High Noon for Population-Wide Mammography Screening?

By Prof. Dr. med. Dr. phil. Nikola Biller-Andorno

Director, Institute of Biomedical Ethics, University of Zurich, Switzerland

Safra Network Fellow, Harvard University (13-14)

Visiting Professor, Div. Medical Ethics, Harvard Medical School (12-14)

It is amazing how much heat a report can draw that simply states what has been all over town for some time now: We do not know if mammography screening does more good than harm, we do not even know for sure if it does any good at all.

The Swiss Medical Board, an independent health technology assessment initiative that was started in 2008, stated that based on the empirical data availability the introduction of mammography screening all over Switzerland could not be recommended.

As could be expected the report drew fire. Curiously, one of the chief complaints was that it was “unethical” to upset women who might no longer know if screening was good for them or not.

This sounds just a little bit paternalistic – particularly given that we know that most women seriously overestimate the benefits of screening when making their decision, a point that my colleague Peter Juni and myself illustrate in a Perspective piece published on May 22, 2014 in the New England Journal of Medicine.

A public health program to which all women of a certain age group are invited by the responsible health authority must leave the impression among invitees that screening is undoubtedly not only good for them but probably very important and effective.

From what we know, however, half of women screened will have a false alarm, and there will be at the very least as many women overdiagnosed and treated needlessly as will be saved from a breast cancer death. This is something, I think, that women might appreciate being told, rather than being protected from possibly unnerving information.

There is a lot at stake: I recently met a friend who I had not seen for some years. She told me that she had had breast cancer, which had been a complete surprise to her as she had none of the usual risk factors. The cancer had been detected by a routine mammogram, followed by operation, radiation, chemotherapy. She worried about a relapse and about seeing her children grow up. Her life was turned upside down. What if she had been one of those women who would never have been bothered by the cancer that was detected through screening?

There is a lot of political concern about taking something away from women they consider valuable. But women need to be properly informed to make an informed choice about what is right for them. If this happened, it might well mean that population-wide screening will become a thing of the past.

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