SOUNDING BOARD: IS ROUTINE HIGH-TECH SCREENING JUSTIFIED IN PEOPLE WITHOUT INCREASED RISK?

A new Dutch paper at a current Breast cancer BRCA congress in Berlin is reported by the BBC as showing that by 2006, “deaths fell by 30% in those women who had screening mammography in their late seventies” ; http://news.bbc.co.uk/go/em/-/1/hi/health/7352483.stm And From New York, “Screening mammography in elderly patients beneficial” – but no actual benefits to the patients are disclosed, unless one considers surgery without symptoms or disease beneficial to the patient rather than the service provider. http://www.eurekalert.org/pub_releases/2008-04/arrs-smi041108.php.

Mammography is by definition diagnostic not screening if there is already a clinical reason for mammography ie a palpable lump worrying the patient or doctor. Screening, like surgery, is surely by definition justified only if it offers some material benefit to the patient?

But do these (reports published without results to see, in studies, not randomised controlled trials) justify doing screening mammography SMG on all postmenopausal women not at known risk ie who do not have/ have never had any risk factors including on regular manual palpation and family history?
What difference does it make if one simply waits till the elderly woman has a palpable ie still relatively small lump picked up (if ever) at (her) routine (monthly) (self)exam, and a simple non-disfiguring excision done?

It is common cause that all common cancer is less aggressive in the elderly and is rarely the cause of death or disability. http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Breast_Cancer_Less_Aggressive_in_Elderly_Women.asp ; http://www.accessibility.com.au/news/noncancer-deaths-more-common-among-breast-cancer-survivors

All Health Authorities advocate regular (~annual) SMG at least on women 50- 69years , with the upper limit being extended to 75years in some countries. Authorities & governments would – such screening means huge sales, jobs , taxes, profits, kudos.

Since BRCA is the commonest cancer in non-smoking better-off women,the pros and cons of presymptomatic diagnosis is an enormously emotive topic – quite apart from the toasted breast sandwich involved.

But the perennial question remains. Is fear, and the widespread availability of expensive high-tech screening, being used to promote the giant profitable screening industry – does high-tech detection of silent asymptomatic breast, colon or pelvic cancer actual give long-term benefit to patients ? when many such silent cancers are present at death without every having caused symptoms, impairment or disease.

The USA Government health authorities in 2007 show that despite policy promoting SMG, the rates of SMG have fallen in 2000 – 2005. Is this negligence, or common sense?http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5603a1.htm

THOSE IN FAVOUR SAY AYE!
Automated high-tech screening mammography is passionately advocated by service providers, who favour all types of high-tech universal screening:

in the Swedish Two-County Trial of SMG, in “ 77 080 women randomised to an invitation to SMG and 55 985 to no invitation, . there was a significant 31% reduction in breast cancer mortality in the invited group . There was 12% non significant increase in deaths from other causes among breast cancer cases in the invited group (95% CI 0.96-1.31; p=0.14). A conservative estimation gave a significant 13% reduction (RR 0.87, 95% CI 0.78-0.97; p=0.01) reduction in deaths from all causes.
<a href=”http://”>

http://www.ingentaconnect.com/content/rsm/jms/2002/00000009/00000004/art00004

In the 14 year follow-up from the Edinburgh randomised trial of breast-cancer screening in 54600 women, unadjusted results showed a difference of just 13% in breast-cancer mortality rates between the intervention and control groups (156 deaths [5.18 per 10,000] vs 167 [6.04 per 10,000]; rate ratio 0.87 [95% CI 0.70-1.06]).. http://www.ncbi.nlm.nih.gov/pubmed/10371567

The 16-year mortality from breast cancer in the UK non-randomised study of Early Detection of Breast Cancer set up in 1979 in England and Scotland recruited women aged 45-64 years. Breast-cancer mortality was 27% lower in the two screening centres combined than in the comparison centres. No reduction in mortality in the two breast self-examination centres combined was seen The results support those from randomised trials in Edinburgh and elsewhere, and show that a reduction in breast-cancer mortality resulting from screening can be achieved in the UK. There was no evidence of less benefit in women aged 45-46 years at the start of screening; the effect of screening in this age-group begins to emerge after 3-4 years. . <a href=”http://”>http://www.ncbi.nlm.nih.gov/pubmed/10371568

THOSE AGAINST generally stay mum– it’s dangerous to go against populist opinion that is driven by major financial interests..
But in 2006, Gøtzsche PC and Nielsen at the Nordic Centre analysed all randomised controlled trials, and controversially questioned “whether mammography screening does more good than harm. The two trials (Canadian) with adequate randomisation did not find an effect of screening (RR risk ratio 1.1) on cancer mortality, including breast cancer after 10 years, or on all-cause mortality, after 13 years. Breast cancer mortality was an unreliable outcome that was biased in favour of screening, mainly because of differential misclassification of cause of death. Numbers were significantly 30% larger in the screened groups. CONCLUSIONS: Screening likely reduces breast cancer mortality. But based on the risk level of women in these trials, the absolute risk reduction was 0.05%. Screening also leads to over-diagnosis and over-treatment, with an estimated 30% increase in eg lumpectomies, mastectomies and radiotherapy, or an absolute risk increase of 0.5%. This means that for every 2000 women invited for screening throughout 10 years, one will have her life prolonged but 10 healthy women, who would not have been diagnosed if there had not been screening, will be diagnosed as breast cancer patients and will be treated unnecessarily. It is thus not clear whether screening does more good than harm. Women invited to screening should be fully informed of both benefits and harms.” http://www.cochrane.org/reviews/en/ab001877.html

THE CANADIAN TRIALS:
Comparing screening mammography alone versus manual examination (usual care) alone from 1980-85,
Tony Miller et al in the Canadian National Breast Screening Study of women followed through for 13 years showed similar breast cancer death rates and similar survival rates whether by manual breast exam or SMG:
In two groups each of 19700 aged 50-59years at outset, http://jnci.oxfordjournals.org/cgi/content/short/92/18/1490 . The average lead time for the mammography plus physical examination group has been estimated to be 3.6 years (95% CI = 2.7–5.5) and that for the physical examination-only group was 1.5 years (95% CI = 1.0–3.3 years); therefore, the lead time gained by mammography was, on average, 2.1 years. All-cause Mortality was similar at 0.35%pa and breast cancer mortality 1/7th of that at 0.05%pa
(c/f .01% in Finland , with no benefit from SMG – Antilla ea 2008 http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=18226204), while invasive BRCA incidence was 0.23%pa ie the BRCA mortality rate from invasive breast cancer irelative to those who got invasive BRCA was about 22%pa. .
In the two cohorts each of 25215 age 40-49yrs at outset, – http://www.annals.org/cgi/content/full/137/5_Part_1/305 ,
all-cause mortality was 0.1%pa and breast cancer mortality 1/3rd of that at 0.034%pa were almost identical comparing the two group while invasive BRCA incidence was 0.19%pa; ie the BRCA mortality rate from invasive breast cancer relative to those who got invasive BRCA was about 22%pa.
In this study, only slightly more BRCA were detected by mammography alone or by manual exam alone than by usual care; but twice as many BRCA ie 0.04% pa- were detected by combination of SMG plus physical exam -. Thus screening mammography offers only marginally more detection than manual exam, and no better survival..”

Analysis of studies of results of high-tech ie technology-based screening for lung; prostate, colon, uterine and ovarian cancers, cholesterol- lipidemia or cardiovascular disease similarly gives no strong evidence favouring widespread screening in asymptomatic people without relevant symptoms or risk factors. It is common cause that, in those without strong family history of common major degenerative disease, of premature deaths and disabling diseases, preventable smoking, obesity- diabetes, vascular disease, dementia and fractures affect probably tenfold more people than preventable cancers.

From the published data, there is just not enough evidence to justify that either the state, or medical schemes, should pay for routine high-tech screening for any disease in those who do not have risk factors or symptoms.

Instead, all patients and doctors should be compelled by Regulators, employers and medical schemes to regularly monitor blood-pressure, dental and eye health, BMI and waist girth, since early simple management of any abnormalities have proven major longterm benefits and cost-savings, without any of the costly risks of eg false-positive high-tech screening, or of waiting for disease – obesity, vascular accident, blindness etc – to present. Changing peoples’
lifestyle, exercise patterns is not easy, but huge benefits accrue therefrom.

So perhaps the compromise, to meet the concern of the hawks, is that since (unlike prostates), removal of small suspicious colon polyps and breast lumps is easy, all at low risk should be accepted for breast/ colon imaging once in midlife; and if this screening be negative, left in peace unless something develops or eg the woman or man starts on HRT.

By contrasr: Only Disease Pays the Disease Industry; so is it ethical to allow people to wilfully continue destroying their health with alcohol, smoking, overweight, neglect of hypertension, then allow them to rely on their health scheme/ insurer (which may be the State) to repair them at enormous cost, support them if disabled, when major disease breaks out?

And is it ethical for low-risk asymptomatic patients who can afford it to be encouraged to have futile repeated high-tech screening? http://news.sky.com/skynews/article/0,,91168-1269537,00.html
http://www.webmd.com/breast-cancer/news/20080304/new-feedback-on-high-tech-cancer-screen</a>
When the only interventions from young age that have been proven to reduce by about 50% all-cause mortality from the common major chronic degenerative diseases of aging are:
Regular exercise; no smoking; avoiding overweight, maintaining normal bloodpressure;
Fish oil a few grams a day;
And other essential multisupplements in balance that deplete in the food chain and with aging and pollution
ie all vitamins , minerals and biologicals- (human, other species’ and plant, and appropriate HRT (thyroid, sex hormone, cortisol replacement).