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BMJ No 7115 Volume 315 Editorial Saturday 25 October 1997
Will you still need me, will you still screen me, when I'm past 64?Breast screening policy is based on ageismBreast screening policy in Britain is based on women's age, as it should be. Age is the most important risk factor for breast cancer, and in younger women the health gain from screening is vanishingly small. A lower age limit is therefore rational. But when age related decisions are irrational or inequitable, they may reflect ageism. Is this the case with the upper limit for breast screening? The NHS screening service follows the recommendation in the Forrest report that in view of poor response rates there is insufficient benefit from offering screening to women aged 65 and over, though it may be available on request.(1) This recommendation was based on the Utrecht study and the United Kingdom trial,(2-3) both of which apparently showed a rapid fall in acceptance of repeated screening over 65.(1) In Sweden, by contrast, uptake was 80% to age 74.(4) However, neither the Utrecht nor the British trial recruited women over 65. Forrest presumably meant the Nijmegen study, where women aged 70 and over had 34% uptake in their first screening round, falling to 21% in later rounds; women aged 60-69 had 80% uptake, falling to 54%.(5) Implementing the Forrest recommendations required a huge effort. Therefore, initially to target the service at the age group most likely to benefit was reasonable. But women aged over 65 dropped off the agenda completely. Their uptake of screening, cancer yield, and benefit from screening were uncertain, but no research was commissioned; and in an otherwise wide ranging update on research evidence after Forrest,(6) the question of upper age limits was ignored. Several studies indicate that screening 65-69 year olds confers benefits similar to those seen in 50-64 year olds: a 25% reduction in breast cancer mortality.(5-7) Results for women aged 70 or more are equivocal, being based on small numbers, and these results needed to be checked in the context of the NHS. But the only British studies were small, in interested centres that had spare capacity.(8-10) Thus their uptake rates may have been atypical; the studies were too small for a precise estimate of cancer yield; and their costs could not be extrapolated. Moreover, these data, although positive, provoked no reaction. This selective blindness in scientific and health policymaking circles is mirrored by the media and the public. The press regularly carries stories of breast cancer in young women, ignoring the predominance of the disease in older women. National policy in Britain is that women over 65 are not invited but can be screened on request, but few women are aware of their rising risk of breast cancer with age, or of the value and availability of screening. Those who try to refer themselves face barriers,(11) and less than 2% of the eligible population are screened. The policy is illogical in equating programme success with a screening uptake of 70%. By that criterion, we should invite women aged 25 and abandon screening of 50-64 year olds in central London, where uptake is low.(9) The costs of invitation are trifling compared with the costs of screening and assessment. So which is the real fear: that older women would fail to attend if invited, or that they would have the temerity to turn up? The crux of ageism is the stereotyped negative view of older people that leads to policy decisions that disadvantage them. Ageism seems to be embedded in NHS culture.(12) This is illustrated by a mental experiment: imagine that your local screening service, aimed at 50-64 year olds, achieves a 75% uptake, 5% above target. This would be cause for pride, and any resource implications would be tackled in a positive spirit of building on success. Now imagine a 5% extra workload from self referrals of older women: cause for dismay perhaps, and resentment of an unfunded extra burden? So while it is true that "if the healthcare system is to serve the greater good of the population then resources must be directed to where they will be most highly valued,"(13) one has to ask whose values will count. For example, when in 1986 Forrest recommended screening of 50-64 year olds, the government supplied the money and political drive to make it a reality. By contrast, in 1995, when the House of Commons Health Committee(14) advocated routine invitation of 65-69 year olds (on much stronger evidence than was available to Forrest), the response was to call for further research. That research takes the form of demonstration projects in East Sussex, Leeds-Wakefield, (where I am an investigator), and Nottingham. These deflect the pressure for routine invitation of older women, and lool like a stalling tactic. Their value will be if they permit a well informed extension of the national programme. Whatever their results, policy judgments will still have to be made, and one wonders what set of values will influence these. Ageism in health policy is not unexpected, but in breast screening, which has a strong scientific basis, it is easier to challenge. Graham C Sutton
Nuffield Institute for Health, References
1 Department of Health and Social Security. Breast
cancer screening. Report to the Health Ministers of England, Wales,
Scotland & Northern Ireland by a working group chaired by Professor Sir
Patrick Forrest. London: HMSO, 1986.
2 Collette H J A, Day N E, Rombach J J, de Waard F. Evaluation of
screening for breast cancer in a non-randomised study (the DOM project)
by means of a case-control study. Lancet 1984;i:1224-6.
3 UK Trial of Early Detection of Breast Cancer Group. First
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breast cancer. Lancet 1988;ii:411-6.
4 Tabar L, Fagerberg C J G, Gad A, Baldecrop L, Holmberg L H,
Gröntoft. Reduction in mortality from breast cancer after mass
screening with mammography. Randomised trial from the Breast Cancer
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Welfare. Lancet 1985;i:829-32.
5 Verbeek A L M, Hendriks J H C L, Holland R, Mavunac M, Scurmans F,
Day N E. Reduction of breast cancer mortality through mass screening
with modern mammography. First results of the Nijmegen project
1975-1981. Lancet 1984;i:1222-4.
6 NHS Breast Screening Programme. Breast cancer screening
1991: evidence and experience since the Forrest report.
Sheffield: NHSBSP-Trent RHA, 1991.
7 Morrisson A S, Brisson J, Khalid N. Breast cancer incidence and
mortality in the breast cancer detection demonstration project.
J Nat Cancer Inst 1988;80:1540-7.
8 Hobbs P, Kay C, Friedman E H I, St leger A S, Lambert C, Boggis
C R M, et al. Response by women aged 65-79 to invitation for screening
for breast cancer by mammography: a pilot study. BMJ
1990;301:1314-6.
9 Horton Taylor D, McPherson K, Parbhoo S, Perry N.
Response of women aged 65-74 to invitation for screening for breast
cancer by mammography: a pilot study in London, UK. J Epidemiol
Community Health 1996;50:77-80.
10 Hendry P J, Entwistle C. Effect of issuing an invitation for
breast cancer screening to women aged 65 to 69. Journal of
Medical Screening 1996;3:88-9.
11 McHugh S. Not at my age: why the present breast
screening system is failing women aged 65 or over. London: Age
Concern England, 1996.
12 Evans J G. Rationing health care by age. The case against.
BMJ 1997;314:822-5.
13 Cairns J. The costs of prevention. BMJ
1995;311:1520.
14 House of Commons Health Committee. Third report. Breast
cancer services. Vol 1. London: HMSO, 1995.
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