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EUROPEAN HOSPITAL Vol 23 Issue 5/14 RADIOLOGY Swiss consider an end to mammo screening Report: Mark Nicholls A panel of experts has recommended that existing programmes be phased out and that systematic screening pro- grammes be replaced with systematic screening information that would give women the opportunity to make indi- vidual choices. The move has been suggested by the seven-member Swiss Medical Board, an independent health tech- nology assessment initiative, which, although sanctioned by some of the country’s leading medical bodies, makes non-legally binding recom- mendations. The board initially published its rec- ommendations in February, triggering a degree of opposition from cancer experts. However, the move was later discussed again by members of the board, which confirmed its position over winding down the breast cancer screening programmes in Switzerland on the basis that screening does not clearly produce more benefits than harm. Two members of the Swiss Medical Board - Dr Nikola Biller-Andorno and Dr Peter Jüni – underlined the position with an editorial in the New England Journal of Medicine, stating: ‘We were struck by how non-obvious it was that the benefits of mammogra- phy screening outweighed the harms.’ With 5,400 women contract- ing breast cancer every year in Switzerland, and with 1,400 deaths from the disease, the board assessed the positive aspects of systematic mammography screening, such as ear- lier detection of tumours, alongside the potentially negative aspects such as excess therapy and psychological stress in the event of false positive results, as well as cost effectiveness. It concluded that mortality rates from breast cancer can be reduced slightly by screening but added: ‘This desirable effect is offset by the unde- sirable effects: specifically with about 100 of 1,000 women with screen- ing, erroneous results are produced, which lead to further investigations and, in part, to unnecessary treat- ments. Furthermore, the cost-effective- ness ratio is very unfavourable.’ This led the board to recommend that no new systematic mammogra- phy screening programmes be intro- duced; a time limit set on existing programmes and a call for all forms of mammography screening to be evaluated with regard to quality and for desirable and undesirable effects. They acknowledged criticism of the recommendations as contradicting‘the global consensus of leading experts in the field’ but maintain they are look- ing at the issue from an unprejudiced standpoint rather than as part of past consensus-building efforts by special- ists in breast cancer screening. Medical ethicist Dr Biller-Andorno is Director of the Institute of Biomedical Ethics at Zurich University and Dr Jüni is an epidemiologist in the Department of Clinical Research at the University of Bern. Other board members are a clinical pharmacologist, oncologic surgeon, nurse scientist, lawyer, and health economist. The Swiss Medical Board – appoint- edandsanctionedbytheConferenceof Health Ministers of the Swiss Cantons, the Swiss Medical Association, and the Swiss Academy of Medical Sciences – has been reviewing mammography since the early part of 2013 and had concerns because they feared the debate was re-analysing out-dated tri- als, with none focused on more mod- ern breast cancer treatments. Drs Biller-Andorno and Jüni wrote: ‘The relative risk reduction of approxi- mately 20% in breast cancer mortality associated with mammography, which is currently described by most expert panels, came at the price of a consid- erable diagnostic cascade, with repeat mammography, subsequent biopsies, and over-diagnosis of breast cancers – cancers that would never have become clinically apparent.’ They suspect there is ‘pronounced discrepancy between women’s per- ceptions of the benefits of mammog- raphy screening and the benefits to be expected in reality.’ Their editorial stated: ‘It is easy to promote mammography screening if the majority of women believe that it prevents or reduces the risk of getting breast cancer and saves many lives through early detection of aggressive tumours. ‘We would be in favour of mam- mography screening if these beliefs were valid. Unfortunately they are not, and we believe that women need to be told so.’ Report: Mark Nicholls A new study has suggested that mammography screening of healthy women can help to significantly reduce deaths from breast cancer. The study used information about women in Norway from 1986-2009 to reach its conclusions and followed all women aged 50-79 years during that period. Principal investigator Lars Vatten, Professor in Medicine/Epidemiology at the Norwegian University of Science and Technology, Trondheim, said: ‘The main finding was that invitation to mammography screen- ing every two years among women 50-69 years of age was associated with 28% reduced risk of dying from breast cancer. The second finding was that 368 women need to be invited to mammography screening to prevent one breast cancer death.’ He explained that a national mam- mography screening programme was gradually implemented in Norway’s 19 counties between 1996- 2005 and that gradual implementa- tion by county, and the near random distribution of invitations within the counties, provided a setting similar to a natural experiment, enabling researchers to compare breast cancer mortality among women who were invited to screening and women who were not (yet) invited. ‘In the analyses we carefully separated breast cancer deaths that occurred among women diagnosed before invitation – without potential for a screening effect – and deaths that occurred among women who had been invited before diagnosis (with a potential for effect),’ Prof. Vatten said. With the research likely to trigger further debate over mammography and the timing of breast cancer screening for women at average risk of the disease, the professor hopes the findings will further inform that debate and underline the need for exact information about screening patterns (date of invitation, date of Benefits: Are they a question of beliefs? New No Experts who oppose an end to screening argue that its value far outweighs the harms Much will now depend on Nikola Biller-Andorno, Professor and Director of the Institute of Biomedical Ethics at Zurich University, studied medicine at the University of Erlangen-Nuernberg as well as philosophy and social sciences at the University of Hagen in Germany, and between 2002-04 worked as an ethicist at the World Health Organisation. In 2004 she was appointed Professor of Medical Ethics at the Charité, Joint Medical Faculty of the Free and Humboldt University, Berlin, and a year later joined Zurich University as Full Professor of Biomedical Ethics. In 2007 she became the founding director of the Institute of Biomedical Ethics. The professor is a member of the Central Ethics Commission of the Swiss Academy of Sciences, a temporary advisor to WHO and deputy editor of the Journal of Medical Ethics. Her bioethics works have been published widely.Mortality rates from breast cancer can be reduced by screening Researchers have found out that mammography screening of healthy women can help to reduce death from breast cancer Photo:Hologic Photo:Hologic 10

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