Britain's breast cancer services need overhaulBMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.6999.211a (Published 22 July 1995) Cite this as: BMJ 1995;311:211
Britain's mortality from breast cancer--one of the highest in the world--could be due to poor treatment, says a report from the government's health committee. The committee makes 42 recommendations for improving services for breast cancer, one of which is that the Department of Health should commission research into why Britain is near the bottom of the league for survival rates. The report also recommends that screening should be extended from 65 years of age to 69. It says that screening should be offered more often than every three years if research currently being carried out shows this is effective.
Britain does not have a particularly high incidence of breast cancer, but in 1992 there were nearly 40 deaths from breast cancer per 100 000 population, compared with the US rate of 34 deaths. The US has an incidence of 89 cases per 100 000 compared with Britain's rate of 56. While the committee accepts that differences may exist in the way countries collect data on the disease and that breast cancer in Britain may be more aggressive, it cites research that shows huge variations in the management of the condition even within one region.
A report by the Yorkshire Cancer Organisation said that the proportion of patients being given radiotherapy varied among hospitals from 20% to 60% and for chemotherapy from 25% to 40%. The committee says that while differences in staging and aggressiveness of the disease could play a part, “It is more likely that these variations in treatment indicate that…chemotherapy and radiotherapy are underused in some cases.” The committee heard evidence that 4000 women die each year because they are not being given treatment that is known to be effective. It recommends that data on survival rates and use of adjuvant treatment and surgical procedures should be published nationally so that the effect of specialist breast cancer centres on survival rates can be evaluated.
These centres should be multidisciplinary and probably see at least 50 new patients with breast cancer a year. The committee says that women want a one stop service and that all services for breast cancer, including screening, could be greatly improved by being integrated into these centres. In the meantime purchasers should start transferring contracts to hospitals which have a high volume of breast cancer work.
The committee supports the government's decision not to change its screening policy until it has results from a trial on the effectiveness of reducing the screening interval. But it does recommend that women up to 69 years of age should be part of the programme and that older women should be made aware of their right to a mammogram every three years on request. It took into account advice from the charity Age Concern that the disease was no less aggressive in older women and that diagnosing breast cancer earlier could mean that women would undergo less radical treatment.
The quality assurance programme is congratulated as “one of the great strengths” of the breast screening programme, but the committee is critical of other aspects of the scheme. In particular, it says that the early recall of women with ambiguous mammograms is not a humane policy. Women can be told they may have an abnormality but be made to wait several months for a repeat mammogram. The committee recommends that the programme should develop ways of giving a firm diagnosis, perhaps by getting a second opinion on the original mammogram or by offering a biopsy.
Earlier the better
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