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Should we use total mortality rather than cancer specific mortality to judge cancer screening programmes? Yes

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d6395 (Published 13 October 2011) Cite this as: BMJ 2011;343:d6395
  1. James Penston, consultant physician
  1. 1Scunthorpe General Hospital, Scunthorpe DN15 7BH, UK
  1. james.penston{at}nhs.net

James Penston believes all cause mortality is a more reliable measure of the effectiveness of screening, but Robert Steele and David Brewster (doi:10.1136/bmj.d6397) think it is too stringent

Cancer screening is a source of much dispute—in the case of breast cancer, arguments have raged for more than a decade.1 One major concern is how the effects are to be measured. Disease specific mortality is used extensively in trials of cancer screening,2 3and as the aim of screening is to reduce deaths from the target disease,2 4 this might seem to be a suitable end point. But the arguments against using disease specific mortality weigh heavily, and all cause mortality is a better measure.

Uncertainties relating to cause of death

Clearly, the accuracy of disease specific mortality depends on correctly identifying the cause of death. However, this is often unreliable,2 and it entails decisions that can introduce biases, either for or against screening.2 3 Claims that bias favouring screening predominates have been disputed.2 4 Nevertheless, one thing is sure: the accuracy of all cause mortality depends solely on the number of deaths identified and …

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