Ramifications of screening for breast cancer: Consent for screening

EDITOR—In 1987, while I was professor of surgery at King's College London, I was given the task of establishing the first mammographic screening unit in southeast England. This followed the findings of the Forrest committee that were announced by Margaret Thatcher two weeks before a general election. My colleagues from the radiology department and I took great pride in setting up a purpose built unit at Camberwell Green, and within a year of receiving our instructions we were up and running and serving as the training unit for the south east of England. I was then appointed to the national steering committee of the NHS breast screening programme.

Working at the “sharp end” provided me with a somewhat different perspective to the epidemiologists, managers, and other servants of the state who served alongside me. I soon learnt first hand of the “toxic side effects” of the process and became increasingly disturbed by the failure of true informed consent among the innocent women who accepted the summons to the screening centre. I am also quite numerate and happened to be running the first national clinical trials unit in my spare time as well. It did not take me long to work out that the 25% relative risk reduction in breast cancer mortality headlined in the invitations could be framed in another way that described the absolute benefits (number needed to screen over 10 years to save one death from breast cancer 1000).1

I soon became a thorn in the side of the programme's committee, and things came to a head in 1997 when I found myself in a minority of one in demanding that the information leaflets expressed benefits in absolute numbers and described harms in an open and fair way. The concern of the committee at that time was that such information would deter women from attending and the target of > 70% acceptance, on which the programme was predicated, would be missed. This perfectly illustrates the conflict of interest that Jørgensen and Gøtzsche describe.2 At this point I did the honourable thing and resigned from the committee. As a surgeon I have a legal and ethical commitment to describe to my patients the harms and the benefits of my interventions, but a double standard clearly exists among the screening community, who seem to be in denial. Well, at least they can't deny the problem of over-diagnosis that was finally confirmed by irrefutable evidence in the online BMJ publication of the Malmö trial follow-up.3

Credit: ISOPRESS/SENEPART/REX