14 February 2004

DEBBIE AND TIM SHORT’S SUBMISSION

TO THE HEALTH SELECT COMMITTEE 25 FEBRUARY 2004

FOLLOWING FROM THEIR

124,000 SIGNATURE BREAST SCREENING PETITION:

“To the House of Representatives:

Respectfully request: That the Parliament urges the Government to urgently amend the Government Breast Screening Programme to include women aged from 40 years to 70 years (the same as Australia) instead of the present 50 to 64 years.”

PRESENTED AT PARLIAMENT 18 NOVEMBER 2003

On the 25^th November 2003, 1,001 additional late signatures were forwarded to the Clerk of the Health Select Committee and since then an additional 420 late signatures have been received which are attached to this submission.

Our motivation in starting this large Petition was initiated by a news item of a report published in the New Zealand Medical Journal 10^th May 2002, by Professor David Skegg, University of Otago, that concluded there was a 28% pro rata mortality of Breast Cancer in New Zealand greater than Australia. Since 2002 there has been significant new evidence strongly supporting Breast Screening from 40years as presented in the contributions from medical specialists that are part of this submission. There are 647 deaths per annum from Breast Cancer which is approximately 50% more than total road deaths.

At the time, Petitioner, Debbie Short was undergoing Radiotherapy, was bald from 3 months Chemotherapy she had had prior, following from a Mastectomy removing 8 malignant tumours and Lymph Nodes in December 2001.

The story of the difference in Breast Cancer between New Zealand and Australia had become yesterday’s news. So, in July 2002, Tim and Debbie Short called a Public Meeting and in September 2002 the Petition commenced. We are a family with our three wonderful daughters Rebecca, Jacinda and Louisa sharing this journey, we are “Mum, Dad and the Kids” and it is equally our girl’s petition. The Petition eventuated in Doctor’s surgeries nationwide and so many other places. Two of our girls are now at Tauranga Girls College, where, with 1,700 pupils, 170 current girls will be diagnosed with Breast Cancer when older.

As part of our submission, there are contributing articles from many eminent Medical Specialists from New Zealand and Internationally, and three personal Case Studies. (see number 10).

It is a tragedy at any age when a woman gets Breast Cancer. It is a greater tragedy, the younger a woman is, and many younger women who get Breast Cancer, still have a young family, are in the work force and are productive contributors to the economy. Many women in their 60’s have said to us that if they could, they would transfer their option of eligibility to screening, to their daughters, who have more life years. More women in the 40 – 50 year age group have high grade cancer (NZ Medical Journal 24^th October 2003) which is many times more costly to treat than for low grade cancer. So in effect, by not picking up more women with Breast Cancer in the 40 – 50 year age group, it is a double whammy i.e. loss of productive contribution and their cancer is likely to be more costly to treat.

So why aren’t we screening women from 40 years?

1. BreastScreen Aotearoa in 1998 began Breast Screening women 50 – 64 years of age, which was a big step forward, but now it is past due to expand the programme. BreastScreen Australia began in 1991 offering free mammography screening from 40 years, but actively recruiting 50 – 69 years. The take-up rates between 50 – 64 years in New Zealand is 56.2% and 50 – 69 years in Australia is 54.3% - so very similar but our survival rate 28% pro rata worse! The reason why we aren’t screening from 40 is we have sadly become a people of debaters, always now needing to seek absolutes before action and more reports before lives. If the same model of absolutes were used in the Court Room instead of the balance of probability, the prisons would be almost empty. The reality is 647 p.a. women are dying of Breast Cancer of which one-third get Breast Cancer under 50.

2. There is no disagreement that early detection saves lives! The highest risk factor in getting Breast Cancer is being a woman and 90% of woman who get Breast Cancer have no family history. The Contributors to the submission(No.10) in their reports cover differentiation i.e. tumours changing to a more aggressive form and the higher rate in younger women. It is accepted that screening 40-49yrs has to be annually but only two yearly 50yrs which speaks volumes about the necessity to screen 40-49yrs. The Contributors will dispel the red herrings of false positives, false negatives and dense breasts.

3. There has been controversy over the effectiveness of screening women 40 – 50 years; there have been flawed studies (Canadian trial), and other data, which has been inappropriately analysed causing confusion. Daniel B Kopans contributing article, “An Overview of the Breast Cancer Screening Controversy”, gives a better understanding how this has happened. Also see Ian Campbell’s (Waikato Hospital) “A Review of the Evidence” and Dr Barbara Hochstein’ contribution.

4. There has been a myth that once woman turn 50 years, they magically change. As is transparent in the articles to the submission, women are at high risk 40 – 50 years, as they are 50 – 69 years and the harms of screening are not suddenly less at 50 years. It has been argued that if a biopsy proves to be benign, that the process was flawed and caused unnecessary anxiety. The harms do not equate to dying from Breast Cancer. The recall rate where screening is offered from 40 years is fairly constant across all ages. WHAT PRICE LIFE?

5 So is screening 40-50 years effective? We refer you to the following contributions whereby the answer has to be a resounding YES!

· Mr John Harman

· Dr Jackie Blue co-signed by 13 other eminent Medical Specialists

· Mr Ian Campbell

· Dr Barbara Hochstein

· Professor Laszlo Tabar-20 yr trial with a 45% mortality reduction by screening woman 40-49 years as published in UK medical Journal The Lancet 26-4-03(attached). “In women aged 40-49 years, there was a significant 48% reduction in breast cancer mortality in those exposed to screening, a non-significant 19% reduction in unexposed women and a significant 45% reduction in the age-group as a whole.” This is a huge 45% mortality reduction. This research has received no criticism - the Minister in a reply to the petitioners 10-12-03 said its only 29% i.e. 48%-19%, this is an incorrect dissection as there is a 45% reduction in the age group as a whole. This is the largest and longest research trial that has ever been done involving 210,000 woman and much larger than another UK trial that won’t be reporting until 2005. Women are dying unnecessarily we need to act now.

Since the collection of data of many of the randomised trials that show the benefit of screening 40-50yrs, mammographic equipment has advanced further identifying tumours not previously detectable.

“Mammography remains the primary screening technique in the diagnosis of breast cancer, with a mammographic detection rate of 92% in this patient group. This is comparable to detection rates reported in the literature. However, breast ultrasound , in conjunction with mammography, has become an integral part of the diagnostic work up for patients with clinical symptoms or mammographically detected abnormalities. Ultrasound was also the method of choice in 77.9% of patients who underwent image-guided needle biopsy.” (NZ Medical Journal – The Auckland Breast Cancer Register: a special project of the Auckland Breast Cancer Study Group). This is the reality in practice despite “the Ministry of Health would not advocate the use of an ultrasound as a screening tool in BreastScreen Aotearoa”. (Letter to the Petitioners, Debbie and Tim Short, from the Minister of Health 10.12.03).

6. Another reason why screening from 40 hasn’t occurred is there is a big reluctance by Medical Specialists to speak out in a small country because either they work directly for the Ministry of Health, District Health Board, or their clinical infrastructure needs the support and goodwill of whichever Government is in power. We have been given the private support of a significant number of other medical specialists that we cannot quote. To many there is a climate of fear.

7. Another reason is younger women, until now, are not getting angry enough. It has been to their detriment because they are too busy, being mothers, and contributing productively to the work force, they are in the age group of being busy people. There has not been a political lobby group for younger women, like Grey Power is for older women. In fact, we have over 1,500 New Zealanders who have confirmed in writing, that they will become members of a protest Breast Cancer Action Party at the next General Election (which is so much hoped won’t be necessary).

8. So is the reason, the cost! of screening annually 40-50yrs? - The infrastructure already exists. The Ministry of Health hasn’t released the cost to operate Breast Screening 40-49yrs and we challenge them to do so. We can though, easily establish the mammogram cost (i.e. without the cost of maintaining a screening register with active recruitment).

There are 275,376 (2001 census) women aged 40 – 49 years and at the current Breast Screening take up rate of 56.2% i.e. 154,761 women X $100 mammogram - this would cost only 15.5 mil p.a.

9. After considering all the evidence, the only logical reason left why screening isn’t offered for women 40 – 49 years is that the Government is not interested in giving women the choice, preferring to take a fiscal punt and gamble with their lives.

10 The most significant part to our submission, is the contributory reports below and evidence that strongly supports Breast Screening from 40 years:

(a) CASE STUDY 1 – DEBBIE SHORT - PETITIONER

(b) CASE STUDY 2 - MARIE AVERIL ROIGARD - PASSED AWAY 15.03.02 - 45 YEARS

(c) CASE STUDY 3 – LIBBY BURGESS – SCREENING MAMMOGRAM AT 40 YEARS

(d) LETTER TO DEBBIE AND TIM SHORT FROM LASZLO TABAR DATED 13 NOVEMBER 2003

Laszlo Tabar, MD, Professor of Radiology, University of Uppsala, Uppsala, Sweden

- Chairman, Department of Mammography, Falun Central Hospital, Falun, Sweden

Including Publication Lancet April 26^th 2003 - LANCET ARTICLE 26 APRIL 2003 – MAMMOGRAPHY SERVICE SCREENING AND MORTALITY IN BREAST CANCER PATIENTS: 20-YEAR FOLLOW-UP BEFORE AND AFTER INTRODUCTION OF SCREENING

(e) WHY SCREENING MAMMOGRAMS SHOULD BE OFFERED TO WOMEN IN THE 40s

Dr Jackie Blue, Breast Physician, St Marks Woman’s Health, Auckland

Dr Benji Benjamin, Clinical Director, Radiation Oncology, Auckland Hospital

Dr Barbara Hochstein, Breast Radiologist, Lakes Radiology and Lakeland Health, Rotorua

Dr David Benson-Cooper Breast Radiologist, Mercy Radiology Auckland

Mr Wayne Jones Clinical Director - General Surgery Auckland Hospital, Head of the Auckland Breast Surgery Unit - General Breast and Endocrine Surgeon, Auckland

Dr Sonja Freese Breast Physician Breast Associates Auckland

Dr Sue McKeage Breast Surgeon Auckland

Dr Margie Weston Breast Radiologist Auckland

Mr Stan Govender, Breast Surgeon, Auckland

Dr Marli Gregory, Breast Physician, Auckland

Mr John Harman, Breast Surgeon, Auckland

Dr Heather McIntyre, Breast Physician, Auckland

Dr Karen Parker, Breast Physician, Auckland

Dr Ken Judd, Breast Radiologist, Auckland

ORAL STATEMENT BY DR JACKIE BLUE - TO THE HEALTH SELECT COMMITTEE - MAMMOGRAPHIC SCREENING IN THE 40'S - ON 25.2.04

(f) MAMMOGRAPHY FOR YOUNGER WOMEN – A REVIEW OF THE EVIDENCE

Mr Ian D Campbell, Breast Surgeon, Clinical Director, Waikato Hospital

- Senior Lecturer, Waikato Academic Division, Auckland School of Medicine

(g) SUBMISSION TO THE SELECT COMMITTEE ON BREAST CANCER SCREENING

Mr John Harman, Breast Surgeon, FRACS, St Marks Womens Health, Auckland

(h) BREAST CANCER SCREENING IN THE 40 – 49 YEAR OLD AGE GROUP

Dr Barbara Hochstein, FRACR, Consultant Radiologist, & Breast Imaging Subspeciality,

Lakeland Health & Lakes Radiology, Rotorua

Clinical Lecturer, Dept of Anatomy with Radiology, Auckland Medical School

(i) BREAST SCREENING 40 – 49 YEARS

Dr Deborah Andrews FRACR, Radiologist, Medex Radiology, Tauranga

(j) NEW ZEALAND BREAST CANCER FOUNDATION LETTER DATED 9 FEBRUARY 2004

Belinda Scott (Mrs), FRACS, Chairperson, NZBCF Medical Committee

(k) LETTER TO DEBBIE AND TIM SHORT DATED 10 FEBRUARY 2004

Belinda Scott (Mrs), Breast Surgeon, Director Breast Associates, Auckland

Mr Wayne Jones, General Breast and Endocrine Surgeon, Clinical Director Auckland Hospital

Mr Alex Ng, Breast and General Surgeon, Auckland Hospital

(l) A PSYCHOLOGISTS RESPONSE CONCERNING ANXIETY, FALSE POSITIVES, FALSE NEGATIVES AND MAMMOGRAPHY CHOICE FROM 40 YEARS

Danute Ziginskas, Consultant Pyschologist to St Marks Breast Centre, Auckland

(m) AN OVERVIEW OF THE BREAST CANCER SCREENING CONTROVERSY

Daniel B Kopans, Associate Professor of Radiology, Harvard Medical School, Cambridge, MA;

Director of Breast Imaging, Massachusetts General Hospital, Boston.

(n) MAMMOGRAPHY RADIATION DOSE AND BREAST ULTRASOUND

Dr Jackie Blue, Bsc, MBChB, FASBP, Breast Physician, St Marks Woman’s Health, Auckland.

(o) SUMMARY OF AMERICAN CANCER SOCIETY GUIDELINES FOR BREAST CANCER SCREENING: UPDATE 2003

(p) POSITIVE PREDICTIVE VALUE OF BREAST BIOPSY PERFORMED AS A RESULT OF MAMMOGRAPHY: THERE IS NO ABRUPT CHANGE AT AGE 50 YEARS

D.B. Kopans, R.H. Moore, K.A. McCarthy, D.A. Hall, C.A. Hulka, G.J. Whitman, P.J. Slanetz and E.F. Halpern Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA