Richard Lehman’s journal review – 10 April 2012
10 Apr, 12 | by BMJ Group
JAMA 4 Apr 2012 Vol 307
1394 A special dread settles on me this week as I know I am going to have to write about breast cancer screening. But let’s leave the dread question of whole-population mammography for later, and consider the add-on benefit of annual ultrasound or single-screening MRI in selected high-risk women. While the war over breast screening rages unchecked in the letters and a book review in this week’s Lancet, let’s take refuge in this little corner of the battlefield, where at least the fog of war is not too thick and we can count a few weapons and estimate a few casualties. The volunteer combatants are women with dense breasts and at least one factor that increases their risk of breast cancer. The ultimate proof of victory, as in all screening studies, will be a reduction in total mortality. The casualty list should include every woman undergoing biopsy or surgery, because nobody comes away from these things altogether unscathed, be it mentally or physically. This study gives us a casualty list, including the number of enemy killed (breast cancers detected and operated on), but cannot give us any idea of the extent or the cost of victory, because it was run over a three-year period only. Our brave lasses certainly saw their share of action: 2725 over the age of 25 (!) went through annual mammography and ultrasound, and 612 ended up having MRI. During that time 110 had 111 breast cancer events: 33 detected by mammography only, 32 by ultrasound only, 26 by both, and 9 by MRI after mammography plus ultrasound; 11 were not detected by any imaging screen. Enough. We can tell from these figures that the three imaging modalities will pick up most cancers; but the true cost—mentally, physically, and financially—can only be hinted at in a study like this. Only very long-term follow-up will give us a true estimate of overdiagnosis and the degree to which such screening detects cancers which would never progress. But in just these three years, a total of 1272 biopsies were performed—more than ten for each cancer detected. So this high risk group may well see a small reduction in all-cause mortality over the course of their “screening lives,” but it will be purchased at a high cost in medical procedures and anxiety. In fact any woman undergoing this cycle of procedures would be extremely lucky to get away with a single fine-needle biopsy during her life—two or three would be more likely. more…
January is the month that heralds the end of procrastination. The New Year is traditionally the time that individuals and organisations look ahead and plan for the future. Among the usual resolutions to do more, eat less, and be more productive, there is also the ubiquitous past-time of predicting the near future. For healthcare the future seems to be focused increasingly on the development and application of technology with a blurring of the distinction between consumer electronics and medical devices.
The golden phrase for countering non-communicable disease (NCD) is that we need a “whole of government and whole of society approach.” An important step on that path is obviously for all parties to talk together, and that’s why the International Diabetes Federation for the first time started its biannual conference with a “global diabetes forum,” with the title of “Harnessing the private sector expertise.” How did it go? 
A large portion of my work as a doctor in Nepal is to treat infections. Even in chronic conditions – COPD, diabetes, malignancy – I find that infectious micro-organisms take the toll more rapidly than the disease itself. It is fascinating how these minute beings have the power to bring human life to a standstill.
“Research highlights” is a weekly round-up of research papers appearing in the print BMJ. We start off with this week’s research questions, before providing more detail on some individual research papers and accompanying articles
