Healthcare - Interview
Why Screening Saves Lives
Interview with Sue Barter
Dr. Sue Barter, 47, is a consulting radiologist with Britain's National Health Service and is Secretary of the Royal College of Radiologists' Breast Group
What is Great Britain doing in the preventive medicine area?
Barter: There are a number of government targets with regard to heart disease, smoking cessation, cervical cancer and others. The breast-screening program is nationally funded and screens all women between the ages of 50 and 65, and it's being extended nationally to those up to 70. The reason for that is pure health economics in that it's not as cost effective in terms of number of lives saved to screen older age groups. Breast cancer gets more prevalent with age. On the other hand, the older they get, the less likely women are to die of it. So if you're looking at it in health economics terms, the most benefit gained is for the women in the age group I mentioned.
How does the UK's breast cancer screening program work?
Barter: Women are automatically sent an invitation every three years. There has been a lot of controversy about that. But trials have shown that in terms of detecting the greatest number of cancers, that is a good interval. The mammograms are processed centrally because the program has been set up with very strict quality assurance criteria. Furthermore, the mammograms are usually read by two professionals. Our target is to screen more than 75 % of the women who are invited. The reason for women failing to come in is either that they are having their screens in the private sector or they just don't want to know.
How successful has the program been?
Barter: The program was rolled out in 1990. Figures show that there has been about a 25 % reduction in mortality after ten years as a result of the breast screening program. There are very high professional standards required in the program and to be accredited you have to do more than 5,000 mammograms a year.
Breast cancer screening and mortality
Breast cancer mortality by year of death for selected age groups, England and Wales, 1971-99. Since the introduction of its breast cancer screening program in 1988 (solid line), Britain's NHS has registered a significant reduction in associated mortality rates. The broken lines indicate expected mortality rates per 100,000 women if screening had not been implemented
Mammography has some disadvantages, such as the slight risk of getting cancer from radiation and the risk of false positive results that could lead to emotional upset or even an unnecessary biopsy. How do you communicate those risks to patients?
Barter: The risk of contracting cancer from radiation is extremely small since the exposure is roughly equivalent to taking a round-trip flight from Britain to Australia. All the women who enter the program get a leaflet informing them that some cancers may not show up and pointing out the risks. They're fully informed. Very, very few fail to go through with it. Usually by the time they come they've made up their minds. Of the total number of screens, the percentage of women called back for assessment is less than 7 % in the first round and less than 5 % in subsequent rounds. Quite a small percentage are called back and very few have to go on to a biopsy. Only one in ten women who are called back for assessment will actually have breast cancer.
How cost effective has the program been?
Barter: If you take the cost to the National Health Service of treatment and all the rest of it for later-stage breast cancer, it is definitely cost effective. The tumors we catch are smaller, so that in terms of ongoing care, there are savings. The government wouldn't do it if it weren't cost effective.
Will the breast cancer screening program be expanded?
Barter: Screening women aged 40-49 is controversial. A trial study is now being conducted to determine the effectiveness of screening for women at age 40. This is being done as part of a national coordinated investigation of the risks and benefits of the screening program. There are no national guidelines at the moment for women with a family history of breast cancer.
Do other preventive programs work on a similar model?
Barter: The UK's other major screening program is for cervical cancer. It works in a similar way. Swabs are sent to a centralized lab. It's all tracked by computer in a central database. Other preventive programs, such as promoting lifestyle changes to prevent cardiac diseases, are driven by the department of health. There are also targets for childhood immunizations and there's a centrally driven strategy for heart disease.
Will the emphasis on preventive medicine increase in the future?
Barter: Yes. I think that the public and the government have come to realize that this is where resources should be focused to improve the health of the nation. It's been a priority for the last four or five years. It all comes down to educating people.
Interview by Karen Rafinski
Breast Cancer Screening: Statistics Show It's Working
Thanks to digital mammography, physicians can evaluate images immediately after an examination has been completed. In addition, digital images can be processed on screen, often avoiding the need for a second scan. The images can be forwarded electronically to obtain a second opinion or sent to a specialized database
In the European Union (EU), a breast cancer diagnosis is made every 2.5 minutes, and a woman dies of the disease every 6.5 minutes. Breast cancer accounts for the largest number of deaths among women aged 35 to 55 in industrialized countries. On average, one in nine women will be diagnosed with breast cancer at some point in their lives. In view of this, the Netherlands, Sweden, the UK and the U.S. operate extensive mammography screening programs. Many of the programs have been running for over ten years, and more than 70 % of women aged 50 to 69 take part. The success of these programs speaks for itself. According to the WHO, mammography screening has led to a drop in the breast cancer mortality rate of up to 35 %. This figure is based on long-term data from the above-mentioned countries. (Source: International Agency for Research on Cancer, IARC, pr138a)
The European Parliament, which is currently preparing a report on breast cancer prevention in the EU, is calling on all member states to introduce mammography screening programs in accordance with EU guidelines. These guidelines establish high quality standards not only for equipment, but also in terms of medical training and second examinations by independentdoctors.
Karl-Jürgen Schmitt