Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
The treatment may be the problem
- M E Godfrey (27 October 2001)
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Take Your Pick.
- B M Hegde (29 October 2001)
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NHS Cancer Screening Programme Office misrepresents our research
- Peter C Gøtzsche (2 November 2001)
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Re: NHS Cancer Screening Programme Office misrepresents our research
- Jeremy Luke (3 November 2001)
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Mammographic screening: belief or evidence driven?
- Hazel Thornton (4 November 2001)
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Agreement is ‘objective’; disagreement is ‘subjective’
- Karen Willis (21 November 2001)
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M E Godfrey, Private practice Tauranga, New Zealand
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Evidence from several physicians I have met coming from Europe and Asia, has persuaded me that the cancer death rate will not improve whilst therapy concentrates on tumour destruction, without treating the environment in which the tumour grew (namely the person surrounding it). For instance, Steinkellner, a Past President of the Austrian Society of Oncology, reduced the 5 year recurrence rate from approximately 50% to 27% in a group of 135 women. He and others of like mind, could spend several months addressing the patient's health including removing dental amalgam and all devitalised teeth, checking for other environmental stressors including the home and workplace, and supplementing with antioxidants, selenium etc., before touching the tumour. This approach will do far more to help our patients than debating the merits of mammography especially as with repeated investigations, it eventually exposes a woman's breasts to sufficient radiation to be a potential hazard. Thermography may well prove to be a more effective investigation that allows the above interventions to forestall overt tumour growth. |
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B M Hegde, Vice Chancellor M.A.H.E.Deemed University
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Dear Sir, The mammography audit makes interesting reading. This kind of uncertainty is the rule rather than an exception. There are rarely black and white results. Grey areas abound in clinical medicine. I think the best judgement would be from the Scottish Law, where they have three possibilities-i.e: "guilty", "not guilty", and "not proven". The best judgement here would be "not proven". We have all along been predicting the unpredictable anyway. "Of the terrible doubt of appearances,
In this context, it would be helpful for the present day researchers, who base all their conclusions on linear mathematical interpretations in dynamic,non-linear human beings, to study Prof. Halstead's original "outcomes data" of breast cancer patients, admitted to his sanatoria for the treatment with good food, fresh air and tender loving care! If I am not mistaken, his results were a shade better than the present ones! I think it was Ciciero, the Roman thinker, who said: "Learn from history; otherwise you will have to relive history." Yours faithfully,
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Peter C Gøtzsche, Director Nordic Cochrane Centre
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In the news section of the BMJ from Oct 27 (p. 956), the office of the NHS Cancer Screening Programme in the UK misrepresents our research entirely. The office says that our findings of more aggressive treatment of breast cancer among screened women are based on only two studies, classified as poor quality. They are not. Numbers of mastectomies as well as numbers of tumourectomies increase when women are screened. This finding is consistent and is based on all the four of the seven screening trials that have published data on this, including the two medium-quality trials from Canada and Malmö (1). It is also incorrect when the office notes that we did not investigate whether more aggressive treatment was beneficial since we have published extensive mortality data (1,2). Further, it is wrong to say that our conclusion about the lack of benefit of mammography comes from an analysis of the two trials of medium quality. Our results for overall mortality and for deaths ascribed to any cancer, including breast cancer, are consistent and relate to both medium-quality and poor-quality trials. There was not even a trend towards a reduction in all-cause mortality or all-cancer mortality. The office notes that many researchers would classify all seven studies as of similar quality. This statement is astonishing. We have demonstrated important quality differences and have shown that the trials from Edinburgh and New York are flawed. For this reason, the editors from the Cochrane Breast Cancer Group suggested to us that we omitted the results from these two studies from our analyses, to which we agreed. There is now ample evidence from four large studies that lack of proper quality assessment of the individual trials in systematic reviews leads to grossly exaggerated claims of benefit (3). Accordingly, we have demonstrated that the estimate for breast cancer mortality in the poor- quality trials is much lower and statistically significantly different from the estimate based on the medium-quality trials (1,2). To disregard this finding is bad science. If anybody disagree with our quality assessments, we would like to know exactly on what grounds. However, to avoid more misquotations, we recommend our critics read our full report first (available at http//image.thelancet.com/lancet/extra/fullreport.pdf). When the office claims that there is clear evidence of the benefit for mammography when all seven studies are combined, they overlook not only that some studies are flawed but also the finding that breast cancer mortality is a misleading and biased outcome measure that favours screening, as we (1,2) and others (4) have documented. Thus, all the statements offered by the office of the NHS Cancer Screening Programme are misleading and misrepresent our research. This is depressing. It is also a disservice to the women’s needs for honest information, and it underlines the importance of the statement given by Richard Horton in his commentary that ‘The implications for women and policy makers are substantial and require careful reflection and discussion’ (5). On top of it all, the statements are anonymous attacks on scientific work. This is improper and unfair since there is no accountability. Who gave these statements? Peter C. Gøtzsche Competing interests: none. 1. Olsen O, Gøtzsche PC. Cochrane review on screening for breast cancer with mammography. Lancet 2001;358:1340-2. 2. Olsen O, Gøtzsche PC. Screening for breast cancer with mammography (Cochrane Review). In: The Cochrane Library, Issue 4. Oxford: Update Software, 2001. 3. Jüni P, Altman DG, Egger M. Systematic reviews in health careAssessing the quality of controlled clinical trials. BMJ 2001;323:42- 6. 4. Early Breast Cancer Trialists' Collaborative Group. Favourable and unfavourable effects on longterm survival of radiotherapy for early breast cancerAn overview of the randomised trials. Lancet 2000;355:1757-70. 5. Horton R. Screening mammography - an overview revisited. Lancet 2001;358:1284-5. |
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Jeremy Luke, GP principal West Sussex England
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The fact that a government agency has annonymously attacked a piece of hard scientific research is not something to be depressed about. Ministers are always happy to show their faces when they have good news. When they are required to "do a Jo Moore" then we can be sure that the researchers are right and the screening effort is wrong. |
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Hazel Thornton, Honorary Visiting Fellow, Department of Epidemiology and Public Health, University of Leicester "Saionara", 31 Regent Street, Rowhedge, Colchester
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The laudable aim of the NHS Breast Screening Programme (NHS BSP) when it was set up in 1988 was to reduce breast cancer mortality by 25% by the year 2000. In her Foreward to the latest Report of the NHS BSP for the year 2000,(1) Yvette Cooper, Under-Secretary of State (Commons), states: "Breast cancer mortality in England and Wales decreased by 21.3% between 1990 to 1998, and it is estimated that 30% of this reduction was due to breast screening." 30% of 21.3% = 6.39%. Evidence published in October 2001 (2) indicates that "there is no reliable evidence that screening for breast cancer reduces mortality". It also states: "breast cancer mortality is a misleading outcome measure". Why then, in launching their long awaited revised leaflet in the Information Campaign, are various figures of up to 40/50% reduction in mortality from the Swedish 2-Counties trials used instead of the findings from this systematic review, undertaken according to the most rigorous protocol for the Cochrane Library? Richard Horton, in his commentary (3) on this review pleads for "careful reflection and discussion" because "the implications for women and for policymakers are substantial." Is anyone listening? The co-incidence of timing of these long awaited leaflets with publication of the overview has made apparent not just the "subjectivity" (4) of the scientific community, but its inability to engage in proper debate about these findings, rather than the very public, unscientific and potentially destructive instant refutations and condemnations it has engaged in so far. For those who launched the information campaign to say that the revised leaflets "heralded a new relationship of trust and honesty between patients and the NHS" is over-optimistic in the extreme, seeing that the leaflet does not provide women with even the most basic details about the benefits, risks, limitations and consequences, or alternatives, of presenting themselves for mammographic screening. The social and financial, as well as the physical consequences can be considerable and unexpected, and should be described, as the General Medical Council recommends.(5) Healthy women should be provided with this information so that they may be enabled to make their own personal trade-offs according to their individual circumstances, health profile and preferences, not fobbed off with "catching it early" persuasion, but none of the most up-to-date evidence. 3 `levels` of leaflet are to be provided for men considering PSA testing for prostate cancer. Why can`t women have this facility? Hazel Thornton. Independent Advocate for Quality in Research and Healthcare. References: (1) NHS Cancer Screening Report: "Reducing the risk, Breast Screening Programme 2000. ISBN 1 871997 24 0 (2) Ole Olsen, Peter C. Goetzsche. Cochrane review on screening for breast cancer with mammography. www.thelancet.com (3) Horton, Richard. Screening mammography - an overview revisited. Lancet 2001; 358: 1284-85 (4) Susan Mayor. Row over breast cancer screening shows that scientists bring "some subjectivity to their work". BMJ 2001; 323:956 (5) General Medical Council: Seeking patients` consent: the ethical considerations. November 1998 |
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Karen Willis, Lecturer School of Sociology and Social Work, University of Tasmania, Launceston 7250, Australia
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The claim that ‘even after 30 years we don’t really have the data we need …, in the case of mammography screening’ (Liberati in Mayor) is an interesting one. The uncertainty about the evidence was not acknowledged as an issue when the trial results were being released during this period. While methodological flaws or the lack of achievement of statistical significance was often acknowledged in the reporting of trial results, trial authors tended to convey the message that the impact of these was minimal, or could be easily accounted for. I have carried out a study reviewing the debates about the trials in medical journals. What is most apparent is the optimism that mammography screening will work, even when trial evidence was not convincing. Critics of screening have tended to be ‘shouted down’ by the proponents of mass screening. Now when reviewers such as Gøtsche and Olsen will not be silenced about their results, it is argued that science has a ‘subjective’ element. Whilst I agree that the recognition of subjectivity is long overdue, it is of little value to the debate when it is viewed as a pejorative attribute. The issues about screening mammography are complex – we need clear debate where interests are acknowledged and, most importantly, where the interests of individual women are paramount. |
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