Objections are being raised to women being presented with an entirely positive picture of breast screening, writes ANN MARIE HOURIHANE
DESPITE OUR howling and perfectly legitimate protests about the health cuts, it is undeniable that an awful lot of modern medicine is patient-led.
We make the demands on the medical system and get pretty emotional when those demands, again most of which are perfectly reasonable, are not met. Politicians are afraid of us. Doctors dismiss us as irrational beings who must somehow be humoured. It is in this context that your ordinary woman in the street should perhaps take a long, hard look at breast cancer screening.
Last week general practitioner Dr Iona Heath, writing in the London Independent newspaper, declared that she would not have a mammogram. This is interesting to those of us who have had several. Dr Heath, who has of course seen patients die of breast cancer, particularly objects to women being presented with an entirely positive picture of breast screening.
She says that the NHS leaflet sent to women in the UK, encouraging them to come for breast screening, conveys a clear expectation that any rational, socially responsible woman will accept the invitation.
In whose interests does this operate? It is always instructive to see what doctors do about their own health. Female doctors, frequently to be found having a quick fag out the back, in my experience, are an interesting case in point.
The NHS leaflet on breast screening to which Dr Heath refers has been scrapped, because it makes no mention of the dangers of overdiagnosis. That is according to an editorial in the British Medical Journal entitled Overdiagnosis and Mammography Screening. It was written by H Gilbert Welch, a professor at Dartmouth Medical School, who says of overdiagnosis in national breast screening programmes, the question is no longer whether, but how often, it occurs.
Put it another way, Prof Welch was one of the authors of a paper entitled Ramifications of Screening for Breast Cancer: 1 in 4 Cancers detected by Mammography are Pseudocancers (BMJ 2006). Now there is a title to conjure with.
The latest research, conducted in Canada, Australia, the UK, Norway and Sweden, and published in the BMJ on July, has found that one in three breast cancer cases diagnosed in routine screening programmes would not have progressed into anything sinister if they had not been detected during the screening process. This rate of overdiagnosis was consistent over the five countries surveyed.
The stress, the surgery, the unpleasant treatments undertaken by women who have not needed them is awful to contemplate.
We, the general public, are pretty dutiful about screening, turning up faithfully to those mobile vans with our appointment cards clutched in our hot little hands. Breast cancer is common enough to keep us permanently frightened.
We all know people who have had it, fought it or succumbed to it: in my case, a dear friend who is in tip-top shape now, thank goodness, and a beloved aunt, my godmother, who died of it more than a decade ago, having lived with a disease for the previous 10 years. In the 20 years since her diagnosis there have been several generations of amazing improvements in the detection and treatment of breast cancer. But I still miss her.
Dr Heath is right when she says that we are the screening generation. She has read about the modern, almost religious, attitude to screening which is generated both by patients and by doctors. A colleague of hers, Dr David Misselbrook, has called screening a psychological trick to manage our fear in his book Thinking About Patients.
It is fascinating that doctors themselves are questioning not just the wisdom of spending millions on screening in a time of desperate recession, but the long-term statistics used to justify huge screening programmes, as well as the distress and unnecessary treatments that they cause to the misdiagnosed.
It is surely no coincidence either that both Iona Heath and David Misselbrook are GPs, working outside the hospital system and pretty close to the sobbing patients who are the inevitable side-effect of screening programmes that are held up to us as the answer to all our woes.
It is a strong patient indeed who, faced with a diagnosis of cancer, refuses medical intervention. I only know one woman who has done this and she was over 70 when she refused surgery on a lump which had been diagnosed as cancerous. I realise that the implications of breast cancer can be different for women in that age group, but it was still very plucky of her to refuse surgery. Happily, she is now over 80 and remarkably healthy.
The interesting thing about her refusal was the reaction of the medical staff to the news. Several nurses in the cancer unit congratulated her on her decision, and even the doctor said he wouldn’t argue with her.
I would just like to make it clear that if I was diagnosed with breast cancer I would gallop to the operating theatre, knocking 70-year-old heroines out of my way.
But in its calmer moments the screening generation must look at screening. The technology is getting better and better, giving us more and more opportunities for intervention. This is a wonderful development, but we should be informed about the downside of the modern urge for screening and not treated as if we were children, unable to cope with bad news.