Abstract
When I was a child and even a young and not-so-young adult, cancer was not a topic that many people were keen to discuss and few people volunteered that they or their relatives had been diagnosed with it. It was often kept secret even after death as if it was contagious like the plague. A good example of this lies in the dénouement of Daphne Du Maurier's novel Rebecca. The prognosis for most cancers was grim as were the treatments (and they're not a walk in the park today, either). However, in more recent years there has been a huge shift to make this and other killer diseases (e.g. AIDS) acceptable for general conversation and debate.
It is surgeons and researchers like Professor Michael Baum who have successfully wrought a positive shift in patients' and doctors' attitudes to dealing with cancer. In his book, Breast Beating (“a personal odyssey in the quest for an understanding of breast cancer, the meaning of life and other easy questions”) 1 Baum explains that it was his mother's death from (ineffectively and horribly treated) breast cancer which prompted him to shift his career to search for better, scientifically proven methods of diagnosis and treatment of the disease and to adopt rigorous standards of critical analysis (whether counter-intuitive or against his own practices or unproven therapies that sound good to the ear) for the rest of his life.
As a result of the work of Professor Baum and many other dedicated colleagues, the mutilating, crippling and painful breast surgery that was once the norm has been proven excessive in all but a tiny minority of cases. Always a champion for a cause he believes to be fair and right, Professor Baum will provide expert advice where there is a possible legal claim for compensation. He is never afraid to say No. No, there is no negligence and/or no there is no case to be made on causation albeit there has been delay and practice falls short of ideal; it can be difficult to prove that the patient has lost a greater than 50% chance of a significantly better outcome.
And what about the medico-legal case for universal screening for breast cancer? Does earlier detection of abnormalities in the breast really increase life-expectancy and reduce morbidity in most patients? Baum does not think so though he was once a keen supporter of screening, and in 1987 after the Forrest Report was published, he was commissioned by the Department of Health to set up the first screening unit and training centre in London. However, he soon became sceptical and increasingly convinced that any benefits from universal screening were outweighed by over-diagnosis, which resulted in unnecessary surgery and other treatments given to healthy women. In 1997 he resigned from the NHS Breast Screening Programme (BSP) “in disgust at the way women were being coerced” into screening.
In February 2009 there was more evidence that general mammographic screening caused harm (and a rise in mastectomies) in a paper published in the British Medical Journal by the independent Nordic Cochrane Centre. 2 Contemporaneously, Baum and 27 other experts wrote to The Times (19 February 2009) explaining the problems and arguing that the “dramatic decline in mortality from breast cancer is as equally likely to be due to better treatments as to earlier detection by screening”. The letter continued “ … there are harms associated with early detection of breast cancer by screening that are not widely acknowledged. For example, there is evidence to show that up to half of all cancers and their precursor lesions that are found by screening, if left to their own devices, might not do any harm to the woman during her natural lifespan. Yet if found at screening they potentially label a woman as a cancer patient: she may then be subjected to the unnecessary traumas of surgery, radiotherapy, and possibly chemotherapy, as well as suffer the potential for serious social and psychological problems. The stigma may continue to the next generation as her daughters can face higher health insurance premiums when judged as high risk … ”. Alarmingly, the letter pointed out that “ … none of the invitations for screening comes close to telling the truth. As a result, women are being manipulated, albeit unintentionally, into attending. It is therefore imperative that the NHS BSP re-writes the information leaflets … ”.
Within days, the NHS agreed that the leaflets needed re-writing. But are even the newest leaflets satisfactory? Are women who are at no particular risk being induced to undergo breast screening without understanding there is a real risk of a false-positive diagnosis and thus of undergoing serious, invasive but unnecessary treatment?
Interestingly, initial consideration of the available data to support screening for prostate cancer was found to be unhelpful: Baum concludes you would need to screen about 1500 men for 10 years to save one prostate cancer death at the expense of over-diagnosing 50 cases of cancer that would be treated with radical surgery that frequently leads to impotence and incontinence and on rare occasions death from the complications of surgery.
If the breast screening data had been more up to date and more carefully analysed, would the whole programme of universal breast screening have ever been launched in the UK? There are strong arguments for reducing it to a smaller and risk-adjusted programme of screening which would reduce the risk of causing harm and over-diagnosis along with reducing costs and the money could be more usefully deployed elsewhere.
But there has been an indirect upside: Baum deduces that it was the centralization of care leading to rapid recruitment of patients into randomized controlled trials (RCTs) for the treatment of cancer that was the major factor contributing to the dramatic fall of deaths from breast cancer in the UK over 20 years and the provision of the best specialist services for diagnosis and treatment. Accordingly, he recommends centralization of programmes to prevent stroke, heart disease and lung cancer in combination with a risk-adjusted screening programme and recruitment of such patients into RCTs.