When it’s worth repeatingBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2973 (Published 22 July 2009) Cite this as: BMJ 2009;339:b2973
- Des Spence, general practitioner, Glasgow
I have a get rich quick idea. Sack all the writers and editorial staff of a typical men’s or women’s magazine, for they just recycle the same old content every year. Then just add a new glossy cover each month, keep up the advertisements, and recycle old fashion photos from the past 20 years to pass off as “new” retro fashion. (Obviously, keep the explicit problem pages, as these form a highly effective sexual abstinence programme for young teenagers who foolishly decide to read them.) Genius! A profitable magazine with no overheads. Even the BMJ recycles ideas and stories—but some ideas are worth repeating, one such being the harms of screening.
The emotional and very public death of Jade Goody saw a widespread demand for yet more and earlier cervical screening, despite the fact that 1000 women must be screened for 35 years to prevent one death and that the lifetime risk of overdiagnosis after a positive smear test result is 40%. Recent research questions the benefit of mammography screening for breast cancer (BMJ 2009;339:b2587, doi:10.1136/bmj.b2587). But have such findings made the debate any more reasoned? Regrettably, no. Blogs and the BBC websites are still full of emotive statements, such as “Screening saved my mum,” and, “It’s worth it whatever the cost,” all aggressively defending screening. In the public psyche there is an unshakeable belief that screening is a good thing. But many doctors, myself included, are sceptical of the absolute benefit of screening; the simplicity of the claim that “early diagnosis” saves lives is too seductive and open to confounding to be wholly true.
We need to examine the facts. The BMJ study indicates that a third of women have been told they have breast cancer when they don’t have a progressive disease. Women are enduring unnecessary chemotherapy, radiotherapy, lumpectomy, or mastectomy. These are not some vague psychological scars of screening. Also, many members of the public and indeed of the profession equate “screening” with surviving “early” cancer but understand that screened patients die too. In the United Kingdom there has been a headline grabbing 40% fall in the number of deaths from breast cancer since screening was introduced in 1988, but in all the debates the proponents of screening have been selective with the facts. For there has also been a near identical reduction in the number of deaths in the younger, unscreened population, which the screening lobby must explain to make screening credible.
Tear stained reasoning should not blind us to the fact that screening for skin, breast, cervical, and prostate cancer (not to mention screening for high cholesterol, hypertension, or osteoporosis) generates overdiagnosis, overtreatment, and health anxiety. Doctors are complicit in the theft of society’s most precious possession of all: a sense of wellbeing. So, let’s repeat: screening, whatever its benefits, also causes widespread, real, and lasting harm.
Cite this as: BMJ 2009;339:b2973
See also Iona Heath on breast cancer screening, “It is not wrong to say no,” BMJ 2009;338:b2529, doi:10.1136/bmj.b2529.