Breast Cancer Awareness Month: The Impact of Even the Most Successful Campaigns Fades

Background For over 35 years the ‘Breast Cancer Awareness Month’ (BCAM) has worked to increase public information about breast cancer and to raise funds for research. The aim of this study was to analyze how the interest generated by this campaign evolved over time, in the US and other countries. Methods We investigated the Google Trends® according to previously recommended methods. The study was based on Internet searches using the term ‘’breast cancer’’ worldwide and in the United-States. Google Trends® gives the relative search volume of every request as an index on a scale from 0 to 100, (100 corresponding to the maximum number of requests during the studied period). We compared the relative searches index using the term ‘’breast cancer’’ during October, the breast cancer awareness month, and the rest of the of the year avec a 10 years period.


Abstract Background
For over 35 years the 'Breast Cancer Awareness Month' (BCAM) has worked to increase public information about breast cancer and to raise funds for research. The aim of this study was to analyze how the interest generated by this campaign evolved over time, in the US and other countries.

Methods
We investigated the Google Trends® according to previously recommended methods. The study was based on Internet searches using the term ''breast cancer'' worldwide and in the United-States. Google Trends® gives the relative search volume of every request as an index on a scale from 0 to 100, (100 corresponding to the maximum number of requests during the studied period). We compared the relative searches index using the term ''breast cancer'' during October, the breast cancer awareness month, and the rest of the of the year avec a 10 years period.

Conclusions
This internet activity study shows that the impact of the 'Breast Cancer Awareness Month' seems to be slowly decreasing. The number of Internet searches generated by the campaign has been reduced by almost 40% in both the United-States and worldwide.

Introduction
For over 35 years the 'Breast Cancer Awareness Month' (BCAM) has worked to increase public information about breast cancer and to raise funds for research.(1) This public awareness campaign started in the US but has become largely international. It was shown to be responsible for an increase in the number of mammograms and early detection of breast cancer.(2) It was also proven that the campaign for breast cancer awareness was more effective than those for lung or prostate cancer awareness. (3) The authors demonstrated this by analyzing internet searches, further demonstrating that today the internet constitutes an important tool for public information as well as research and sanitary surveillance. It has for example been used to reveal the seasonality of certain diseases, (4) and more recently to analyze people's behavior during the COVID-19 epidemic.(5) A number of studies in different countries have used this tool to evaluate the impact of educational campaigns about cancer.(6-9) The aim of this study was to analyze how the interest generated by an educational campaign about cancer evolved over time, in the US and other countries.

Methods
We investigated the Google Trends® according to previously recommended methods. (10) The study was based on worldwide Internet searches using the term ''breast cancer'' without any exclusion criteria. It was our primary end-point. A second analysis focused on the United-States was performed. It was our secondary end-point. Google Trends® gives the relative search volume of every request as an index on a scale from 0 to 100, 100 corresponding to the maximum number of requests during the period of interest.
We compared the relative searches index using the term ''breast cancer'' during October, the breast cancer awareness month, and the rest of the of the year. For this comparison we used a Student's T test. A value of p<0,05 was considered as signi cant. The evolution of the index was studied calculating the Pearson's correlation coe cient (R 2 ). Correlation was considered strong if R 2 was greater than 0.6 and very strong if For both worldwide and US analysis, the ten rst related searches were correlated to breast cancer (Tables  Annexes). Discussion This internet activity study shows that the impact of the 'Breast Cancer Awareness Month' seems to be slowly decreasing. The number of Internet searches generated by the campaign has been reduced by almost 40% in both the United-States and worldwide. This is preoccupying as the campaign was shown to be linked to a signi cant improvement in the management of breast cancer.(2,3) It contributed to increasing the number of mammograms performed as well as early diagnosis of breast cancer. A fading of the impact of the 'Breast Cancer Awareness Month' has been previously suggested. (11) This strongly contrasts with the increasing number of organizations and countries involved in this campaign. The WHO promote the campaign worldwide.(https://www.who.int/cancer/events/breast_cancer_month/en/) Many actions such as painting the White House, the Sydney Opera House or the Eiffel Tower in pink or wearing a pink ribbon also promote the campaign.
The main limitation of this study is that these results don't inform us on how this impact women's health. Nevertheless, Internet activity is a strong enough warning to consider this evolution as an alert signal. Physicians involved in breast cancer management and prevention have to be aware of this recent evolution.

Declarations
Ethics approval and consent to participate: not applicable    Figure 1 Evolution of worldwide (A) and in the United-States (B) Internet researches for 'breast cancer' during the last 10 years. The orange line indicate the trends for October searches over the studied period.