This very important report from the United Kingdom assessing breast cancer screening
clearly states that we must balance the potential benefits and harms of screening
(Marmot et al, 2013). If we are not honest about the contributing causes of the adverse
consequences in population screening, we have no chance to improve what we do. Importantly,
understanding the magnitude of harms and benefits is a starting point for developing
a comprehensive strategy to significantly improve the field (Esserman and Thompson,
2010).
This report concludes that the benefits of screening still outweigh the harms, but
the UK Panel elevates this tension so that we can put screening into perspective.
The panel outlines the opportunities to reduce harm, and therefore improve the net
benefit of screening. Importantly, this report describes the likelihood of women participating
in screening being diagnosed and also overdiagnosed with breast cancer. Of the approximately
307 000 women aged 50–52 years who are invited to screening each year, just over 1%
would have an overdiagnosed cancer during the next 20 years. The table below summarises
the reported results of women invited to screen and provides the appropriate perspective.
There are several points that can be made from this assessment of screening. First
is that the panel definitively acknowledges overdiagnosis (Esserman et al, 2009; Welch
and Black, 2010). Second, women participating in a screening programme are more likely
to be overdiagnosed than to have their life saved by screening. However, saving a
life has much higher priority to most women than going through additional treatments
that they many not need. We have this discussion regularly about all treatments and
the majority of women opt for more aggressive therapy even when they recognise that
it may not improve their health.
The third point is that the chance of a woman having her life saved because she had
a screen-detected cancer is not 100%, which is what most people assume. In fact, this
report indicates it is 1320/20 907, or 6.3% of women have a mortality benefit from
screening. This is consistent with what others have reported (Welch and Frankel, 2011).
In fact, the 6.3% figure is likely to be an overestimate given that the original trials
were conducted prior to the use of modern adjuvant/neoadjuvant therapy and we know
that the contribution of adjuvant therapy to further reducing mortality is in the
range of 50–67% (Berry et al, 2005; Kalager et al, 2010), indicating that the current
chance of a woman having her life saved from screening is closer to 2–3%. That is
not to say that there is no benefit of screening, but simply to say that it is small
and not as great as we would have hoped. The needed effort to improve screening is
surely worth the significant amount of time and energy.
We do not have to accept the current situation as immutable. The final point to be
made is that there are significant opportunities to make big changes that would alter
the benefit risk ratio. Overdiagnosis, for example, would not be a problem if recognised
and overtreatment was therefore averted. There are several promising signatures that
are in the process of development to identify cancers that have an extremely low risk
of ever progressing even in the absence of any systemic therapy (Buyse et al, 2006;
Esserman et al, 2011a, 2011b; Naoi et al, 2011). The validation of such signatures
should be made a priority. Concomitant development of more appropriate thresholds
for intervention based on mammographic findings would also reduce the burden of overdiagnosis,
overtreatment and the harms due to false positives. European and Scandanavian countries
already have significantly lower recall thresholds than are routinely used in the
United States. In the United States, the mammography score BIRADS 4 is the standard
for recommending a biopsy, though it encompasses a huge risk range that spans 3–95%
of risk for either DCIS or invasive cancer. Further, the translation of BIRADS scores
to English language terms that are ‘loaded' with meaning, such as the term ‘suspicious',engenders
fear (of missing a cancer, or of being sued for malpractice if the lesion is not worked
up) and has resulted in cancer-to-biopsy rates that are much lower in the United States
than in Europe. Interestingly, the United Kingdom have developed a different lexicon
(the UK 5-point Breast Imaging Scoring System), in which the threshold for invasive
cancer must be higher prior to recommending a biopsy (Taylor et al, 2011).
As a community, we must make a concerted effort to think about what disease is worth
identifying. The problem of surfacing 20–30% of precancerous lesions in the course
of screening for cancer is not even mentioned in this report. DCIS, for example, was
never intended as the target for screening. We have yet to demonstrate that early
intervention for DCIS has made an impact on mortality, and the majority of these lesions
are not destined to develop into invasive cancer (Ozanne et al, 2011). At the very
least, the low and intermediate grade DCIS lesions should not have the term cancer
in the diagnostic lexicon. DCIS should be reclassified as high-risk lesions, those
that confer increased risk for development of invasive cancer over 5–10 years, and
perhaps trigger prevention interventions and more frequent screening. Introducing
the notion of disease dynamics to determine when to intervene for conditions that
have a slow growth trajectory may allow us to learn what should and should not constitute
a meaningful trigger for diagnostic intervention. Surely if screening every 3 years
is considered safe or optimal in the United Kingdom, then following a potentially
concerning lesion at 6 - to 12-month intervals would also be safe.
We need less religious fervour around the topic of mammography. If a case is found
through screening, we need to recognise that there is a small chance that we will
have impacted mortality for that individual, and a higher chance that they will undergo
treatments that they do not need. Having a less inflated sense of the benefits of
screening will lead us to embark on the necessary changes for significant improvements
in screening performance. The promise of precision medicine is perhaps most ripe for
fuelling such changes. We must embrace the challenge of learning how to redirect our
screen detection features to finding consequential cancers, to using disease dynamics
to enable us to ignore inconsequential cancers or precancers, and to develop and apply
robust molecular diagnostics at the point of diagnosis to determine how we can safely
test doing less to reduce the harms and promote the benefits of screening.