• The Benefits and Harms of Breast Cancer Screening: An Independent Review

    The Lancet, Early Online Publication, 30 October 2012

    doi:10.1016/S0140-6736(12)61611-0Cite or Link Using DOI

    The benefits and harms of breast cancer screening: an independent review

    Original Text

    Independent UK Panel on Breast Cancer Screening

    Summary

    Whether breast cancer screening does more harm than good has been debated extensively. The main questions are how large the benefit of screening is in terms of reduced breast cancer mortality and how substantial the harm is in terms of overdiagnosis, which is defined as cancers detected at screening that would not have otherwise become clinically apparent in the woman’s lifetime. An independent Panel was convened to reach conclusions about the benefits and harms of breast screening on the basis of a review of published work and oral and written evidence presented by experts in the subject. To provide estimates of the level of benefits and harms, the Panel relied mainly on findings from randomised trials of breast cancer screening that compared women invited to screening with controls not invited, but also reviewed evidence from observational studies. The Panel focused on the UK setting, where women aged 50—70 years are invited to screening every 3 years. In this Review, we provide a summary of the full report on the Panel’s findings and conclusions. In a meta-analysis of 11 randomised trials, the relative risk of breast cancer mortality for women invited to screening compared with controls was 0·80 (95% CI 0·73—0·89), which is a relative risk reduction of 20%. The Panel considered the internal biases in the trials and whether these trials, which were done a long time ago, were still relevant; they concluded that 20% was still a reasonable estimate of the relative risk reduction. The more reliable and recent observational studies generally produced larger estimates of benefit, but these studies might be biased. The best estimates of overdiagnosis are from three trials in which women in the control group were not invited to be screened at the end of the active trial period. In a meta-analysis, estimates of the excess incidence were 11% (95% CI 9—12) when expressed as a proportion of cancers diagnosed in the invited group in the long term, and 19% (15—23) when expressed as a proportion of the cancers diagnosed during the active screening period. Results from observational studies support the occurrence of overdiagnosis, but estimates of its magnitude are unreliable. The Panel concludes that screening reduces breast cancer mortality but that some overdiagnosis occurs. Since the estimates provided are from studies with many limitations and whose relevance to present-day screening programmes can be questioned, they have substantial uncertainty and should be regarded only as an approximate guide. If these figures are used directly, for every 10 000 UK women aged 50 years invited to screening for the next 20 years, 43 deaths from breast cancer would be prevented and 129 cases of breast cancer, invasive and non-invasive, would be overdiagnosed; that is one breast cancer death prevented for about every three overdiagnosed cases identified and treated. Of the roughly 307 000 women aged 50—52 years who are invited to begin screening every year, just over 1% would have an overdiagnosed cancer in the next 20 years. Evidence from a focus group organised by Cancer Research UK and attended by some members of the Panel showed that many women feel that accepting the offer of breast screening is worthwhile, which agrees with the results of previous similar studies. Information should be made available in a transparent and objective way to women invited to screening so that they can make informed decisions.

  • Breast Cancer Screening Causes More Damage than Previously Thought

    Around 4,000 women have unnecessary treatment for a disease that will never threaten their health, though tests should continue

    Sarah Boseley, health editor

    The Guardian, Monday 29 October 2012

    Around 1,300 lives are saved by mammography, but many women have unnecessary breast cancer treatment. Photograph: Rui Vieira/PA

    Breast cancer screening causes more harm than has previously been recognised, even though it saves lives, according to an independent review set up following years of scientific controversy surrounding the NHS programme.

    Around 1,300 lives are saved every year by mammography, which women are invited to undergo between the ages of 50 to 70, said the review, which recommends that screenings should continue.

    But 4,000 women will undergo unnecessary treatment, including surgery, radiotherapy and chemotherapy, for a cancer they would not otherwise have known about and which would have done them no harm in their lifetime. Some breast cancers are so tiny and slow growing that they would never be a threat to a woman’s health, the review says.

    The government is embarking on an immediate revision of the leaflet which invites women for screening, said national cancer director Sir Mike Richards, so that women can weigh up the benefits against potential harm and make their own decision as to whether to be screened.

    While he welcomed the review panel’s support for screening, he added: “The key thing is that we communicate this new information to women so they can make an informed choice for themselves.

    “NHS Cancer Screening Programmes have already asked independent academics to develop new materials to give the facts in a clear, unbiased way. I hope to see them in use in the next few months. If any woman has concerns about breast screening she should talk to her GP or health professional.”

    The independent review panel was set up by the government and the charity Cancer Research UK under the chairmanship of Sir Michael Marmot and comprised scientists who had never published on breast screening before, in order to establish their impartiality on an issue that has provoked impassioned argument between epidemiologists.

    The leading critic of screening is Professor Peter Gøtzsche, director of the Nordic Cochrane Centre, whose team has spent years analysing the data from the trials carried out in several countries prior to the setup of national screening programmes – as well as more recent studies. Gøtzsche says the harm of screening outweighs the benefits.

    Marmot’s team also reviewed data from original breast screening trials, many of which took place in Scandinavia. They acknowledged that they had limitations because they mostly date from the 1980s or earlier – the NHS programme was set up in 1988. But they dismissed other criticisms, such as that some of the women had died of other diseases and not breast cancer.

    The review judged that screening reduces the risk of dying from breast cancer by 20%. It prevented 43 deaths for every 10,000 women invited to be screened, or one death per 235 women invited. Among those 10,000 women, 681 cancers would be diagnosed and 129 of those would be over-diagnosed – the mammogram would have picked up an otherwise undetectable tumour which the woman would never have known about. As with many prostate cancers in men, it would grow so slowly that without treatment she would die with it, rather than of it.

    “Our best estimate is around 4,000 cancers a year which is about 19%,” said Professor David Cameron from Edinburgh University, who presented the findings which are published today in the Lancet medical journal.

    “Breast cancer screening should continue, but we felt that the information given to women needs to be reviewed with our findings taken into account, so women are given an accurate picture of the benefits and harms.”

    The current NHS leaflet mentions misdiagnosis almost in passing. “Screening can find cancers which are treated but which may not otherwise have been found during your lifetime,” it tells women.

    Marmot said the information must now be available for women to make a choice. “Clear communication of these harms and benefits to women is essential, and the core of how a modern health system should function,” he said.

    The government and the NHS screening programme will be hoping that the controversy will die away, but Gøtzsche is unlikely to change his opinion. The review panel was wrong to assume that the effect of screening is the same today when we have much better treatments than in the original screening trials, he said, and the panel has also underestimated overdiagnosis substantially.

    Although he is pleased that the panel recommended giving women better information, he does not accept that screening reduces the risk of dying from breast cancer by 20%. From more recent observational studies of ongoing screening programmes, he says, “we cannot see any effect of screening”.

    Much has changed since the early days of screening. Most important, the numbers of advanced cancers have not dropped as a result of screening, he says – which was the main reason for setting up the programmes. “Screening has not reduced the number of advanced cancers per 100,000 women, and when that’s the case, screening cannot work,” he added.But most worrying is that the numbers of advanced cancers, which carry the greatest threat of death, have not dropped as a result of screening, he says – which was the main reason for setting up the programmes. “Screening has not reduced the number of advanced cancers per 100,000 women.”

    Three breast cancer charities in a joint statement said they urged women to go for screening. Breakthrough Breast Cancer, Breast Cancer Campaign and Breast Cancer Care said the review had provided much needed clarity. “This is good news for women as they can now be assured that breast screening can be beneficial,” they said. “However, some women who attend screening may be diagnosed and treated for a cancer that may not have caused them harm in their lifetime. To ensure women understand what this may mean for them it is important they have access to clear and balanced information.”