And Women Over 70, over 80? 12 October 2007
Joseph More, Retired Retired Send response to journal: Re: And Women Over 70, over 80?	Is there an age beyond which one should no longer have screening mammography, or colonoscopy? It seems that few studies are being conducted on the benefit or otherwise of screening for cancer in older people. I guess that this is due to fear of being labeled an "ageist". It would seem that there is no benefit in very early detection of a cancer that, on average, would take a significant number of years years to become clinically manifest, in a person whose life expectancy is shorter that. But I have not been able to find any data on this question. Competing interests: None declared
False positives donīt result in overdiagnosis 13 October 2007
Christian Weymayr, medical journalist, author of Mythos Krebsvorsorge 44623 Herne, Germany Send response to journal: Re: False positives donīt result in overdiagnosis	Sir, I loved to read the editorial by Schwartz and Woloshin. But one thing is not quite correct, I think: In the table one can find the sentence "Patient has at least one false positive screening examination that results in unnecessary diagnosis and treatment for breast cancer". Overdiagnosis results from in situ- cancer and invasive cancer, that means they result not from false but from true positives. This differentiation is important because even cancer experts sometimes regard false positives and overdiagnosis as the same. Competing interests: None declared
Additional harms/benefits of screening 15 October 2007
Anne Peticolas, Information Analyst Trainee University of Texas 78705 Send response to journal: Re: Additional harms/benefits of screening	I really liked this article, and would add that false positives and overtreatment are not the only important harms that play a part in my personal decisions about mammography. On the minus side of screening is that (were I to live with or die from the cancer anyhow) screening might discover the cancer several years earlier. That would lengthen years of my life lived knowing I had cancer and dealing with that knowledge and with cancer treatment and its side-effects. Since I personally do not value a year where I have to deal with cancer and its treatments the same as years where I do not, this matters to me. If the result is the same, I would in general much prefer to find a cancer later. On the other side of the ledger, finding a cancer earlier could conceivably result in less extensive and aggressive treatment, even if the result with respect to living/dying was the same. That would matter and would definitely be a screening benefit. It is hard to factor this in though, since I don’t know enough to even approximately guess the magnitude of this potential benefit. email: petico@austin.rr.com Competing interests: None declared
Correction & acknowledgments 15 October 2007
Steven Woloshin, author VA Outcomes Group (111B), 215 N. Main Street, White River Junction, VT 05009, USA, Lisa Schwartz Send response to journal: Re: Correction & acknowledgments	Christian Weymayr is right. Due to an editing error, the text in the last row of the table is incorrect. The entry should read "Receive an unnecessary diagnosis and treatment for breast cancer". Overdiagnosis is completely distinct phenomenon from false positives. Overdiagnosis refers to pathological "true positives" which are not destined to become clinically important. False positives are resolved with subsequent testing (because they are never cancer pathologically). The BMJ is in the process of posting a corrected version. We would also like to express our gratitude to Barnett Kramer, MD, MPH, William Black, MD and H. Gilbert Welch, MD, MPH for thoughtful comments on an earlier draft. Competing interests: None declared
Patient decision aid is available 15 October 2007
Andrew Hutchinson, Acting Education and Development Manager, National Prescribing Centre L69 3GF Send response to journal: Re: Patient decision aid is available	Drs Schwartz and Woloshin conclude their editorial by saying "Rather than telling women what they should do, policy makers should encourage women to make a decision that is right for them". We hope that readers will find the patient decision aid available on the Breast Cancer floor of NPCi (www.npci.org.uk) helpful when discussing the pros and cons of screening (see http://www.npci.org.uk/therapeutics/therap/breast/patient_decision_aids/patient_decision_aid1.php). This should, of course, be used in conjunction with the leaflet "Breast Screening - the facts" produced by the NHS Breast Screening Programme. Other resources relating to breast cancer are also available on this floor of NPCi. The NPCi site is still under development and we welcome feedback and comments on any of the content or, indeed, the NPCi concept. A feedback link is located at the bottom left hand corner of every room. Competing interests: Commissioned by NPC from employing PCT
Breast Screening and Choice of participation 16 October 2007
MOHAMMED S ABSAR, Specialist Registrar in Breast Surgery North west of England,OL2 5DQ. Send response to journal: Re: Breast Screening and Choice of participation	The article by Lisa Schwartz and Steven Woloshin is very well written.The discussion about screening younger women has been going on for time since the publication of the trials showing benefit in younger women. There is a higher recall rate in women in the younger age group when compared to women over 50 because of the denser breast tissue,lower sensitivity of mammogram and difficulty in interpretation.NICE ( National Institute of Clinical Excelence ) recently issued guidlines for screening high risk patients in which MRI(Magnetic Resonance imaging) takes a leading role for the same reasons.But MRI does not come without it's own problem with a higher recall and biopsies rate.Till we have a better diagnostic modality for this group with high sensitivity and specificity it seems reasonable to give women an informed choice to enable them to avail the benefit fully understanding the drawbacks. The recommendation of the American college of Physician is laudable in giving patients the rights they deserve.The discussion will go on and Dr Schwart and Dr Woloshin have aptly presented both sides of the coin. Competing interests: None declared
At last 19 October 2007
Michael Baum, Professor of Surgery University College Hospital University College London Send response to journal: Re: At last	I was delighted to read the editorial by Lisa M Schwartz and Steven Woloshin concerning informed consent for mammographic screening. A little over 10 years ago I resigned from the NHS breast screening committee over the ethical issue of coercion versus consent for screening and went public with my concerns. [1] Since then I've been fighting a pretty lonely battle for the improvement in the quality of information contained in the invitations from the NHSBSP for screening.[2,3]I now would like to challenge the managers of the NHSBSP to include the harm/benefit table published by Schwartz and Woloshin in future leaflets that accompany their invitations. It would be patronizing in the extreme to deny women this information and if substantial numbers make the rational decision not to accept screening, after weighing up all the pros and cons; so be it. [1]Baum M Screening for breast cancer, time to think--and stop? Lancet. 1995 Aug 12; 346(8972): 436-7; [2] Baum M. Commentary: false premises, false promises and false positives --the case against mammographic screening for breast cancer. Int J Epidemiol. 2004 Feb;33(1):66-7 [3] Baum M. Ramifications of screening for breast cancer: consent for screening. BMJ. 2006 Mar 25;332(7543):728 Competing interests: None declared
Consenting adults 26 October 2007
John Doherty, Medical Director IAEA, Vienna, Austria 1400 Send response to journal: Re: Consenting adults	Consent for screening is only valid if it based on understanding. Women deserve to be fully informed and not misled [1]. In addition to the harm/benefit table of Schwartz and Woloshin [2] women should be given an explanation of slippery-linkage bias: a reduction in breast cancer mortality does not equate to a reduction in all-cause mortality [3]. The current reluctance to give adequate information prior to screening [4] will be swiftly reversed should an aggrieved woman take succesful legal action against those responsible. John Doherty [1] Baines CJ. Mammography screening: are women really giving informed consent? J Natl Cancer Inst 2003;95:1508-1511. [2] Schwartz LM Woloshin S. Participation in mammography screening. BMJ 2007; 335: 731-732 [3]Black WC Haggstrom DA Welch HG All-cause mortality in randomized trials of cancer. J Natl Cancer Inst 2002;94:167-173. [4] Jorgensen KJ Gotzche PC content of invitations for publicly funded screening mammography. 2006 BMJ 332; 538-541. Competing interests: None declared
FNACor Core Needle biopsy is still the best choice for early dignosis of breast cancer in West Bengal than Mamography as it is cheap, reproducible Early dignosis and of high sensitivity,specificity 28 October 2007
Professor Pranab kumar Bhattacharya, professor pathology, incharge unit, cytogenetics, Blood bank &VCTC, Ex _incharge Malaria Clinic Institute of pOst graduate Medical Education &Research,244A AJC Bose Road, kOlkata-20, W.B, India, Roy Chaudhuri supriyo MD(PGT) Patho, Saha Sandip MD(PGT) Patho,BHattacharya Rupak BSc(cal) Msc(JU), Sarkar Diptendra MS(Cutttack) DNB Send response to journal: Re: FNACor Core Needle biopsy is still the best choice for early dignosis of breast cancer in West Bengal than Mamography as it is cheap, reproducible Early dignosis and of high sensitivity,specificity	Among Female breast diseases neoplastic disease is the most common ,producing Latest estimates suggest that more than 1,050,000 new breast cancer occur world wide annually with nearly 580,000 cases occurring in the developed countries and reminder in developing countries. Autopsy shows that 20% of asymptomatic women have visible breast disease & statistics in the West Bengal state of India says that 23 in 1 lack women develops the breast cancer per year. . In US each year approximately 100,000 new cases are diagnosed & approximately 30,000 patients die of the disease. The incidence of breast carcinoma in Europe & USA is very high ; 91.4 new cases per 1lack women per year & comparatively lower in Asian & African countries. In India too, breast carcinoma is on rise, especially in metropolitan cities and in affluent class socities. It is now the commonest cancer in Mumbai (annual incidence rate -29) & in Delhi (annual incidence rate 28) . In West Bengal incidence of breast cancer is 20% in age group of 35-39 years age followed by 12% In 40-44 years and12% in65-69 years age as it is shown in our study in 1 year period. In a study at IPGMER, by the authors in Kolkata with 108 patients in a year, in pre menopausal(14%) period lactation for 6 months 46 patients and non lactating 8 patients and in post menopausal(29%) period lactation more than 6 months 38 patients and non lactating16 patients were found by us which indicate that lactation and parity is insignificant and is important above the age of 50 years. The family history of breast cancer was found in 3 patients/108(2.5%) only , when in western countries incidence rate is5-10% In view of high proportion of malignancy in higher age groups & also sporadic occurrence in young women, a palpable lump is a common diagnostic problem to both the GP & the surgeon. So attentions are now focused on the earlier diagnosis of breast cancers. Other diseases like fibroadenomas & fibroadenosis are extremely common & affect up to 5% of the general population of West Bengal, presenting as breast lump or as diffuse nodularity. Other conditions as Phylloides tumors, Lactating adenomas, Galactoceles, cysts, Duct papillomas too occur commonly in breast in West Bengal, India as we pathologists do find in both histopathology and in FNAC All over the globe, in addition to detailed clinical examination, self palpation , FNAC, histopathology, immunohistochemistry, gene analysis ( Her2Neu,BrcA1&BRCA2 )are being increasingly used to diagnose different breast conditions. However in West Bengal state, MRI, mammography ,gene analysis is not yet a routine investigation even in tertiary standard public/teaching hospital set up, as these are costly and patients can not often provide it. However mammography is done at very few private set up along with FNAC. More over sensitivity of mammography in kolkata is 67% and mammography is considered as an inferior tool for diagnosis in mass population ,mammography requires waiting lists also for a long period also in referred cases and delays diagnosis of breast cancers. More over breast cancer screening trial of mammography showed that mortality can be reduced by 25%-30%. As such FNAC or core needle biopsy is holding a very important position in the diagnosis of various breast diseases and is cost effective, early, in West Bengal tertiary level teaching institutes and also in private laboratories of metropolis. The average sensitivity of this procedure is 85%, specificity close to 100%, the predictive value for a positive diagnosis is also nearly 100%, and the negative predictive value is about 60-90%.FNAC is found to be readily acceptable to all in general population, can be repeated & is an OPD procedure. The process is cheap, reproducible and reports are readily available (we in our institute give report by two days time [with MGG stain, PAP,&HE stain] so that further treatment can be planned early. In benign conditions unnecessary surgery can be avoided by virtue of FNAC. Stage of diagnosis of breast cancer in Kolkata Most of the carcinoma of breast present at advanced stage 72% PITFALLS IN THE DIAGNOSIS OF MALIGNANT BREAST LUMPS WE AUTHORS Often FACED in FNAC A benign pattern may be caused by a dominant benign lesion in the vicinity of a carcinoma or may represent normal benign tissue adjacent to a small carcinoma. So proper sampling during FNAC is extremely important. Smears from small cell infiltrating carcinomas with a desmoplastic stroma may show a dominant benign pattern. Then careful search under high power only shows occasional cells with obvious malignant features. Very fibrous a cellular lesions like scirrhous carcinomas, sclerosing adenosis etc may not yield cells even on repeated aspirations. Excision biopsy should be advised in these cases. Tubular carcinomas mimic benign epithelial hyperplasia with mild atypia.. It is very difficult to distinguish between well differentiated papillary carcinoma & intraduct papillomas. Nuclear enlargement & pleomorphism, poor cell cohesion, necrosis favor malignancy. Cytology cannot tell if a well differentiated papillary carcinoma is invasive or non invasive. Benign breast disease is also an important risk factor for a later breast cancer which can develop in either breast. It comprises of spectrum of histological entities usually subdivided into non proliferative lesions, proliferative lesions without atypical and atypical hyperplasia with an increased risk of breast cancer associated with proliferative or atypical lesions. Important question remain however to be solved about the degree of risk associated with common non proliferative benign entities and extent to which family history influences the risk of breast cancer in women with proliferative or atypical lesions. Another important factor is over diagnosis by histopathologists in Kolkata metropolis for giving a histological diagnosis as” Ductal carcinoma in Situ” particularly when radiologists report of micro- calcification in mammography is associated. It is classified here as commedo and non commedo type. As a result there remains chance of Over treatment, the authors feels. One should know that the diagnosis never tells a precursor lesion of breast carcinoma but it is associated with increased risk for future development of breast cancer. A separate breast unit should help the public sectors hospitals in west Bengal to diagnose breast cancers by FNAC , histopathology, immunohistochemistry, gene analysis and treatment and health dept. of govt. of West Bengal should think over it seriously where the general physicians can directly refer the suspected cases for FNAC diagnosis at very low cost and have treatment by 2weeks time Authors_:1) Professor Pranab Kumar Bhattacharya MD(cal) Path, FICpath(Ind) Professor of Pathology, INcharge of Unit, Incharge of Blood Bank&VCTC, Cytogenetics Institute of Post Graduate Medical Education &research 244A AJC Bose Road, KOlkata-20, West Bengal, India Email-profpkb@yahoo.co.in 2) DR. Supriyo Roychoudhury MBBS(cal) MD(PGT) Post graduate Trainee, Dept. of Pathology Institute of Post Graduate Medical Education &research 244A AJC Bose Road, KOlkata-20, West Bengal, India 3) Mr. Rupak Bhattacharya BSC(cal) MSC(JU) 7/51 purbapalli, PO=Sodepur, Dist-24 parganas (N) Kolkata-110 E.mail- pranab@unipathos.com 4)Dr. Diptenddra Sarkar Ms(cal) DNB FRCS(eng) Asst. Professor, Dept of Surgery Institute of Post Graduate Medical Education &research 244A AJC Bose Road, KOlkata-20, West Bengal, India Email-dipendrasarkar@yahoo.co.in Competing interests: None declared