SUBMISSION TO THE SELECT COMMITTEE ON BREAST CANCER SCREENING

John Harman , Breast Surgeon  FRACS

There have been multiple studies on breast cancer screening over the last 30 years.

Now it is clear that the same benefit for screening the 50 and over age group also occurs in the 40 and over age group.

There is one proviso.  The screening interval needs to be shorter, once every year, rather than once every two years.  The reasons for this are that the young women have more rapidly growing tumours and in order to detect the tumour when it is small, with an excellent prognosis, the screening interval needs to be shortened.

In associated with dedicated film, dedicated radiographers and dedicated breast radiologist, the screening within New Zealand has been shown to be state of the art.  In particular, at Breast Screen Aotearoa Auckland and North, we have detected more tumours than any other screening programme worldwide.  The Canadian screening study, which has been reputed and used as an example for lack of benefit of screening, is flawed in many ways.

The flaws are firstly in randomisation; women were not randomly selected.  Secondly, the standard of mammography in Canada at that time was poor and many radiologists have commented that they found the quality of mammography was so poor that the only facts that can be derived from the Canadian screening project are these – bad screening is worse than no screening at all.

Why then the continuing debate about screening the 40 to 50 year old.  In my opinion, there is no debate.  If we look at the maximum incidence for cancer detection in New Zealand, the age is 51 and 52.  By the time the tumour is detected, it has been there for approximately five to ten years.  The average size of these tumours is 2 cm.  The rate of death from these tumours is approximately 30-40%.  In order to impact on survival, these tumours need to be detected 5-10 years earlier.  Therefore, it is a no-brainer.  We need to start mammographic screening 10 years earlier than the peak incidence of our current detection rate, i.e. from 40 onwards. 

Recruitment:

Unfortunately, the message that is given to the women in our community is this.  Breast cancer screening is performed for women 50 and over.    This message then goes out further and women 40-50 do not realise that they are at almost equal risk of developing breast cancer as the older age group.  This misinformation leads to a delay in diagnosis of this group, which is compounded by attitudes prevalent within the medical community.

Women from 40 and over are greatly aware of health concerns and this group would be easily more able to be recruited than women in the 65 age group plus, who have other priorities than their health.

A woman of 40 is arguably at the peak of her family, financial, professional and personal career.  Losing a woman at 40 should be compared with losing a woman at 70 from breast cancer and the resources should be therefore aimed at the younger population in terms of cost effectiveness as a community.

Why is there no one championing the cause for women screened at 40 and over and this initiative is patient and young women initiated:

The reason for this is that there is no ownership of the issues.  Breast surgeons see women at the end of the screening progress, and help them and support them onwards in the process.  Breast radiologists are few and far between and there is a continuing recruitment problem, as this is a low-tech high medico-legal risk, low status occupation.  Not surprisingly, ownership of the screening issue has been taken over by non-clinical doctors who practise in corridors and libraries.

Small wonder then, that the opponents of screening do not see the undoubted benefits of screening in their every day practice and do not see the negatives of poor or inadequate screening of this 40-50 age group, as they are not in the clinical frontline.

Resources:

When the screening group met and the SKEGG committee reported, they stated that screening in New Zealand should not be undertaken for two reasons:

i)                    There were inadequate personnel to manage breast screening.  However, this Committee has, to my knowledge, made one recommendation about training doctors and technicians in breast screening and indeed, there is a shortage of personnel as a result of this.  They therefore met and have delayed breast cancer screening in our country for at least a decade.  This needs to be addressed urgently and is being addressed with breast physicians.  In my opinion, the breast physician is a multi-potent breast screening, breast cancer doctor who is able to read mammograms, perform biopsies, talk to women, manage programmes and be invaluable in this area.  They are cost-effective, highly trained resource which we need to embrace and support.

ii)                   The SKEGG committee stated that they are unsure whether the society of New Zealand would embrace breast cancer screening.  This has proven to be not the case.  The screening programmes have recruited women and over 60% of women in the Auckland area are having national breast cancer screening and over 20% of those not having screening are accessing private screening.  This means that the amount of breast screening occurring in our community is 80% - a very high uptake in a very short space of time.

The underlying reason for the lack of screening and the lack of extension and screening in New Zealand is the lack of financial and personnel resources.  In my opinion, this represents a gross under-utilisation of the breast physician resource.  It also is an under-utilisation of community initiatives.  The ramifications of detection of breast cancer in a young woman and excellent survival figures as a result of this detection improves the outcome and shortens the resources which need to be used for expensive chemotherapy, terminal care and ongoing costs, due to increased death of this age group.

There is no area of medicine that has been submitted to more clinical trials, has more issues surrounding it, than breast cancer screening.  Indeed, one can say that doctors are either pro breast cancer screening or anti it.  It is difficult to tease out the individual reasons, which make a doctor thus.  There is no doubt that there is a high degree of breast cancer resource available in New Zealand and we should nurture the resource by following the guidelines of advanced recommendations from people as diverse as the American Cancer Society and the Scandinavian Radiological Society.

Put simply, all women aged 40 to 70 are undergoing breast cancer screening in Sweden and the death rate has dropped dramatically when compared to countries such as ourselves.  We need to embrace this information and to allow women aged 40 and over access to free high quality accredited screening services.