Breast problems

I am reporting good news, for a change. The UK Breast Screening Service has said it intends to rip up the leaflet which is currently sent to women with breast screening appointments. A recent paper in the British Medical Journal outlined the kinds of uncertainties and likelihoods the authors thought would have counted as “fair information” to give to women. This seems to have prompted UK Breast Screening to review the content of its leaflet and try to give better information.

I am a GP, and so my perspective on what is “better” will likely take account of the difficulties which I observe breast screening leading to. My wish list starts with wanting the new leaflet to describe screening explicitly as an intervention which one can accept or decline. Breast screening should not be something which is sold, or which one is persuaded or coerced into. Women should be treated as competent adults who have the pros and cons explained to them: it is simply not ethical for breast screening to proceed without proper counsel.

People have written entire books about the problems of screening. I will stick to just two things: “overdiagnosis” of what is sometimes called “pseudodisease”, and limited gain. “Overdiagnosis” relates to the fact that it’s not just full-blown cancers that are detected. Some of the abnormalities seen and biopsies examined can represent situations where the prognosis is uncertain. Some of these are a condition called “ductal carcinoma in situ”. This makes up about 20 per cent of “breast cancer” diagnosed at screening in the UK. While these are commonly treated with surgery and possibly chemotherapy and radiotherapy, only a minority may end up progressing to a life-threatening cancer. Studies done at autopsy imply that 15 to 39 per cent of women die with, rather than from, this type of cancer.

The remainder of the article can be read here. Please post comments below.

Pleased to see that ripples from the UK have now reached the US.

This follows on from a post a couple of weeks ago about this paper in the BMJ and the duty of doctors to explain both pros and cons of breast screening to patients. Here is a letter and article on this subject today in the Times.

For several years I have been trying – and, evidently, failing – to suggest that the information that women get about breast screening isn’t very balanced. The problem- as I see it anyway – is that services are geared to get women to turn up for screening. Whereas, I would like services judged not on how many women turn up, but on how many women make good informed decisions about whether or not they want to have screening at all. As we have had more and better research evidence about breast screening it has become apparent that there are, as well as measurable potential benefits, also measurable potential harms. Just like operations or tablets, doctors should be explaining the pros and the cons, and trying to help people reach a decision about them. (And Gerd Gigerenzer is the master on explaining risk – his book Reckoning with Risk is brilliant.)

So, in the BMJ this week is a vastly improved information leaflet about breast screening, written by the Director of the Nordic Cochrane Centre and his colleagues; it’s available here.

I forgot to include a link to the paper – the start of it is here.

A very interesting paper just published in the Archives of Internal Medicine. The study followed women before and after the introduction of a breast screening programme in Norway. They were compared to a control group of women who did not take part in the screening programme, but who would have been, had the programme been started in their area. This control group were invited for a one-off screening at the end of the observation time in order to work out how many had invasive breast cancers.

When the two groups were compared, the amount of invasive breast cancers was found to be significantly higher in the group of women who had regular screening. On first glance, this may appear to be a good thing – it seems that screening picked up more invasive breast cancers. But is it? The problem is that the natural history of these “invasive breast cancers” may not be as predictable as we would like to think, in that not all may cause a life-threatening situation. The authors concluded that “it appears that some breast cancers detected by repeated mammographic screening would not persist to be detectable by a single mammogram at the end of 6 years. This raises the possibility that the natural course of some screen-detected invasive breast cancers is to spontaneously regress”.

This is but one paper in a complex field, and I wouldn’t suggest that this research alone should make women decide what to do when the invitation to breast screening comes in. However, there are already uncertanties about how beneficial breast screening is. I think this paper does emphasise that there are still a lot of unknowns when it comes to breast cancer screening. The NHS Behind the Headlines service provides a useful analysis of the news coverage of this story but concludes that “women should continue to attend screening programmes”. I think this is a bit unfair; surely the best position is to invite women to weigh up the pros and cons for themselves, as they become known. But maybe this is also unfair; most people probably don’t have the time to devote to investigating this sort of thing and they should be able to expect disinterested, fair advice from their health professionals. 

When I was at medical school, hormone replacement therapy was not just the treatment of choice for the flushes and sweats of menopause. It was also thought to reduce the risk of heart attacks, strokes, dementia, colon cancer, bone and even teeth loss.

Yet over the past few years new research has made many doctors reluctant to prescribe HRT in the longer term. Their concern stems mainly from a study conducted during the US Women’s Health Initiative (WHI), a government-funded project to investigate the health of postmenopausal women.

The large, randomised, placebo-controlled trial was stopped early, in 2002, when researchers became concerned by the increased rate of heart attacks and strokes in the HRT group, compared with those taking the placebo. HRT did seem to reduce the rate of bone fractures and colon cancer, but the investigators decided that the adverse effects outweighed the beneficial ones. In the UK, research projects such as the Million Women Study have also found HRT to prompt side-effects such as breast and ovarian cancers.

The remainder of the article can be read here. Please post comments below.

It  seems so sensible to try and find breast cancers early. Yet the truth in medicine is often counterintuitive, and this is one such example.  

The headlines today are about breast self examination – regular exams done by women themselves looking for lumps – being ineffective to reduce deaths from breast cancer. 

Margaret McCartney’s Blog

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A forum on healthcare policy and professional issues, by Glasgow-based GP and FT Weekend columnist Margaret McCartney.

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