Richard Smith: My vain search for a pro-mammography speaker

Richard SmithFor the past two months I have been trying to find somebody to speak in in favour of mammography in a debate, but I have failed. Some six people have turned me down. Why, I wonder?

The debate will take place in Edinburgh as part of a meeting on “Controversies in Breast Cancer.” It’s a small, long standing meeting of scientists and clinicians from all over the world interested in breast cancer. The atmosphere is friendly but challenging. My impression is that most of those who attend believe in the benefits of mammography. In other words, they are no rabble.

I’m charged with organising a session on how we disseminate information on complicated scientific stories, including through the media. We want as well to stay away from the standard structure of Powerpoint presentation plus questions. I chose mammography as a good example of a topic in breast cancer where the public are presented with extremely confusing information.

The BBC website reported a study from the BMJ with the headline and standfirst of “Breast screening benefits queried; Screening has not had a significant impact on the fall in deaths from breast cancer, a study claims.”  Three months ago another BBC website story said “Breast screening does more good than harm with any over-treatment justified by the number of lives saved.”
These ping pong reports have been going on ever since mammography was introduced, which is why some countries have adopted screening programmes and others have not.

I have devised a session in Edinburgh whereby we hope to see two high quality researchers with opposing views debate the value of mammography with some 15 minutes each. Before the debate we will have filmed a short Newsnight style interview with both of them. In addition, I will interview them and write a story from each in two styles, one tabloid and one in the style of a “quality daily.” We will give these to our panel and the audience to read in advance together with a collection of conflicting stories from the media. Finally, a panel discussion chaired by Sheena McDonald, a well known professional television and radio presenter, will try and draw some general lessons. The panel will include a patient with breast cancer, a woman citizen, a GP, and the two protagonists. The audience will do most of the talking.

So why can’t I find a scientist or leader of a mammography programme to take part? Most of those who turned me down didn’t give a reason, but one said “We’re tried of this debate. We’ve been through it again and again.”

This strikes me as appalling. While women are bombarded with conflicting and hard to understand information those who favour mammography—and have persuaded governments to spend millions on programmes and hundreds of thousands of women to undergo an uncomfortable procedure with many receiving a false positive diagnosis—are unwilling to discuss the issue. I think of myself as a neutral, but if one side won’t debate—the essence of science and democracy—inevitably I begin to turn against it.

Competing interest: RS is organising the session at the meeting in Edinburgh and will have his expenses paid, including a first class return to Edinburgh bought well in advance so that it’s cheaper than a standard return. He’s not being paid a fee—despite his wife saying “Why do you do all these things for nothing?”

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

  • Pwward

    Maybe they find it too difficult to defend their position and just hope the opposition will go away?
    There is something similar going on with the cycle helmet debate.  The 'pros' are unwilling to debate the issue with the 'skeptics' giving a similar excuse.

  • Michael Baum

    I'm not surprised. The pro-screening lobby is bored with the debate and promote the view that somehow repetition of inconvinient truths dilutes them.
    Those in high places have erected a brick wall and no longer respond or acknowledge our attempts to communicate with them.
    Shame on them

  • Mangesh Thorat

    There comes a point in several successful careers when what you have believed for so long is proved wrong, data against your belief becomes strong enough to convince you (if you are conscience driven) in private but you lack the courage to admit it in public for various reasons (read: conflict of interests) or perhaps deciding not to debate in public is an intermediate step in the bereavement process (death of your belief). There are very few who have that humility and courage to admit and accept, history remembers only them!

  • Richard Smith

    An acute observation, but it's one thing to cling to your cherished beliefs in your own sitting room harming nobody and another to put millions of women through a painful process and to cost the country millions.

  • Richard Smith

    Surely it's something that health or science and technology committees in parliament should look at. I'll suggest it to my contacts.

  • Michael Baum

    I agree. I was invited to speak to the all party group on science and technology last year and they received very well. This is an ongoing scandal leading to unneccesary suffering and the oportunity cost of £90,000,000 at a time of economic recession. At least give the money to help relieve the famine and infant dehydration in Somalia!

  • Mangesh Thorat

    Cannot agree more!

  • Michael Baum

    Anyway I could communicate with you directly?

  • Richard Smith
  • Richard Smith

    I've just been turned down by the seventh person I invited, my stand by. Would anybody out there like to put the case for mammography at the meeting? I may well have to do it myself. I will be convincing.

  • Richard Smith

    Somebody has emailed me to point out that simply not responding can be a very effective strategy if you are the dominant party. I've seen it other contexts.
       But I alss think of the sketch on “Not the 9 O'clock News” that shows a house being blow down by a hurricane. The presenter, Mel Smith, says “We rang the Gas Board. They said 'no comment.'” In some circumstances “No comment” sounds like an admission of guilt.

  • B_mitzi

    I’m a breast cancer patient, medical writer and until recently was a campaigner for a national breast cancer charity. At their conference last autumn I was prevented from raising a question on the issue of mammography screening with Professor Mike Richards. No-one would discuss the matter, but delegates were urged to lobby MPs, during arranged meetings, to extend the screening age at both ends of the range. Pink fluffy blinkers! Delegates I spoke to on the subject were left completely in ignorance of recent evidence against mammography screening. I resigned from the group.

    I have been following and contributing to opinion on this subject over the past 2 years and believe the present screening programme to be unethical for the following reasons:

    Beneficence – it is not beneficial (Breast cancer mortality in neighbouring European countries with different levels of screening but similar access to treatment: trend analysis of WHO mortality database, Philippe Autier et al, BMJ 2011; 343:d4411)

    The claim it saves lives is not properly referenced.

    Nonmaleficence – it can cause harm by anxiety, investigations, overdiagnosis, and unnecessary surgery and other ‘treatments’ (with major lifelong side effects).

    Autonomy – the written information offered is not independent: women should be told the full facts and they are not.

    Justice – the money could be better spent elsewhere.

    See also the General Medical Council’s Consent Guidance.

    I have recently received an invitation to breast screening – because I am in the extended age range. This ignored my earlier response to a previous invitation declining screening (which should be on file) which informed them I would not be attending since I was under the care of a breast oncologist. If I do not turn up my medical record will be labelled DNA (did not attend) – but the onus should not be on me to answer an unsolicited invitation. If the author is convinced (despite all evidence) that screening will benefit me more than it will harm me, they should provide completely full and open information and leave me to make a fully informed decision – and an appointment if that is my wish (patient autonomy/patient centred service).

    The (new) information leaflet (as before, written by those who run the screening programme and therefore with vested interests in recruiting women to screening) still does not provide honest information on potential harms – but has pretty pink flowers scattered on every page. To allay fears? Sugar the pill? Attempt to aid what could be seen as coercion?

    When will there be an independent investigation into screening?
    When will the information offered to women be written by unbiased people?
    And when will women be treated as if they are competent to make an informed choice?

    Mitzi Blennerhassett

  • Suzanne Richards

    Hello from the States. I am a Womens Imaging specialist…having been in the field for 30 years, teaching digital Mammography. I have worked with women with both true and false positive findings. We have had teens, 20-40 yr olds with very agressive Cancers. It no longer  matters if “nobody in my family ever had it”.  To this I say…”and whats your point?” It doesn't seem to matter. I think Oxidation of cells through everyday pollutents, possible hormones…especially in 30+ yr old with the increased use of infertility drugs.

    I would rather have a false positive…than a false negative any day!…Thats why we do Biopsies….some news is good some is not. So they are angry that the news is Good?
        I do not have a Doctorate, but would speak to anyone regarding the positive view of Screening Mammography. Debate can fade in the face of Truth.