Independent breast screening review

Public Archive
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The results of an independent breast screening review, commissioned by Cancer Research UK and the Department of Health, have been published in today’s Lancet.

It’s been widely reported in the media today, with some discussion about how effective screening for breast cancer is.

We’ve posted a blog post about the results and a video by our Clinical Director Dr Emma Pennery explaining a bit more about what the results mean. I’ve copied it below for you to read:

The results of an independent breast screening review, commissioned by Cancer Research UK and the Department of Health, have been published in today’s Lancet.

Over the last year, a panel of experts have reviewed existing evidence. All the trials included were 20-30 years old, nevertheless they represent the best evidence available.

The reviewers estimate that for every 235 women invited for routine screening between the ages of 50 and 70, (and for every 180 women who attend screening), one breast cancer death would be prevented. This amounts to 1300 deaths prevented per year.

But the review also concluded that screening can result in over-diagnosis. This refers to cancer diagnosed by screening that would not otherwise have caused harm in a woman’s lifetime, were it not for screening. The consequence of this is that these women may undergo unnecessary surgery and other treatments, as well as the emotional impact of the diagnosis.

To put it in a bit more context, of the approximately 307,000 women aged 50-52 years who are invited to begin screening every year, just under 0.5 % (1307) will be prevented from dying from breast cancer and just over 1% (3971) would have an over-diagnosed cancer during the next 20 years.
But importantly, no individual woman (or their doctor) can know if a breast cancer found at screening was over diagnosed (so would have remained undetected throughout her lifetime). Nor will she know if she survives breast cancer, whether it was because of screening.

The review panel recommends breast screening continues but with improved information to better convey to women the benefits and harms.
Breast Cancer Care has responded, together with Breakthrough Breast Cancer and Breast Cancer Campaign. We believe that the review has provided clarity that screening can save lives and we encourage all eligible women to consider attending. However, some may be diagnosed and treated for cancer that would not have caused them harm. We think it’s extremely important that women can access clear and balanced information on the pros and cons of breast screening.

Anyone with questions, worries or concerns should call our free, confidential Helpline 0808 800 6000 or email our clinical team using our Ask the Nurse service.

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[video:http://vimeo.com/52453542]

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I find this type of ‘statistical’ information VERY difficult to comprehend.
Where is the control group? i.e. women who didn’t have screening, and the associated incidences of breast cancer, whether it required treatment or not, whether it metasised, whether it was terminal or just lay dormant and for how long before a dormant cancer started to grow.
And how can anyone assess whether removed cancer tissue was virulent or dormant?
For women to be told that screening may lead to them having invasive treatment unnecessarily really is not helpful.

grumpy

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Thank you for this.
I am most concerned that this report might deter ladies from attending for their routine breast screening. Certainly after I was Dx quite a few friends did dither about attending for their routine screenings, but thankfully they did and were all OK.
There was no doubt about my Dx in fact after more scans etc the size and stage got worse, and the histology bore this out.
This is such an emotive subject that I feel that there could be a reduction in non attendances for screening.
J xx

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Could never understand the fuss about all this, how the heck do people know if they have been over dx? there is currently no test to say which DCIS will go on to become invasive and which wont, so to me this review was a complete waste of time, apart from the fact that it is now proven that screening should continue and it certainly does save lives!!
Surely people would much rather know and get rid of it than potencialy liveing with a ticking timb bomb? Just dont understand it!!

Linda x

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Yes, I just drove back here to England and I heard it on the radio the whole way. I heard interviews with the same two women the whole time. Miriam, who regretted being ‘overtreated’, should at most have had better advice, but what good would it have done her not to be screened? Like others here, I just don’t understand it.
There was a German soap actress who made a film of her breast cancer journey which I found rather odd, because she did everything she could to keep her breast, including getting her parents’ help for a 23,000 euro operation only possible in France, because only one surgeon could do it, and then it turned out that the cancer had spread so she couldn’t have this kind of probably WLE she wanted. Later I discovered she had been diagnosed with DCIS three years earlier and probably offered a mastectomy, and she decided to wait and see. By the time the invasive cancer had spread, it was Grade 3 and she had to have a mastectomy, and she didn’t even have the advice to freeze her eggs - she was 35 or so. Fortunately I gather she has now had a baby, a couple of years on.
Lond story, but I think people with DCIS should at least have the choice, and probably more facts. The way the media is reporting this is, as usually, in catchphrases: instead of explaining DCIS, they say ‘overtreated’ and add ‘but no one knows who is overtreated’ - I’m not sure non-cancer people listening to the news understand what it all means.

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I’ve found a summary of the report in the Lancet
thelancet.com/journals/lancet/article/PIIS0140-6736(12)61611-0/fulltext
and also links to editorial
thelancet.com/journals/lancet/article/PIIS0140-6736(12)61775-9/fulltext
and similar articles previously published in the Lancet
thelancet.com/journals/lanonc/article/PIIS1470-2045(07)70380-7/abstract
thelancet.com/journals/lanonc/article/PIIS1470-2045(11)70250-9/abstract
The last one, a Swedish study, is interesting.
Eeeek, sorry for the horrid format of the links!!!

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I totally agree with cornishgirl - as long as there is no proof that DCIS will not develop into invasive cancer it needs to be treated. I am so grateful that mine was detected, and absolutely think it was worth having a mastectomy to take away that risk.
I am really concerned that this report will be used as an excuse to cut breast screening services and hold back on treatment for so-called over-diagnosed cases.
I am also worried that women will listen to certain scaremongering areas of the media and choose not to attend their screening appointments and subsequently go on to develop cancers which could have been detected. I have encouraged all my family, friends and acquaintances to go for their screening appoinments.

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I was horrified by this report, too, and am concerned that it could lead to women not attending vital screening for fear of being “over-treated”. Am I the only one that thinks this is part of a wider political agenda to save money on the screening programme?

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Can I just ask a question please…“However, some may be diagnosed and treated for cancer that would not have caused them harm.”… how can you have a cancer that doesn’t cause you harm??..cancer is malignant…not benign…am I reading this wrong…can someone explain please…I had a mammogram in Nov 2010… came back clear…then was dx with a stage 3…or grade 3…I’m never sure of that one…Pr+ Er+ Hr- 30mm tumour in August 2011…I had right Mx to make sure it was gone and had to have chemo anyway…and as grumpy says…where is the control group?? As far as I am concerned you can’t be over treated for cancer…chuck all you’ve got at it…that was my philosophy…I was borderline for chemo but opted for that as well…didn’t have rads…I just hope this doesn’t put any lady off going for routine screening!!!I agree…it sounds like our crappy govt trying to save money again…it would be different if one of their wives or daughters were dx…obviously they would be able to afford private care…not have to rely on the NHS which they are doing their level best to destroy!!!

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The national news report i watched late last night was the usual sensationalist reporting which made my jaw drop, at no time dureing the report was the term “DCIS” mentioned only Breast Cancer, images of women were shown where 1 womans life would be saved and the other 4 women would be over DX, the report then went on to say that most of these over dx women then went on to have unessesary surgery, chemotherapy and radiatherapy following this a woman was being interviewed and she said she would not be attending for any breast screening as she had done her research and she had a healthy lifestyle and no history of breast cancer in her family so she was low risk, they did a half heated balance where another woman said she was glad she had breast screening as she couldnt feel her lump and wouldnt have know it was there.
Yesterday upon meeting a male friend the first thing he said to me was, “did you see the news about people like you being over Dx with breast cancer?” i spent the next half hour trying to explain that this report was refering to something called DCIS ,pre cancer cells, not invasive breast cancer and that there was no test to prove which DCIS would go on to become invasive and which wouldnt. Im still not sure he “got it” .
What worries me greatly now, is that people like that woman in the report and i expect many like her who havent been given the correct information will be so scared of attending breast screening that we will see many more cases of breast cancer presenting at a later satge becase of scaremongering like this. This whole report has done nothing to educate the public in regards to breast cancer but has put the fear of god into them.
An utter waste of time, which no doubt will prove to be very costly in more ways than one.
Linda

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Hi applestreet the cancer they are talking about is called DCIS ductal cancer in situ.This is cancer that is contained in the ducks and hasn’t developed the ability to spread yet.This is the type that they say could be over treated as it may never develope the ability to spread.I had ductal cancer in situ grade 3 and invasive grade 2 and was told that if left the DCIS would develope into invasive because of it’s high grade.
What I don’t understand is why the media are saying that these women are overtreated with Chemotherapy as DCIS would not require Chemotherapy.More bad reporting.

Melxx

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BCC, am also quite shocked that you havent clarified either that this review refers to DCIS either, i think the public when hearing these news stories regarding breast cancer over DX and reading your blog/video posts also dont understand or differenciate between what is a true (invasive cancer) and which is a pre cancer. I think it needs clarifying to allow people to be properly informed which is what this review is supposed to do. As i pointed out in my earlier post a friend of mine assumed that i might have been over DX becuse the only term used in all these reports was Breast Cancer.
Linda

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Another point of view?
“Getting the establishment with its vested interests to accept that the evidence for over- diagnosis is irrefutable. The evidence that examining well women without a family history of breast cancer saves lives, is poor, and based on old data that does not take into account the improved outcomes for treatment The money would be much better spent on further improving treatment. Sadly it will probably take another 5 years before we stop frightening healthy wopmen and abandon this expensive harmful screening.
Most women find mammography stressful and unpleasant. Even among those who receive a normal result there is an emotional cost. Those who are recalled further examination or biopsy but found to not have cancer, are caused even further distress for nothing. The ethics of making 4,000 healthy women seriously ill each year to possibly prolong the lives of 1,300 other women is very questionable. I have not attended - and will not be attending for screening. I will not subscibe to the superstition that my refusal puts me more at risk of disease”
These are not my words- they are those of a doctor writing in today’s Times…but i have a lot of sympathy with what she is saying. The current media coverage re the efficacy of screening and the ethical aspect of overtreatment is not new: there have been many informed voices raised on this issues for years- but the suggestion that the NHS should cut back on breast screening - or be more selective in who is screened, is such a hot potato that it may well be years beofre there is a radical re evaluation. - meanwhile thousands upon thousands of pounds have been spent, which I also believe could have been better used in research and treatment.
Despite my own BC having been detected by routine mmammography I remain unconvinced that I would not have soon presented with other symptoms and would have sought treatment. In years to come, I think we shall look back with hororor that so many women lost their breasts and many more had to face anxiety and stress - when there was no test to determine whose DCIS would go on to become invasive BC and whose wouldn’t .

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topsymo, this is what i dont understand "“Getting the establishment with its vested interests to accept that the evidence for over- diagnosis is irrefutable.” where is the evidence? there can only be evidence for over DX when a test is available to show that a woman presenting with DCIS will not go on to become invasive breast cancer .
Perhaps i missing something.
Linda

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The report itself, and press coverage is incredibly confusing. The original report (free if you register) is just as ambiguous as the press - they don’t clearly say that when they are are talking about over treatment, they are referring to treatment of DCIS. There is a section on DCIS and lack of knowledge about whether this will always develop into breast cancer, but this is not explicitly linked to the whole over treatment issue.

The main point is that 4000 or so women are diagnosed with DCIS after screening.Scientists don’t know whether DCIS wil always result in invasive cancer. The story: we need more research on DCIS. In the meantime, specialists should advise women on current understandings/risks/prognoses to do with DCIS in order to help them make decisions about treatment. In the same way that women with lower grade cancers can be given a choice about chemo, or can choose between lumpectomy and mastectomy.

I find it absurd that no one is saying any of this public ally. Not even experts on the radio, newspapers, or indeed BCC. Why not?

MeanwhIle, a French doctor was on air saying that women die from unnecessary radiotherapy?!

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Hi I just read the article from the Lancet.

“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.”

I would disagree that breast screening “prolong’s life”…It saves lives.

Here’s the full article.

Cite or Link Using DOI

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

melxx

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I guess we sometimes get so worked up by the fear of cancer killing us that we forget other things can kill us too - and sometimes this might be treatment. For example, herceptin can (and does) cause heart failure. People can die during surgery, or from the effects of chemo. These treatments have passed clinical trials that show they cure more than kill - but that’s little comfort if you are one of the few that they kill. Even if they don’t kill you straight away, they can also reduce life expectancy and/or life quality. Then there is the five percent of the population with the gene that makes them less able to repair damage from radiation - for them, a mammogram / radiotherapy is very risky, and the majority won’t know they have the gene. The tools available for diagnosing and treating cancer are less than perfect. It might seem counterintuitive not to attend routine mammograms but I think the issue is not clearcut. As well as the possiblitly of overtreating cancers (really pre-cancers if we are talking about DCIS), there’s the risk of false negatives that may give women a false sense of security and prevent them from being observant to symptoms. My lump didn’t show on a mammogram even though it proved to be a 21mm invasive tumour. Had I been old enough to have routine mammograms rather than rely on self-checking, I might not have noticed the symptoms myself, or taken them seriously enough to go to a GP. The radiographer was only able to do a biopsy that found the cancer because I put my finger on where I felt the lump was.

I think women should be offered routine mammograms - but think it’s right that they should be informed of the potential downsides. In fact, I’d extend the offer of screening to younger women but favour physcial exam by trained medical professional followed by ultrasound.

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Topsymo, I feel the need to reply to your comments about thinking you would have soon enough presented with other symptoms which would have caused you to then seek treatment. My experience is that I was too young to be in the screening programme and I scored very low in the risk of getting breast cancer. The symptom I was presented with that first made me realise I had a problem was when I found a swollen lymph node in my armpit. I had DCIS and IDC but it had spread to 5 lymph nodes and one with extra nodal extension, plus lympho vascular invasion and satellite tumours. So perhaps mine started with the DCIS and then progressed. I would have rather had the offer of screening and to have found it all earlier rather than my current situation with an NPI of 6.5 and poor prognosis.

I think my preference would be the option of screening along with an explanation of the risks so I could make an informed decision. The number of deaths prevented may sound low compared to those over dx - unless you’re one of those in the non surviving category. But I do understand, for example, the devastation (that’s how I feel about it) of having to have a mx, particularly if someone feels it may not have really been necessary.

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hi keyfeatures, you say “. Then there is the five percent of the population with the gene that makes them less able to repair damage from radiation - for them, a mammogram / radiotherapy is very risky, and the majority won’t know they have the gene”
was just wondering what you mean.
melxx