NHS changes advice on breast cancer amid concerns of unnecessary medical treatment
FEWER women in Scotland will be routinely checked for breast cancer under radical changes to the national screening programme being considered by the NHS.
Scotland on Sunday has learned that women are to be warned about the potential risks of mammogram diagnosis under plans being looked at as part of a UK-wide review of the screening programme.
The move could see many of the 170,000 women in Scotland who have breast cancer checks each year decide to abandon the scheme, which has been running since 1988.
Significant changes to the programme, which is credited with saving hundreds of lives a year, are being considered amid mounting concern that regular screening can result in some women undergoing cancer treatment, including invasive surgery, when it is not medically necessary.
There are also calls for women to assess their own risk – based on family history and self-examination – to make an informed decision on the need to have a mammogram.
It is hoped that the review will clarify the conflicting advice women receive on the subject of breast screening.
Three-quarters of all Scottish women aged between 50 and 70 attend hospital or a clinic for a routine NHS mammogram every three years. But statistics show that for every life saved during routine screening for breast cancer, up to ten women undergo needless treatment.
Such treatment usually follows the discovery of a pre-cancerous condition, ductal carcinoma in situ (DCIS), which is picked up during the screening process. Research shows the condition can – in some cases – develop into invasive cancer, but left alone it can remain innocuous. However, once detected, the NHS offers cancer treatment, which can result in some or all of a breast being removed.
The policy is being called into question by some cancer specialists, who believe that women should be made more fully aware of their options, including the right to turn down surgery and opt for more regular check-ups.
In Scotland, almost 4,500 women are diagnosed with breast cancer each year, while 1,000 women die from the disease annually, according to Cancer Research UK.
Moira Adams, director of the charity Challenge Breast Cancer Scotland, said: “There is a huge debate about the harms and benefits of screening and women need to be made aware of the facts to make up their own mind.
“The leaflet that women are currently receiving does not explain that screening could do them more harm than benefit and is very biased. Women believe their lives have been saved by breast screening, but in some cases it might have just made them into cancer patients needlessly.”
Two reviews into breast screening advice are under way. The NHS in Scotland is looking at ways to clarify information contained in the leaflet sent to women inviting them to attend for a mammogram. And a UK-wide review – being led by Professor Sir Michael Marmot, director of the Institute of Health Equity at University College, London – is assessing the effectiveness of the screening programme. It is expected to report next year.
Last night, a source close to both reviews said: “Women do have to make a choice about screening. It is a choice to attend, and that is to be acknowledged in the information women are given so that they can decide whether to take a personal risk. The NHS will be given clear guidance on giving balanced and independent information to women.”
The new leaflet to be sent out in Scotland will spell out the details of DCIS clearly and will not refer to it as “cancer”, the term used in previous literature. It is understood that the information will stop short of entering into the debate around the issue, but guidance to be given to the NHS next year is expected to advise that all future leaflets be more explicit about the fact that DCIS may not develop into cancer.
The review led by Prof Marmot is expected to identify aspects of the breast screening programme that could be improved, including clearer guidance to the NHS on risk, uncertainty and effectiveness. Early briefings from the group suggest it is going to tell the NHS it must ensure women are fully informed of the pros and cons of mammograms.
The proposed changes will reassure some campaigners who say women are not being given enough information about the risks versus benefits of screening. However, other charities have urged women to continue their regular screens.
Audrey Birt, Scotland director at Breakthrough Breast Cancer, said: “We believe in the importance of women having the best possible information to make an informed choice about whether or not to attend breast screening.”
Dr Emma Pennery, clinical director at Breast Cancer Care said: “We believe all women should have access to clear, evidence-based information about the benefits and limitations of breast screening.
“This includes the facts about potential over-diagnosis of conditions that may never cause harm. We know from calls to our helpline that conflicting opinions on the value of screening can be confusing and cause anxiety for many people.
“In the majority of cases, the sooner breast cancer is detected, the greater the chances of a better outcome, and screening remains an effective option for detecting breast cancer as soon as possible.”
Ellie Bentley, breast care nurse at Spire Murrayfield Hospital, said most women diagnosed with DCIS do choose to have surgery. She said: “DCIS as it stands is not going to harm women, but we can’t predict what is going to happen to them. The consultant would want to remove it.
“Women do have mastectomies if it is widespread in many ducts and that is very difficult when there is no immediate risk to your health.
“Everyone’s risk-averse status is different. They usually say they want the surgery. But women do have reconstructive surgery afterwards.”
Last night, a Scottish Government spokeswoman said: “The National Screening Committee’s recommendation, which is based on strong evidence, is that screening for breast cancer should be provided. The resource to support Scotland’s national breast screening programme is going through its annual review.
“The review has taken account of the key interim messages of the English review on informed choice, which is currently out to consultation.”
The Scottish Government has also announced that it will spend £12 million over the next three years on upgrading equipment used to screen for breast cancer. The funding will be spent across the NHS to replace analogue mammography machines with digital units which use more advanced technology.
A spokesman for NHS Health Scotland, which is overseeing the review of the Scottish leaflet, said: “Once the annual leaflet review is complete, in autumn 2012, final decisions will be made about changes to content, which currently includes reference to ductal carcinoma in situ.
“The current review of the public leaflet is in line with regular review cycles that NHS Health Scotland conducts for all screening and immunisation communications.
“The current review aims to ensure it has appropriate breast awareness messages in line with Detect Cancer Early and current evidence and practice in order to provide women with adequate information to make an informed choice.”
Screening and awareness
■ Women aged 50-70
are invited for mammograms every three years.
■ Around 75% attend.
■ In the year 2010-11:
170,664 were screened, 8,596 were recalled because of a problem.
1,530 cancers were detected, 271 were non-invasive, of which DCIS is the most common.
What changes should I look and feel for?
■ Nobody knows your body like you do, so you’re the best person to notice any unusual changes.
■ Changes in size or shape.
■ Changes in skin texture, such as puckering or dimpling.
■ Inverted nipple.
■ A lump or thickening of breast tissue.
■ Redness or a rash on the skin/around the nipple.
■ Discharge from one or both nipples.
■ Constant pain in breast or armpit.
■ Swelling in armpit/around collarbone.
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