend over 2 years on a
increase in understanding of the basic
breast cancer research program. The
biological processes underlying both
Commission notes the effort being made
normal cell division and growth and the
by the Army to ensure that this money is
biology and genetics of cancer. This
well spent, including an Institute of
knowledge is beginning to be applied to
Medicine study commissioned by the
breast cancer. Many excellent investiga-
Department of Defense to recommend
tors have been supported in a broad
funding priorities. The Institute of
spectrum of breast cancer research by
Medicine advised that most of the
the National Cancer Institute, the
money be spent on investigator-initiated
American Cancer Society, and other fed-
research projects, with some funds allo-
eral agencies and private organizations.
cated to training, recruitment, and infra-
This and other basic biomedical and
structure enhancement.
cancer research have increased our
understanding of many aspects of breast
There is a widespread sense of urgency
cancer and led to some promising new
that more can and should be done to
approaches for patients. However, more
address the problem of breast cancer in
detailed information is needed about the
this country. This report provides our
biology and action of hormones on the
findings and recommendations. The
normal breast, the genetic changes that
Commission concludes that more and
lead to breast cancer, biologic factors
sustained resources are required to
that cause these genetic changes, and
address breast cancer problems effec-
the means by which breast cancer cells
tively. Specific areas and approaches
grow and spread. It is reasonable to
that we believe are most likely to result
hope that this information will lead to
in meaningful progress are emphasized.
new, more specific methods of earlier
Our recommendation for support of
detection and diagnosis, treatment, and
breast cancer research at a level of no
prevention.
less than $500 million per year is con-
gruent with the funding level recom-
In Fiscal Year 1993, the Department of
mended in the Fiscal Year 1995 NCI
Defense received an appropriation of
bypass budget.
7
Special Commission on Breast Cancer
BREAST CANCER ETIOLOGY AND PREVENTION
Findings
Hormones
The ultimate goal of breast cancer
research is prevention. To develop effec-
Being a woman is the major risk factor for
tive prevention strategies, basic and epi-
breast cancer. Women develop breast
demiologic research must first identify
cancer not only because they have
risk factors that can be modified.
breasts, but also because they have
Prevention studies can then determine
ovaries. Sex hormones, particularly the
the most useful approaches to reducing
steroids made by the ovaries, have a
breast cancer risk by modifying such fac-
central role in breast cancer. They
tors. Prevention trials can evaluate the
increase the circulating level of two key
relative effectiveness of modifying sever-
ovarian hormones-estradiol and proges-
al risk factors and determine the impact
terone-and modify the levels of other
of changing single risk factors.
hormones and locally acting growth fac-
tors. These changes alter the hormonal
Today, the most promising areas of
environment in the breast, increasing
breast cancer risk.
research for understanding breast cancer
causes and developing optimal preven-
tion methods include: genetics, hor-
Other proxy indicators of hormonal activity
mones, diet, physical activity, environ-
support the concept that an altered hor-
mental risk factors, premalignant and
monal environment is a major influence
tumor markers, and, for secondary pre-
on breast cancer risk. Early age at menar-
vention, understanding the metastatic
che, late age at menopause, obesity in
postmenopausal women, nulliparity, and
process.
older age at first full-term pregnancy are
each associated with increases in risk.
Genetics and Tumor Markers
The effects of steroid hormone contracep-
There is both molecular and epidemiolog-
tives and hormone replacement therapy
ic evidence that genetic changes are
have been studied extensively, but the
involved in the development of breast
findings have not been totally consistent.
cancer, as has been observed for all can-
However, with each of these hormonal
cers. Mutations in normal genes, loss of
treatments, some elevation in breast can-
tumor suppressor genes, and altered
cer risks are noted for specific subgroups
expression of cellular proto-oncogenes
of women or in relation to particular char-
may all be involved in converting a nor-
acteristics of the hormonal regimen.
mal breast cell to a malignant one.
Additional genetic changes altering
expression of proteins on the tumor cell
Diet
surface can increase or decrease tumor
Five-fold international differences in
aggressiveness or metastasis.
Knowledge of these genes and the pro-
breast cancer incidence rates and major
teins they encode potentially may be
changes in rates among migrating popu-
lations indicate that non-heritable factors
used to facilitate early detection and diag-
nosis and to identify high-risk women for
play a major role in disease development.
prevention trials.
Correlations between dietary factors and
9
Special Commission on Breast Cancer
breast cancer incidence rates internation-
methodologic biases. Protective effects of
ally, as well as animal studies, suggest
very low fat intake or alterations in dietary
that nutritional factors strongly influence
fat early in life cannot be excluded by
development of breast cancer. At this
available data.
time, no dietary change has been proven
to reduce breast cancer risk in humans.
Vitamin D: Women in latitudes with low
sunlight exposure, and presumably lower
Alcohol: A modest positive association
vitamin D levels, appear to have higher
between alcohol consumption and breast
breast cancer incidence rates, but more
cancer risk has been shown in many
direct evidence for a protective effect of
case-control and cohort studies.
vitamin D is lacking.
Vitamin A and precursors (carotenoids):
Little is known about the influence of
Animal studies show reduced mammary
dietary factors on breast cancer prognosis.
carcinogenesis from high doses of vitamin
A and related synthetic compounds;
human case-control and cohort studies
Physical Activity
suggest a modest protective effect of pre-
formed vitamin A and carotenoids.
A few studies have suggested that breast
cancer risk is lower among female ath-
Total energy intake: In animal models,
letes and among women who have
restricting total energy intake profoundly
engaged in moderate physical activity.
and consistently reduces mammary
carcinogenesis. Human epidemiologic
Environment
data are consistent with an important
effect of childhood and adolescent ener-
There have been few studies of environ-
gy balance (caloric intake and energy
mental or occupational exposures as eti-
expenditure) as rates of breast cancer
ologic agents for breast cancer. Most
are associated with height.
conducted to date were severely flawed
methodologically or based on small sam-
Plant constituents: In several studies,
ples. Research on the effects of expo-
women with higher vegetable intake expe-
sures to environmental and occupational
rienced lower rates of breast cancer.
agents must include assessment of
Epidemiologic evidence does not general-
known breast cancer risk factors.
ly support a major role for dietary fiber in
breast cancer prevention, although this
For none of the 30 known human chemi-
was suggested in some laboratory studies.
cal carcinogens is the human breast the
primary site for the initiation of cancer.
Dietary fat: In some animal models,
Exposure to high doses of ionizing radia-
high-fat diets increase mammary tumors;
tion, such as that experienced by female
polyunsaturated fats appear to have the
atomic bomb survivors in Japan and
strongest influence. Some human case-
women who had multiple fluoroscopic
control studies show an association
examinations for tuberculosis, is known
between fat intake and breast cancer
to increase the risk of female breast can-
risk, but little or no association has been
cer. Whether non-ionizing radiation from
shown in all recent, large, prospective
electromagnetic fields increases breast
studies, which are less subject to
cancer risk is currently being studied.
10
The President's Cancer Panel
Recommendations
Hormones
Etiology
Study epithelial cell proliferation and hor-
monal control of the normal breast during
Genetics and Tumor Markers
the adolescent and adult menstrual cycle,
during pregnancy and lactation, during
Evaluate the role of proto-oncogenes in
systemic contraceptive use, and during
normal breast tissue growth, differentia-
hormone replacement therapy.
tion, and reproduction.
Identify the genes in the normal breast
Identify genetic changes during the trans-
and in breast cancers that are specifically
formation from normal mammary tissue to
regulated by endogenous hormones and
premalignant to frankly malignant tissue.
growth factors, and by hormones in con-
traceptives and hormone replacement
Evaluate the specific effects of point
therapy.
mutations or deletions of specific onco-
genes, tumor suppressor genes, or chro-
Conduct human research on "low-dose"
mosomal segments associated with
hormonal contraceptive regimens, and
breast cancer.
compare the effects of estrogenic versus
progestational components of systemic
Identify intermediate or premalignant
contraceptives on breast tissues.
events or markers of events that occur in
the interval from the start of breast abnor-
malities to the detection of breast cancer.
Diet
This will lead to earlier diagnosis, higher
cure rates, and the development of ratio-
Study basic mechanisms of the preven-
nal preventive measures.
tive role of retinol and carotenoids.
Study new marker technologies for the
Define the dose-response relationships
identification of premalignant changes
and the relative contributions of various
that could be targets for preventive inter-
forms of dietary vitamin A.
ventions. As such technologies become
available, they should be evaluated in
Elucidate the mechanisms whereby ener-
multi-investigator or multi-institutional
gy restriction reduces mammary carcino-
cooperative clinical research groups,
genesis.
which should establish quality control
guidelines and design and conduct peer-
Investigate the relationship between spe-
reviewed clinical trials with adequate
cific types and amounts of dietary fat and
power to validate the sensitivity and
protein and breast cancer incidence.
specificity of new markers and tests.
Such studies should include a wider
range of dietary intakes and examine
Enact federal regulations to limit the
diets beginning in childhood.
widespread sale and clinical use of mark-
ers of modifiable premalignant changes
Expand laboratory, clinical, and epidemio-
(when they become available) that are
logic research on non-nutritive protective
still experimental, and for which firm qual-
factors in vegetables and fruits, including
ity control guidelines and usefulness
screening the food supply for potential
have not been established.
preventive agents.
11
Special Commission on Breast Cancer
Study mechanisms by which moderate
markers of exposure and susceptibility,
alcohol intake could increase the risk of
improved methods of assessing dose-
breast cancer, with one focus being the
response relationships, and mechanisms
relationship of alcohol consumption to
of enzymatic transformations of precursor
hormone levels.
molecules to active carcinogens in
humans.
Evaluate the interaction between dietary
factors and markers of genetic predispo-
Determine the variable effects of individ-
sition as the latter become available.
ual and multiple etiologic factors on
breast cancer risk by age at exposure.
Investigate the possible relationship
between vitamin D status and breast can-
Continue studies of Japanese atomic
cer risk.
bomb survivors, particularly women
exposed in utero and during adoles-
Conduct observational studies and clini-
cence; evaluate the effects of hormonal,
cal trials on the effect of dietary factors
dietary, and genetic factors on suscepti-
on breast cancer prognosis.
bility to breast cancer due to radiation
exposure.
Environment
Prevention
Investigate the molecular nature of the
carcinogenic process in breast epithelium
Develop approaches to modulate or elim-
to understand mechanisms by which
inate the expression of specific oncogene
environmental chemicals might influence
products or abnormal genetic segments
mammary carcinogenesis.
in premalignant breast tissue.
Conduct animal studies on mechanisms
Investigate hormonal chemoprevention
of species differences in susceptibility to
intensively through basic, epidemiologic,
chemically induced mammary cancers to
and clinical studies. Research should
increase understanding of human diversi-
focus on the development of pure
ty in susceptibility.
antiestrogens and antiprogestins, the elu-
cidation of hormonal regimens that mimic
Study occupational exposures to chemi-
the protective effects of early pregnancy,
cal and other carcinogens and breast
work with retinoids and other vitamins,
cancer risk in the context of other known
non-steroidal hormones and hormonal
risk factors.
antagonists as systemic contraceptives,
and non-hormonal contraceptive methods.
Investigate exposures to natural and syn-
thetic estrogenic chemicals in the environ-
Conduct observational studies and clini-
ment and their effects on breast cancer
cal trials on the effects of modifying
risk, particularly during prenatal, prepu-
multiple risk factors-for example, diet,
bertal, and pubertal periods. Such expo-
physical activity, and hormones.
sures must be evaluated in the framework
of known breast cancer risk factors.
Complete the Tamoxifen trial to deter-
mine whether it can prevent breast can-
Develop methodologies needed to study
cer among high-risk women.
environmental risk factors: molecular
12
The President's Cancer Panel
SCREENING AND EARLY DETECTION AND THE DEVELOPMENT OF
NEW TECHNOLOGIES FOR DETECTION AND DIAGNOSIS
Findings
modalities such as positron emission
tomography and magnetic resonance
While prevention is the ultimate goal, ear-
imaging are still under development and
lier detection increases the likelihood of
should be used only in the context of
reducing mortality and should have a
well-designed studies.
high research priority.
Mammography in conjunction with breast
Recommendations
physical examination has been shown to
reduce mortality from breast cancer in
Practice and Outreach
women ages 50-69. Data regarding the
benefit from mammography screening in
Immediately implement the Mammo-
women ages 40-49 are inconclusive,
ography Quality Standards Act to ensure
possibly due to limitations in study design
that all women receive mammography of
or implementation.
acceptable quality, and remove overlap-
ping and conflicting standards. Current
The technology of film-screen mammog-
multiple certifications required at federal
raphy has improved greatly over the past
and state levels and from private organi-
decade, but its sensitivity and specificity
zations impose an excessive burden on
are still not adequate to detect all breast
mammography facilities, waste tax
cancers at an early stage, especially in
dollars, and increase costs.
premenopausal women.
Promote utilization of screening mam-
Screening mammography is underuti-
mography and clinical breast examination
lized, especially by women aged 60 and
for groups of women who are currently
older, who are most at risk. Racial and
being screened at disproportionately low
ethnic minorities and low-income women
rates (e.g., older women, rural women,
are also less likely to get mammograms.
women of lower socioeconomic status,
and specific racial and ethnic popula-
Failure of health care providers to recom-
tions, especially African American, Native
mend mammography is a major cause of
American, Latino, and Asian women).
poor utilization.
This will require gathering additional
information on barriers to screening and
The Mammography Quality Standards
the information needs of these groups,
Act, designed to ensure high-quality
and using existing information to develop
mammography facilities across the coun-
effective educational materials and pro-
try, was passed in 1992, but has not yet
grams. Special attention should be given
been implemented. The Food and Drug
to conveying the message that increasing
Administration is responsible for imple-
age is the major risk factor for developing
menting this law, but instead is expending
breast cancer. These efforts should recog-
its efforts modifying it.
nize the diversity of needs among and
within specific groups and the necessity
Ultrasonography has limited use for
to develop materials, services, and inter-
breast cancer detection. Newer imaging
ventions that address these specific needs.
13
Special Commission on Breast Cancer
Educate and encourage physicians to
Develop a system designed to provide
recommend screening mammography
information about the practice of breast
actively.
cancer screening in the United States.
Provide screening and appropriate follow-
Assess the effects of co-morbid medical
up services for women, regardless of
illnesses on breast cancer screening out-
financial status or extent of insurance
comes in women in different age groups.
coverage.
Determine the full range of breast cancer
Help women assure their own breast
screening roles that nurses and physician
health by providing financial and psycho-
extenders can play.
logical support, enabling them to take
responsibility for following recommended
breast cancer screening guidelines and
New Technologies Research
practicing breast self-examination.
Develop better technologies for detection
and diagnosis. Such technology should
Screening Research
detect breast cancer at its earliest stages,
be highly sensitive and specific, non-
Conduct further studies to determine the
invasive, and effective for women of all
mortality benefit of screening in women
ages.
ages 40-49 and in women ages 70 and
older, the optimal periodicity of screening
Study the feasibility of earlier detection
in relation to age, and the relative utility of
using computer-assisted mammography
mammography and clinical breast exami-
interpretation and techniques using digiti-
nation. Investigators should first assess
zation of mammographic images.
whether case-control studies could
Continue research into improving ultra-
answer some of these questions as a
sonography.
less costly and more rapid approach than
randomized controlled trials. Such stud-
Determine the comparative efficacy of
ies should use state-of-the-art mammog-
stereotactic fine-needle and core biopsy
raphy and must be well designed and
and ultrasound-guided fine-needle and
well executed. Consideration should be
core biopsy with the goal of reducing the
given to providing support for the ongoing
need for excisional biopsy.
trial in the United Kingdom to resolve
questions related to screening women in
their 40s.
14
The President's Cancer Panel
IMPROVING THE OUTCOME FOR BREAST CANCER PATIENTS:
TREATMENT AND QUALITY-OF-LIFE EFFECTS
Findings
Recommendations
Despite some recent improvements in
Treatment
treatment, many thousands of women
diagnosed with breast cancer die of the
Exploit advances in molecular biology to
disease. No currently available treatment
find a cure for breast cancer. In particular,
can be defined as curative.
new and more specific therapeutic strate-
gies should be developed, including:
Since current treatments result in modest
therapy directed at tumor growth factors
improvements in survival, assessing the
or growth factor receptors; inhibitors of
effects of treatment on quality of life is
angiogenesis and metastases; gene ther-
important to inform patients adequately
apy; and immunologic therapy, including
vaccines. Innovative research should be
about treatment options. Quality-of-life
issues include functional status, psycho-
encouraged.
logical well-being, social (work and
home) functioning, sexuality and fertility,
Identify cell surface factors associated
and spiritual well-being. Quality of life is
with the ability of tumors to invade and
influenced by personal factors (e.g.,
metastasize; develop strategies to modu-
developmental stage and social support),
late the expression of such factors.
clinical factors (e.g., stage of disease and
Explain the predilection of metastatic
type of treatment), and demographic
cells to home to some but not other target
factors (e.g., ethnicity and geographic lo-
organs.
cation). The effects of treatment on long-
term quality of life are not adequately
Improve current treatment strategies to
known at this time.
make them more effective-identify
mechanisms of resistance to hormonal
Adjustment to breast cancer is an ongo-
and chemotherapy, develop ways to
ing process. While some patients do well
avoid or overcome resistance, evaluate
following diagnosis and treatment, many
dose intensification of chemotherapy in
experience adjustment difficulties in suc-
primary and metastatic breast cancer,
ceeding years. Fear is an overriding
evaluate pre-operative chemotherapy
issue for women who have had a diagno-
effectiveness, and optimize the long-term
sis of breast cancer.
results of breast-conserving treatment
and breast reconstructive surgery.
Treatment recommendations are best
made in a clinical setting that includes
Determine prognostic and predictive fac-
experts in the various disciplines.
tors (or markers) for systemic therapy in
Patients should be empowered to partici-
order to select patients who are likely to
pate actively in making treatment deci-
benefit. However, it is necessary to regu-
sions.
late the clinical use of breast cancer
markers that are still experimental.
Markers should be made available out-
side the confines of a clinical trial only
15
Special Commission on Breast Cancer
when they have been adequately validat-
implants or other methods of reconstruc-
ed and when firm quality control guide-
tion, must be developed.
lines for their use have been established.
Include quality-of-life measures in clinical
Continue drug development research to
trials of new treatment and prevention
discover new, more active agents.
regimens and approaches.
Ensure adequate funding for clinical
Develop guidelines for psychosocial eval-
investigations of new treatments and pro-
uation and support over time of women
vide positive inducements for physicians
diagnosed with breast cancer and those
and patients to participate in studies of
at risk for the disease; develop and test
promising new approaches. In particular,
effective interventions to improve psy-
continue support of single institution pilot
chosocial adjustment. Specifically, stud-
studies and of cooperative group ran-
ies should involve patients of all ages,
domized clinical trials.
women at high risk for developing breast
cancer, and patients with recurrent dis-
Define the natural history of ductal carci-
ease. Research also should include the
noma in situ and other proliferative breast
effects of diagnosis and treatment on
lesions, including factors strongly associ-
patients' families and social functioning.
ated with progression to invasive breast
cancer.
Develop better strategies for supportive
care of end-stage breast cancer patients
and ensure availability of these services
Quality-of-Life
to patients and their families.
Evaluate the frequency, severity, and per-
Conduct clinical trials to provide informa-
sistence of adverse physical changes
tion on the effects on survival and quality
caused by treatment and develop strate-
of survival of systemic hormonal contra-
gies to deal with these changes. In partic-
ceptives, pregnancy, and hormone
ular, evaluate treatment effects on fertility
replacement therapy at menopause in
in premenopausal patients, and on sexual
breast cancer survivors, including women
function in women of all ages. Strategies
in whom treatment of premenopausal
to treat menopausal symptoms and arm
breast cancer induced premature
edema, as well as improved breast
menopause.
16
The President's Cancer Panel
INFRASTRUCTURE, EDUCATION, AND TRAINING
Findings
(Specialized Programs of Research
Excellence), the National Cancer
Breast cancer research requires
Institute's Surveillance, Epidemiology,
resources such as repositories, registries,
and End Results program, and other
and specialized research centers which
high-quality cancer registries capable of
must operate for many years. It is difficult
providing data to monitor long-term
to obtain stable, long-term funding to
trends in breast cancer, relevant animal
establish and maintain such resources
models and cell lines, and repositories for
outside an hypothesis-driven research
biological specimens.
proposal.
Develop an information-sharing network
Advances in understanding the biology
for breast cancer researchers.
and genetics of breast cancer are not
likely to be immediately applicable to
Fund training grants specifically targeted
improved prevention and treatment meth-
to the next generation of investigators in
ods. A new generation of trained, basic,
all aspects of breast cancer research.
translational and clinical investigators is
needed to ensure that the knowledge
Train investigators in translational
gained from basic research leads to
research and in clinical trials to facilitate
human benefit, specifically the prevention
the development of improved prevention,
and cure of breast cancer.
detection, and treatment strategies.
It is essential to ensure that clinical stud-
Emphasize during research training the
ies of prevention, detection, diagnosis,
role of ethnic and sociocultural diversity
and treatment include women of diverse
in risk of breast cancer, as well as the
ethnic and sociocultural backgrounds.
need to develop acceptable and sensitive
Culturally acceptable study design and
strategies for research on prevention,
recruitment of women from varied ethnic
early detection, diagnosis, and treatment
and racial groups are facilitated by the
for diverse population groups.
participation of investigators sensitive to
sociocultural issues and who also come
Train future clinical investigators in both
from diverse backgrounds.
translational and clinical trials research.
These investigators need broad training
in the biology, genetics, and clinical mani-
Recommendations
festations of breast cancer, and in epi-
demiology and biostatistics.
The preponderance of research funding
should be directed to investigator-initiated
Utilize tumor boards in institutions that
inquiry. A major emphasis should be
treat breast cancer to ensure optimal
placed on supporting innovative and
care through proper and timely input from
imaginative research.
various cancer specialists and to help
train young physicians.
Expand or create specialized research
resources: breast cancer SPOREs
17
Special Commission on Breast Cancer
Ensure that oncologists (medical, surgi-
Ensure that medical school, residency,
cal, radiation, and nursing) receive inter-
and fellowship training programs and
disciplinary training to improve the quality
training for advanced nursing practice
of breast cancer care.
include education on the need for regular
breast examinations, including mammog-
Train clinicians of diverse ethnic heritage
raphy and clinical breast examination,
in breast cancer care.
and on the performance of a thorough
clinical examination of the breast.
Promote continuing education programs
for all professional and technical person-
Encourage health care providers to edu-
nel dealing with breast cancer patients to
cate patients about breast cancer, includ-
ensure that advances in care are translat-
ing treatment and rehabilitation options.
ed to practice.
18
The President's Cancer Panel
PUBLIC COMMUNICATION
Findings
A significant segment of the U.S. popula-
tion has a low level of literacy. It is essen-
Information appropriate for and appealing
tial to present educational materials and
to the mass media and information nec-
media messages in diverse formats so
essary for public education differs sub-
that all target audiences are reached. In
stantially. A fundamental principle of
some situations, it may be best to present
communicating with the public about
both news and education via audio and
breast cancer issues is to distinguish
visual channels (radio and television).
between information that is newsworthy
and that which is needed for educational
purposes. News media professionals
Recommendations
generally consider it their responsibility to
report news accurately, but not to serve
Support a national work group on low liter-
as public educators. Therefore, channels
acy and cancer information and education.
other than the media are required for
education.
Make publicly funded public information
and educational materials understand-
There is a discrepancy between the
able to individuals at all literacy levels.
media attention given to breast cancer
and its importance as a public health
Encourage breast cancer scientists, clini-
problem. While the media do give some
cians, and advocates to collaborate to
attention to breast cancer, more
determine the most effective methods for
resources could be expended by the
presenting clear messages to the public
media to present breast cancer-related
which neither understate nor overstate
issues to the public. For example, news-
specific issues or overall progress in
papers, television stations, and radio
breast cancer research and care.
stations send reporters to international
conferences on AIDS, but are very
Emphasize coordination of public informa-
unlikely to send anyone to scientific
tion efforts between components of the
meetings concerned with breast cancer.
National Institutes of Health and with other
To some extent, this discrepancy is attrib-
federal agencies, such as the Centers for
utable to advocacy groups. It is clear that
Disease Control and Prevention.
news media respond to activism. The
more assertive breast cancer advocacy
Work with news media to promote accu-
groups are, the more attention breast
rate, responsible, and adequate coverage
cancer will receive from the press.
of breast cancer issues.
19
Special Commission on Breast Cancer
PATIENT ADVOCACY
Findings
although there are some exceptions.
Improved communication between
Breast cancer is a public health problem
patient advocacy groups and voluntary
involving multiple constituencies. It must
and government organizations would be
be a high priority for all concerned with
beneficial to all.
the health of women. Improving breast
cancer research, prevention, detection,
Breast cancer advocates want more par-
and treatment is a shared responsibility
ticipation in decision-making concerned
of consumers, health care providers,
with research and the optimal use of
biotechnology and pharmaceutical indus-
breast cancer research funding.
tries, health educators and researchers,
public health agencies, legislators, third-
party payors, the National Cancer
Recommendations
Institute, and other government agencies.
Encourage patient advocates and volun-
Over the past decade, patients and their
tary organizations to work cooperatively
families have promoted breast cancer as
to achieve legislation that provides fund-
a national priority and have focused
ing, research, treatment, education, and
attention on the need for a cure and for
support for women with breast cancer.
prevention.
Support voluntary and advocacy organi-
Service, patient support, and advocacy
zations' work to ensure access to care for
organizations exist for women, including
all women and fund community-based
underserved and minority women, at
programs to bring breast cancer informa-
local, state, regional, and national levels.
tion, education, and interventions to
These organizations are valuable
affected groups where they live and work.
resources for many women and are influ-
ential in shaping public policy. Voluntary
Ensure that health care reform implemen-
organizations fund and operate breast
tation in each state reflects breast cancer
cancer screening programs, often target-
issues specific to that population and
ed to underserved and minority women,
geographic area.
and provide outreach and support to
women during and following treatment for
Educate physicians about the medical
breast cancer. Some fund breast cancer
and psychosocial aspects of breast can-
research. Patient organizations provide
cer and women's needs for screening,
psychosocial support; advocate for indi-
diagnosis, treatment, and continuing
vidual patients within the health care sys-
care. Physicians must include the woman
tem and with payors; urge specific
as a partner in arriving at a diagnosis and
research emphases; and work at local,
choosing the most suitable care.
state, and national levels for policies and
legislation on many breast cancer issues.
Integrate breast cancer advocates into
Unfortunately, many minority and low-
decision-making regarding the optimal
income women do not feel that most
use of breast cancer research funding.
existing organizations represent them,
21
Special Commission on Breast Cancer
Encourage efforts by patient advocate
organizations and other voluntary and
educational groups to ensure that women
are fully informed and educated about
their own breast health, including adopt-
ing healthy lifestyles, practicing monthly
breast self-examination, following recom-
mended guidelines for early detection,
and obtaining immediate diagnostic and
treatment services when an abnormality
is observed.
22
The President's Cancer Panel
PUBLIC POLICY
Findings
Payment Policies
National and State Legislation
Payment policy for all aspects of breast
cancer care has a major health, psy-
Recent breast cancer research funding
chosocial, and economic impact on
increases have provided a large infusion
women. Current problems in payment for
of support for this area of biomedical
breast cancer care include inadequate
investigation and raised the priority level
insurance coverage of screening mam-
of breast cancer within biomedical
mography and breast clinical exam; no
research. However, increased National
reimbursement for preventive interven-
Cancer Institute support for research on
tions; limited or no payment for routine
breast and other specific cancers without
care associated with clinical trials; no
the addition of sufficient funds has
reimbursement for drugs that have been
required redirection of resources from
approved by the Food and Drug
other areas of cancer research. A sus-
Administration for cancers other than
tained level of increased funding should
breast cancer, but not for breast cancer
include additions to the budget to
(off-label-use); lack of reimbursement for
strengthen breast cancer research specif-
physical and psychological rehabilitative
lically, and cancer research generally.
services; lack of coverage for prostheses,
wigs, transportation, or other indirect
In addition to federal legislation pertaining
treatment or rehabilitation costs; and no
to aspects of breast cancer detection and
reimbursement for reconstructive surgery
treatment, states have enacted laws to
following mastectomy.
provide quality assurance for mammogra-
phy, ensure that treatment options are
The ability to purchase health insurance,
presented to women diagnosed with
enroll in a group policy, or obtain publicly
breast cancer, mandate payment for
funded care is critical for access to care.
some off-label uses of chemotherapeutic
Exclusion of pre-existing conditions
drugs, and improve access to mammog-
leaves women previously diagnosed with
raphy by requiring insurance companies
breast cancer without coverage in the
and Medicaid programs to cover breast
event of a recurrence. Women who have
cancer screening.
been diagnosed with breast cancer can-
not change jobs because future treatment
Impending health care reform is projected
for breast cancer would be excluded from
to improve access to breast cancer
coverage. Women with no coverage or
screening, education, treatment, and
inadequate insurance often experience
supportive care. The main principles ex-
delays in diagnosis and treatment.
pected to govern these reforms include
security in health care coverage, eliminat-
Affordability of care and of health insur-
ing exclusions for pre-existing conditions;
ance is an important issue. In small com-
provider of quality of care and account-
panies, breast cancer patients may be
ability; cost controls; and comprehensive-
discriminated against and feel guilty if
ness of care.
the costs of their care lead to a large
insurance premium increase for their co-
23
Special Commission on Breast Cancer
workers. Increased premiums and
our society and take into consideration
patients' out-of-pocket costs for breast
the society as a whole, government responsi-
cancer care can affect family resources
bilities, and the concerns of business.
and cause the breast cancer survivor to
feel guilty.
Increase access to affordable health care
coverage by:
There is a very specific problem with
regard to reimbursement for mammogra-
eliminating pre-existing condition
clauses;
phy. While the current guidelines of the
National Cancer Institute, the American
providing a universal health care pack-
Cancer Society, and other professional
age regardless of financial status or job
organizations recommend annual mam-
or career changes; and
mograms for women 50 and older,
Medicare provides reimbursement every
utilizing and adequately reimbursing
other year for women 65 and older and
primary care physicians and other
does not provide any coverage for breast
providers such as nurse-practitioners and
clinical examination.
physician assistants.
Provide comprehensive coverage for rea-
Recommendations
sonable costs of screening and diagnos-
tic tests, treatment, rehabilitation, and
National Legislation
psychosocial services by:
New funds should be appropriated to
consensus development of practice
support the President's Cancer Panel
guidelines; and
Special Commission on Breast Cancer's
covering treatment known to be effec-
recommended program at a level no less
tive and listed in the three compendia
than $500 million per year until breast
(AMA Drug Evaluations, United States
cancer prevention and cure are achieved.
Pharmacopeia, Hospital Formulary)
This research effort should be under the
whether or not FDA-approved specifically
leadership of the National Cancer
for breast cancer.
Institute.
Encourage and support breast cancer
clinical research by:
State Legislation
providing coverage of standard health
Support state legislation to provide quali-
care costs incurred in peer-reviewed clini-
ty assurance for mammography and
cal trials;
insurance coverage for screening, diag-
nostic tests, treatment, and patient care
providing coverage of interventions not
costs of clinical trials.
yet proven to have medical benefit only
in the peer-reviewed clinical trial setting;
and
Payment Policies
providing incentives to industry and the
Decisions about health care coverage in
private sector to support treatment costs
this country should involve all members of
of clinical trials.
24
The President's Cancer Panel
SPECIAL ISSUES FOR MINORITY AND UNDERSERVED WOMEN
Findings
these populations and fails to encompass
their issues in developing strategies for
Minority and underserved women are
optimal care.
heterogeneous, encompassing diverse
ethnic groups (e.g., Native Americans,
African Americans, Latinas, and Asian
Recommendations
Americans); rural women; women with
low literacy; women with inadequate
Where scientifically appropriate, structure
health care, health insurance, or financial
clinical trials to reflect the racial and eth-
resources; women with disabilities from
nic population diversity.
other illnesses or injuries; and women 65
and older, who often do not receive
Build partnerships with underserved com-
breast cancer screening or obtain state-
munities to encourage their involvement
of-the-art treatment.
and self-advocacy in health care. Hospi-
tals, clinics, health departments, and
Diversity must be a key word in breast
other providers should be encouraged to
cancer research, prevention, diagnosis,
assist the underserved in navigating the
treatment, and supportive and continuing
health care system. Such strategies will
care. No subgroup of women is homoge-
increase early detection and reduce costly
nous: white women in the United States
use of emergency rooms.
are considered as a single, homoge-
neous entity, yet they have diverse demo-
Precede design of outreach and research
graphic, socioeconomic, and ethnic back-
projects in minority populations with con-
grounds which influence their risk of
sultation and interaction with community
breast cancer and their potential for
leaders where the project will take place.
access to the full range of appropriate
Provide adequate funding for long-term
care from prevention and early detection
efforts.
to rehabilitation. Similarly, other ethnic
groups, such as Latino, African
Conduct behavioral/social research on
American, and Asian women are treated
culturally sensitive approaches to current
as if they all were similar. Diversity within
and future primary prevention strategies
these groups in culture, tradition, lan-
and ways to increase access to and uti-
guage, education, and other factors asso-
lization of early detection techniques and
ciated with breast cancer risk and access
state-of-the-art treatment.
to optimal care must be considered in
developing culturally sensitive programs.
Reduce geographic barriers to optimal
education, early detection, treatment, and
Access to breast cancer education, early
rehabilitation, particularly in rural areas.
detection, treatment, and rehabilitation is
often restricted among women having
Investigate the psychosocial impact of
one or more of the characteristics
breast cancer on women and their fami-
described above. Breast cancer research
lies and differences related to diversity by
rarely includes women from many of
ethnicity, urban/suburban/rural residence,
and socioeconomic status.
25
Special Commission on Breast Cancer
Conduct studies to determine risk factor
Target public information and media
prevalence across diverse ethnic, socio-
channels for providing breast cancer edu-
economic, and cultural (e.g., urban/sub-
cation to specific ethnic communities by:
urban/rural) populations.
focusing on their media outlets, empha-
sizing radio advertisements and print
Make available breast cancer incidence
media, and developing diverse program-
and mortality data for all major ethnic
ming that takes into account differences
groups: African American, Latino, Native
within an ethnic group in acculturation, lit-
American, Chinese, Japanese, Native
eracy, language, and traditional cultural
Hawaiian, etc. The U.S. Census Bureau
practices and beliefs.
should provide intercensal population esti-
mates for these groups. The National
Remove linguistic and cultural barriers to
Cancer Institute's Surveillance, Epidemi-
screening, treatment, and rehabilitation.
ology, and End Results program should
provide the incidence data, while the mor-
tality information should be provided by
the National Center for Health Statistics.
26
The President's Cancer Panel
APPENDIX A: PRESIDENT'S CANCER PANEL SPECIAL COMMISSION ON BREAST CANCER
MEMBERSHIP ROSTER
Chairman
Jay R. Harris, M.D.
Nancy G. Brinker
Clinical and Educational Director
Founding Chairman
Professor in Radiation Oncology
Susan G. Komen Breast Cancer Foundation
Shields Warren Radiation Laboratory
Dallas, Texas
Joint Center for Radiation Therapy
Harvard Medical School
Dorit D. Adler, M.D., M.P.H.
Associate Professor of Radiology
Kathryn B. Horwitz, Ph.D.
Associate Director
Professor of Medicine and Pathology
Division of Breast Imaging
University of Colorado
University of Michigan Medical Center
Health Sciences Center
Karen H. Antman, M.D.
Barbara S. Hulka, M.D., M.P.H.
Chief, Division of Medical Oncology
Kenan Professor and Chair
Columbia Presbyterian Medical Center
Department of Epidemiology
New York, New York
School of Public Health
University of North Carolina
Zora K. Brown
Founder and Chairman
Mary-Claire King, Ph.D.
Cancer Awareness Program Services
Professor of Epidemiology
Washington, D.C.
School of Public Health
University of California-Berkeley
Pelayo Correa, M.D.
Professor of Pathology
Sherry L. Lansing
Louisiana State University Medical Center
Chairman and CEO
Paramount Motion Picture Group
Gerald D. Dodd, M.D.
Los Angeles, California
Radiologist and Professor of Radiology
The University of Texas M.D. Anderson
Sam Shapiro
Cancer Center
Professor Emeritus
Health Services Research and
Karen Hassey Dow, R.N., Ph.D.
Development Center
Nurse Researcher
School of Hygiene and Public Health
Beth Israel Hospital
The Johns Hopkins University
Cambridge, Massachusetts
S. Eva Singletary, M.D.
Harmon J. Eyre, M.D.
Chief
Deputy Exec. V.P. for Medical Affairs and
Breast Surgical Section
Research
Department of General Surgery
American Cancer Society
The University of Texas M.D. Anderson
Atlanta, Georgia
Cancer Center
27 Special Commission on Breast Cancer
G. Marie Swanson, Ph.D., M.P.H.
Professor of Medicine
Director, Cancer Center
Michigan State University
Reed V. Tuckson, M.D.
President
Charles R. Drew University of Medicine
and Science
Los Angeles, California
Frances M. Visco, Esq.
President
National Breast Cancer Coalition
Philadelphia, Pennsylvania
Walter C. Willett, M.D., M.P.H., Dr.P.H.
Nutrition Department
Harvard School of Public Health
Executive Secretary
Iris J. Schneider
Assistant Director for Program Operations
and Planning
National Cancer Institute
28
The President's Cancer Panel
APPENDIX B: MEETINGS OF THE PRESIDENT'S CANCER PANEL
SPECIAL COMMISSION ON BREAST CANCER
May 28, 1992
June 25, 1993
Overview of Breast Cancer Research
Information Dissemination and the
Role of the Media
July 8, 1992
Issues in Basic Research
July 21, 1993
Public Policy and Legislation
September 23, 1992
Radiation and Toxic Exposures as
Risk Factors
Dietary Influences on Risk and
Implications for Prevention
October 23, 1992
Patient Advocacy and Voluntary
Organizations
November 12, 1992
Hormonal Factors
January 11-12 1993
Treatment, Rehabilitation, and Quality
of Life
February 23, 1993
New Product Development for
Breast Cancer Prevention, Treatment,
Detection, and Diagnosis
March 18-19, 1993
Screening and Early Detection
Copies of meeting agendas, transcripts,
Development of New Technologies for
and meeting summaries available by
Detection and Diagnosis
writing to:
President's Cancer Panel Special
April 29, 1993
Commission on Breast Cancer
Possible Environmental Influences on
Attention: Nora Winfrey
Breast Cancer
National Cancer Institute
Health Care Delivery and the Role of
Building 31, Room 4A34
the Payors
Bethesda, MD 20892
29 Special Commission on Breast Cancer
APPENDIX C: PRESIDENT'S CANCER PANEL MEMBERS
Harold P. Freeman, M.D.
Chairman
Director of Surgery
Harlem Hospital Center
1991 to 1994
Henry C. Pitot, M.D., Ph.D.
Professor of Oncology and Pathology
McArdle Laboratory
University of Wisconsin
1992 to 1995
Nancy G. Brinker
Founder
Susan G. Komen Breast Cancer
Foundation
1992 to 1993
Frances M. Visco, Esq.
President
National Breast Cancer Coalition
1993 to 1996
30
The President's Cancer Panel
NATIONAL
ANCER
INSTITUTE
October 1993