15 April 2020
Synthesis of the article published in the BMJ blog of Pr.Susan Bewley
by Cécile Bour, MD
Susan Bewley is Professor Emeritus of Obstetrics and Women's Health at King's College London and Chair of Healthwatch (Collective for Science and Integrity in Medicine). She is highly critical of breast cancer screening and has published a multi-faceted analysis of the ongoing UK trial for extending screening.
On her blog BMJ she writes about the suspension of organised breast cancer screening, which was in force during the covid-19 pandemic in several countries.
For Pr. Bewley, the suspension of systematic breast cancer screening during covid-19 offers an opportunity to take into account the criticisms made of these mass screening programs, these reproaches and controversies that have existed for three decades now, insufficiently relayed in France, particularly during Pink October, a national campaign that absolutely annihilates any contradiction in the public space.
Priority to patients
The NHS (National Health Service) has given priority to the needs of the ill and vulnerable through this suspension, explains Susan Bewley.
In the middle of a global pandemic, writes Susan Bewley, we can no longer afford the politically popular luxury of needlessly making the general public unwell through anxiety and overdiagnosis. Routine mammographic breast cancer screening and the AgeX clinical trial—which was designed to generate evidence about extending screening to women even outside the current 50-70 age group—have stopped (Editor’s note : the links are those proposed in the original text).
Although it was not obvious from national websites, or in the media, letters, texts, and phone calls have been informing women since mid March that all routine screening appointments are cancelled. Services have since been suspended in parts of Canada, Italy, Scotland, and Australia (Editor’s note, also in Belgium, in addition to above mentioned countries).
Mobile mammography screening vans are parked and silent. Staff are clearing the decks and helping those women already in the system after a positive screen. Once this is done, staff will be redeployed for the Herculean task of constraining coronavirus or keeping other parts of the NHS afloat.
No safety risk posed to the public by stopping screening
This recognition that breast cancer screening is non-urgent must be applauded, and the general public reassured. It suggests that stopping screening poses little overall danger (and even, by some people’s interpretations, possibly none whatsoever) to women. Anyone with a lump, skin dimpling, or other symptoms who might have an active cancer, should be encouraged to call their GP as usual, as the urgent pathways remain open.
In the UK, regional breast screening services are telling women that screening is “on hold.” The intention appears to be to resume screening when, and if, the coronavirus pandemic ends. But this is a golden opportunity for the National Screening Committee (NSC) to pause, reconsider criticisms of the screening programme, and evaluate whether to modify a programme that does not impress clinically or cost effectively.
Susan Bewley explains that breast cancer treatments have been revolutionised since screening was introduced in 1987, thus long ago traversing the “sweet spot” between pointlessness, through usefulness.
Screening can be useless at first, when a disease is discovered without effective treatments.
Second, it can be useful when it meets Wilson and Jungner's criteria and identifies early patients who will do better with available treatment than if they had waited until symptomatic.
But it becomes pointlessness again when good treatments for symptomatic cancer are available, as they are now, and at the same time the balance of benefit/risk in mammographic screening tilts towards its causing excessive harm to the well.
In other words : the more effective the therapies currently available, the more pointless systematic screening becomes, especially if it causes more disadvantages than benefits.
The good news story—that treatment for symptomatic breast cancer nowadays is excellent—has been drowned out by a thirst for “more” searching and resoothing of anxiety. Going “cold-turkey” on screening may be an unexpected, but welcome, way to wean the public off its dependence on searching for diseases that might never have harmed anyone.
The termination of certain screening programs already mentioned
Even before covid-19, Mike Richards, the UK government’s chief inspector of hospitals in the Care Quality Commission, had already called for a halt to PSA prostate cancer screening. More, even different, screening is not an acceptable answer to the difficult question for urologists of why prostate cancer death rates have risen during an era of opportunistic PSA screening with ever increasingly numbered multi-needle biopsies used for diagnosis and surveillance. (Editor's note: this screening does not figure in the official French recommendations).
This moment can be seized, says Pr. Bewley, to discuss popular myths about screening. There is no evidence that “health checks” achieve anything in terms of long term outcomes, barring diverting NHS resources away from looking after those who are actually ill.
Reducing smoking and alcohol consumption and lowering obesity would do a lot more for the population’s health.
Read also: "It's time to stop early detection of cancer".
Susan Bewley concludes : If mammography screening does return post pandemic, it must be reinstituted without any alarmist messaging, pre-booked appointments, reminders and disclaimers, or financial targets for GPs to encourage attendance. We need better processes and an “informed consent” leaflet that makes it entirely clear that it’s a choice—and not necessarily a bad one—to decline.
We can only agree with all these considerations expressed by Pr Bewley for the United Kingdom and make similar requests for France. Professor Autier's synthesis work in 2018 already supported what Professor Susan Bewley is stating today, in favor of the suspension of the breast cancer screening program in the UK and other countries.
- In populations where mammography has had a high penetration, screening mammography has had no or only a limited influence on the burden of advanced breast cancer, and no influence at all on the burden of meta- static breast cancers at diagnosis.
- Over-diagnosis is a source of considerable harm to women who undergo screening mammography. It is no longer acceptable nowadays to minimize the burden of it, nor its consequences, the over-treatments.
- If screening mammography has some influence on breast cancer mortality, this influence is fading away with progress in patient care management. This means that the more effective the patient management, the less useful screening is, especially if the risks outweigh the benefits.
- Decision-makers implementing national cancer action plans must be aware of the serious gaps in the data presented to them as indisputable, they must take greater account of data from independent international scientific studies implicating mammography screening, and alerting women to the risk of unnecessary disease experience.
- The information given to women on the risks of screening is insufficient , a notion that the 2016 citizens' consultation on screening conducted in France had already pointed out.
The covid19 current context has shown us the importance of conducting sound clinical trials and of the EBM, evidence-based medicine. Proper data analysis is essential and studies strongly contesting the benefits of mammography screening should no longer be systematically and deliberately hidden, ignored by decision-makers and concealed from women.
We therefore ask French decision-makers to reconsider the relevance of the mammography screening program in France, to take into account the demands of citizen consultation, to work for the creation of neutral and objective information tools and decision-making aids for women, and to suspend the costly, disinforming and anxiety-provoking Pink October incentive campaigns.
This program must be taken out of the ROSP system (Remuneration on Public Health Objectives for french doctors), suspend the system of scheduled convocations and guilt-triggering reminders for women when they do not attend appointments.This screening should be presented as a choice, with the option of refusal, and not as a requirement.
The woman must be confident, free of anxiety, free of guilt, and consider mammography screening as an optional possibility, without proven harm or loss of chance when she does not adhere to it.
We call on authorities in power to use this time of screening suspension to rethink the system, to stop the program as requested by citizens, and to undertake an in-depth reflection before restarting the program.