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EDITORIALS: J Michael Dixon Screening for breast cancer BMJ 2006; 332: 499-500 [Full text]

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Maturity is the capacity to endure uncertainty.

BM Hegde   (4 March 2006)

More debate and better information still needed

Hazel Thornton   (5 March 2006)

Breast Screening

J Michael Dixon   (8 March 2006)

Prevention of Breast Cancer Rather than Screening

Arne N. GJORGOV   (28 March 2006)

Maturity is the capacity to endure uncertainty. 4 March 2006
BM Hegde, Retd. Vice Chancellor Mangalore-575 004, India Send response to journal: Re: Maturity is the capacity to endure uncertainty.	Dear Editor, Karl Popper and other logical positivists of his time were right in questioning the validity of what we now call evidence base! The scientific knowledge that we talk about (statistical data on breast cancer) is based on the observed facts. Any observation requires tools: e.g. mammography machine in this case. The components of the machine in this case are not observable. The observations depend on the theory that the unknown components of the machine are reliable in the first place. Similarly, in randomized controlled studies the data depend on the assumption that randomized controlled studies are sufficiently valid. If one goes deep into the correct mathematical basis of the dynamic human body (being non-linear) and its time evolution being based on the total initial state of the organism, and not based on small bits of information like the shadows of suspected growth etc, the debate about breast screening or, for that matter, any other screening programme in asymptomatic individuals, should throw up similar inconsistencies. Even if one were to see dysplastic cells in cervical screening, leave alone the shadow in the mammogram, there is no way one could prophecy that those cells would eventually grow into clinical cancer. There could be so many slips between the cup and the lip, as time evolves. The correct term in physics is the “butterfly effect” of Edward Lorenz. The industry, of course, would be more than interested in creating confusion in the minds of the doctors and the population. The latter are told that routine screening is the best bet to remain healthy and live long! Haven’t doctors been predicting the unpredictable future of their patients all along, aided and abetted by the screening industry? Every now and then a new report based on the “mix-master technique” of the so-called Meta analysis should throw up such pro-screening messages. It should not be a surprise as the “judgment among experts generates uncertainty just as real as the probabilistic uncertainty of statistical calculations.” Yours ever, bmhegde Competing interests: None declared
More debate and better information still needed 5 March 2006
Hazel Thornton, Honorary Visiting Fellow, Department of Health Sciences, University of Leicester "Saionara", 31 Regent Street, Rowhedge, Colchester, CO5 7EA Send response to journal: Re: More debate and better information still needed	Rather than end the debate about screening, as Dixon`s editorial [1] suggests, and look to the future, it would be preferable to raise the current level of debate by presenting balanced arguments, avoid misleading presentation of statistics, and consider current evidence about over- treatment [2] and poor quality information. [3] Efforts may have been made, as Dixon suggests, to provide women with sufficient information to make an informed choice, but they have not been successful: the quality still falls far short. The criticism made in 2003 [4] is still valid. Barratt and colleagues have since devised a model of outcomes of mammographic screening showing estimates of benefits and harms that is readily usable by women considering breast screening. [5] They advise that comprehensive information about cancer screening, in line with GMC recommendations, should be balanced (describing benefits and harms over a similar time frame, such as 10 years) and that estimates should be presented with a constant denominator (such as per 100 or per 1000 people). This model and advice, and other decision aids and tools are available, but none have been provided by the NHS breast screening programme to women, as [4] recommended in 2003. If breast screening is to move on, then it is time the proponents of breast screening moved on, not just to the future, but to the present. Women today do not want to be patronized, or fobbed off with unbalanced, insufficient information, but to be treated with respect, so that they can make up their own minds. Decision-making, to give proper consent, requires good quality information. It is evident that they are not getting it. [3] Hazel Thornton, Independent Advocate for Quality in Research and Healthcare. [1] J.Michael Dixon. Screening for breast cancer. BMJ 2006; 332:499- 500 [2] Zackrisson S, Andersson I.BMJ, Janzon L, Manjer J, Garne JP. Rate of over-diagnosis of breast cancer 15 years after end of Malmö mammographic screening trial: follow-up study doi:10.1136/bmj.38764.572569.7C (published 3 March 2006) [3] Jorgensen KJ, Goetzsche PC. Content of invitations for publicly funded screening mammography. BMJ 332: 538-41 [4] Thornton H, Edwards A, Baum M. Women need better information about routine mammography. BMJ 2003; 327:101-3 [5] Barratt A, Howard K, Irwig L, Salkeld G, Houssami N. Model of outcomes of screening mammography: information to support informed choices. BMJ 2005; 330:936-8 Competing interests: None declared
Breast Screening 8 March 2006
J Michael Dixon, Consultant Surgeon and Senior Lecturer Edinburgh Breast Unit, Western General Hospital, Edinburgh EH4 2XU Send response to journal: Re: Breast Screening	There are real efforts in the UK to provide patients with sufficient information to make an informed choice on screening. These efforts are in my view to be applauded. Harms and benefits are mentioned. For those who wish more detailed information this is now readily available from the independent group CancerBACUP. This is a significant move forward. Competing interests: None declared
Prevention of Breast Cancer Rather than Screening 28 March 2006
Arne N. GJORGOV, M.D., M.P.H., Ph.D. Visiting Professor Send response to journal: Re: Prevention of Breast Cancer Rather than Screening	Dear Sir or Madam, Re: PREVENTION OF BREAST CANCER, RATHER THAN SCREENING PROGRAMME With reference to the BMJ Editorial “Screening for Breast Cancer” (1) and the underlying NHSBSP Report (2) I would like to convey to you my remarks and comments. Skeptic considerations about and re-assessments of the ostensible usefulness of breast cancer screening seem to be widespread and enduring (3). Mainly, the controversy seems to be fueled by the failure of the breast cancer screening and early detection program to make any impact upon the unabated and ever-rising breast cancer epidemic in the country and elsewhere (4). The main defense for the extensive ‘downstream” activity of a mammography screening program (salvage of women with breast cancer, at early or any stage) is seemingly related to the mortality of the disease, that early detection “saves lives,” as supported by the observation of decreasing mortality rates of breast cancer, which is contested by many. Perhaps the greatest shortfall in both the Editorial and the NHSBSP Report is the fact that NO mention about the PREVENTION of breast cancer as an epidemic disease (5) is made or referred to. The almost unintelligible allusion to the improved in the future “armamentarium against breast cancer deaths for decades to come” is calculated on the assumption that either the current breast cancer contingency will continue as such in infinity, or that the breast cancer epidemic will conveniently ‘disappear’ sometime ahead. Breast cancer is considered a systemic disease, and the treatment after the ‘early detection’ referral could hardly cover all aspects of the disease in terms of therapy and survival. More than 70 percent of women with breast cancer have discovered the disease by themselves rather than in the ‘early detection’ screening program. Moreover, many scientists used the results of this ‘early detection’ approach as a false ‘proof’ to deny the rapid rise of breast cancer as an epidemic disease and as a growing political and public health crisis in the country and the world over. Moreover, the breast cancer epidemic proved to be quite a different development from the textbook models of the known epidemics in the historical past. The breast cancer epidemic showed no sign of subsiding after its rapid inception at the beginning of 1981; the epidemic never attained a peak (acme) and never showed a decline for more than two-and-a-half decades. Instead of an expected tailed decline, it has continued its speedy rise ever since, creating a political and public health CRISIS in society. The first Breast Cancer Screening Programmes, including the one in the U.K., began in 1988 and after, as a response to the first wave of the breast cancer epidemic and the perplexing rise and spread of the incidence rates, of 57.1 percent per 100,000 women in the United States, between 1981 and 1986 (5). Apparently, the breast cancer crisis will not decline by itself, but it has to be terminated by a planned, community-based intervention, that is, by eliminating the main and almost the sole breast-cancer risk factor in the population, the highly prevalent and persistent CONDOMIZATION of female sexuality. (For cervical cancer, for instance, the detection program by Pap smear, proved to be useful for curing the disease, which is viewed as a topical disease in the early stages. But, for lung cancer, no detection program has been considered feasible, since, not unlike breast cancer, no treatment is satisfactory and because of high mortality.) The mass screening of women could hardly be a future part of the human intervention plan for primary prevention of breast cancer as an epidemic disease (to the level of sporadic cases). The assertion that the “future… continued improvements in diagnosis and treatment” (by mass mammography screening) that would bring about very low mortality death rates of breast cancer, “where screening is no longer necessary,” seems to confirm the inadequacy of the screening activities in this regard. Thus, the envisioned future of the screening programs remains unclear, or to remain within clinical settings for diagnosis. Another question remains, as to whether the possible decline of mortality rate is observed only among the participants in the mammography screening program, or among all breast cancer cases in the community as well. In addition, whether the decline of breast cancer mortality rate is because of the (‘cost-effectiveness’) effect of early detection screening program, or whether the declining mortality rate is, perhaps, due to some other treating modalities, including the triple surgery of hysterectomy-oophorectomy? Hysterectomy along with oophorectomy (one- or two-sided), not unlike oral-contraception pills, is a known (albeit not fully understood) protective factor of breast cancer. Which of the two modalities, non-mastectomy treatment(s) or the frequently applied surgical interventions on the reproductive system exerts any impact on the observed decline of breast cancer mortality rates? Prevention of the breast cancer epidemic remains almost certainly the only viable option in human terms nowadays and into the future (6). Evidence of the potential of primary (non-chemical) prevention of breast cancer has been tested and reported by an American research study during the mid-1970s (long before the AIDS saga ever emerged), and the study has never been rebutted. Given the backdrop of incomplete report and controversy of breast cancer screening, there is new, quite recent information of budget cuts of the screening programs in the United States (7). The budget cuts were related almost entirely to the breast cancer ‘early detection’ program by mammography screening of women (now aged 40 years and over) in the American general population. Some initial, necessary steps for prevention of breast cancer seem to have already been taken in the United States with the “condom-paradigm shift” in favor of the anti-condom reproductive policy. Steps, confronting head-on the long overdue, self-defeating neglect of the crisis, and perhaps foreboding a policy/legacy towards prevention of breast cancer as an excess epidemic disease in the country and beyond. Respectfully yours, Arne N. Gjorgov, M.D., M.P.H., Ph.D. (UNC-SPH, Chapel Hill, NC) Active Member of the New York Academy of Sciences (by invitation) G. Hadzi-Panzov Street, No. 2; 1000 Skopje, Republic of Macedonia; E-mail: arne_gjorgov@hotmail.com References: 1. Dixon JM. Screening for breast cancer (in England). BMJ 2006; 332: 499-500 (4 Mart); doi: 10.1136/bmj.332.7540.499 2. Beral V et al. Screening for breast cancer in England: past and future. Sheffield, NHSBSP Publ. # 61, February 2006 (Advisory Committee Report). Internet 3. Baum M. Screening for breast cancer, time to think—and stop? Lancet 1995; 346: 436 (August 12) 4. Gjorgov AN. Breast cancer: Primary prevention versus the current policy of rescue. New Balkan Politics (Skopje), 2003; 6-7: 143-169;: www.newbalkanpolicy.org.mk/issue6.asp 5. Gjorgov AN. Barrier Contraception and Breast Cancer. S.Karger, Basel- New York, 1980: x+164 6. Gjorgov AN. Prevention of Breast Cancer (Part 1). September 8, 2005. Internet. Web: http://www.makedonija.com/mic/vesti.php?pn=view&seite=11 7. Herbert B. Illogical cutback on cancer. Editorial. New York TimesSelect, March 20, 2006. Competing interests: None declared