By Professor Michael Baum and Dr Michael Michell For The Hippocratic Post Published: 13:03, 3 March 2016 | Updated: 18:44, 7 March 2016
Last week, it was revealed that the number of women attending a breast screening is the lowest in a decade. The proportion of eligible women aged 50-70 screened for breast cancer after their first invitation fell to 63.3 per cent in 2014-15, down from 70.1 per cent in 2004-5. And breast screening coverage – which is the overall number checked – has also fallen for the fourth year in a row, official NHS figures revealed. Under the programme, women are invited for their first routine check between the ages of 50 and 53 and are usually invited back every three years until the age of 70.
The Government considers screening a success if 70 per cent of women take up the offer- something that was only just achieved this year, everywhere except London. But why, when screening promises to save lives, are so many women shunning it?
In recent years, a mounting body of evidence has suggested breast cancer screening may do more harm than good for some women.
Scientists have concluded that women risk false positives, where abnormal results turn out to be normal.
And experts fear women are being subjected to over-treatment, which has included needless breast removal and surgery on harmless cancers that would never have caused symptoms or death during a patient’s lifespan.
So when you receive your invitation to have a mammogram, what should you do?
Surgical oncologist Professor Michael Baum, of University College London, specialises in breast cancer treatment, and was one of the architects of the screening programme when it was set up in 1988.
More than 25 years later, he has called for the programme to be shut down, arguing it leads to healthy women being labelled ‘cancer victims’ and has not reduced the number of invasive tumours.
But Dr Michael Michell, a consultant radiologist based at King’s College Hospital, insists cancer screening saves lives and would like to see women screened every two, rather than three, years.
Below, writing for The Hippocratic Post, they lay out their arguments on whether or not the programme should be scrapped…
Back in 1998, in all good faith, I set up the service for the NHS Breast Screening Programme.
Since then, I have become one of the most vociferous proponents for closing it down.
You probably want to know why I changed my mind so completely.
At the heart of this is the question, how do you explain to a woman that she is ‘lucky’ that we caught breast cancer early yet she ends up having a mastectomy?
And that she probably wouldn’t have needed treatment at all if we hadn’t called her in for a routine scan?
This is because mammograms can pick up a type of low-grade breast cancer called duct carcinoma in situ (DCIS). This is contained just in the milk ducts and has not spread into any of the surrounding breast tissue – about 60 per cent of DCIS cases are picked up by routine breast screening.
Around half of these cancers turn out to be harmless. It is my view that too many healthy women are harmed by breast cancer screening.
SETTING UP THE SCREENING PROGRAMME
The story starts back in 1987 when the Forrest report was published just two weeks before a general election called by Margaret Thatcher.
This report was based on the review of all the available evidence that included two randomized trials plus three case control studies that predicted a 25 per cent relative risk reduction in breast cancer (cause specific) mortality favoring those who were invited to screening.
It is noteworthy that little space was allocated to the potential harms of population based screening by mammography.
Back in 1998, in all good faith, I set up the service for the NHS Breast Screening Programme. Since then, I have become one of the most vociferous proponents for closing it down
Not surprisingly, the government of the day endorsed the recommendations and promised that, if re-elected, a comprehensive screening program involving women 50-65 who would be invited every three years for mammography, would be established.
The NHS BSP was to be rolled out across the UK between 1988 and 1990.
The service would be based on fixed screening units close to population of high density and mobile units for remote areas.
All of these district units would feed into a select group of regional specialist centers in major hospitals who would be provided with additional facilities and manpower to handle the predicted surge in activity following the first round of screening.
At that time I was professor of surgery at King’s College Hospital, a major teaching hospital in South East London caring for a socially deprived population.
We were also given the task of setting up the training centre for all the clinicians, radiologists and radiographers who would staff the other units serving the South East of England as the program was rolled out.
We were given 12 months to finish the job that was completed on time and on budget in spite of continuing with our full time day jobs.
I was proud of what we had achieved and in good faith, accepted the evidence available at that juncture.
I threw myself into my leadership role in the NHSBSP and was rewarded by being offered a seat on the National committee running the show.
My love affair with the NHSBSP was short lived.
HEALTHY WOMEN LABELLED CANCER VICTIMS
Unlike most of the other members of the National Committee, I was directly involved in the day to day care of those women referred on to me as a consequence of the activities on the front line of the screening program.
I found it very distressing to have to cope with otherwise well women who had popped into the screening unit in Butterfly Walk for a mammogram at the invitation of the Department of Health (DoH) and then found themselves labelled as a cancer victim.
Worst of all were the unexpected high numbers diagnosed with duct carcinoma in situ (DCIS), a condition we rarely saw before screening began.
Many of these cases were multifocal and ended up with a mastectomy, yet they may well have turned out to be harmless.
None of the Department of Health staffers or public health specialists on the National committee had to face the reality of these heart-breaking interviews.
We were soon to learn that 20 per cent of the cancers diagnosed in Butterfly Walk were DCIS, yet before we opened our doors they amounted to less than one per cent of our practice.
I drew short term comfort from this observation assuming that in the fullness of time this initial peak in the incidence of DCIS would be followed by a fall in the incidence of invasive breast cancer.
I couldn’t have been more wrong.
NO FALL IN DIAGNOSES OF FAST-GROWING TUMOURS
Within a few more years others noted that the ‘interval cancer’ rates were far too high to achieve the predicted 25 per cent reduction in cause specific mortality.
Interval cancers are those that appear as clinically detected lumps in the intervals between two invitations for screening examination.
These tend to be the fast growing tumors that slip through the net.
It rapidly became clear to me that we would never meet our targets and also there was no evidence for the predicted fall of invasive cancers following the mopping up of all these cases of DCIS.
Furthermore, updated analysis of the evidence in the Forrest report – together with the publication of new trial reports – persuaded independent authorities to lower the estimate for the reduction in breast cancer mortality in a population based screening program from 25 per cent to 15 per cent.
After six or seven years into the programme, by which time it had been rolled out to the four corners of the UK, including the Islands and Highlands of Scotland, it became obvious to me that the benefits of screening had been grossly overestimated whilst the downside had been virtually ignored.
Yet the letter inviting women into the NHSBSP remained unchanged, optimistic, pretty pink and frankly coercive.
Things came to a head for me in December 1994. The deputy chief medical officer called an emergency meeting of the NHSBSP national steering committee in the week between Christmas and the New Year.
The meeting was set up in order to come up with a strategy to protect the program in the face of the accumulation of adverse publications in the medical media.
I argued passionately for a revision of the false promises in the leaflet that went out with the invitations so that the lay public would at least be able to make an informed choice, as in my mind it was a pretty close call to judge whether the benefits outweighed the harm.
I was a lone voice at the table and the chairman summed up the opinion of the gathering as follows: ‘Professor Baum, if we include all this new information in the leaflets then the women are unlikely to attend and we will fail to reach our target of 70 per cent uptake.’
To which I replied: ‘If that is indeed the view of this committee then I can no longer serve as I believe that women have the right to self determination, I hereby resign and intend to make my feelings felt by going public on the topic’.
True to my word I published a long letter in the Lancet entitled Screening for breast cancer; time to think and stop, a few months later.
Twenty five years after the NHSBP was launched, the Department of Health was at last forced to set up an independent review that considered the adverse effects of screening.
It also had to accept women should no longer be denied the facts in helping them to decide whether or not to accept the call that was to be rewritten as an invitation and not like a summons.
Following on from that a new information leaflet has been produced to accompany the invitation for screening that allows women to weigh up the balance of benefit versus harm so that she can reach an informed choice.
Sadly this is not the case in the USA where women at all ages are coerced to attend for screening with the mantra, ‘catch it early, save your life and save your breast.’
Dr Michael Michell is a Consultant Radiologist based at King’s College Hospital, Director of the South East London Breast Screening Programme and National Breast Screening Training Centre and Chairman of the Royal College of Radiologists Breast Group.
I know that the breast cancer screening programme for the over 50s saves lives.
When I started working in Breast Clinics at King’s College Hospital in the 1980s, it was common to see female patients for the first time with advanced cancer and tumours that were already destroying skin and breast tissue.
Now, that is rare.
The evidence is strong for breast screening for cancer being effective in women aged between 50 and 70 years old.
Over the last 20 years, the programme has screened 19 million women and has probably saved at least 25,000 women from a premature death from breast cancer.
At the moment, we screen around 1.8 million women each year.
I would like to see the time gap reduced from every three years to every two years.
That would bring us more into line with other European countries and would help catch faster growing aggressive cancers.
MAMMOGRAMS ARE NOW PRECISE AND EFFICIENT
The biggest technical advance in breast screening is digital mammography which came in over the past five years.
All mammography screening in the UK is now digital which offers greater precision, better quality and higher efficiency.
The development of MRI screening has also leapt ahead and ultrasound is also very important.
Biopsy technology is now extremely accurate and more finely tuned than a couple of decades ago.
In the future we can look forward to 3D mammography for front line screening. However, trials need to take place before this comes into practice.
Research has given us a better understanding of the biology of breast cancers.
MORE WOMEN SHOULD BE SCREENED
I am currently involved in exciting research called The Age Extension Trial – a study to evaluate an age extension to the NHS’s breast screening programme (NHSBSP).
At present all women between the ages of 50 and 70 are invited for Breast Screening as part of the NHS Breast Screening programme.
The age range is being broadened to include women between the ages of 47 and 73 to investigate whether there is much benefit to extending the age range.
The age extension to the NHSBSP is being phased in over a number of years.
During this time some women between the ages of 47-49, and others between the ages of 71-73 will be invited for breast screening.
Researchers are collecting information about the numbers of women who are diagnosed with breast cancer and the number of women who die from the disease over the next 10 years.
This trial is being supported by Public Health England, the University of Oxford and the NHS Screening Programme.
Initial results look promising, but the main results of the study are expected in the mid 2020s.
I’d like to see breast cancer screening broadened to include younger and older age groups of women aged 47-50 and 70-73 enabling doctors to save more women’s lives.
Screening is actually one of our best weapons in defence against deaths from breast cancer and of course it should continue.
This article first appeared and has been reproduced with the permission of The Hippocratic Post.
Source: Daily Mail Online