Re: Harms from breast cancer screening outweigh benefits if death caused by treatment is included
Breast cancer screening has been rolled out in Ireland. The newer digital mammogram machine has replaced older screen film mammogram facilities.
The introduction of digital mammography screening has been accompanied by an increase in the incidence of breast cancer. The following is information from the National Cancer Register of Ireland. The initial Irish publication in the American Journal of Radiology involved a comparison between digital and screen film mammography. This demonstrated a statistically significant increase in the incidence of breast cancer when digital equipment was utilised. The increase in detection rate in first round screening was followed by a statistically significant increase in second and all subsequent screenings. These observations would indicate an increase in incidence in breast cancer with this new equipment.
Interval tumours are a feature of screening programmes. It is always very disconcerting to witness a breast mass following a clear breast screening. The National Cancer Register states; “The proportionate incidence of interval cancer was 27% in the first year after screening, rising to 48% in the second year. Table presents interval cancer detection rates from the Irish screening programme in comparison with those in neighbouring countries for which published estimates exist. In the first year after screening, the incidence of interval cancers in Ireland was highest (7.5/10,000 woman years) of the countries listed” It is noteworthy that Ireland was the first country to my knowledge to convert almost entirely to digital mammography.
There are numerous epidemiological analyses which demonstrate an increase in breast cancer diagnosis following screening. The published data in the National Cancer Register for Ireland also shows that the converse applies. The Eastern European countries which have not as yet introduced screening are those with the lowest incidence of breast cancer.
Digital mammography involves a reduced radiation exposure, but increase in compression. The increase in Stage 4 cancers following such compression might logically be anticipated. It would never make sound scientific sense to compress a soft tumour. Compression might thus reasonably be expected to cause an increase in metastatic disease. This anticipated outcome is realised with an increase of 5)% in incidence of metastatic disease over the ten year interval. Could this compression also account for the demonstrated increase in interval tumours which we have documented in Ireland? It is noteworthy in this regard that these interval tumours tend to be larger, more ill-defined and more aggressive than those detected on screening.
Failure to ameliorate the incidence of Stage 4 cancer with screening, and to watch it remain as a constant 7% of an exponentially increasing incidence, is perhaps the most disconcerting feature of the entire program. The hypothesis that early detection from screening improves life expectancy for women is now shown to be a complete fallacy. Any morbidity and mortality improvement in the Irish cohort must be attributed solely to improved therapies and protocols.
The effects of screening mammography on the health and well-being of Irish women are now evident. The cancer clinics are over-crowded. The workforce has had to cope with debilitating illnesses of women age 50 – 64 years. The National Cancer Register confirms what is clearly visible on the ground. It confirms that the increase in breast cancer incidence is not confined to Stage 1 tumours, but extends to all grades of breast cancer.
The evidence from Ireland would suggest that a Safety Statement is mandatory at this point in time.
A manufacturers Safety Statement should be a prerequisite for use of any equipment. Review of the pathology on which the diagnosis was confirmed might also be indicated. The wisdom of including digital mammography as a diagnostic tool in symptomatic patients with soft lumps would also be questioned.
Yours Sincerely,
Bridget O’Brien
References:
1. Comparison of Digital Mammography and Screen-Film Mammography in Breast Cancer Screening: A Review of the Irish Breast Screening Program. Hambly N et al, AJR 2009 1010 – 1016
2. National Cancer Registry of Ireland Breast Cancer Incidence, Mortality, Treatment and Survival in Ireland:1994 – 2009
3. Effect of Three Decades of Screening on Breast Cancer Incidence Bleyer A t al N EngJ Med 2012;367:1998 2005
Rapid Response:
Re: Harms from breast cancer screening outweigh benefits if death caused by treatment is included
Breast cancer screening has been rolled out in Ireland. The newer digital mammogram machine has replaced older screen film mammogram facilities.
The introduction of digital mammography screening has been accompanied by an increase in the incidence of breast cancer. The following is information from the National Cancer Register of Ireland. The initial Irish publication in the American Journal of Radiology involved a comparison between digital and screen film mammography. This demonstrated a statistically significant increase in the incidence of breast cancer when digital equipment was utilised. The increase in detection rate in first round screening was followed by a statistically significant increase in second and all subsequent screenings. These observations would indicate an increase in incidence in breast cancer with this new equipment.
Interval tumours are a feature of screening programmes. It is always very disconcerting to witness a breast mass following a clear breast screening. The National Cancer Register states; “The proportionate incidence of interval cancer was 27% in the first year after screening, rising to 48% in the second year. Table presents interval cancer detection rates from the Irish screening programme in comparison with those in neighbouring countries for which published estimates exist. In the first year after screening, the incidence of interval cancers in Ireland was highest (7.5/10,000 woman years) of the countries listed” It is noteworthy that Ireland was the first country to my knowledge to convert almost entirely to digital mammography.
There are numerous epidemiological analyses which demonstrate an increase in breast cancer diagnosis following screening. The published data in the National Cancer Register for Ireland also shows that the converse applies. The Eastern European countries which have not as yet introduced screening are those with the lowest incidence of breast cancer.
Digital mammography involves a reduced radiation exposure, but increase in compression. The increase in Stage 4 cancers following such compression might logically be anticipated. It would never make sound scientific sense to compress a soft tumour. Compression might thus reasonably be expected to cause an increase in metastatic disease. This anticipated outcome is realised with an increase of 5)% in incidence of metastatic disease over the ten year interval. Could this compression also account for the demonstrated increase in interval tumours which we have documented in Ireland? It is noteworthy in this regard that these interval tumours tend to be larger, more ill-defined and more aggressive than those detected on screening.
Failure to ameliorate the incidence of Stage 4 cancer with screening, and to watch it remain as a constant 7% of an exponentially increasing incidence, is perhaps the most disconcerting feature of the entire program. The hypothesis that early detection from screening improves life expectancy for women is now shown to be a complete fallacy. Any morbidity and mortality improvement in the Irish cohort must be attributed solely to improved therapies and protocols.
The effects of screening mammography on the health and well-being of Irish women are now evident. The cancer clinics are over-crowded. The workforce has had to cope with debilitating illnesses of women age 50 – 64 years. The National Cancer Register confirms what is clearly visible on the ground. It confirms that the increase in breast cancer incidence is not confined to Stage 1 tumours, but extends to all grades of breast cancer.
The evidence from Ireland would suggest that a Safety Statement is mandatory at this point in time.
A manufacturers Safety Statement should be a prerequisite for use of any equipment. Review of the pathology on which the diagnosis was confirmed might also be indicated. The wisdom of including digital mammography as a diagnostic tool in symptomatic patients with soft lumps would also be questioned.
Yours Sincerely,
Bridget O’Brien
References:
1. Comparison of Digital Mammography and Screen-Film Mammography in Breast Cancer Screening: A Review of the Irish Breast Screening Program. Hambly N et al, AJR 2009 1010 – 1016
2. National Cancer Registry of Ireland Breast Cancer Incidence, Mortality, Treatment and Survival in Ireland:1994 – 2009
3. Effect of Three Decades of Screening on Breast Cancer Incidence Bleyer A t al N EngJ Med 2012;367:1998 2005
Competing interests: none