Intended for healthcare professionals

Rapid response to:

News Roundup [abridged Versions Appear In The Paper Journal]

Incidence of breast cancer is rising in Australia, while death rate falls

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7574.876-a (Published 26 October 2006) Cite this as: BMJ 2006;333:876

Rapid Response:

Mammographic screening and totalitarian medicine

Two headlines in the current issue of the BMJ caught my eye
today:"Incidence of breast cancer is rising in Australia, while death rate
falls" and "Germany will penalise cancer patients who do not undergo
regular screening". These coincided with the publication this week from
the Cochrane Collaboration, "Screening for breast cancer with mammography
(review)" by Gotzsche & Neilsen (www.thecochranelibrary.com)which made
for sobering reading.

We are in the midst breast cancer awareness month (black October)when the
popular press are hungry for breast cancer stories.The month started with
descriptions of rising incidence and falling mortality for breast cancer
in the UK as well. Our women folk were blamed for the rising incidence by
poor lifestyle choices wheras our screening service was credited with the
fall in mortality. The opposite is closer to the truth.

Whenever a
population is screened for breast cancer the incidence shoots up and stays
up due to the overdiagnosis of latent or pseudo cancers. [1,2]The new
Cochrane review of the very mature follow up of all the screening trials
provides a precise estimate of 1.30 that alone can account for a 30%
increase in incidence that is an artifact of screening.The fall in
mortality is unlikely to be related to screening activity as it first
became apparent before screening started in the UK and is of the same
magnitude in the under 50s who are not invited for screening as in the
over 50s.[3]The magnitude of this fall is precisely what you would expect
from improvements in treatment as illustrated by the latest EBCTCG
overview.[4]Furthermore the latest benefit of screening described in the
Cochrane report suggests that you have to screen 2000 women for ten years
for one to benefit.Faced with these data many wise women might decline the
invitation for screening.

Yet here we have the German Chancellor, Angela
Merkel,suggesting that women diagnosed with breast cancer who failed to attend
for screening in the past would face a financial penalty!

The late Petr Skrabanek,in his book The death of Humane Medicine
[5]reminds us of the danger of totalitarianism in public health policy
that culminated in the doctrine of "social hygeine" in the service of the
state."Gesundheit ist Pflicht" (health is duty)was one of the slogans of
the Third Reich.
How long before the EU makes screening compulsory I wonder?

Michael Baum

references

[1] Zackrisson S, Andersson I, Manjer J and Garne JP, Rate of over-
diagnosis of breast cancer 15 years after end of Malmö mammographic
screening trial: follow up study. BMJ 2006;332:689-92

[2] H.Gilbert Welch, “Should I be tested for Cancer?”
University of California Press, 2004, ISBN 0520239768

[3]Hermon C, Beral V (1996). Breast cancer mortality rates are levelling
off or beginning to decline in many western countries: analysis of time
trends, age-cohort and age-period models of breast cancer mortality in 20
countries. Br J Cancer 73: 955-960.

[4] Early Breast Cancer Trialists' Collaborative Group. Effects of
chemotherapy and hormonal therapy for early breast cancer on recurrence
and 15-year survival: an overview of the randomised trials. Lancet
2005;365:1687-1717

[5]The death of humane medicine. Petr Skrabanek,Pub. The social affairs
unit, St Edmundsbury press, Bury St Edmunds 1994

Competing interests:
A longstanding belief in informed choice.

Competing interests: No competing interests

28 October 2006
Michael Baum
Professor emeritus of surgery University College London
The Portland Hospital, Great Portland Street, London W1N6AH