Wednesday, March 28, 2012

The expert branded a woman hater for saying breast cancer screening ruins lives

A rare medical researcher who looks at the big picture

What could be more sensible than having a mammogram?  If a tiny tumour is growing in your breast, you want to find it as soon as possible and treat it before it has a chance to spread and become life-threatening.  This simple idea is the basis of a worldwide breast scanning industry that costs billions every year.

The UK programme was launched in 1988, and according to triumphant figures released last week it is screening more women than ever before — nearly 1.9million a year (at a cost of around £96 million).

‘By bringing forward detection and diagnosis, screening helps us find those cancers that might otherwise not be caught until later in life,’ said Sarah Sellars, assistant director for the NHS Cancer Screening Programmes.

However, some experts question whether national screening programmes for breast cancer are such a good idea.  For more than a decade, Peter Gotzsche, a leading Danish professor and statistician, has argued they are a serious mistake: not only do they do little to reduce the death rate from breast cancer, but because women haven’t been told the truth about the risks of mammography, some endure painful disfigurement and completely unnecessary treatment that may have shortened their lives.

Two years ago, when he looked at the figures produced to mark the 20th anniversary of the UK screening programme, Professor Gotzsche’s analysis suggested that for every 2,000 women screened regularly for ten years, just one will benefit from the screening.   At the same time, ten healthy women will, as a consequence, become cancer patients and be treated unnecessarily.

The director of the NHS cancer screening programme, Julietta Patnick, says Gotzsche’s analysis is ‘inaccurate’.  Rather than one life being saved for every ten women who received unnecessary treatment, she says, the true figure was much closer to a one-to-one ratio.

But Gotzsche has blue-chip credentials — he is professor of clinical research design and analysis and leader of the Nordic Cochrane Center at Rigshospitalet in Copenhagen, and an expert in the statistics needed to assess the risks and benefits of screening.

Yet for almost ten years there has been a concerted campaign to discredit him, while scanning authorities in the UK, U.S. and Europe have done little to address his criticisms.

Many women will be vaguely aware that recently there have been some criticisms of mammograms.  Some may recall the news last October that the NHS leaflet on scanning given to women is to be reviewed following claims it exaggerated benefits and did not spell out the risks.

Analysis of the problems quickly becomes technical and is only available in hard-to-obtain, specialist journals.  Which is why Professor Gotzsche has written a book, Mammography Screening: Truth, Lies And Controversy.

He claims there has been a shocking campaign by the authorities to keep his alternative analysis from women.

The first time he raised concerns was in 2000.  Professor Gotzsche set out his case in an explosive article in the medical journal The Lancet.

Based on analysis of the results of the screening programme in Sweden it concluded mammography was ‘unjustified’ — and it generated a furious response.  Experts in the screening industry expressed ‘dismay’ that it would erode public confidence in screening and urged women to ignore it.

The Department of Health issued a press release saying the NHS Breast Screening programme was a success and there was no new evidence in The Lancet report.

‘Our review was described as riddled with misrepresentations, inconsistencies and errors of method and fact,’ says Professor Gotzsche.  ‘But often the attacks didn’t even challenge my research — they were simply personal. I was said to be ignorant, careless and on a crusade against screening.’

His report was originally commissioned by the Danish Board of Health, but when it was delivered the board tried to classify it as a ‘non-paper’, so it couldn’t even be accessed through the country’s Freedom of Information Act.

One of Professor Gotzsche’s chief opponents, Laszlo Tabar, was the author of one of the Swedish trials analysed in The Lancet.  He claimed it showed scanning to be effective and safe and still holds that view.  Recently Tabar said scanning was the best thing to happen for women in 3,000 years, adding: ‘There are still people who don’t like mammography.  'Presumably, they don’t like women.’

Professor Gotzsche says: ‘People who like women, and women themselves, should no longer accept the pervasive misinformation they’re consistently exposed to.’

But what can be wrong with checking to catch breast cancer as early as possible?  If every tumour that showed up on a mammogram eventually spread around the body, no one could object. But cancer isn’t like that.

‘It is a biological fact of life that we cannot avoid getting cancer as we get older,’ says Professor Gotzsche.  ‘It’s so common nearly all middle-aged people will have some sign of it and most of them will die without having had any symptoms as a result.’

In other words, scanning finds cancerous changes that would otherwise never have caused a problem in your lifetime.

But once a mammogram picks up something that might be a tumour, you’re on your way to becoming a cancer patient because there are no reliable ways of telling if you’ve got the slow-growing or disappearing type, or if it is going to become dangerously invasive.

You will be sent for a biopsy and, if it’s cancerous, you get the full cancer works — surgery, chemotherapy and radiation, and possibly have your breast removed.  Thousands who would otherwise have remained perfectly healthy — because their cancers would never have caused a problem — become cancer patients.

In his book, Professor Gotzsche quotes a British woman who described what it could involve.  Her scan found a carcinoma in situ — a type of cancerous change in a cell that, in most cases, does not develop into the potentially lethal, invasive form of the disease. 

‘I expect I have been classified a screening success,’ she said.  ‘Yet everything about my experience tells me the opposite. Screening has caused me considerable and lasting harm.  'Two wide excisions, one partial mutilation (sorry, mastectomy), one reconstruction, five weeks’ radiotherapy, chronic infection, four bouts of cellulitis (a bacterial skin infection), several general anaesthetics, and more than a year off work.’

Thousands of women don’t go through anything as gruelling, but the sheer number overdiagnosed comes as a shock.  Professor Gotzsche has calculated that each year about 70,000 British women are recalled after a ‘false positive’ mammogram result.

In some cases, the cell changes detected by the mammogram weren’t cancerous.  But Professor Gotzsche is really concerned about cells that are cancerous but would never have caused problems.

Known as overdiagnosed cancers, they result in women treated unnecessarily.  Working out how many women had this unnecessary treatment is very complicated, which is why the debate gets so fierce.

‘The crucial question is, how many lives does it save?’ Professor Gotzsche adds.  ‘Is it enough to justify the harms inflicted on the healthy population?’

The screening programme officially saves an estimated 1,400 lives every year, but the professor found this couldn’t be true.

By using these figures, says Professor Gotzsche, the NHS has failed to give women honest information on which to make a decision and that just one life is saved while 10 women will be treated unnecessarily.

Some scanning experts have launched vicious personal attacks in response to Professor Gotzsche’s statistical analysis.

‘What is remarkable to me,’ wrote one, ‘is that this man calls himself a scientist since he obviously, knowingly ignores the scientific method to further his own agenda. I cannot believe his is so intellectually deficient.’

Professor Gotzsche has never said women shouldn’t be scanned — he believes women should get a realistic estimate of the benefits and risk, which, right now, they aren’t. That, he says, is a scandal.


More cholesterol needed

ONE patient persuaded John Kastelein to explore the radical idea that would anchor his future career. The cardiologist was at work in an Amsterdam hospital when a 36-year-old was brought into emergency. Tall and lean, non-smoking and physically fit, the man had collapsed with a heart attack.

"All his coronary arteries were terribly obstructed and he got operated on right away," said Professor Kastelein, now chairman of the genetics of cardiovascular disease at the University of Amsterdam. The damage was so severe that seven of his arteries had to be bypassed.

"In young people, surgeons often use the mammary artery that runs parallel to the breastbone on both sides, to patch into the heart,'' he said. "That artery never has atherosclerosis [blockages] so the surgeon was totally amazed to find both mammary artery walls had become diseased."

Investigations revealed the patient, Piet Snoek, had a gene mutation that blocked all production of high density lipoprotein (HDL) - the "good cholesterol".

His case "completely convinced" Professor Kastelein that the protective effects of HDL were as significant a part of the heart disease story as the well-known damage wrought by low density lipoprotein "bad" cholesterol. He set out to demonstrate a heresy: that raising cholesterol could help the heart, provided the cholesterol in question was HDL.

"Every manipulation that raises HDL in a mouse or a rabbit is beneficial," said Professor Kastelein, who will deliver a plenary address in Sydney today at the International Symposium on Atherosclerosis.

Fifteen years later, Mr Snoek is still alive. Professor Kastelein and colleagues have used drugs to completely eliminate LDL from his body, compensating for the absence of HDL. "Heart disease is the result of the balance of these two," he said.

Several drug companies have begun synthesising HDL - which attaches to cells that mop up LDL, steering them into the circulation - following a heart attack.

"We have shown we can mobilise cholesterol from the arterial wall. We can move amounts of cholesterol that in my mind are very clinically significant," Professor Kastelein said. The next step is to use heart scans to evaluate whether this reverses artery damage.

Philip Barter, of the Heart Research Institute in Sydney, said raising HDL had ''the potential to be as important on top of [cholesterol-lowering] statins as statins were on nothing".


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