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Europe continues breast screening despite doubts
Newsdesk Europe continues breast screening despite doubts
258
Sweden, which produced pioneering work in favour of screening, also has a national programme, as do Finland and Luxembourg. Other countries such as Belgium, Norway, and Ireland have put a lot of work into developing national programmes over the past few years and screening is already available in many areas. Germany has set up three pilot schemes in preparation for implementation of a national scheme and
Courtesy of Jo Marsden
Mammographic breast screening is currently one of the most hotly debated subjects in oncology. Although already in routine use in many countries, doubts have been raised about whether it actually provides any benefit. Several studies have suggested that screening can reduce breast-cancerrelated death by 30–60% (Semin Breast Dis 2001; 4: 62–67). However, scientists who dispute these findings claim that many of the trials were flawed and that screening could even increase mortality through encouraging aggressive treatment (Coch Data Syst Rev 2001; 4: CD001877; Lancet 2000; 355: 129–33; Lancet 2001; 358: 1340–42). The variety of interpretations of these findings have caused immense confusion and left screeningprogramme coordinators unsure whether or not to continue. The issue has become one of international concern, prompting organisers of the 3rd European Breast Cancer Conference, (Barcelona, Spain, March 2002) to dedicate an entire day to the topic. Also, the American Society of Clinical Oncology is in the process of assembling a panel of experts to discuss the issue at its next meeting, to be held in Orlando (FL, USA) in late May. One of the reasons for the intensity of debate surrounding mammographic screening is that it has implications for many different sectors of society. For the medical profession, being sure that screening is effective is essential because it could save lives. For politicians, the sheer cost of screening, which runs into millions of euros, makes a confirmation of effectiveness essential. And all women, ultimately, have their own health to consider. So where does all the confusion leave national screening programmes? There are differing opinions about what should be done in the future, but the majority of European countries are pushing ahead with current plans. Britain and Holland have had national programmes in place since the early eighties and are unlikely to stop in the near future (although new guidelines are currently being implemented in the UK’s programme because of a series of recently reported misdiagnoses).
A typical mammogram.
Portugal, France, and Greece are moving in the same direction through EU-funded schemes. Italy has set up large, regional, screening programmes. Spain, whose health system now runs on a regional basis, is also moving forward. “We began with Navarre in 1990 but by the end of the decade all regions had started their own programmes,” said Rafael Salvador, President of the European Group for Breast Cancer Screening (EGBCC). “Our hope is that by the end of this year, everyone [in Spain] will have access to screening.” Switzerland was recently cited in the American press as having abandoned the idea of screening. But this is not true, explains Chris de Wolf of Geneva University. “Each canton decides how it wants to organise its public health services. Although the statement might be valid for one, it cannot be generalised to the other 25.” Denmark is the only country to have taken a wait-and-see attitude to national programmes, and with the prospect of a complete change in opinion about breast-screening, this approach may prove fortuitous. However, despite their apparent
ubiquity, screening programmes are not standardised. Some countries start screening women at 40 years of age, others at 45, and still others at 50. The period between mammograms also varies. Most countries cite cost as the main factor driving screening decisions. “Countries and regions have different resources. The sad truth is that authorities have to take into account the ‘mean cost per year of life saved’. It would be great if we could screen every woman over 40 each year, but programmes have to work within what they can realistically afford,” says Salvador. But it seems that all the planning and debate merely draws attention away from the real issue: that women’s lives are at risk. No programme, irrespective of its funding and frequency, is perfect, and there is a growing feeling that women should be informed of this. Mammograms can give falsepositive results leading doctors to order a biopsy which, although proving a lump benign, can still cause tremendous anxiety. False-negative results can have worse consequences, as cancers may be detected too late for curative treatment. “Women should be properly informed about the benefits and disadvantages so they can decide if they want to be screened,” says Robin Wilson, secretary of the EGBCC. “What is right for governments, which tend to concentrate on the benefits of the population as a whole, might not be right for the individual.” When asked whether screening might lead to more aggressive and unwarranted treatment as suggested in some research papers, Melchor Alvarez del Mon, University of Alcalá, Spain, told TLO: “I don’t think women should worry about this: they should trust in the professional judgement of those who treat them.” While the debate goes on, screening programmes look set to continue. However, the ongoing rhetoric will hopefully not obscure the simple fact that we still have no magic bullet for breast cancer. Regardless of the prevelance of screening programmes, this disease remains one of the most common causes of death for women. Adrian Burton
THE LANCET Oncology Vol 3 May 2002
http://oncology.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
258
Sweden, which produced pioneering work in favour of screening, also has a national programme, as do Finland and Luxembourg. Other countries such as Belgium, Norway, and Ireland have put a lot of work into developing national programmes over the past few years and screening is already available in many areas. Germany has set up three pilot schemes in preparation for implementation of a national scheme and
Courtesy of Jo Marsden
Mammographic breast screening is currently one of the most hotly debated subjects in oncology. Although already in routine use in many countries, doubts have been raised about whether it actually provides any benefit. Several studies have suggested that screening can reduce breast-cancerrelated death by 30–60% (Semin Breast Dis 2001; 4: 62–67). However, scientists who dispute these findings claim that many of the trials were flawed and that screening could even increase mortality through encouraging aggressive treatment (Coch Data Syst Rev 2001; 4: CD001877; Lancet 2000; 355: 129–33; Lancet 2001; 358: 1340–42). The variety of interpretations of these findings have caused immense confusion and left screeningprogramme coordinators unsure whether or not to continue. The issue has become one of international concern, prompting organisers of the 3rd European Breast Cancer Conference, (Barcelona, Spain, March 2002) to dedicate an entire day to the topic. Also, the American Society of Clinical Oncology is in the process of assembling a panel of experts to discuss the issue at its next meeting, to be held in Orlando (FL, USA) in late May. One of the reasons for the intensity of debate surrounding mammographic screening is that it has implications for many different sectors of society. For the medical profession, being sure that screening is effective is essential because it could save lives. For politicians, the sheer cost of screening, which runs into millions of euros, makes a confirmation of effectiveness essential. And all women, ultimately, have their own health to consider. So where does all the confusion leave national screening programmes? There are differing opinions about what should be done in the future, but the majority of European countries are pushing ahead with current plans. Britain and Holland have had national programmes in place since the early eighties and are unlikely to stop in the near future (although new guidelines are currently being implemented in the UK’s programme because of a series of recently reported misdiagnoses).
A typical mammogram.
Portugal, France, and Greece are moving in the same direction through EU-funded schemes. Italy has set up large, regional, screening programmes. Spain, whose health system now runs on a regional basis, is also moving forward. “We began with Navarre in 1990 but by the end of the decade all regions had started their own programmes,” said Rafael Salvador, President of the European Group for Breast Cancer Screening (EGBCC). “Our hope is that by the end of this year, everyone [in Spain] will have access to screening.” Switzerland was recently cited in the American press as having abandoned the idea of screening. But this is not true, explains Chris de Wolf of Geneva University. “Each canton decides how it wants to organise its public health services. Although the statement might be valid for one, it cannot be generalised to the other 25.” Denmark is the only country to have taken a wait-and-see attitude to national programmes, and with the prospect of a complete change in opinion about breast-screening, this approach may prove fortuitous. However, despite their apparent
ubiquity, screening programmes are not standardised. Some countries start screening women at 40 years of age, others at 45, and still others at 50. The period between mammograms also varies. Most countries cite cost as the main factor driving screening decisions. “Countries and regions have different resources. The sad truth is that authorities have to take into account the ‘mean cost per year of life saved’. It would be great if we could screen every woman over 40 each year, but programmes have to work within what they can realistically afford,” says Salvador. But it seems that all the planning and debate merely draws attention away from the real issue: that women’s lives are at risk. No programme, irrespective of its funding and frequency, is perfect, and there is a growing feeling that women should be informed of this. Mammograms can give falsepositive results leading doctors to order a biopsy which, although proving a lump benign, can still cause tremendous anxiety. False-negative results can have worse consequences, as cancers may be detected too late for curative treatment. “Women should be properly informed about the benefits and disadvantages so they can decide if they want to be screened,” says Robin Wilson, secretary of the EGBCC. “What is right for governments, which tend to concentrate on the benefits of the population as a whole, might not be right for the individual.” When asked whether screening might lead to more aggressive and unwarranted treatment as suggested in some research papers, Melchor Alvarez del Mon, University of Alcalá, Spain, told TLO: “I don’t think women should worry about this: they should trust in the professional judgement of those who treat them.” While the debate goes on, screening programmes look set to continue. However, the ongoing rhetoric will hopefully not obscure the simple fact that we still have no magic bullet for breast cancer. Regardless of the prevelance of screening programmes, this disease remains one of the most common causes of death for women. Adrian Burton
THE LANCET Oncology Vol 3 May 2002
http://oncology.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.