Intended for healthcare professionals


Financial incentives for breast cancer screening undermine informed choice

BMJ 2022; 376 doi: (Published 10 January 2022) Cite this as: BMJ 2022;376:e065726
  1. Theodore Bartholomew, GP specialty registrar1,
  2. Mirela Colleoni, patient2,
  3. Harald Schmidt, assistant professor3
  1. 1Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
  2. 2Hauts-de-France, France
  3. 3Department of Medical Ethics and Health Policy, University of Pennsylvania, USA
  1. Correspondence to: T Bartholomew tb.public{at}

Theodore Bartholomew, Mirela Colleoni, and Harald Schmidt argue that the focus should be on decision making not uptake when the balance of benefit and harm is subjective

Breast cancer is the most common cause of cancer death for women worldwide.1 Various measures have been explored to reduce breast cancer mortality. One approach is to encourage screening through financial incentives for patients or providers, as recently proposed in France and the UK, respectively.234 Several countries already use some form of incentive, and the extent to which they are being offered, in combination with ambitious screening targets, could suggest that their use is an appropriate way to promote population health. This, however, is far from clear: there are major concerns about breast cancer screening, the effectiveness of financial incentives is unclear, and there is an urgent need to ensure that women have given their valid consent—that is, informed and without undue influence—for screening. Some trans men and women and non-binary people are also eligible for breast cancer screening, and although the data mostly relate to cisgender women, the arguments on informed consent apply to everyone.

Health effects of breast cancer screening

Breast cancer screening is controversial on several grounds. For every woman who avoids a breast cancer death through screening, 3-10 women will be treated unnecessarily and over 200 will experience psychological distress because of false positive results (table 1).567 Although a 2012 UK review stated that screening conferred “significant benefit and should continue,” with one breast cancer death averted for every 235 women invited to screening over 20 years,5 its conclusions have been widely challenged.8910 Major concerns include the harms of overdiagnosis (box 1), substantial uncertainty over cost effectiveness,11 and that most reductions in breast cancer mortality can be attributed to improved breast cancer …

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