I’ve written several times on this site about the practice of mammography. In short, here’s what I believe to be true:
- mammography is marketed to women as a bit of a ‘no-brainer’ – it’s effective for picking up breast cancers earlier than they would be otherwise, saves lives, and women would be mad not to attend.
- mammography is actually not very good at saving lives, and many, many women need to be screened to prevent one death.
- mammography has hazards, including the fact that it picks up cancers that would never have bothered women if left alone, and therefore opens up the risk of unnecessary investigation and treatments (over-diagnosis).
The British Government has been sternly criticised by some researchers who claim it continues to mislead women about the benefits and harms of mammography. See here for more on this.
Now, the issue has really blown up on the publication, this week, of an open letter from a female doctor to Mike Richards – Britain’s ‘cancer tsar’. In this letter, published on-line in the British Medical Journal, Dr Susan Bewley, takes Richards to task over the lack of transparency regarding the pros and cons of mammography [1]. Here’s some excerpts from her letter.
I declined screening when it was offered, as the NHS breast screening programme was not telling the whole truth. As a non-expert in the subject, I found myself examining the evidence for breast screening with increasing doubts. I compared the NHS and Nordic Cochrane Centre leaflets and found that the NHS leaflets exaggerated benefits and did not spell out the risks. Journals showed a reputable and growing body of international opinion acknowledging that breast cancer screening was not as good as used to be thought. The distress of overdiagnosis and decision making when finding lesions that might (or might not) be cancer that might (or might not) require mutilating surgery is increasingly being exposed. The oft repeated statement that “1400 lives a year are saved” has not been subjected to proper scrutiny. Even cancer charities use lower estimates. I expressed my misgivings to you “behind the scenes” as a work colleague. You replied in a personal email “that the large majority of experts in this country disagrees with the methodology used in the Cochrane Centre reviews of breast screening.
Women should be reassured that the NHS treats breast cancer more successfully now, but screening is only of marginal benefit, at best. The medical profession needs to find ways to cope with the complex issues. Trust is at stake if the public is not told the full story. In the past few years British women have not been told about the genuine doubts. Those millions of women passing through the breast screening treadmill have been unaware of the problems, criticism, and real numerical risks they face.
Susan Bewley goes on to say:
It’s uncomfortable to change set beliefs in the face of changing evidence but unforgivable not to. I am not convinced that you have challenged your experts competently and mercilessly, rather than hidden behind them. Thus I support the calls for an independent review of the evidence—a real, unbiased review that will not be kicked into the long grass, whose findings will be widely and properly disseminated, and that will adjust screening policy appropriately and will lead to proper pursuit of the research implications.
Mike Richard’s response [2], published the same day in the BMJ, informs us that an independent review is underway, and that:
Should the independent review conclude that the balance of harms outweighs the benefits of breast screening, I will have no hesitation in referring the findings to the UK National Screening Committee and then ministers. You also have my assurance that I am fully committed to the public being given information in a format that they find acceptable and understandable and that enables them to make truly informed choices.
I like the sound of an independent review, but I was a little concerned by Mike Richard’s comment that:
I will do my best to achieve consensus on the evidence, though I realise this may not ultimately be possible.
This, of course, opens the door for some more mealy-mouthed rhetoric. But, on the face of it, the British Government appears to be doing the decent thing over mammography. And at the end of the process, I hope very much that women will have more clarity over its benefits and harms, and as Mike Richards says, will enable women to make ‘truly informed choices’. Once truly informed, though, let’s not be too surprised if large swathes of women decide that mammography is not the no-brainer women have generally been led to believe it to be.
References:
1. Bewley S. The NHS breast screening programme needs independent review. BMJ 2011;343:d6894
2. Richards M. An independent review is under way. BMJ 2011;343:d6843
Another thing never mentioned is that for many the procedure is painful. I never see this mentioned and yet have many friends who tell me this and several who have refused to go back for further x-rays as a result. That’s fine if the research shows they are not effective, but the issue is not acknowledged anywhere I’ve seen.
Bang go Dr. Susan Bewley’s chances of promotion!! Well done her for being brave enough to speak out – this is the most succinct analysis I have seen of the (let’s face it) profit-driven insistence on continuing to subject women to dubious and possibly hazardous procedures, even as evidence becomes less and less convincing.
Interesting how the elephant in the room is being ignored – mammograms are x-rays, and there is increasing disquiet about the amount of radiation that people are subjected to throughout their lives. Why isn’t thermography being considered? For comfort, effectiveness in detecting relevant earlier cancers, and lack of radiation it would appear to be a much better option.
where do you stand and what is your understanding / thoughts on thermography?
In Australia it is said:
Studies have shown that a tumour has to be large (several centimetres in diameter) before it can be detected by thermography (Homer 1985). Screening mammograms have the ability to detect breast cancer at a much smaller size, and therefore to reduce deaths from breast cancer. Less than 50% of breast cancers detected by mammography screening have an abnormal thermogram (Martin 1983).
There is no current scientific evidence to support the use of thermography in the early detection of breast cancer and in the reduction of mortality.
I do not myself take a yearly mamogram.
I found this TEDtalk interesting:
“Dr. Deborah Rhodes developed a new tool for tumor detection that’s 3 times as effective as traditional mammograms for women with dense breast tissue.”
http://www.ted.com/talks/deborah_rhodes.html
Re. Jo says ‘for many the procedure is painful’. After years of regular painful (and negative) mammograms I found a lump in my own (small)breast. I saw a consultant about it and an aspiration biopsy proved it was merely a cyst. Stupidly I continued regular Mammograms and it took a bullying nurse to finally convince me that (at age 65)mammography is not for me. I sometimes wonder if the procedure itself caused my benign lump and wish I’d made my own decision years ago.
The physician’s coalition of misinformation is at it again. Let’s face it folks: Docs only want to see you if you are terribly sick. They couldn’t care less about prevention.
Lesley, don’t beat yourself up – women have been largely cut out of the decision-making; there has never been any respect for informed consent. It has always been acceptable to provide women with a biased and incomplete summary of the evidence and simply order us to screen to achieve a govt-set target. Look how men are respectfully offered prostate screening, with full information and doctors stressing their informed consent is important. How may women feel they must or should have cervical and breast cancer screening? How many women feel they fully understand the risks and benefits of these programs?
IMO, most women who screen have either been pressured or misled – only a small number have been able to make an informed decision.
I did my own research and rejected both programs on the basis of information that is not released to women. (cervical screening almost 30 years ago now)
It concerns me greatly that these programs have a free reign to harm and worry as many women as they like in Australia. No one is keeping them honest and ethical – there is virtually no discussion of informed consent in women’s cancer screening and no critical scrutiny of these programs. I think these programs now serve vested and political interests and are more likely to harm us.
I’m not anti-screening, but our cervical screening program is long out-of-date and harmful – we screen too often and far too early – we harm and worry far more than necessary. The Dutch, Finns and English have programs that make some attempt to minimize the negative impact of this unreliable testing on healthy women – the more than 99% who can’t benefit from testing. This is a rare cancer, but has been turned into a billion dollar industry of over-detection and potentially harmful over-treatment.
Breast screening – Breast Screen are desperately pursuing a political target – to screen 70% of women aged 50 to 69 – and to hell with informed consent. Ms Zorbas from Breast Screen recently mentioned a Swedish study that showed 30% less mortality from breast cancer in screened women over the long term, so she assured us we should feel confident to have a mammogram. She failed to mention a more recent study that showed the fall in mortality from breast cancer is about better treatments, and NOT screening. Most women are still unaware of the controversy surrounding the so-called benefits of screening and the very real risk of over-diagnosis.
It is this selective use of the facts that is so terribly unethical and unfair to women – we’re entitled to hear ALL of the evidence. Who do these people think they are? Are they above the law and proper ethical standards? Are women second class citizens?
It’s an indication to me that Ms Zorbas is not concerned about women and informed consent & what’s best for them, but is simply trying to get as many women into the screening machine as possible to achieve her target – to protect the program and meet her govt-set target.
Men are not treated in this way and it is offensive to suggest this is acceptable for women.
BUT the really disappointing thing: the near silence from our doctors, academics and others who could warn women and fight these programs to put women first. The silence is deafening and damning…
It’s time our doctors stopped recommending and co-operating with these programs – they should never have been allowed to corrupt the doctor-patient relationship. Doctors are doing much of the dirty work for these programs. We currently have doctors being rewarded for reaching pap testing targets (most women are unaware of these payments) – and I read that now they want GPs to “recommend” breast screening to women during unrelated/general consults. The consult is increasingly being used by these programs and our valuable ad limited time with our GP is being used to push screening. Do doctors serve these programs or their patients? Opportunistic screening is unfair and does not respect informed consent – it is used purely to boost screening numbers. We should not be rushed, pressured or misled into these programs. My GP has been told I do not want to discuss these programs and my informed decisions not to participate have been noted on my file. I also object to Papscreen providing “tips” to our GPs to increase coverage – flagging files, contacting/harassing women, opportunistic screening ie. “suggest you could do the test straight away”…these measures violate the trusted doctor-patient relationship. The patient’s interests should come first, not the program and “tactics” to increase coverage violate our rights.
Dr Margaret McCartney, Scottish GP, wrote an article for the BMJ recently, “Doctors should not support unethical screening programs”…
I totally agree…the programs need to butt out – they’re destroying trust in and respect for the medical profession.
Elizabeth, really brilliant commentary from an informed healthcare consumer. You need to spread the word about cancer screening. For many years the evidence has pointed up the fact that cancer screens find harmless abnormalities that look like cancer, but are harmless. Please post everywhere you can! I think the tide is turning, and you can help bring about long- overdue change. Cheers to you, my dear.
Now that mammograms have been examined, how about colonoscopies? I 4 people who have died or been severely wounded from colonoscopies, an aunt who died from a “preventitive” operation for something that maybe wouldn’t have killed her (she was well over 80) and my mother, who regardless of having repeted c’s died of colon cancer. Maybe they didn’t see the cancer? Did it develop so fast?