Richard Smith: Clinicians support a review of mammography

Richard SmithFive weeks ago I wrote about the difficulty I was having in finding somebody to speak in favour of mammography at a conference on controversies in breast cancer. I feared that the establishment was adopting a strategy of non-engagement in the face of what seems to be growing criticism of mammography. Now that the conference has happened I thought that I ought to report back. I thought the outcomes interesting.

Eventually Tony Howell, professor of medical oncology in Manchester, agreed to speak “for” mammography, but his main message was that the “experts” needed to try and get together and find a middle road, perhaps conducting a review of the randomised trials using individual patient data and designing a programme based on risk. He was sure that women should be given better information and that they must decide whether to have mammography.

Karsten Jørgensen from the Nordic Cochrane Centre, one of the main critics of mammography, agreed with much of what Howell said and was not in favour of stopping the breast cancer screening programme. He was, however, for a review.

You can see them being interviewed by Sheena McDonald, a professional presenter, in an 8 minute video.

Despite both of them saying that women should choose for themselves based on all the evidence, there was a strong sense that this was extremely difficult because the evidence is complex and conflicting.

At the end we took a vote with the audience of around 100, most of them breast surgeons or medical oncologists. I asked if there should be a review of the UK screening programme and almost everybody voted yes on a show of hands. We learnt at the meeting that Scotland does plan a review, although it will be a one off process that will not question the cost effectiveness of breast screening.

Then I asked with the voting machine whether the programme (currently for women aged 50-70 in UK) should be extended to women over 40, kept as now, offered only to women at high risk, or scrapped. Most voted for keeping it as now. Finally, I asked for a vote on whether the information given to women should be simplified, kept as now, include much more information on overdiagnosis, or include much more detailed information on benefits and risks. Three quarters voted for giving much more detailed information.

I was left with a strong impression that the status quo is not acceptable.

Competing interest: RS had his expenses paid for attending the conference and organising the session on mammography. He enjoyed a Burns Supper (yes, in September) and a ceilidh. The haggis was magnificent, and the bagpipes, as always, made him cry. Using his usual hourly rate, RS estimates he contributed £3000 to the conference but doesn’t begrudge a penny.