Editor's Choice

Breast screening and other fights

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c4096 (Published 29 July 2010) Cite this as: BMJ 2010;341:c4096
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}bmj.com

    The BMJ finds itself in the middle of many spats—academic, clinical, and political. I like to think that’s when the journal is really earning its keep. The BMJ’s rapid responses are its gladiatorial forum; open to all who are willing to engage with the arguments, preferably with references and data, and provided always that they refrain from ad hominem attacks on opponents. Several good clean fights are under way: is the H1N1 vaccine safe in children (www.bmj.com/cgi/eletters/340/jun09_3/c2994) and should homoeopathy be provided on the NHS (www.bmj.com/cgi/eletters/340/jun30_2/c3513), as well as thoughtful discussions on carotid endarterectomy (www.bmj.com/cgi/eletters/341/jul21_1/c3879), assisted suicide (www.bmj.com/cgi/eletters/341/jul20_3/c3943) and Iona Heath’s article on how and when we die (www.bmj.com/cgi/eletters/341/jul21_3/c3883). You can watch or join in.

    Some fights get into the letters pages, where we also now have a Response section for those who have been written about in the journal and want to put their side of the story. But occasionally a fight is just too difficult to compress into a few hundred words. This was the case with breast cancer screening. A BMJ article—one of several published in the past few years by the Danish team led by Peter Gøtzsche—again questioned the benefits of mammography and highlighted the harms from overdiagnosis (BMJ 2010;340:c1241). Supporters of breast cancer screening howled in alarm at the damage this was doing to the uptake of mammography (www.bmj.com/cgi/eletters/340/mar23_1/c1241). The two sides have thrown data across the divide and the BMJ has been accused of taking sides. I think I can speak for all the editors in saying that the BMJ doesn’t take sides on such matters: we look to the evidence. Unable to see sufficient light amidst the heat of this debate, we asked a highly trusted observer of preventive health strategies, Klim McPherson, to take a look and come to a view.

    My reading of his helpful article (doi:10.1136/bmj.c3106) is that those who argue that screening may be almost as harmful as it is beneficial could have a point. “There is no doubt that screening for breast cancer has limited benefit and some possibility of harm for an individual woman and marginal cost effectiveness for a community,” he writes. He calls for a full and dispassionate examination of individual patient data from all recent studies and, in the meantime, much more honesty from the NHS screening programme about the scientific uncertainties. There is also a sense of measured outrage. How could such an important national programme exist for so long with so many unanswered questions? Could it have done so purely on face validity (“early detection must be good”) plus uncertainty fuelled by polarised debate? If so, he says, that would be “irresponsible.”

    Heated discussion is also bubbling around the proposed reorganisation of the NHS and we now have a sizeable collection of related articles, discussion threads, blogs, podcasts, and BMJ learning modules at doc2doc.bmj.com/whitepaper. In the journal we have Martin Roland’s editorial (doi:10.1136/bmj.c3985) and Nigel Hawkes’s commentary (doi:10.1136/bmj.c4035), and we have asked a range of other commentators to share their thoughts (doi:10.1136/bmj.c3977). One of them is John Appleby, who notices that opinions seem unconventionally split, with ex-Labour advisers supporting the proposals and right of centre think tanks opposing them. We would welcome your own views via rapid responses on bmj.com.

    Notes

    Cite this as: BMJ 2010;341:c4096

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