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Editorial




The trouble with screening
It seems so simple: if a screening test can detect future        indicated that the UK’s Cancer Screening Programme will
disease in an otherwise healthy person, why not be               revise its information leaflet.
tested? The answer is far from simple. For example,                Next, enter the UK’s Department of Health which
the debate about screening mammography for breast                announced last week a massive programme—called
cancer continues to rumble. In an April 2 paper in BMC           Putting prevention first—of screening of otherwise
Medical Informatics and Decision Making, John Keen and           healthy people for vascular diseases and diabetes. Such
James Keen calculate that such screening started at              checks, argues the Department, would lead to a higher




                                                                                                                                                                   Science Photo Library
age 50 and repeated will, over 15 years, avert 1·8 deaths        uptake of primary prevention interventions (statins, anti-
from breast cancer per 1000 women screened. Their data           hypertensives, exercise interventions, weight manage-
were criticised in a commentary in the same journal, by          ment, lifestyle management for impaired glucose
Stephen Duffy from Cancer Research UK, because they               tolerance, and smoking cessation). The aim is to reduce
used modelling. His view of the data from randomised             the risk of vascular disease and to allow earlier detection
trials gives a figure of about 3 per 1000.                        and treatment of kidney disease and diabetes. If applied
   In February this year in the British Medical Journal, Peter   to 15 million people aged 40–74 years, the programme
Gøtzsche, a long-time (some might say controversial)             could prevent 9500 heart attacks and strokes a year
critic of screening mammography, presented his views             (2000 of them fatal), prevent at least 4000 people a
about the facts given to women before agreeing to                year from developing diabetes, and detect a year earlier
the procedure. He claims that information leaflets are            at least 25 000 people with diabetes or kidney disease.
simply misleading. The main downside of screening—               Screening will be done in general practices and possibly
overdiagnosis and overtreatment—is often not                     in community pharmacies. The average annual cost
mentioned, and claims in some leaflets of less invasive           for checks every 5 years and subsequent interventions
surgery or simpler treatment are wrong, because                  will be £332 million, with savings of £3678 million in
screening mammography can lead to more surgery,                  quality-adjusted life years gained. The Department’s
more mastectomies, and more use of radiotherapy.                 view is that the extra staffing resources required will be
Gøtzsche’s views led to a letter in The Times of London,         modest, even though the programme will need an extra
by a well-known slew of mammography screening                    800 general practitioners, 470 nurses, and 750 health-
sceptics. “The most disturbing statistic is that none of         care assistants per year of implementation. But then
the invitations for screening comes close to telling the         there is the ominous warning that the extra number of
truth. As a result, women are being manipulated, albeit          general practitioners needed might put “upward pressure
                                                                                                                               For the Keen and Keen paper
unintentionally, into attending”, they wrote. The irony          on input costs”.                                              see BMC Med Inform Decis Mak
                                                                                                                               2009; 9: 19. DOI:10.1186/1472-
is that the title of the leaflet by the Cancer Screening            Around the world, different countries have screening
                                                                                                                               6947-9-18
Programme in the UK is called Breast screening: the facts.       programmes for many diseases, including cervical, breast,     For the Duffy commentary see
   Gøtzsche and other authors have drafted an alternative,       prostate, and colorectal cancers, and cardiovascular          BMC Med Inform Decis Mak 2009;
                                                                                                                               9: 19. DOI:10.1186/1472-
and they would say properly informative, leaflet. The             diseases. Each one is surrounded by controversy, not          6947-9-19
leaflet’s summary starts: “It may be reasonable to attend         only because the data on benefits and harms are not            For the BMJ paper see BMJ 2009;
                                                                                                                               338: b86. DOI:10.1136/bmj.b86
for breast cancer screening with mammography, but it             straightforward, but also because of the vested interests
                                                                                                                               For The Times letter see http://
may also be reasonable not to attend, as screening has           (eg, fee per service) that make screening into a business.    www.timesonline.co.uk/tol/
both benefits and harms.” The leaflet goes on to say that          The public is left totally confused, and usually at the       comment/letters/article
                                                                                                                               5761650.ece
one woman will avoid dying from breast cancer out of             mercy of screening providers. Before becoming a patient,
                                                                                                                               For the alternative leaflet on
2000 screened regularly for 10 years. But, at the same           a healthy individual deserves fully informed consent, with    mammography screening see
time, ten healthy women will become cancer patients              information provided at the individual and population         http://www.screening.dk/folder_
                                                                                                                               uk.pdf
and be treated unnecessarily (lumpectomy, mastectomy,            level. In the April issue of the Journal of Medical Ethics,   For Putting prevention first see
radiotherapy, and sometimes chemotherapy). And                   Gøtzsche returns to the fray with a sensible decision: keep   http://www.dh.gov.uk/en/Public
                                                                                                                               ationsandstatistics/Publications/
about 200 healthy women will have a false alarm, with            the responsibility for the information provided separate      PublicationsPolicyAndGuidance/
                                                                 from that for the screening programme. ■ The Lancet
attendant psychological distress. News reports last week                                                                       DH_083822



www.thelancet.com Vol 373 April 11, 2009                                                                                                                  1223

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El Negocio de La Prevencion

  • 1. Editorial The trouble with screening It seems so simple: if a screening test can detect future indicated that the UK’s Cancer Screening Programme will disease in an otherwise healthy person, why not be revise its information leaflet. tested? The answer is far from simple. For example, Next, enter the UK’s Department of Health which the debate about screening mammography for breast announced last week a massive programme—called cancer continues to rumble. In an April 2 paper in BMC Putting prevention first—of screening of otherwise Medical Informatics and Decision Making, John Keen and healthy people for vascular diseases and diabetes. Such James Keen calculate that such screening started at checks, argues the Department, would lead to a higher Science Photo Library age 50 and repeated will, over 15 years, avert 1·8 deaths uptake of primary prevention interventions (statins, anti- from breast cancer per 1000 women screened. Their data hypertensives, exercise interventions, weight manage- were criticised in a commentary in the same journal, by ment, lifestyle management for impaired glucose Stephen Duffy from Cancer Research UK, because they tolerance, and smoking cessation). The aim is to reduce used modelling. His view of the data from randomised the risk of vascular disease and to allow earlier detection trials gives a figure of about 3 per 1000. and treatment of kidney disease and diabetes. If applied In February this year in the British Medical Journal, Peter to 15 million people aged 40–74 years, the programme Gøtzsche, a long-time (some might say controversial) could prevent 9500 heart attacks and strokes a year critic of screening mammography, presented his views (2000 of them fatal), prevent at least 4000 people a about the facts given to women before agreeing to year from developing diabetes, and detect a year earlier the procedure. He claims that information leaflets are at least 25 000 people with diabetes or kidney disease. simply misleading. The main downside of screening— Screening will be done in general practices and possibly overdiagnosis and overtreatment—is often not in community pharmacies. The average annual cost mentioned, and claims in some leaflets of less invasive for checks every 5 years and subsequent interventions surgery or simpler treatment are wrong, because will be £332 million, with savings of £3678 million in screening mammography can lead to more surgery, quality-adjusted life years gained. The Department’s more mastectomies, and more use of radiotherapy. view is that the extra staffing resources required will be Gøtzsche’s views led to a letter in The Times of London, modest, even though the programme will need an extra by a well-known slew of mammography screening 800 general practitioners, 470 nurses, and 750 health- sceptics. “The most disturbing statistic is that none of care assistants per year of implementation. But then the invitations for screening comes close to telling the there is the ominous warning that the extra number of truth. As a result, women are being manipulated, albeit general practitioners needed might put “upward pressure For the Keen and Keen paper unintentionally, into attending”, they wrote. The irony on input costs”. see BMC Med Inform Decis Mak 2009; 9: 19. DOI:10.1186/1472- is that the title of the leaflet by the Cancer Screening Around the world, different countries have screening 6947-9-18 Programme in the UK is called Breast screening: the facts. programmes for many diseases, including cervical, breast, For the Duffy commentary see Gøtzsche and other authors have drafted an alternative, prostate, and colorectal cancers, and cardiovascular BMC Med Inform Decis Mak 2009; 9: 19. DOI:10.1186/1472- and they would say properly informative, leaflet. The diseases. Each one is surrounded by controversy, not 6947-9-19 leaflet’s summary starts: “It may be reasonable to attend only because the data on benefits and harms are not For the BMJ paper see BMJ 2009; 338: b86. DOI:10.1136/bmj.b86 for breast cancer screening with mammography, but it straightforward, but also because of the vested interests For The Times letter see http:// may also be reasonable not to attend, as screening has (eg, fee per service) that make screening into a business. www.timesonline.co.uk/tol/ both benefits and harms.” The leaflet goes on to say that The public is left totally confused, and usually at the comment/letters/article 5761650.ece one woman will avoid dying from breast cancer out of mercy of screening providers. Before becoming a patient, For the alternative leaflet on 2000 screened regularly for 10 years. But, at the same a healthy individual deserves fully informed consent, with mammography screening see time, ten healthy women will become cancer patients information provided at the individual and population http://www.screening.dk/folder_ uk.pdf and be treated unnecessarily (lumpectomy, mastectomy, level. In the April issue of the Journal of Medical Ethics, For Putting prevention first see radiotherapy, and sometimes chemotherapy). And Gøtzsche returns to the fray with a sensible decision: keep http://www.dh.gov.uk/en/Public ationsandstatistics/Publications/ about 200 healthy women will have a false alarm, with the responsibility for the information provided separate PublicationsPolicyAndGuidance/ from that for the screening programme. ■ The Lancet attendant psychological distress. News reports last week DH_083822 www.thelancet.com Vol 373 April 11, 2009 1223