Screening mammography and public health policy: the need for perspective

doi:10.1016/S0140-6736(95)92655-0

The Lancet

Volume 346, Issue 8966, 1 July 1995, Pages 29-32

https://doi.org/10.1016/S0140-6736(95)92655-0 Get rights and content

Abstract

Summary

The early trials of screening mammography, reporting 30% relative reduction in mortality from breast cancer in women over 50 years of age, led to strong professional and public demand for screening programmes. There has been little publicity about the subsequent trials showing no significant benefit in any age group, or about the harm and costs associated with screening mammography. For women under 50, there is a reluctant consensus that screening is not beneficial, but there is increasing pressure for publicly funded programmes for older women.

When analysed in terms of population benefit, the randomised controlled prospective trials showed that the numbers of women screened to achieve one less death per year ranged from 7086 (Health Insurance Plan of New York), to 63264 (Malmo), to infinity (Canadian National Breast Screening Study). About 5% of screening mammograms are positive or suspicious, and of these 80-93% are false positives that cause much unnecessary anxiety and further procedures including surgery. False reassurance by negative mammography occurs in 10-15% of women with breast cancer that will manifest clinically within a year. Our calculations confirm others that the mean annual cost per life "saved" is around $1·2 million (£558 000).

In the allocation of limited resources, public health policy on a proposed mass population intervention must be based on a critical analysis of benefits, harm, and cost. Since the benefit achieved is marginal, the harm caused is substantial, and the costs incurred are enormous, we suggest that public funding for breast cancer screening in any age group is not justifiable.

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From facts to arguments: A study of the 2014 Swiss controversy over systematic mammography screening
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Citation Excerpt :
Mammography screening has become one of the greatest controversies in health care policies, capturing the attention of professionals, the media, and the public [1]. In 1995, Wright and Mueller called for perspective and critical analysis of benefits, harms, and costs of mammography screening, whose demand was increasing among professionals and the public [2]. However, the debate over its benefits started with the 2000 meta-analysis by Gøtzsche and Olsen in which they concluded that “Screening for breast cancer with mammography is unjustified […] there is no reliable evidence that screening decreases breast-cancer mortality” [3]; this meta-analysis was followed by two publications of Olsen and Gøtzsche in The Lancet [4] and the Cochrane Review [5].
The Swiss Medical Board (SMB) has recently revived the controversy over mammography screening by recommending to stop the introduction of new systematic mammography screening programs. This study aimed to examine the Swiss media coverage of the release of the SMB report.
The dataset consisted of 25 newspaper and “medical magazine” articles, and TV/radio interviews. The analytic approach was based on argumentation theory.
Authority and community arguments were the most frequent types of arguments. With respect to authority arguments, stakeholders for instance challenged or supported the expertise of the SMB by referring to the competence of external figures of authority. Community arguments were based on common values such as life (saved thanks to systematic mammography screening) and money (costs associated with unnecessary care induced by systematic mammography screening).
The efficiency of mammography screening which was the key issue of the debate appeared to be largely eluded, and the question of what women should do endures.
While interpersonal and interprofessional communication has become a major topic of interest in the medical community, it appears that media communication on mammography screening is still rather ineffective. We call in particular for a more fact-based discussion.
Ethical and Societal Considerations in Breast Cancer Screening
2016, Breast Cancer Screening: An Examination of Scientific Evidence
In this chapter we discuss social and ethical dimensions of breast screening. Breast screening has influenced, and been influenced by, attitudes toward the breast and breast cancer, increasing emphasis on responsibility and risk in healthcare, and prevailing in biomedical approaches to early detection of cancer, technological innovation, and evidence-based medicine. Commercial and advocacy interests, and the political nature of breast screening have shaped its social character. Ethical considerations in breast screening include maximizing benefit (within resource constraints), minimizing harm, delivering more benefits than harms, respecting autonomy, maintaining honesty, transparency and just decision-making, respecting privacy, distributing benefits and burdens fairly, and valuing reciprocity and solidarity. We discuss these, and consider ethical challenges including disputes over evidence of benefit and harm, and balancing conflicting ethical principles. Attending to social and ethical aspects of screening will assist policymakers and practitioners to proceed in a justifiable and legitimate way.
The impact of advances in treatment on the efficacy of mammography screening
2011, Preventive Medicine
The objective of this commentary is to argue that advances in therapy are diminishing the efficacy of mammography screening.
Key studies which demonstrate this effect are briefly reviewed.
The author argues that, for screening to be beneficial, the treatment of screen-detected cancers must be more effective than that of clinically-detected cancers. If there was no effective therapy for breast cancer, then screening would offer no benefit. Furthermore, as breast cancer treatments improve over time, both the absolute and relative benefits of screening will diminish. This is evident in the overview of the nine successive mammography screening trials, which have shown a decrease in the benefit of mammography screening over time, with the three most recent trials showing no benefit at all. Breast cancer adjuvant therapy was widely available in the three most recent mammography screening trials, but not the earlier trials. Additionally, population-based studies seem to suggest that the benefit of mammography screening is diminishing as treatments continue to improve.
Thus, in the years ahead, further declines in breast cancer mortality will likely be fueled by advances in therapy, and not by improvements in screening technology.
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Breast cancer screening [4]
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A place for fiber diffraction in the detection of breast cancer?
2006, Cancer Detection and Prevention
Aims: To review the potential relevance and the place that a particular change in the fiber diffraction of hair might have in the future management of breast cancer and other pathologies. Method: A comprehensive overview was obtained using a complete search of the Australian National University Library (data range) and Medline (data range) using the search terms “review breast cancer screening/diagnosis/detection” and “X-ray diffraction of hair”. Publications in the past 5 years were selected but older reports that were commonly referenced were not excluded. Results: To date, our results have demonstrated that a specific change occurs in the diffraction pattern of hair for persons with breast cancer. Further research has shown that this change is present in the hair at an earlier stage of the cancer growth than is detectable by mammography. In addition, the change has been found to disappear when the cancer has been successfully removed. Discussion/conclusion: This technology uses only a few hairs, is totally user-friendly, non-invasive and does not require the patient to be exposed to any radiation. As a low-risk procedure, it could potentially provide a much needed, cost-effective early screening test for the presence of breast cancer in women of any age. As the patients are not required to be present during the test, it could also provide a testing service for women in remote areas. In this review, the origin of the diffraction pattern and the diagnostic information that can be gleaned from it are outlined.

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Screening mammography and public health policy: the need for perspective

Abstract

Lancet

J Clin Epidemmol

Lancet

Cancer of the breast: its outcome as measured by the rate of dying and causes of death

Ann Surg

Breast cancer detection demonstration project: five-year summary report

Cancer J Clin

Determining the efficacy of breast cancer screening

Cancer

Breast cancer: reporting results with inflationary arithmetic

Am J Clin Oncol

Control of breast cancer through mass screening: from research to action

Cancer

Pamphlet 86-(30 mm); no 2077-LE

False premises and false promises of breast cancer screening

Lancet

Ten to fourteen year effects of breast cancer screening on mortality

J Natl Cancer Inst

Mammographic screening and mortality from breast cancer: the Malmo Mammographic Screening Trial

BMJ

Edinburgh trial of screening for breast cancer: mortality at 7 years

Lancet