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June 2013

Professor Jacob (Jack) Canick

Medical Screening Society founding member Jack Canick died on 19 May 2013. As a tribute to him and his teaching a new page provides downloads of many of his talks.

Thursday 13 September 2012

First comprehensive review of European breast cancer screening programmes finds benefits outweigh harm

A major review of breast cancer screening services in Europe, published in a special supplement of the Journal of Medical Screening[1], has concluded that the benefits of screening in terms of lives saved outweigh the harms caused by over-diagnosis.

The results show that for every 1,000 women screened every two years from the age of 50 to the age of about 68-69, between seven and nine lives would be saved, and four cases would be over-diagnosed.

The European Screening Network (EUROSCREEN) working group [2], with members from nine European countries where outcome of screening programmes have been assessed, reviewed the estimates of benefit in published European studies in terms of breast cancer deaths prevented, and the major harms, in particular, the rates of what are called “over-diagnosed” cancers. These are breast cancers diagnosed as a result of screening, which would never have given rise to any symptoms during a woman’s lifetime and would not have been diagnosed had she not been screened.

A second working group – European Network for Indicators on Cancer (EUNICE) – reviewed the organisation, participation rates and main performance parameters of 26 screening programmes in 18 countries, involving 12 million women, between 2001 and 2007 [3]. The reports from both working groups have contributed to the review published today.

Stephen Duffy, Professor of Cancer Screening at the Wolfson Institute of Preventive Medicine at Barts and The London School of Medicine & Dentistry, part of Queen Mary, University of London (UK), who is one of the coordinators of the EUROSCREEN working group and co-author of the supplement, said: “This is the only comprehensive review of the results of breast screening services in Europe. It reports results from screening millions of women, and confirms that the screening services are delivering the benefits expected from the research studies conducted years ago. In particular, it is good news that lives saved by screening outweigh over-diagnosed cases by a factor of two to one.”

The researchers also found that for every 1,000 women screened, 170 women would have at least one recall followed by a non-invasive assessment before absence of cancer could be confirmed (a negative result), and 30 women would have at least one recall followed by invasive procedures, such as a biopsy, before confirming a negative result. Screening results that lead to recalls in these circumstances are called “false positives” and can cause women stress and anxiety until the negative result is confirmed.

Dr Eugenio Paci, Director of the Cancer Prevention and Research Institute in Florence, Italy, who is a second EUROSCREEN coordinator and co-author, said: “By weighing up the pros and cons of breast cancer screening programmes we hope to ensure that women are fully aware of the chief benefits and harms and can make a fully informed choice when they decide whether or not they wish to attend screening. There has been quite a lot of discussion recently over the worth of breast cancer screening and for this reason it is timely that the international group of experts has assessed the impact of population-based screening in Europe and has found that it is contributing to the reduction in deaths from the disease.

“We believe that not only should our conclusions be communicated to women offered breast screening in Europe, but that, in addition, communication methods should be improved in order to raise women’s awareness, and to make information more accessible, relevant and comprehensible.”

 

[1] “Summary of the evidence of breast cancer screening outcomes in Europe and first estimate of the benefit and harm balance sheet”, by the EUROSCREEN working group. Journal of Medical Screening 2012, volume 19, supplement 1.
[2] The EUROSCREEN working group included representatives of nine European countries: Denmark, Germany, Italy, France, Norway, Spain, Sweden, The Netherlands, United Kingdom.
[3] The EUNICE working group included representatives from 18 European countries: Belgium, Czech Republic, Denmark, Estonia, Finland, Germany, Hungary, Italy, Luxembourg, Norway, Poland, Portugal, Republic of Ireland, Spain, Sweden, Switzerland, The Netherlands, United Kingdom.
[4] Financial support was provided by the National Monitoring Italian Centre to host EUROSCREEN meetings and the supplement publication, and by the National Expert and Training Centre for Breast Cancer Screening, Nijmegen, The Netherlands to host a EUROSCREEN meeting.
[5] Breast cancer facts and figures:

  • Worldwide, breast cancer is the most frequent cancer among women and approximately 1.38 million women were diagnosed with this disease in 2008 (the year for which most recent figures are available).
  • In Europe, including non-European Union (EU) countries, 425,000 new cases of breast cancer were diagnosed in 2008 and 129,000 European women died of the disease.
    Data source: Ferlay J et al. GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide. International Agency for Research on Cancer, 2010 (http://globocan.iarc.fr).
  • In the UK breast cancer is the most common cancer among women, with more than 48,400 women diagnosed each year and around 11,550 women dying from the disease. The lifetime risk of being diagnosed with breast cancer is one in eight.
  • The UK’s NHS breast screening programme detected almost 16,500 cases of breast cancer in 2009/2010.
    Data source: Cancer Research UK key facts (http://info.cancerresearchuk.org).
  • In Europe, approximately 100,000-140,000 cancers are detected by screening each year among women aged 50-69.
  • The UK is conducting a review of breast cancer screening in order to assess benefits and harms, chaired by Professor Sir Michael Marmot, and to which Prof Duffy submitted evidence earlier this year.

Screening Code of Practice

On 22 May 2009 the Medical Screening Society, in conjunction with the Royal Society of Medicine, held a one day workshop entitled “Professional Responsibility in medical screening”. The meeting was very successful.

Members of the workshop discussed the current problem of unevaluated and unregulated screening, including presentations on the requirements for worthwhile screening tests and programmes. Examples of both sound and unsound screening were given. The question of professionalism vs consumerism was discussed. We concluded that professional standards were needed, and proposals were made on what criteria needed to be adopted in assessing screening services offered. We plan to publish a summary of the conclusions.

The following contributors attended the meeting:

Dr Gary Bolger (PPP)
Mr Harry Burns (CMO, Scotland)
*Professor Jack Canick (Women and Infants Hospital, Rhode Island)
*Professor Stephen Duffy (CRC UK)
Dr Raanon Gillon (Imperial College London)
Dr Fergus Gleeson (Churchill Hospital, Oxford)
*Dr James Haddow (Inst. for Prev. Medicine & Medical Screening, Maine USA)
Professor Kay Tee Khaw (University of Cambridge)
*Professor Malcolm Law (Wolfson Institute of Preventive Medicine)
*Dr Peter Mace (BUPA Wellness)
*Dr Anne Mackie (National Screening Committee)
Dr David Misselbrook (RSM)
*Professor Joan Morris (Wolfson Institute of Preventive Medicine)
Rustam Salman (Hon Consultant in Neurology, Edinburgh)
Professor John Scholefield (Professor of Surgery, University of Nottingham)
*Dr David Wald (Wolfson Institute of Preventive Medicine)
*Sir Nicholas Wald (President, Medical Screening Society)

(Medical Screening Society members are marked with an asterisk*)

We thank all Medical Screening Society members who offered and gave their support to the workshop. Copies of the presentations made will shortly be available on the MSS website.


FOR IMMEDIATE RELEASE: 10 DECEMBER 2007

Screening expert calls for public to be protected from over–zealous promotion of medical screening.

A leading epidemiologist and preventive health expert has criticised over-zealous promotion of health screening services by insurance companies and other commercial concerns who offer tests of dubious benefit and possible harm. Professor Nicholas Wald argues that there needs to be a Medical Screening Code of Practice to protect the public.

“Contrary to popular belief, screening is usually a weak means of providing reassurance because screening generally misses most cases of the disease for which screening is carried out.”

Writing in the December issue of the Journal of Medical Screening – of which he is the Editor – Professor Wald questions the promotion, often by insurance companies, for screening tests which have no real benefit and which may even be harmful. “There is, emerging in Britain, a culture in which judgements on medical screening practice are being made in the absence of evidence….The culture needs to change, so that screening is subject to professional scientific assessment.”

Professor Wald, who is also Director of the Wolfson Institute of Preventive Medicine and President of the Medical Screening Society, points out that the examinations and tests offered by, for example, Saga Insurance in their Saga MultiScan, have not been shown to be worthwhile.

The author cautions that, as yet, there have not been enough trials to show that either computerised tomography (CT) scanning of the heart, nor virtual (CT) colonoscopy, are of benefit, and the X-ray radiation exposure involved in both procedures is a concern, as described in a paper by Amy Berrington in the same issue of the Journal.

Bone density and cholesterol levels are important factors in the causation of osteoporosic fractures and ischaemic heart disease respectively. This may have led people to believe that they would also be good screening tests, but they are not; within a population they are poor discriminators of who will develop these disorders and who will not. Whether screening for diabetes is worthwhile is also still uncertain.

In referring to screening using CT scanning, Professor Wald writes: “Not only do we lack evidence that this sort of screening confers a benefit, we do know that it will also cause harm.” This is not just from the radiation risk of some imaging techniques – other techniques can carry a risk of physical harm. Also anxiety over the risk of false positives and the false reassurance of false negatives is a concern. “In medical screening there is always some harm, which is only acceptable if there are also confirmed benefits that outweigh the harm.”

Professor Wald believes that if government regulation is to be avoided, health service providers, insurers and scientists need to work together to produce a Medical Screening Code of Practice. Such a code would help to reassure the public and better enable them to judge the value and benefit of screening services.


ENDS

Note to editors

Screening: a step too far. A matter of concern is in the current issue of the Journal of Medical Screening. Professor Wald is available for comment. There is a related article in the current issue of the BMJ.

The Saga product is provided by Lifescan Ltd. 

Professor Nicholas Wald is the Director of the Wolfson Institute of Preventive Medicine at Bart's and The London School of Medicine and Dentistry in the University of London. He is the editor of the Journal of Medical Screening and is President of the Medical Screening Society. His main research interests are medical screening (particularly antenatal and cancer screening) and epidemiology, including the etiology and prevention of birth defects (such as neural tube defects), cancer and cardiovascular disease.

The Journal of Medical Screening is published by RSM Press, the publishing arm of the Royal Society Of Medicine. The Journal is concerned with all aspects of medical screening, particularly the publication of research that advances screening theory and practice. It aims to increase awareness of the principles of screening (quantitative and statistical aspects), screening techniques and procedures and methodologies from all specialties.

 
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