Views & Reviews Personal View

Harms from breast cancer screening outweigh benefits if death caused by treatment is included

BMJ 2013; 346 doi: (Published 23 January 2013) Cite this as: BMJ 2013;346:f385

Re: Harms from breast cancer screening outweigh benefits if death caused by treatment is included

Informed Choice about Cancer Screening is currently preparing new information leaflets. From their website it can be seen they are basing the information on the Marmot review. They are following “recommendations” from the ill-conceived Citizen’s Jury held in November – this was a group of screening-eligible women briefed by witnesses basing their presentations on the review findings.

The Marmot review is not definitive. Experts continue to disagree about critically important factors, including whether anybody lives longer because of screening, whether screening leads to deaths from other causes and how many are overdiagnosed.

To tell women only of the Marmot conclusions will seriously distort the information. It will result in women choosing to be screened believing that it will reduce their risk of death from breast cancer when no such assurance is warranted by the evidence. The decision of the review panel to ignore all-cause mortality has already been challenged by the Nordic Cochrane researchers, and is cast in serious doubt by the considerations Professor Baum discusses here and by other research which finds no mortality benefit from breast screening. Women cannot without distortion be told that screening saves lives or that it reduces breast cancer mortality. It is not known that it does and it is possible that it does not.

The Citizen’s Jury didn’t want the leaflets to state the number overdiagnosed because it might frighten women and put them off attending. ICCS appears to take this seriously as a consideration about what to put into the leaflets, or rather, what to leave out.

They also found that some people want to receive a recommendation to attend along with information about screening, and they appear to take this seriously as a consideration for the leaflets – indeed they appear to intend to recommend attending screening either in the invitation letter to be sent with pre-arranged appointments for breast screening or in the information leaflet or both.

ICCS do not appear to see the absurdity in being asked to recommend screening because that is what people want to hear. Nor do they appear to grasp the conflict between recommending attendance and the requirement to present the evidence fairly to enable people to make their own free choice.

In light of these factors, if a recommendation is to be given, the only recommendation in keeping with the evidence, the only recommendation a conscientious practitioner could make, would be to decline screening. That would confuse. Offering a service that cannot be recommended is incongruent. Therefore an explanation would be needed. The truth works best; that would be: “Screening is still being offered because the professionals involved have invested so much for so long that they are unwilling to accept the evidence and let go. That is why screening is still being offered in spite of the lack of evidence of benefit, and the obvious harms, but the NHS cannot recommend it.”

Competing interests: Diagnosed through screening

28 January 2013
Miriam Pryke
PhD student
King's College London
Strand, London, WC2R 2LS