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Should we use total mortality rather than cancer specific mortality to judge cancer screening programmes? No

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d6397 (Published 13 October 2011) Cite this as: BMJ 2011;343:d6397
  1. Robert J C Steele, clinical director 1,
  2. David H Brewster, director2
  1. 1Scottish Bowel Screening Programme
  2. 2Scottish Cancer Registry, Edinburgh, UK
  1. Correspondence to: R J C Steele, Surgery and Molecular Oncology, Ninewells Hospital and Medical School Dundee, Dundee DD1 9SY, UK r.j.c.steele{at}dundee.ac.uk

James Penston (doi:10.1136/bmj.d6395) believes all cause mortality is a more reliable measure of the effectiveness of screening, but Robert Steele and David Brewster think it is too stringent

All medical interventions have the potential to cause harm. This is particularly important in the case of cancer screening because the intervention is offered to people who are, or at least believe themselves to be, in good health, and the tolerance limit of harm must accordingly be low.

Screening may cause harm in several ways.1 If the screening test is not highly sensitive, false negative results may induce reassurance and create a “certificate of health effect.” In other words, people who have received a false negative test result may ignore symptoms or continue to engage in risky behaviour. Then the test itself can cause harm—for example, colonoscopy as a consequence of colorectal screening may lead to colonic perforation or other complications, and this must be monitored. Given that most people who are screened will not have disease, unnecessary psychological morbidity may also be created. Finally, screening inevitably leads to a degree of overdiagnosis —that is, people will be found to have disease that …

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