Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Full information gives a clearer picture
- Mitzi AJ Blennerhassett (18 June 2009)
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Surnames and Breast Screening Uptake in a Cohort in Wales
- Diane L Brook (19 June 2009)
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Means of breast and cervical cancer screening are not sufficient
- Souhail Alouini (21 June 2009)
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Breast cancer and cervical screening in South Africa
- Elsabe Bornman (24 June 2009)
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Inequalities in reported use of breast and cervical screening: raising the question of health inequities
- Tremblay Dominique (25 June 2009)
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Evidence of "the arrogance of preventive medicine"
- Hazel Thornton (25 June 2009)
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Mitzi AJ Blennerhassett, medical writer/author, patient advocate home YO62 4AQ
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Collecting women's individual experiences of screening might well also inform policy. What had dissuaded them from (further) attendance? Had they initially felt coerced into attending by the commanding tone and lack of options and information in the invitation letter and booklet? If they did attend, had they later discovered information on disadvantages and risks that had not been given with the invitation to screening? Consequently, had coercion discouraged them from taking part in further screening? Had they experienced unexpectedly high levels of pain? Had they found this unacceptable? Had they been informed beforehand that mammographic compression could be matched to a patient's tolerance, yet still give a useful picture? How did the answers to these questions differ between educated and uneducated women? Competing interests: None declared |
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Diane L Brook, Head of Information, Screeinng Services, Wales Screening Services, 18 Cathedral Road, Cardiff CF11 9LJ
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Breast Test Wales, the NHS breast screening programme in Wales, has audited uptake for breast screening using surnames as a proxy for ethnicity. Surnames were classified by linguistic and cultural origin into British, European or Other surnames. 438,333 closed breast screening episodes for a 4 ½ year period, 2001- mid-2005, were compared for outcome codes. Uptake differed significantly for the groups; British 78.7%, European, 70.1%, Other, 50.2%. These initial results are being refined and prepared for publication. Screening history, numbers of episodes per woman and ever attendance, were examined for the most common surname in each group. Women with the most common British or European surnames attended at least one episode in 74% of cases compared with no more than 69% for women with the most common Other surname. There are a number of limitations as the method is only a proxy for ethnicity. The approach does address the issue of full coverage of the relatively small numbers of women of breast screening age in Wales who are not of British origin. Dr Diane Brook, Head of Information, Screening Services, Velindre NHS Trust Competing interests: None declared |
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Souhail Alouini, Gynaecologist and Obstetrician, M.D., Ph.D. Centre Hospitalier Regional d'Orléans, 45000, France
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Kath Moser et Al. (1) report that 84% of 3185 women interviewed between 2005 and 2007 had mammography and cervical smear for cancer screening. Although these rates of adhesion to methods of screening are high, the means of screening by mammography and cervical smear are not sufficient any more and enough adapted. Indeed, the mammogram fails to screen some asymptomatic cancers (2). The use of breast ultrasonography combined to the mammography is very useful to detect false negatives, in women with breast dense tissue in particular (3). The cervical smear should also be associated with HPV detection to screen women with high risk (HPV +) that should be treated and followed up in a more frequent and prolonged way (4). References 1. Moser K, Patnick J, Beral V. Inequalities in reported use of breast and cervical screening in Great Britain: analysis of cross sectional survey data. BMJ. 2009;338:b2025. 2.0Honjo S, Ando J, Tsukioka T, Morikubo H, Ichimura M, Sunagawa M, Hasegawa T, Watanabe T, Kodama T, Tominaga K, Sasagawa M, Koyama Y. Relative and combined performance of mammography and ultrasonography for breast cancer screening in the general population: a pilot study in Tochigi Prefecture, Japan. Jpn J Clin Oncol. 2007;37:715-20. 3. Houssami N, Lord SJ, Ciatto S.Breast cancer screening: emerging role of new imaging techniques as adjuncts to mammography. Med J Aust. 2009;190:493-7. 4. Naucler P, Ryd W, Törnberg S, Strand A, Wadell G, Elfgren K, Rådberg T, Strander B, Johansson B, Forslund O, Hansson BG, Rylander E, Dillner J. Human papillomavirus and Papanicolaou tests to screen for cervical cancer. N Engl J Med. 2007;357:1589-97. Competing interests: None declared |
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Elsabe Bornman, SeniorLecturer School of Nursing Science, North West University, Potchefstroom, South Africa. 2520
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Dear Editor Following their study on inequalities in the reported use of breast and cervical screening in Great Britain the authors conclude that additional sociodemographic information would aid the monitoring of inequalities in screening coverage and information policies to correct them. This statement prompted me to write this short commentary about breast and cervical screening in South Africa and the influence of sociodemographics on this screening. In rural South Africa where resources are limited, it is only patients with detected abnormalities of the breasts that are referred for mammograms in the public sector. In the private sector patients with medical insurance are allowed one screening per year and only if referred by a medical practitioner. Because of this the health education given by health workers on self examination of the breast is therefore very important for all patients visiting public health facilities. In comparison to the survey done in Brittan, a survey done in South Africa on how many private patients get any information or screening on breast self examination on an ad hoc basis may show a reverse of the data found in Britain, as it is not routinely done as in the public sector. With regard to the survey done in the UK it might be interesting to know how many women do self examination and what the inequalities are in this regard. According to research a public breast cancer screening prevention program do not exist in South Africa, even though the practice is embraced by the country’s health system. With regard to cervical smears, in the public sector in South Africa, cervical screening is done with 3% to 5% acetic acid (VIA) and visual inspection, in the clinic by the primary health care nurse and referred if abnormalities are found. In the private sector pap smears are routinely done, usually during a yearly visit to the gynaecologist. This visit is again voluntary although some gynaecologists’ offices send out notices to remind patients. Despite this, research done in this regard shows that only 2% of women in South Africa are annually screened and that there was a high prevalence of abnormal cervical smears in young sexually active women co-infected with HIV in rural Kwa Zulu Natal. The implication of these findings, as in the case of the survey done in Brittan, will have to be taken into consideration by the health policy makers. Yours sincerely
Competing interests: None declared |
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Tremblay Dominique, Postdoctoral Fellow_Health Services Research University of Ottawa
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Moser et al (2009) have investigated the relationship between women’s reported use of breast and cervical screening and their individual and household sociodemographic characteristics. Doing this, the authors certainly contributed to the evidence base on inequalities in cancer screening. One of their results shows that only ethnicity was a significant predictor of ever having had a cervical smear after adjusting for age and socio-demographic factors (P=0.0005). More specifically, white British women were more likely to report ever having had a cervical smear OR 2.20 (95% CI: 1.41 to 3.42) than women of other ethnicities. This result is particularly troubling illustrating a hidden unfair and unjust access to health services associated to ethnic origin. This is not only about the distribution of health and how personal health services are allocated but in fact, a question of health equity embedded in social justice considerations. According to Margaret Whitehead, health inequity refers not only to inequalities that are unnecessary and avoidable 1. It must be seen as unjust, as it is the case for unequal access to health services associated with ethnic origin. According to Whitehead, the equality in available access for equal need and the equality of utilization for equal need relating to the adequate distribution of existing health resources among individuals who needs them are related to equity. This perspective on equity is particularly relevant for cancer services knowing that this disease affects the whole person life, the life of the relatives and compromise the health care systems capacity to meet person needs at the individual and the population level. Inequities contribute to the burden of the disease for individual and contribute in part to health system failure to actualise his mission. Moreover, the lower access to screening for ethnic group could be only the tip of the iceberg of the unequal and unfair access to cancer treatments and end of life care or to general health services. Researchers should not only focus on sociodemographic characteristics of potential service users but also investigate characteristics of health services and policies that may contribute to inequities for specific groups. Looking beyond of a purely mathematical sense, the results of this study call policy makers to reconsider government priorities as outlined in the Cancer Reform Strategy (2007), and to shift from an emphasis on tackling inequalities to a focus on inequities. This is a requirement to reduce avoidable gaps in health status and health service usage between groups with different levels of social privilege, as reflected in ethnic, religious, socio-economic, gender, geographical location, and age differences. Reference: 1. Whitehead M. The Concept and Principles of Equity and Health. International Journal of Health Services 1992; 22:429-445. Competing interests: None declared |
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Hazel Thornton, Honorary Visiting Fellow, Department of Health Sciences, University of Leicester "Saionara", 31 Regent Street, Rowhedge, Colchester, CO5 7EA
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The article by Moser, Patnick and Beral [1] is behind the times: the case for population breast screening has been challenged [2] by reference to robust evidence from a Cochrane Systematic Review. [3] The rapid response by Souhail Alouine goes to the nub of the matter: “the means of screening by mammography and cervical smear are not sufficient any more.” Elsabe Bowman`s rapid response from South Africa emphasised the importance of health education being given by health workers about breast self-examination. Yet the Cochrane systematic review of the evidence [4] shows that this means of early detection cannot be recommended. Iona Heath suggests “we need to remember Dave Sackett`s description of the arrogance of preventive medicine” that pursues “symptomless individuals telling them what they must do to remain healthy”. [5] Why do proponents of early detection of breast cancer by mammography screening, and by breast self-examination, choose to disregard robust evidence that the harms of these interventions are greater than the benefits? And, to quote Iona Heath again: “The unforgivable feature of this leaflet [Breast Screening: The Facts] is that, despite protests and promises of improvement, it still emphasises only the benefits of screening and makes no mention of the possible harms.” [1] Kath Moser, Julietta Patnick, Valerie Beral. Inequalities in reported use of breast and cervical screening in Great Britain: analysis of cross sectional survey data. BMJ 2009; 338:b2025 [2] Baum M, McCartney M, Thornton H, Bewley, S, Pharoah P, et al. Breast Cancer Screening Peril. Negative consequences of the breast screening programme. The Times. 19th February 2009. page 31. http://www.timesonline.co.uk/tol/comment/letters/article5761650.ece?print=yes&randnum=1235056456247 [3] Goetzsche PC, Nielsen M. Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews. 2006; (4):CD001877 [4] Kösters JP, Gøtzsche PC. Regular self-examination or clinical examination for early detection of breast cancer. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD003373. DOI: 10.1002/14651858.CD003373 (No change, Update, Issue 3, July 2008) [5] Iona Heath. It is not wrong to say no. Why are women told only the benefits of breast screening and none of the possible harms? BMJ 2009;338:b2529 Competing interests: None declared |
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