Breast screening review? I predict a riot.

What if the review does show breast screening benefits have been overstated and risks underplayed?

 

It has just been announced that there will be a review of breast screening. This is because of concerns that harms are bigger than previously supposed. Most women are unaware that there are risks other than pain and some X ray exposure. Not being told clearly in the information leaflet or in general breast cancer awareness raising rhetoric is to blame. The big risk is the exposure of women to over diagnosis and overtreatment. This means that some women are getting diagnosed so early through screening that they are having vigorous treatment to tumours which would have had no effect on their lives, ever. There is also some uncertainty about the real number of lives saved too – the benefit for which screening was brought in.

 

Screening is the call action for breast cancer charities, a helpful high profile thing to do in raising awareness. The lack of such a thing in other cancers casts them into the shadows of public awareness, because there isn’t an ‘action’ to advise people to take.

 

Breast cancer charities will be worried that it might go, or be severely modified. But it may not be. We don’t know the result of the review yet. But it is a possibility. The charities will start planning out their media campaigns on all scenarios round about ….oooh.... now!

 

Breakthrough Breast Cancer, as usual, already know an answer, sans review, but fail to offer a comment that suggests they had really noticed the story they were being asked to comment on. There they are on the BBC website pressing, as usual, the benefits of screening. The BBC  (I was going quickly, otherwise I would have checked Breakthrough's website) may have misquoted him utterly. In which case the BBC should apologise, as I do, now.

 

Breakthrough Breast Cancer's chief executive Chris Askew said: "Breast screening is vital as it can detect breast cancer at the earliest possible stages when no other symptoms are obvious.

 

"The earlier breast cancer is picked up the better for the one in eight women who are diagnosed every year with this disease, as treatment options are more likely to be less aggressive and have successful outcomes."

 

He brooks no challenge to screening, doesn't mention over treatment of indolent breast cancers or even apparently notice there is going to be a review because of it. I fear this is a stock screening comment recycled by the Press Team, who seem not have realised it’s a very important story. If the CEO wasn’t there, this was a good time to turn down the chance to comment for the Beeb. Or use another senior staff member who knows stuff. There will be one. You don’t look very bright or engaged.

 

So, moving on from Breakthrough Breast Cancer’s predictability, here are some other predictions.

 

Even if evidence against the programme emerges, it won’t be possible to scrap or down grade it without a fight. It was brought in by the pressure of many women asking for it. How easy will it be for the next generation of women to contemplate that those efforts may have been misguided?

 

When the review comes out there will be efforts to trash the expertise of the reviewers. Mike Richards (Cancer Czar) stated on Radio 4 'Today' that they would be using expert statisticians who have no previous history wrangling over the statistical interpretation of breast screening. This means no conflicts of interest, axes to grind or entrenched views. Good.

 

However, that will open them to the counter accusation that these people don’t understand breast cancer and have no business looking into it with their airy fairy statistical expertise because, as we all know, statistics can be made to say anything. Then there'll be arguments about selective use of evidence, or the right evidence but wrongly evalutated.

  

This would be a spurious argument, of course, that will play well with the public and make no sense. Convincing but not relevant, but I predict 'convincing' will win. The argument will be along the lines of breast screening is a special case and women's voices in favour of it should be heard – as if that makes the statistics on lives saved and harm done a secondary outcome of the screening programme, and women’s feelings about the service the primary one. 

 

Screening does not exist to prove breast cancer and the women who have it are important. If screening is removed or modified breast cancer and women who have it won't suddenly become unimportant.  

 

It’ll be interesting to see which, if any, of the cancer charities might line up quietly behind a 'don't change the screening' cause, pulling a few strings here and there, not actually supporting it overtly but helping out behind the scenes by find women with breast cancer prepared to articulate it. So look out for the disingenuousness.

 

I predict that if the review comes out either against or equivocal about breast screening, the breast cancer charities will find it hard to let go of their enthusiasm for it. It’s like admitting they were wrong.

 

Be brave. You weren’t wrong. The evidence changed, that's all. Look to the present and the future.

 

Some years ago I was a children’s nurse, taught to put babies tummy side down, to sleep. Eventually global research evidence revealed that prone sleeping was the single most important risk factor in causing cot death. The Americans were slower, by about four years, in changing practice because they didn’t want to admit that their advice was wrong. They carried on giving the same wrong advice because to do otherwise meant acknowledging they had been wrong in the past. Their professional status depended on them being in the right all the time, for ever. Not good enough. Babies died unneccesarily.

 

So man up, if you have to, breast cacner charities. Admit you were following convention and the evidence as it seemed to be, in good faith. That's a positive, not a negative. If the evidence changes to something else (we don’t know what, or even if, yet) let your advice follow the evidence and maybe change too…..

 

The point is not to hang on to breast screening at all costs. The point is to inform on how much benefit, how much harm and let each woman decide.

 

And somewhere in the background the prostate cancer lobby for PSA testing might be sitting up and taking notice. Men commonly believe, and will say, it’s sexism that created the breast screening programme in the first place and the ongoing cost of it now denies them the resources for an early diagnosis screening programme for prostate cancer by PSA testing. Now breast cancer screening may be considerably more ambiguous in its effects than previously supposed this could rob them of some reason for their occasionally misogynist bleatings on PSA screening. I predict though that it wouldn’t make any difference to that lobby's fascination with the PSA test, even though the same statistical questions about the risks of the PSA test are the exactly the ones raised that mean the review of breast screening will now occur.

 

Almost finally, I predict that any finding that proposals to downgrade the NHS breast screening programme will easily be campaigned against as another anti-woman cost cutting measure in public services.  

 

So I predict the breast screening programme won't change, no matter what the evidence.

 

Women voters are vital. Will the coalition government really risk taking on the huge breast cancer lobby if the review is anything other than out and out in favour of screening? Ha! Nope. They won’t.

 

Evidence based health policy anyone?