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Independent breast screening review

43 REPLIES 43
Lemongrove
Member

Re: Independent breast screening review

Esha Ness, I think your experience convinces me that this breast screening review is potentially very dangerous indeed. As you say there is no way of knowing which cancers will become life threatening, because cells can break away into the bloodstream and are undetectable. Doctors can only see what is under the microscope, and what may look like a fairly harmless DCIS, could in fact have some aggressive cells.
I just think this move towards a more hands off approach is a disaster waiting to happen, and will cost the NHS dearly in terms of the compensation claims it will face. I remember a similar instance when the Govt introduced a hands off approach to childbirth. They said that Obstetrician led childbirth had become un-necessarily medicalised, was leading to dangerous interventions, and should become midwife led. The result? In just four years between 2006 and 2010, claims for compensation have risen from £11.8m to £85.8m.

Esha_Ness
Member

Re: Independent breast screening review

Just to say I had a 3mm lobular cancer that did not show up on mammagram/screening. It was found after a mastectomy for a ductal cancer.All tests showed that there was no spread to lymph glands and I had a good prognosis.
After 10years I was diagnosed with secondary breast cancer to my bones, origin being the lobular cancer. The point is that the Doctors and the tests don't know everything and Cancer can behave in shocking ways.
Esha

Angelfalls
Member

Re: Independent breast screening review

Almost forgot! An undiagnosed early stage cancer may not go on to kill an 80 year old who dies of something else first, but the screening programme we're discussing is for 50-70 year olds, of course. So Linda's statement that "most cancers if not treated and left will eventually go on to kill you" is factual based on the wider population.

Again, as Linda says, it's all about risk Vs benefit and while it is true that cancer treatments are not 100% safe, they certainly do not pose anything like the same risk as cancer itself.

Angelfalls
Member

Re: Independent breast screening review

Being given more information is not the same thing as changing the advice to go for screening. 

I only hope that the information given to women attending screening will explain the present limitations of diagnosis, i.e. that nothing can currently predict which early stage cancers will go on to be life-threatening (which is why I STILL don't understand how the report has come up with a figure for those who are over-treated!!). And if this is properly explained, I doubt that it will have a huge impact on the number of otherwise healthy women who will opt for treatment for their Stage 0 and 1 cancers; it's a little like the e.g. which Keyfeatures has given of knowing that chemo will only give her a benefit of 6-7%, but feeling the need to go for it anyway, because most of us feel that we have to throw everything we can at the cancer in order to give ourselves the best possible chance. In fact, according to the BBC article on the link provided above by Keyfeatures, the risk of "over diagnosis" is only 1%. So it really doesn't make sense to place too much emphasis on this.

I would also want to see a programme of regular and careful monitoring for those who decide to "watch and wait", so that intervention could then be as quick as possible if the cancer were to progress. There would have to be additional follow-up, not just another mammogram 3 years later. I don't, therefore, believe that much money would be saved in this way.

Similarly, I don't believe that only screening high risk women will save money in the long run, as if women are only diagnosed when they present with later stage BC, the chance of them requiring more treatment increases. Not to mention the fact that the higher the stage at initial diagnosis, the higher the chance of recurrence and/or secondaries. And we see time and again on these forums how the number of people diagnosed who are seemingly low risk for BC just seems to keep rising. Because we still don't understand why we get BC or just what the risk factors are. So, those who we currently believe to be low risk may prove to be extremely high risk in the future, when medicine better understands the different diseases of BC.

Finally and slightly off topic, but in response to Key features's post, in the same way that MRIs don't lead to treatment without a biopsy, as far as I'm aware, the same is true of mammograms and ultrasound. It is my understanding that only a biopsy can give an indication of whether a tumour is malignant or benign and that even a biopsy can sometimes miss cancerous cells, given that the cells in most tumours are not uniform. But perhaps I'm wrong and there are people going through treatment for cancer based on a mammogram alone. 

cornishgirl
Member

Re: Independent breast screening review

I suspect that would be because most people in their 80s keyfeaures will most likely have other health problems that sometimes outweigh the odds, not excludeing their age, it would also depend on the type of cancer they had ,how agressive it was and how advanced ,and whether it was invasive or not. lots of things to consider in each individuals breast cancer dx ,they are all not the same and behave differently not only to treatments but also in individuals. This is the problem will clumping all breast cancers together, unless you know a persons individual dx you cannot assume it wasnt the breast cancer that wouldnt have killed them but that other health factors or just plain old age got their first.
topsymo
Member

Re: Independent breast screening review

Hi evryone- this post is getting rather technical isn't it?!
I think the points keyfeatures made in her 1st post chime with a lot of my own thoughts; screening has a down side - so does treatment for BC - there are risks involved in surgery, chemotherapy, and rads- not to mention the pyschological dimension which is so often overlooked. (eg the blunderbuss effect of bombarding our bodies with cell- destroying poisons thro chemotherapy ..... and all its attendant miseries; surely chemo will become more targetted as knowledge increases?)
Flori 35 - your situation sounds very like that of my own daughter who was dx after finding a lump in her neck . There is no history of BC in our family either so we were also at low risk - it's just a rotten co-incidence that we were both diagnosed in a 5 year period- she at 32 and me at 64. Like you, she was found to have well established BC - but screening would not have helped her or you as mammography on younger, denser breast tissue is notoriously unreliable. I beleive that the main reason breast screening continues in its present form is because there would be such a public outcry if it was suggested that it ought to be more targetted and restricted and - as keyfeatures says, with ultrasound and physical examinations for those at high risk.
Unfortunately, as my daughter and you have discoveredd there are always going to be people who don't fit the usual pattern - that why ongoing research is so important. That brings me back to my previous point: mega bucks have been spent on mass screening for many years now- and has that money really been best spent?
Keyfeatures also makes the point that women should continue to be offered routine mammograms, but also be told - in good time- of the potential downsides- ie their consent should be informed. OK if you don't want to know all this - that's a perfectly valid response - though not one I share, but we all know that in the past screening was seen as uniquely beneficial - and the potential for over treament was never mentioned. (though my husband was certainly told all the pros and the cons of prostate screening!)

Guest user
Not applicable

Re: Independent breast screening review

Re: Most cancers if untreated will go on to kill you. I'm not sure about this. 50 percent of women in their 80s will have a breast cancer, but in the vast majority of cases it won't be the thing that kills them.
Guest user
Not applicable

Re: Independent breast screening review

Women invited for breast cancer screening in the UK are to be given more information about the potential harm of being tested.

http://www.bbc.co.uk/news/health-20121043

Yes, MRIs can give false positives, but wouldn't lead to treatment without a biopsy. My MRI gave a false positive of two extra tumours which proved clear on biopsy, therefore my treatment plan stayed the same. It's not only younger women who have dense breasts. Sometimes they stay dense into older age - especially if you don't have children.

Angelfalls
Member

Re: Independent breast screening review

MRIs also throw up many more false positives, so have the potential to lead to even more "over-treatment". And younger women are not part of the screening programme being discussed anyway, so keyfeatures's comment on that point isn't really relevant, of course.

The report in question doesn't advocate changing the advice on mammograms, as keyfeatures suggests, precisely because there is currently no accurate diagnostic tool to predict which cancers will become life-threatening and which won't, much less the time frame for this. The report also acknowledges that the screening programme DOES save lives. If someone with BC can misunderstand the report's conclusions, what hope is there for the general public?

cornishgirl
Member

Re: Independent breast screening review

Its all about risk vrs benifit keyfeatures, and each individuals cancer dxs . There is a risk with everything in life and every kind of drug. One thing for certain is ,most cancers if not treated and left will eventualy go on to kill you.
Linda
Guest user
Not applicable

Re: Independent breast screening review

I see where you come from with the better safe than sorry. The problem is that aggressive treatment isn't safe. I remember when I looked into the stats on herceptin and they were pretty shocking such as that for every 3 women saved, two women die from heart failure (and this is even with the MUGA scans). Here is what wiki says
http://en.wikipedia.org/wiki/Trastuzumab
Even among the 20% of first-time breast cancer patients for whom trastuzumab is an appropriate treatment, the actual net benefits are not overwhelming when viewed in terms of all-cause mortality. All-cause mortality helps balance a reduced risk of death from cancer against the increased risk of death from a treatment's side effects. Repeated, large-scale studies show that it is usually necessary to treat between 25 and 100 patients to prevent a single death during the next two to four years. For each life saved, between ten and 25 patients will develop heart disease; despite effective treatments, some of these patients will die from heart disease. For example, in the N9831 (arm C) and NSABP B31 joint analysis, approximately two patients died of excess heart disease or other complications for every three lives saved by reducing breast cancer. The excess heart disease induced by the drug explains why it is necessary to treat up to 100 cancer patients to save a single life during a two-year study period.
There was debate in 2006 as to whether these benefits may have been over-stated.
The media have sometimes misrepresented trastuzumab as a "cure all" or "wonder drug" and this has caused confusion amongst women with breast cancer about whether they should be receiving the drug or not.

Shortly before I started chemo, my friend's mum died from complications with her second round of chemo (admittedly for lymphoma, not breast cancer). For younger women, the preference may well be aggressive treatment, because they potentially have so much more life ahead of them. But with non-symptomatic cancers in older women I really do wonder if the stress of diagnosis along with the risks from the treatment can be worse than the risk from the disease itself, given their life expectancy may not be more than 10 or 15 years anyway.

I do think it's the right thing to change the advice on mammograms, whilst still giving women the choice to have them. It's wrong to present them as lifesaving, because they're not. They're merely a tool that detects some cancers, but fail to detect others. There is no guarantee that all of the cancers they detect can be cured. There is no guarantee that the treatment involved will not do serious longterm damage, some of it shortening lifespan itself.

MRI is a better bet for younger women, or those with dense breasts, particularly if they haven't had children. My mammogram looked like two white clouds - no chance of spotting a tumour in that. But MRIs are very expensive and time consuming compared with mammograms, so with the current political climate, I doubt they will become standard.
cornishgirl
Member

Re: Independent breast screening review

This review is just another example of ambigious reporting by the media and i think also cancer charitys, because it isnt made clear anywhere in the statements "what" type of breast cancer this review is refering to, useing the term "Breast Cancer" is grouping all breast cancers type/grade ect into one catagory and will be seen that way by the general public .I thought this review was meant to provide clarity and informed choice? where it does neither ,what it does do is cause even more confusion and puts the fear of god into the general public who may very well think twice now about going for breast screening.
Like another poster i assume where the Lancet refers to "invasive cancer" it is refering to a low grade breast cancers ie grade 1, which we are told sometimes can take up to 30yrs to kill someone because it can be very slow growing,depending on the age at Dx this may mean that some people with low grade cancers will go on to die of other causes before their cancer would have killed them, BUT ,we also know that this is not a given and certainly isnt always the case , there are many people including ladies that have been on this forum, who have been DX with a low grade cancer and have since gone on to have recurrences or secondries, the clue is in the "Invasive" not the grade, any breast cancer which is invasive whatever the grade has the potencial to spread, full stop, so shouldnt be presummed by anyone to be over Dx and therefore safe to leave no matter what the age!
It is also known that a cancer can change its receptors and grade, often a biopsy at Dx which shows low /high grade can be upgraded or downgraded, and the full path report CANNOT be correctly given untill the tumour is removed .
So all in all, i think this review brings up more questions than answers and has now only served to scaremonger the public,it has by no means giveing clarity and informed choices in my opinion, as it stands, there is no test to dectect which of these cancers or pre cancers will not go on to harm someone in their lifetime, so over Dx is a misleading term , NO ONE can know for sure whether they were Over Dx or not, because of this ,in my opinion it would be foolish of anyone once a potencial problem is picked up to leave it and wait and see. The earlier a cancer is dealt with the more chance of a sucessfull outcome.
There will im sure, because of this review which has caused more harm than good in my view, and before long i suspect , be even more sensationalist and dramatic news grabbing headlines of law suits from people now declaring how they were over Dx and have been mutilated and scarred for life by the NHS screening program , im sure lawyers are lineing up as we speak!
The good news which should help in all this ambiguty is that CRUK has been working on how to improve the screening program, they say, "Gazing into a crystal ball is always dangerous in medical research, but in this case, we feel justified in doing so. The research we’ve discussed above outlines a tentative sketch of what breast screening may look like in the next decade – call it 2020s vision, if you will…"
http://scienceblog.cancerresearchuk.org/2012/10/30/how-can-we-improve-the-breast-cancer-screening-pr...
Linda
Angelfalls
Member

Re: Independent breast screening review

When having chemo, I have often sat with men and women who are well into their 70s and 80s and who are coping well with their treatment, while I have seen much younger patients with secondaries struggle until their last. The issue of treatment is less about age and more about the health of the patient. One of the dilemmas for those with advanced secondaries is indeed knowing when to stop treatment and accept the inevitable when, for most people, their instinct is to keep on with treatments while they are still available and while there is still the chance that they can extend life, even for a few more months or weeks.

You may feel that 70 is a reasonable cut-off point for you now, keyfeatures, but may feel very differently if you make it to 70. And what would you say to those who are going through treatment in their 70s and beyond? That they are wasting their time?

And on the point of not treating if there are no symptoms, there are many people who have been diagnosed through screening and who have been found to have secondaries at that same time, but who still have no symptoms.

If you only have a 6-7% benefit from chemo, I imagine you turned it down, given that they are far lower odds than the 1:3 chance of having your life saved by screening as opposed to being over-treated.

It seems to me that things really aren't as clear cut as we might hope.

Lemongrove, your argument makes perfect sense to me.

stressy_messy
Member

Re: Independent breast screening review

haha sing up lol.I mean SIGN up xx

stressy_messy
Member

Re: Independent breast screening review

Hi keyfeartures,thanks for explaining.The thing to remember about this is that with the BRCA 1/2 gene it is only women under 30 who may be at risk from Xrays.It doesnt apply to over 30's.also younger women under 30 are usually offered MRI's not mammograms as a mammogram may not detect anything in younger breasts.
Hi Lemongrove the report didn't conclude that DCIS was unlikely to spread.It concluded that there are cases of overdiognosis but it's all estimates and based on observational studies and randomised trials (very old trials) . I really don't see the point in the report and as it has already been said they don't know which DCIS would go on to become invasive and until they take the DCIS away they don't know if there could be some invasive cancer there. I think just give the correct information to women and let them make their own mind up.The media again are giving out the wrong information and could discourage women from going for mammo's when it could just save their lives.
I've printed this from the lancet.It won't let me share the link, but if you sing up on the site you can read all the full reports.

Ductal carcinoma in situ

Ductal carcinoma in situ is a malignant tumour that arises from the epithelial tissues of the breast and consists of neoplastic cells. However, these cells do not infiltrate beyond the limiting basement membrane and therefore remain within the ducts where they arose. Ductal carcinoma in situ is usually grouped by grade into high, intermediate, or low grade. Although the cells have the appearance of malignancy, they do not show invasiveness, so carcinoma in situ is not in itself a life-threatening disease.
The importance of ductal carcinoma in situ in breast screening is that it occurs more frequently in screen-detected than in symptomatic cancers (about 20% vs 5%). Although ductal carcinoma in situ can be associated with invasive cancer, and therefore can be a marker of malignancy, it can also relapse. For example, in the UK, Australia, and New Zealand trial,27 after wide local excision of screen-detected ductal carcinoma in situ, without any further treatment, relapse in the breast occurred in about 19% of cases, and was invasive in half of these cases. This frequency of relapse in ductal carcinoma in situ that has been treated shows that although it may contribute to overdiagnosis, it is wrong to assume that all ductal carcinoma in situ represents overdiagnosis.
The relevant question is therefore not whether ductal carcinoma in situ progresses to invasive cancer (which it can) but whether it might progress to an invasive cancer that causes symptoms within the lifetime of the woman concerned. Progression will depend mainly on the age of the woman, her life expectancy at the point of diagnosis, and perhaps other factors, such as hormonal exposure and obesity. Studies do not show any significant effect of ductal carcinoma in situ on survival, even at 20 years of follow-up, but the increasing survival rate might mean that, for women in their 50s and even 60s, a diagnosis of ductal carcinoma in situ could affect their longer-term survival.28
Thus, in the diagnosis of ductal carcinoma in situ with a screening programme, a balance has to be struck between the potential benefits for some women of the identification and treatment of a precancerous lesion and the risks for others of the treatment of something that would never have affected the woman in her lifetime.
Melxx

Lemongrove
Member

Re: Independent breast screening review

Foxy that is my point precisely. I cannot understand how, in the absence of genetic profiling, these scientists were able to conclude that some cancers were never likely to be problematic. No diagnosis can guarantee 100% accuracy, and the microsope can miss a few aggressive cells (and of course a few is all it takes). So I would have thought the first rule of medicine would apply (better safe than sorry).

Downbutnotout
Member

Re: Independent breast screening review

May I just mention - ectopic pregnancy - and they can kill as well.

Yes, more research and development is needed but for now we have what we have and people (who are eligible for screening) have the choice of whether to have screening or not and whether to accept the treatment that's offered, or not, and to accept whatever happens in the future as a result of that choice/.
X
I just tried to edit a typo but now it's moved the post to the bottom, so if you've already read it sorry it's appeared as new.

Foxy
Member

Re: Independent breast screening review

If you read the summary posted by Stressy-messy (thanks for that) it is clear they are not just talking about DCIS - here is the extract:
"129 cases of breast cancer, invasive and non-invasive, would be overdiagnosed"
So are they also talking about Grade 1 cancers? As someone who had both DCIS and grade 1 invasive, mx because they were behind the nipple and rads because they couldn't get clear margins on one area of DCIS, was I overdiagnosed? Actually, I'm relieved I've been treated. The key for me is the definition of overdiagnosis:
"which is defined as cancers detected at screening that would not have otherwise become clinically apparent in the woman's lifetime"
I was diagnosed at 61 and provided I don't fall off Striding Edge or otherwise suffer an accident I expect to live to 90/95 based on general motality rates, my lifestyle and family genetics. So my lifetime could be longer than many, bc aside. I have just taken my 87 year old mother to see her oncologist, she has lung mets. She was diagnosed at 85 and has had an mx, rads, Xeloda and is now on paclitaxel. She can't cope with the treatment, can't eat and is down to 6.5 stone and can hardly breathe, and I wouldn't put a dog through what she is enduring but she is of an age where she believes doctor knows best. If it's offered she'll take it. My grandmother was also diagnosed at 87 but was too frail for surgery so was given hormone therapy. Quite frankly, I'd rather have the treatment at 61 when I've been able to cope with it than take the risk it finally appears when I can't.
To sum up, they don't know which cancers will become "clinically apparent", and a "lifetime" is subjective, so all in all I'm glad I did it. But it was my choice.

Foxy
xxxxxx

Lemongrove
Member

Re: Independent breast screening review

Keyfeatures the point is that no diagnosis can be 100% certain - there is no way of knowing whether what appears to be a DCIS has some invasive cells present. As to whether chemotherapy is worthwhile and represents over treatment, I think the subject is highly debatable. If you look at the results of the hospital with the best survival stats in the world (The Anderson Cancer Centre at the University of Texas), you will find they are renowned for taking a very aggressive approach (including, for stage 4 BC, surgery, high dose chemo supplemented with stem cell transplantation, and specialist radiotherapy). While aggressive treatment may be innapropriate for those with seemingly early stage BC, my view is that in the absence of absolute certaintly, it's better to be safe than sorry.

Guest user
Not applicable

Re: Independent breast screening review

If some of the cells had the capacity then they were either incorrectly diagnosed with DCIS, or the DCIS became invasive post biopsy. DCIS cells do not have the capacity to create mets. They are as likely to be able to make tumours elsewhere in the body as a recently fertilized egg is able to develop into a baby outside the womb. Even people with a clear mammogram and no evidence of cancer are not 'safe' - but does this mean they should receive treatment just in case?
For someone in their 70s, with no symptoms, there are very good reasons for thinking it would be better to just take the risk of not diagnosing and treating. Should I be lucky enough to reach 70 I think that would be the point at which I wouldn't bother going for screening mammograms - not least because breast cancers are typically a lot slower to progress by that age. I'd rather deal with the risk of cancer than the ordeal of results and treatment by then.
Even for me with an invasive HER2 ER positive tumour, the benefit of chemo is only 6-7percent. That means for every 100 women treated, only 6-7 of us are actually getting a benefit from the chemo. Given the risk of longterm side effects and even death that's quite a hard probability to swallow. For someone older, with a good chance of the cancer not progressing to a lethal level within their lifetime, it may well be better to not diagnose.
I think these are issues for which there is no 'right' or 'wrong' answer - only informed consent. It just goes to show how much more research and development is needed.
Lemongrove
Member

Re: Independent breast screening review

Keyfeatures, the probem is there is no way of knowing if a primary ductal carcioma (even if it is in situ), has the capacity to metastasise. Some people have a DCIS and believe they are safe (for the reason you mention), but later have a recurrence, because in fact some of the cells did have the capacity.These cells broke away into the bloodstream, and then formed tumours when the time/conditions were right. This is why doctors offer radiotherapy and systemic treatment to patients with DCIS.
Of course nobody should be exposed to treatments that they do not require, but the point is until genetic profiling is standard there is really no way of knowing which cancers will become problematic.

Guest user
Not applicable

Re: Independent breast screening review

Lemongrove - No DCIS can't spread via the blood stream as the cells lack the biological capacity to metastasize elsewhere in the body. Also, less than a quarter of DCIS will turn into an invasive cancer within 5-10 years.
Guest user
Not applicable

Re: Independent breast screening review

stressy-messy, there are various genetic markers that make some people more vulnerable to low dose radiation. They still don't know all of them, or how much more vulnerable. I read 5 percent of the population are at increased risk somewhere (it was an article by a woman who had decided not to go for routine mammograms and her reasoning) but now can't find the link. However, here are some related studies.
http://newscenter.lbl.gov/news-releases/2012/10/15/cancer-risk-low-dose-radiation/
And one that specifically mention BRCA1 and BRCA2 mutations as increasing radiation sensitivity.
http://www.nycaribnews.com/news.php?viewStory=2887
Lemongrove
Member

Re: Independent breast screening review

Stressy can you clarify something for me ? On what basis did the report conclude that DCIS in situ, is unlikely to spread. My understanding is that even if cancer is confined to the breast and there are no cancerous cells within lymph nodes, cancer cells can still break away into the bloodstream. As this type of metastases would be undetectable, I would have thought that even DCIS in situ would require treatment. My understanding is that until genetic profiling is standard, there is really no reliable way of knowing what cancers will progress, and so I find it hard to understand how they can decide which represent a threat and should be treated, and which do not and are needlessly treated.
Thanks LG

stressy_messy
Member

Re: Independent breast screening review

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

Downbutnotout
Member

Re: Independent breast screening review

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.

Guest user
Not applicable

Re: Independent breast screening review

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.
stressy_messy
Member

Re: Independent breast screening review

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.

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

Sika
Member

Re: Independent breast screening review

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?!
cornishgirl
Member

Re: Independent breast screening review

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
topsymo
Member

Re: Independent breast screening review

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 .

cornishgirl
Member

Re: Independent breast screening review

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
stressy_messy
Member

Re: Independent breast screening review

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

cornishgirl
Member

Re: Independent breast screening review

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

applestreet
Member

Re: Independent breast screening review

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!!!

Angelfalls
Member

Re: Independent breast screening review

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?

Guest user
Not applicable

Re: Independent breast screening review

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.
Guest user
Not applicable

Re: Independent breast screening review

I've found a summary of the report in the Lancet
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61611-0/fulltext
and also links to editorial
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61775-9/fulltext
and similar articles previously published in the Lancet
http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(07)70380-7/abstract
http://www.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!!!
Zeppa
Member

Re: Independent breast screening review

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.

cornishgirl
Member

Re: Independent breast screening review

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
libby_2010
Member

Re: Independent breast screening review

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

grumpy
Member

Re: Independent breast screening review

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

Guest user
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Re: Independent breast screening review

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

Guest user
Not applicable

Independent breast screening review

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.