SUBMISSION TO THE SELECT COMMITTEE ON BREAST CANCER SCREENING
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
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.
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.
is there no one championing the cause for women screened at 40 and over and
this initiative is patient and young women initiated:
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.
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
the screening group met and the SKEGG committee reported, they stated that
screening in New Zealand should not be undertaken for two reasons:
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.
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.
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.
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.
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.