In a blistering BMJ blog that has just gone online, HealthWatch's chair announces that the pandemic has resulted in the NHS' routine mammographic breast cancer screening programme being quietly suspended. Despite the misery of COVID-19, we do have one cause for celebration, she says.
“In the midst of a global pandemic, we can no longer afford the well-paid and politically popular luxury of needlessly making the general public unwell through anxiety and overdiagnosis,” says Dr Susan Bewley, obstetrician and a leading expert on women's health.
Although it is not obvious from national websites and has been largely unnoticed by the media, letters, texts and phone calls have been informing women since mid-March that all routine breast screening appointments are cancelled, while staff are being redeployed for the Herculean task of constraining coronavirus or keeping other parts of the NHS afloat. Screening services are also suspended in parts of Canada, Italy, Scotland, and Australia.
“This recognition that breast cancer screening is non-necessary must be applauded, and the general public reassured,” says Bewley. “Anyone with a lump, skin dimpling or other symptoms who might have an active cancer, should be encouraged to call their GP as usual, as the urgent pathways remain open.”
Mammography screening aims to find breast cancer before a lump can be felt. The current UK screening programme offers mammography every three years to all women from age 50 to 70. The age range is based on evidence of when mammography is most effective at detecting tumours in the breast. But breast cancer treatments have been revolutionised since screening was introduced in 1987, to the point that treatments today for symptomatic cancer are now so good that the benefit of catching breast cancer early by screening is vanishing, and is dwarfed by the harms resulting from ‘false positives’ and the aggressive treatment of screen findings that would never have hurt a women in her lifetime.
“The good news story - that treatment for symptomatic breast cancer nowadays is excellent - has been drowned out by the thirst for searching for diseases that might never have harmed anyone,” says Bewley. “This is a golden opportunity for the National Screening Committee (NSC) to pause, reconsider serious criticisms of the breast screening programme, and evaluate whether to mothball a programme that does not impress clinically or cost-effectively.”
By pausing breast screening, the pandemic has also called a temporary halt to the controversial AgeX trial—a vast clinical study targeting 6 million women in England, designed to generate evidence to support extending screening to women even outside the current 50-70 age group but which has attracted harsh criticism for its ethical flaws, poor science and failure to get explicit informed consent from patients.
Most people – and even many doctors – overestimate the benefits of screening and underestimate the potential for harm. Bewley is calling on the NSC to address and correct popular myths and misunderstandings about screening generally, stand up to vested interests from private healthcare and screening service providers whose profits come with potential health damage, and to switch their focus to public health - in particular, measures such as reducing smoking, obesity and alcohol consumption are more effective at reducing cancer than screening.
She also asks for better decision aids to help patients make properly informed choices about whether or not to take up screening invitations, for example, the use of evidence-based Fact Boxes. “We need better processes and an “informed consent” leaflet that makes it entirely clear that it’s a choice, and not necessarily a bad choice, to decline,” says Bewley.