tag:theconversation.com,2011:/au/topics/breastscreen-3772/articlesBreastscreen – The Conversation2016-10-03T19:16:27Ztag:theconversation.com,2011:article/661252016-10-03T19:16:27Z2016-10-03T19:16:27ZWomen should be told about their breast density when they have a mammogram<figure><img src="https://images.theconversation.com/files/139540/original/image-20160928-736-273r8y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Breast density appears white or bright on mammograms – so do breast cancers. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-196939097/stock-photo-x-ray-mammogram-image-of-breast-with-cancer.html?src=pp-same_artist-196939100-1&ws=1">Tomas K/Shutterstock</a></span></figcaption></figure><p>Women with higher breast density for their age are more likely to develop breast cancer. High breast density also makes it harder for doctors to detect breast cancer on a mammogram. But Australian women are not routinely tested for and told about their level of breast density when they undergo a mammogram. </p>
<p>A woman’s breasts are made up of dense breast tissue and fatty breast tissue. Almost <a href="http://jnci.oxfordjournals.org/content/106/10/dju255.short">8% of women aged between 40 and 74 years</a> have extremely high breast density. This means they have more connective tissue and less fat surrounding their glands. </p>
<p>Breast density can’t be determined just from looking at or physically examining the breasts; it’s measured from a mammogram, an X-ray of the breast. Breast density appears white or bright, while non-dense breast tissue appears dark.</p>
<p>Breast cancers also appear white on a mammogram. So having high breast density can mask or hide the cancer, making early detection more difficult. This is especially important because women whose breast cancers that are found within 24 months of a “clear” mammogram tend to have poorer outcomes.</p>
<p>Across the population, a woman has a 12.5% chance of getting breast cancer in her lifetime. Women who have high breast density for their age and body mass index (BMI) have a <a href="https://www.ncbi.nlm.nih.gov/pubmed/16775176">four to six-times higher</a> risk of developing breast cancer in the future compared to women with low breast density. </p>
<p>We are a group of breast cancer scientists concerned that Australian women are not being made aware of the significance of breast density in the diagnosis and prevention of breast cancer. We want to start a conversation about what density is, even though we don’t yet have all the answers.</p>
<p>We would like to see health professionals (including researchers, radiologists, GPs and BreastScreen) begin talking with women about the best way to measure and report breast density. </p>
<h2>What can women do about it?</h2>
<p>A woman’s breast density is established at the time her breasts form, and is largely determined by genetic factors. </p>
<p>“Environmental” factors then can modify breast density over time. This includes having children, which reduces breast density, and taking certain hormone therapies: hormone replacement therapy increases density, while the drug <a href="https://www.ncbi.nlm.nih.gov/pubmed/21483019">Tamoxifen</a> decreases density.</p>
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<p><strong>Further reading:</strong> <a href="https://theconversation.com/how-does-breast-density-impact-on-cancer-screening-34700">How does breast density impact on cancer screening?</a></p>
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<p>We don’t yet have a straightforward answer about what women with high breast density for their age should do. </p>
<p>Being “breast aware” is important for all women, but particularly women with higher breast density. Get to know how your breasts feel and check them regularly for changes. </p>
<p>Mammography is the best breast cancer screening test for women aged 50-74 who aren’t showing any symptoms. Early detection improves the outcomes for women with breast cancer, as therapies are more effective at early stages of disease and chances of survival are increased. </p>
<p>For women aged 40 to 49 and over 75, the research is less clear about the benefits of breast screening. </p>
<p>Supplemental screening options such as ultrasound and MRI (magnetic resonance imaging) are available for women with high breast density. However, these also have a number of limitations and are not covered by Medicare for this purpose. </p>
<p>Ultrasound often results in high rates of false positives, indicating that breast cancer is present when it is not. A false positive can be a distressing experience, with additional tests sometimes being required such as a breast biopsy. </p>
<p>MRI does not lead to higher false positives, but it is not a feasible option for a population-based screening program because of the high costs and insufficient MRI resources (equipment and trained staff). </p>
<p>A further problem is there are few options to reduce breast density once it is detected. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/21483019">Tamoxifen</a> is a drug used to prevent or treat breast cancer that reduces breast density and breast cancer risk. But it has significant side effects such as hot flashes, vaginal dryness, low libido, mood swings and nausea, which need to be considered on a patient-by-patient basis. </p>
<p>In counselling women about their breast cancer risk and screening options, clinicians will also ask about a women’s other breast cancer risk factors, particularly family history of the disease.</p>
<h2>What might be available in future?</h2>
<p>Researchers and clinicians have been investigating breast density for around 40 years. But there is still a lot we do not know. </p>
<p>The long-term goal of our research – in Australia and abroad – is a tailored screening program where women undergo good-quality screening measures based on their levels of breast density and their breast cancer risk. </p>
<p>First, we need to determine if women with higher breast density would benefit from supplemental screening mentioned above, or annual mammograms. </p>
<p>Our research teams are currently investigating:</p>
<ul>
<li><p>the underlying biology of breast density to inform the development of new drugs to decrease density </p></li>
<li><p>the optimal methods of measuring breast density across the population and in younger women, for whom mammography is not recommended</p></li>
<li><p><a href="http://www.lifepool.org/">breast cancer risk prediction models</a> to determine the individual likelihood of developing the disease or having it go undetected </p></li>
<li><p>breast density in <a href="http://crowdresearch.uwa.edu.au/project/are-your-breasts-dense/">Aboriginal women and younger women</a></p></li>
<li><p>and the genetic determinants of breast density and breast cancer risk to inform individual risk prediction models.</p></li>
</ul>
<p>We don’t want to scare women that have higher breast density for their age. Rather, we want to inform them about their risk of breast cancer and the additional care they should take until we find treatments that can reduce density and breast cancer risk. Not all women with high breast density will develop breast cancer, but they should be aware that they are at an increased risk.</p>
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<p><em>For more information on breast density, visit the <a href="http://www.informd.org.au">INFORMD website</a>.</em></p><img src="https://counter.theconversation.com/content/66125/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kara Britt receives funding from National Breast Cancer Research Foundation of Australia and the Peter MacCallum Cancer Research Centre. She is a member of INFORMD (Information FORum on Mammographic Density), an Australian alliance of breast cancer researchers who aim to increase awareness of the importance of breast density in screening, diagnosis and prevention of breast cancer.</span></em></p><p class="fine-print"><em><span>Honor Joy Hugo has received funding from the National Breast Cancer Foundation, Victorian Cancer Agency and is currently funded by a Translational Research Institute SPORE grant and a National Breast Cancer Foundation collaborative research grant called EMPathy. She is a member of INFORMD.
</span></em></p><p class="fine-print"><em><span>Jennifer Stone received grant funding to conduct breast density research from The National Breast Cancer Foundation, Cancer Australia, Cancer Council Western Australia, Cancer Council Victoria, National Health & Medical Research Council, Royal Perth Hospital Medical Research Foundation, Breast Cancer Research Centre Western Australia, Victoria Cancer Agency, and the Victorian Breast Cancer Research Consortium. She is a member of INFORMD.</span></em></p><p class="fine-print"><em><span>John Hopper receives funding from the NHMRC, Cancer Australia, the National Breast Cancer Foundation, the National Institutes of Health and Cancer Council Victoria. He is a member of INFORMD. </span></em></p><p class="fine-print"><em><span>Pallave Dasari receives funding from The Hospital Research Foundation. She is a member of INFORMD.</span></em></p><p class="fine-print"><em><span>Rik Thompson has received funding from the St Vincent's Hospital Research Endowment Fund, the Princess Alexandra Hospital Foundation, the Victorian Breast Cancer Research Consortium and the Translational Research Institute. He is a member of INFORMD.</span></em></p><p class="fine-print"><em><span>Wendy Ingman receives funding from the National Health and Medical Research Council, the National Breast Cancer Foundation and The Hospital Research Foundation. She is a member of INFORMD.</span></em></p>Women with dense breasts are more likely to develop breast cancer. Density also makes it harder for doctors to detect breast cancer on a mammogram.Kara Britt, Senior Research Fellow at Peter MacCallum Cancer Centre; Adjunct Lecturer, Monash UniversityHonor Joy Hugo, Postdoctoral Research Fellow, Queensland University of TechnologyJennifer Stone, Senior Research Fellow, Centre for Genetic Origins of Health and Disease, The University of Western AustraliaJohn Hopper, NHMRC Australia Fellow, The University of MelbournePallave Dasari, Australian Breast Cancer Research Postdoctoral Fellow, The Queen Elizabeth Hospital and The Robinson Institute, University of AdelaideRik Thompson, Professor of Breast Cancer Research, Institute of Health and Biomedical Innovation and School of Biomedical Sciences,, Queensland University of TechnologyWendy Ingman, Associate Professor, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/297502014-08-18T20:21:22Z2014-08-18T20:21:22ZAnatomy of an Ant: Doomsday in Phase IV<figure><img src="https://images.theconversation.com/files/55263/original/3z38yb6x-1406694866.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">This is carnal science fiction cinema.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/sanchom/4487685929/in/photolist-7QyyFk-6AeFFu-o7NBi-mNWEP-P6DdH-6SKMsQ-4UEwpC-8L6G6n-6jo7mV-3eJn3B-6Mp-mVJ4BH-b3dga-6oC1yN-ffKkzB-5hVrNm-68DawN-9isNaL-2S1NRi-oy8z51-a926nV-njqq44-sqM8-o2Uq1R-7QBTfN-b3FQAD-fJoFGM-4TtzzC-9yyi8A-bvkZ4R-6cpp3u-oR9wa-gGwet-dcXrvG-ESBH2-fuPmpC-aabarY-anA9LU-aNSZH-25y9Bi-4Ji7hp-N4Ws3-bSMrtV-fAtHT-a8XNRJ-djnj4h-319Tke-9AbyuJ-3KFDuV-8hz4bA">Sancho McCann/Flickr</a></span></figcaption></figure><p>I will often say to my film students that if you want to know what aches a culture at a particular historical juncture then you need to visit and spend time with the catastrophic imagination of science fiction. For it is in the restless dreaming of future horizons where the hopes and fears of the present are laid bare.</p>
<p>Showing at the Melbourne International Film Festival in a lush restored 35mm print and with its original montage ending restored, <a href="http://miff.com.au/program/film/6023">Phase IV</a> - the only film to be directed by the exquisite poster and title sequence designer, <a href="http://www.imdb.com/name/nm0000866/">Saul Bass</a> - explores what happens when humankind is threatened by hyper-intelligent ants intent on colonising Earth. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/IuhgBvOWb_k?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Trailer for Phase IV (1974).</span></figcaption>
</figure>
<p>Set in the Arizona desert – but filmed at Pinewood Studios in England and on-location in Kenya – Phase IV narrates the struggle between two scientists, James Lesko <a href="http://www.imdb.com/name/nm0614526/">(Michael Murphy)</a> and Ernest Hubbs <a href="http://www.imdb.com/name/nm0202638/">(Nigel Davenport)</a> as they seek to understand and overcome the mysterious unification of all ant colonies and the (alien) hive mind that controls and advances their collective cause. </p>
<p>It is suggested that if Lesko and Hubbs cannot stop these super ants, then human civilisation is doomed. Doomed, I tell you.</p>
<h2>Doomsday visions</h2>
<p>Visually and aurally the film is indebted to a heady mixture of influences including the wildlife documentary; the anti-realism of European art cinema; the topography of the desert Western and the rural road movie; and to the new wave of electronic music and atonal chords that is so effectively used to eerily score the film and its often ferocious feral sound effects. </p>
<p>The ants enunciate like a ravenous and telepathic army on the relentless march to herald in the Armageddon, while the bleeps, squeaks, hums and drones that also saturate the soundscape creates the impression that invisible forces haunt every space. </p>
<p>These are not ants that can be trampled upon or squished between ones fingers but super centurions of the insect world.</p>
<p>The film’s cinematography is composed of two distinct styles.</p>
<p>Firstly, there are the intimate and naturalistic close ups of the ants, their colonies, machinery, computers, the sun and the moon, obelisques, and the various textures - such as skin, electrical wires, yellow poison - that colour and wash the entire <a href="https://theconversation.com/explainer-mise-en-sc-ne-27281">mise-en-scène</a>. </p>
<p>One feels as if one is in the laboratory or desert with the ants, and in that transferable relationship between film and viewer, as one watches one scratches skin and hair as if their phantom legs are beginning to crawl over and burrow down deep into you. This is carnal science fiction cinema.</p>
<p>The wildlife photographer <a href="http://www.imdb.com/name/nm0585453/">Ken Middleham</a> shot the insect sequences for Phase IV, as he also did for the documentary <a href="http://www.imdb.com/title/tt0067197/">The Hellstrom Chronicle</a>. Through a microscopic lens, the anatomy of an ant has never been so diabolically well chronicled.</p>
<p>Phase IV is also composed of long shots, frames of deep focus and wide panoramas, so that the shimmering heat of the desert and the liquid fire of the sun appear enormous and awesome in their power. The film is full of sublime cinematography. It simply takes one’s breath away and makes one feel like a tiny dot, like a single ant, in a giant universe.</p>
<p>This oscillation between near and far, between claustrophobia and agoraphobia, positions Earth in a never ending and expanding cosmos, but also under a forensic microscope where all our activities are being closely monitored. Ultimately this is a film caught in a paranoid state of delusion and allusion, as the troubles of America seep its way into its metaphoric visual and aural palettes.</p>
<h2>Signs of the times</h2>
<p>Narratively, Phase IV speaks to a number of critical concerns of America at the time the film was made: ecological and environmental collapse; the Cold War, and the Vietnam war; the ambivalent relationship that society has to science and their hyper-rationalist scientists; and to the irrational fear of miscegenation. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/56652/original/5gf5pkcn-1408326959.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/56652/original/5gf5pkcn-1408326959.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/56652/original/5gf5pkcn-1408326959.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=407&fit=crop&dpr=1 600w, https://images.theconversation.com/files/56652/original/5gf5pkcn-1408326959.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=407&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/56652/original/5gf5pkcn-1408326959.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=407&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/56652/original/5gf5pkcn-1408326959.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/56652/original/5gf5pkcn-1408326959.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/56652/original/5gf5pkcn-1408326959.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Velvet ant stinger tip scanning electron microscope</span>
<span class="attribution"><a class="source" href="http://upload.wikimedia.org/wikipedia/commons/8/8f/Velvet_ant_stinger_%28tip%29--scanning_electron_microscope_image.jpg">Janice Carr/Wikimedia</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p><em>Phase I: Ecological and Environmental Apocalypse</em> <br>
One of the concerns of Phase IV is the relentless expansion of the suburbs, population growth, unsustainability and the mechanisation of farming. </p>
<p>The film’s first land-based shots are of new town billboards and half completed homes. The yellow poison used to destroy the ant colony is a coda for industrial fertilisation and the dangers it brings to agriculture. The ants, which wipe out species that are above them in the food chain, are the avatars that put the ecology of Earth out of balance and as a consequence threaten the survival of all species, of the planet itself. </p>
<p>However, we realise late in the film that they are actually custodians of the future – it is we who must be stopped or over-taken in the evolutionary chain if Earth is to prosper.</p>
<p><em>Phase II: Red Ants under the Bed</em><br>
Phase IV was made at a time when the Cold War and Vietnam was uppermost in the American nation’s psyche. The ants in the film become both the fifth column, and the personification of Soviet norms – working collectively for the greater good and without individuality or individualism, always willing to sacrifice so long as the cohering centre is maintained. </p>
<p>The ant army can also be likened to the Viet Cong or the National Liberation Front, fighting against the superior technology and firepower of the American military. The ants build a series of connecting tunnels and traps, infiltrate the compound, and in consort with the “natural” environment turn the desert and sun on the scientists. </p>
<p>The scientists, secured in their hi-tech fortress compound, use yellow poison (agent orange, napalm) to kill the ants, but the ants only grow stronger. Eventually, the scientists have to abandon their laboratory and the ants begin to secure their victory as their centurions march on its grounds.</p>
<p><em>Phase III: Mad Science</em><br>
Phase IV offers up an ambivalent representation of science. Hubbs is the archetypal mad scientist, one who seeks truth in rational method and through reason alone, but is solely intent on destroying the ants at whatever cost. He uses science in a destructive way and is impervious to the human death that occurs around him. The film is a warning about letting too much science into the world.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/56648/original/grkjqpr8-1408325729.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/56648/original/grkjqpr8-1408325729.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/56648/original/grkjqpr8-1408325729.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=430&fit=crop&dpr=1 600w, https://images.theconversation.com/files/56648/original/grkjqpr8-1408325729.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=430&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/56648/original/grkjqpr8-1408325729.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=430&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/56648/original/grkjqpr8-1408325729.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=540&fit=crop&dpr=1 754w, https://images.theconversation.com/files/56648/original/grkjqpr8-1408325729.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=540&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/56648/original/grkjqpr8-1408325729.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=540&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ant.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/sanchom/4487685929/in/photolist-7QyyFk-6AeFFu-o7NBi-mNWEP-P6DdH-6SKMsQ-4UEwpC-8L6G6n-6jo7mV-3eJn3B-6Mp-mVJ4BH-b3dga-6oC1yN-ffKkzB-5hVrNm-68DawN-9isNaL-2S1NRi-oy8z51-a926nV-njqq44-sqM8-o2Uq1R-7QBTfN-b3FQAD-fJoFGM-4TtzzC-9yyi8A-bvkZ4R-6cpp3u-oR9wa-gGwet-dcXrvG-ESBH2-fuPmpC-aabarY-anA9LU-aNSZH-25y9Bi-4Ji7hp-N4Ws3-bSMrtV-fAtHT-a8XNRJ-djnj4h-319Tke-9AbyuJ-3KFDuV-8hz4bA"> Sancho McCann/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>By contrast, Lesko is the humanist scientist. Through his mathematical formulations he seeks to communicate with the ants, to understand them better. Lesko cares about human and ant life and looks to reason and emotion to bridge the species gap. </p>
<p>However, the film suggests that Hubb’s approach maybe the one that needs to be followed, offering the viewer a powerful Cold War message about weapons proliferation and the need for aggressive responses.</p>
<p><em>Phase IV: Inter-Species coupling</em><br>
Phase IV has a fear of borders being breached and is full of images of thresholds being overtaken, overrun. The film offers us images of “white flight” in which the ants become marauding rioters intent on taking over the “neighbourhood”. There is one scene of a house being “looted”, flames licking its grounds. The film’s context can be set in the context of the race riots and civil rights abuses that dominated the period.</p>
<p>Nonetheless, Phase IV brings the two species together, ant and human, suggesting that in their communion a new dawn will be reached, a new age will be born. In the newly restored cut of the film, this future horizon is a psychedelic trip where a new inter-species reaches the astral plane. </p>
<p><br>
<strong>The <a href="http://miff.com.au/">Melbourne International Film Festival 2014</a> screened during August 2014. See all MIFF 2014 coverage on The Conversation <a href="https://theconversation.com/topics/miff-2014">here</a>.</strong></p><img src="https://counter.theconversation.com/content/29750/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sean Redmond does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>I will often say to my film students that if you want to know what aches a culture at a particular historical juncture then you need to visit and spend time with the catastrophic imagination of science…Sean Redmond, Associate Professor of Media and Communication, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/142292013-05-17T01:06:14Z2013-05-17T01:06:14ZBreast cancer screening needs to make more than economic sense<figure><img src="https://images.theconversation.com/files/23992/original/tzppfwg9-1368750585.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The harms from over-diagnosis and over-treatment mean that not everyone benefits from breast cancer screening.</span> <span class="attribution"><span class="source">Ian Hunter</span></span></figcaption></figure><p>A <a href="https://theconversation.com/a-rational-expansion-of-breast-cancer-screening-14159">recent article</a> in The Conversation’s <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a> series endorsed the government’s decision to extend the BreastScreen program to women aged 70 to 74 (from 50 to 69), based on the results of a 2009 cost-effectiveness analysis of the program. </p>
<p>But the landscape of breast cancer screening changed irrevocably in late 2012, with the publication of <a href="http://www.cancerresearchuk.org/prod_consump/groups/cr_common/@nre/@pol/documents/generalcontent/breast-screening-review-exec.pdf">a report</a> by an independent UK panel that reviewed breast cancer screening.</p>
<p>The panel confirmed that screening reduces the risk of dying from breast cancer by about 20%, but also concluded that screening causes over-diagnosis. Over-diagnosed cancers are those that would never have been found without screening. They are not destined to cause symptoms or become life-threatening but, nonetheless, they lead to more women getting treatment for breast cancer. </p>
<p>The panel estimated that 681 cancers would be diagnosed for every 10,000 UK women screened from 50 years of age for 20 years. Of these 681 cancers, 129 would represent over-diagnosis and 43 deaths would be prevented. </p>
<p>In other words, for women invited to be screened, the chance of avoiding dying from breast cancer is about 0.4% and the chance of being over-diagnosed and over-treated is about 1.3%. So, for every breast cancer death prevented, three women will be over-diagnosed and over-treated.</p>
<p>Breast cancer screening is a finely balanced trade-off of benefit versus harm. And there are important question marks over the argument to expand the program based on cost-effectiveness analysis alone. </p>
<p>This is particularly problematic because the analysis itself is based solely on survival statistics, when there are also major impacts on quality of life from both potential harms and benefits of screening.</p>
<p>More important than economic considerations, such as whether the program’s “cost per life-year saved” is improved by screening older (or younger) women, is the question - will we do more good than harm by expanding screening?</p>
<p>The <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/br-economic-cnt">2009 cost-effectiveness analysis</a> that was used to assess the implications of expanding the screening program was done as part of a wide-ranging evaluation of the BreastScreen Australia program.</p>
<p>That evaluation also included an assessment of the mortality benefit (percentage of breast cancer deaths averted) by screening in Australia. <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/br-mortality-ecological-cnt">It found</a> that, while screening significantly reduced the risk of dying from breast cancer among women aged 50 to 69 years, there was no significant reduction in breast cancer mortality among women aged 70 to 74 years.</p>
<p>So why have we expanded a program that will likely harm women over the age of 70 through over-diagnosis, without clear evidence that it will deliver a benefit for this age group?</p>
<p>While the 2009 cost-effectiveness estimates included treatment costs, they did not explicitly consider the effects of over-diagnosis and subsequent over-treatment on either survival or on quality of life. </p>
<p>The UK panel’s report suggested that new cost-effectiveness estimates should be made, taking account of over-diagnosis. This needed to be done before the decision to expand the program was made.</p>
<p>The <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/8463830B90E5BDF5CA25762A000193C6/$File/ch%201-3.pdf">2009 BreastScreen Australia Evaluation</a> recommended a focus on increasing screening participation rates through social marketing and other strategies. But is it ethical to promote screening to women in their 70s when we cannot demonstrate that it will reduce the risk of dying of breast cancer in this age group? </p>
<p>Might we not inadvertently pressure older women to undergo breast cancer screening and treatment that they may not need nor benefit from? An example from <a href="http://www.bmj.com/content/346/bmj.f158">recent research</a> conducted by our group is revealing in this regard. </p>
<p>When presented with information about both the benefit of screening and the risk of harm through over-diagnosis, one study participant was angry that she and her mother (aged in her 70s) had not received this information before her mother underwent breast cancer treatment. Her mother died shortly after the operation and our participant believed the death was a direct consequence of treatment.</p>
<p>Breast cancer screening <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/br-economic-cnt">currently costs</a> an average of A$136 million a year. The expansion of the program is being funded at a cost of an additional A$55 million. The opportunity cost (the forgone benefit of alternative use/s of the money spent) of the expansion is considerable. </p>
<p>All things considered, there may be better ways to address the burden of breast cancer that would be more beneficial and less harmful. Such strategies might include more resources directed towards better information about the benefits and harms of screening, as called for by the independent UK panel, to ensure women are able to make informed choices to screen or not. </p>
<p><a href="http://jnci.oxfordjournals.org/content/early/2013/02/01/jnci.djs649">Deliberative methods</a>, such as citizen juries may also be effective way to proceed. These methods allow evidence on complex health decisions to be presented to communities so they can make informed recommendations about where they feel government funds would be best invested. </p>
<p>Better information and better consultation initiatives are priorities for screening programs now that the harm of over-diagnosis has been confirmed. Or, money could be directed to primary prevention of breast cancer through lifestyle modification, breast cancer research or other health-care priorities.</p><img src="https://counter.theconversation.com/content/14229/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexandra Barratt receives funding from NHMRC for research on the evidence and ethics of cancer screening.</span></em></p><p class="fine-print"><em><span>Kirsten Howard works with the Screening and Test Evaluation Program which is funded by the NHMRC, and receives funding from the ARC.</span></em></p><p class="fine-print"><em><span>Kirsten McCaffery is currently working with the Screening and Test Evaluation Program which has program grant funding from the National Health and Medical Research Council.</span></em></p>A recent article in The Conversation’s Health Rationing series endorsed the government’s decision to extend the BreastScreen program to women aged 70 to 74 (from 50 to 69), based on the results of a 2009…Alexandra Barratt, Professor of Public Health, University of SydneyKirsten Howard, Professor, Health Economics, University of SydneyKirsten McCaffery, NHMRC Career Development Fellow & Associate Professor in Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/105312012-11-18T19:10:22Z2012-11-18T19:10:22ZIs routine breast cancer screening doing more harm than good?<figure><img src="https://images.theconversation.com/files/17594/original/sd6ypdhw-1352854005.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Even without routine mammographs, women with a family history of the disease should be screened.</span> <span class="attribution"><span class="source">Zanthia</span></span></figcaption></figure><p>Public discussion about the risks of over-diagnosis of breast cancer have left some women wondering whether they should take part in the government’s breast screening program.</p>
<p>Let’s take a look at what the evidence says and how women might be enabled to make their own decisions about whether to participate.</p>
<p>Last year Sir Michael Marmot, Professor of Epidemiology and Public Health at University College London, was asked to chair an independent panel to review the benefits and harms of screening mammography in the United Kingdom. The panel focused on the findings from randomised trials, even though most of these trials were carried out a long time ago, in the 1970s and 1980s. </p>
<p>A <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61611-0/abstract">report on the findings</a> of the review and an <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61775-9/fulltext?elsca1=ETOC-LANCET&elsca2=email&elsca3=E24A35F">accompanying editorial</a> were published in the Lancet late last month. In summary, the report said that screening resulted in an estimated ratio of cases over-diagnosed, to deaths from breast cancer prevented, of 3:1. An <a href="http://jnci.oxfordjournals.org/content/102/9/605.abstract">over-diagnosed case</a> is one where screening has identified a breast cancer that will never cause harm. </p>
<p>As it is not currently possible to distinguish breast cancer identified through screening which will never cause harm from cancer that will, all breast cancer identified by screening is treated - with surgery and various combinations of radiotherapy, chemotherapy, endocrine and biologic therapies. </p>
<p>A woman treated needlessly will have no way of knowing that her cancer was harmless and that her well-being has been sacrificed, without her knowledge or consent, for the sake of others who may have benefited from screening.</p>
<h2>Assessing the benefits of screening</h2>
<p>The benefits of screening appear to have been over-estimated. </p>
<p>Advances in treatment have changed the outlook for women with breast cancer so profoundly over the past two decades that the potential for screening to further reduce deaths from breast cancer has been <a href="http://www.ncbi.nlm.nih.gov/pubmed/21956213">considerably reduced</a> since the original randomised trials were performed. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/17597/original/38hshd4y-1352856418.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/17597/original/38hshd4y-1352856418.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/17597/original/38hshd4y-1352856418.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/17597/original/38hshd4y-1352856418.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/17597/original/38hshd4y-1352856418.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/17597/original/38hshd4y-1352856418.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/17597/original/38hshd4y-1352856418.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women need to understand the risk of over-diagnosis.</span>
<span class="attribution"><span class="source">MBK Marjie</span></span>
</figcaption>
</figure>
<p>Furthermore, limiting the estimated benefit to reduced deaths from breast cancer is <a href="http://www.ncbi.nlm.nih.gov/pubmed/16360786">misleading</a> because radiotherapy after surgery for breast cancer materially increases the risk of dying from heart disease. </p>
<p>The magnitude of overdiagnosis has also been underestimated. An estimate of overdiagnosis from Australia – adjusted for confounders and lead time and assuming 60% of invited women attend – found an over-diagnosis rate of 30% to 40% depending on the expected incidence without screening, rather than the 19% in the <a href="http://www.ncbi.nlm.nih.gov/pubmed/19894130">Lancet report</a>. </p>
<p>The Nordic Cochrane Center <a href="http://www.cochrane.org/news/blog/mammography-screening-ten-years-reflections-decade-2001-review">review of screening mammography</a> has estimated the ratio of cases over-diagnosed to deaths from breast cancer prevented at 10:1. Our estimate of the ratio in Australia, using a lower estimate of deaths prevented due to the <a href="http://www.ncbi.nlm.nih.gov/pubmed/21956213">impact of improved treatment</a> and the higher rate of over-diagnosis, is closer to 15:1. </p>
<p>The clear message is that over-diagnosis exists, it happens regularly as part of the screening process and women need to understand this.</p>
<h2>An informed decision</h2>
<p>When an asymptomatic woman requests screening mammography through her doctor or when a doctor recommends that an asymptomatic woman be screened, the doctor has a responsibility to inform her about the potential harms and benefits so she can decide whether she will have the mammogram in the context of her situation and preferences. </p>
<p>But when a woman receives an invitation for screening from a government body that makes little or no reference to screening-related harm, she may reasonably expect that that there is no real likelihood of harm. It could be argued that the weight of responsibility for full and frank disclosure of risks and benefits is even greater when the invitation comes from a trusted government agency that has been historically responsible for promoting screening. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/17596/original/ghmndvwy-1352856418.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/17596/original/ghmndvwy-1352856418.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=815&fit=crop&dpr=1 600w, https://images.theconversation.com/files/17596/original/ghmndvwy-1352856418.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=815&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/17596/original/ghmndvwy-1352856418.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=815&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/17596/original/ghmndvwy-1352856418.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1025&fit=crop&dpr=1 754w, https://images.theconversation.com/files/17596/original/ghmndvwy-1352856418.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1025&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/17596/original/ghmndvwy-1352856418.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1025&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women can still be screened for breast cancer without routine invitations.</span>
<span class="attribution"><span class="source">Topeka Shawnee County Public Library</span></span>
</figcaption>
</figure>
<p>It’s time to review the routine invitation for screening to all women aged 50 to 69 years. </p>
<p>The <a href="http://www.aihw.gov.au/publication-detail/?id=6442468276">proportion of women</a> in the invited age group who currently attend for screening in Australia is between 50% and 60% so not all women currently respond to the invitation by attending. </p>
<p>Stopping the routine invitation for screening would not prevent women being screened. Women with a high risk of cancer - those with a family or personal history of breast cancer – should still be screened. There may be others who should consider screening because they have a combination of <a href="http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-risk-factors">less powerful risk factors</a> which might put them at above average risk. </p>
<p>Other women, not at above-average risk, could request screening if this is what they want. </p>
<p>If women elect <em>not</em> to be screened and only enter the medical system when a clinical problem presents itself, they can be reassured that they will have the benefit of the recent improvements in breast cancer treatment.</p>
<h2>Next steps</h2>
<p>Government should undertake a review of the invitation for screening. But this will take time.</p>
<p>For the time being, it is imperative that all women be provided with comprehensive information about the disadvantages as well as the advantages of mammographic screening. The <a href="http://www.cochrane.dk/screening/mammography-leaflet.pdf">pamphlet</a> produced by the Nordic Cochrane Center, which presents the information in terms of the impact of screening on absolute risks and benefits, would make an excellent model. </p>
<p>But a pamphlet alone is insufficient. Given the risks, each woman must be given the opportunity to discuss her options and decide what is best for her, with those who are in a position to provide accurate and helpful advice.</p><img src="https://counter.theconversation.com/content/10531/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robin Bell receives funding from the Victorian Cancer Agency, the BUPA Health Foundation and the National Health and Medical Research Council of Australia.</span></em></p><p class="fine-print"><em><span>Michael Baum's department is funded by HTA, with an additional educational grant from Carl Zeiss.</span></em></p><p class="fine-print"><em><span>Bebe Loff and Robert Burton do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Public discussion about the risks of over-diagnosis of breast cancer have left some women wondering whether they should take part in the government’s breast screening program. Let’s take a look at what…Robin Bell, Professor & Deputy Director, Women's Health Program, School of Public Health and Preventive Medicine, Monash UniversityBebe Loff, Associate Professor and Head of Human Rights & Bioethics, Monash UniversityMichael Baum, Emeritus Professor of Surgery, UCLRobert Burton, Professor School of Public Health and Preventive Medicine, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/73962012-09-10T20:25:03Z2012-09-10T20:25:03ZOver-diagnosis and breast cancer screening: a case study<figure><img src="https://images.theconversation.com/files/15291/original/89ysp677-1347258264.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women need to be made aware of over-diagnosis and given enough information to make up their own minds about screening.</span> <span class="attribution"><span class="source">Johan/Flickr</span></span></figcaption></figure><p><em>OVER-DIAGNOSIS EPIDEMIC – Today Robin Bell and Robert Burton examine breast cancer to evaluate the role of population-wide screening in over-diagnosis.</em></p>
<p>Since the national <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442454634">screening mammography program</a> (Breastscreen) began in Australia in 1991, <a href="http://www.aihw.gov.au/data">mortality from breast cancer</a> has declined by 28%. We wanted to know how much of this improvement was due to Breastscreen and how much was due to advances in breast cancer treatment.</p>
<p>This is an important question to ask in light of the recent passionate debate about the benefits and harms of mammographic screening in <a href="http://www.bmj.com/content/340/bmj.c3106?tab=responses">medical literature</a> as well as in the lay <a href="http://www.theage.com.au/national/behind-the-screen-20111103-1mxrh.html">press</a>. We published an <a href="http://www.ncbi.nlm.nih.gov/pubmed/21956213">analysis</a> that addressed this issue using three different approaches.</p>
<h2>Who avoids breast cancer death?</h2>
<p>We started by comparing the relative reductions in breast cancer-specific mortality between 1991 and 2007 (the latest data year available) in women across different age groups. We know women aged 50 to 69 years were invited to screen, so their uptake of mammographic screening should have been higher than other age groups. So if screening was important, this is where we would expect to see the most impact.</p>
<p>But what we found was that the greatest relative reduction in breast cancer mortality (44%) occurred in the youngest age group. These women (aged 40 to 49 years) are not invited for screening. In contrast, women aged 60 to 69 years, who <em>are</em> invited to screen, had the smallest relative reduction in mortality (19%). </p>
<p>Given that three times as many women aged 60 to 69 (about 60%) participated in Breastscreen (compared to 20% of women aged 40 to 49 years), our finding <em>is not consistent</em> with screening having a major impact on the reduction in breast cancer mortality since 1991.</p>
<h2>When was mortality reduced?</h2>
<p>We then considered <em>when</em> Breastscreen could have had an impact on breast cancer mortality between 1991 and 2007. </p>
<p>The proportion of invited women who attended for screening didn’t exceed 50% until 1996. And we know from randomised trials of screening that the impact of screening on mortality was not seen for four to six years after the commencement of the trials (they had an even higher level of <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(02)08020-0/fulltext">participation of 70% and more</a>). </p>
<p>So <a href="http://www.ncbi.nlm.nih.gov/pubmed/21956213">we compared the reductions</a> in mortality that occurred in two time periods – (1) between 1991 and 1999 when we wouldn’t have expected Breastscreen to have an impact and (2) between 2000 and 2007 when the impact of Breastscreen would’ve been expected. </p>
<p>For women invited for screening (50 to 69 years), most of the reduction in mortality that occurred between 1991 and 2007 took place prior 2000. The reduction was <em>before</em> the impact of screening could be expected. </p>
<p>Only about a third of the total 28% reduction in breast cancer mortality seen in this age-group over the full time period occurred after 1999 (9%). This finding is also inconsistent with mammographic screening having a major impact on the observed reduction in breast cancer mortality since 1991.</p>
<h2>Improved treatment</h2>
<p>Finally, we used a number of different data sources to estimate the likely impact on breast cancer mortality of changes in the use of <a href="http://www.cancer.gov/cancertopics/factsheet/Therapy/adjuvant-breast">adjuvant chemo</a> - and <a href="http://breastcancer.about.com/lw/Health-Medicine/Conditions-and-diseases/Endocrine-Treatments-for-Breast-Cancer.htm">endocrine therapy</a> over the same time period. We obtained published data from the Early Breast Cancer Trialists’ Collaborative Group (<a href="http://www.ncbi.nlm.nih.gov/pubmed/15894097">EBCTCG</a>) to provide the <a href="http://www.ncbi.nlm.nih.gov/pubmed/21802721">estimated impact</a> of regimens of chemo and endocrine therapy on women in different age groups with early breast cancer. </p>
<p>We used this data, together with data from a population-based <a href="http://onlinelibrary.wiley.com/doi/10.1002/cncr.20401/abstract">survey</a> of women treated for early breast cancer in Victoria in 1999, to calculate the impact the use of adjuvant chemo- and endocrine therapy could have had on breast cancer mortality in these women. We found that the adjuvant therapy Victorian women received in 1999 could have produced a mortality reduction of about 26% in women in the age group invited to screen. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/15283/original/38jdcdv4-1347257115.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/15283/original/38jdcdv4-1347257115.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/15283/original/38jdcdv4-1347257115.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/15283/original/38jdcdv4-1347257115.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/15283/original/38jdcdv4-1347257115.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/15283/original/38jdcdv4-1347257115.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/15283/original/38jdcdv4-1347257115.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Diagnosis comes with its own worries and stresses.</span>
<span class="attribution"><span class="source">Ronny-André Bendiksen</span></span>
</figcaption>
</figure>
<p>Indeed, improvements in the treatment of breast cancer could explain almost all of the reduction in breast cancer mortality that has occurred in women invited to screen since 1991.</p>
<p>We estimate mammographic screening is responsible for a minority of the reduction in breast cancer-specific mortality seen in Australia since 1991 and that advances in adjuvant therapies adequately explain the majority of the observed mortality reduction.</p>
<h2>Breast cancer and over-diagnosis</h2>
<p>A modest reduction in mortality as a result of mammographic screening would seem acceptable if it were not for the issue of over-diagnosis. Over-diagnosis is the diagnosis and treatment of breast cancer that would have never have made a woman ill in her lifetime – she would never have known about it if she had not been screened. </p>
<p>The extent of the problem of breast cancer over-diagnosis has been estimated in the <a href="http://www.ncbi.nlm.nih.gov/pubmed/21249649">Cochrane review of screening mammography</a> at 30%, based on the randomised trials. In Australia, based on increases in new case rates, over-diagnosis was estimated at 30% to 40% in the women aged 50 to 69 years invited to screen in New South Wales in <a href="https://www.mja.com.au/journal/2012/196/1/do-benefits-screening-mammography-outweigh-harms-overdiagnosis-and-unnecessary-0">2001 and 2002</a>. </p>
<p>Putting their estimates of the relative mortality reduction in breast cancer (15%) and over-diagnosis (30%) together to calculate the balance of benefits versus harms, <a href="http://www.ncbi.nlm.nih.gov/pubmed/21249649">the Cochrane review summarised</a>:</p>
<blockquote>
<p>“… for every 2000 women invited for screening throughout 10 years, one will have her life prolonged. In addition, 10 healthy women, who would not have been diagnosed if there had not been screening, will be diagnosed as breast cancer patients and will be treated unnecessarily.”</p>
</blockquote>
<p>Our estimate of the likely breast cancer-specific <a href="http://www.ncbi.nlm.nih.gov/pubmed/21956213">mortality reduction from screening</a> in women aged 50 to 69 years (9%) and the New South Wales estimates of 30% to 40% over-diagnosis <a href="http://www.ncbi.nlm.nih.gov/pubmed/19894130">in this age group are similar</a> to the Cochrane estimates. </p>
<p>Based on these Australian estimates and the incidence and mortality of breast cancer in women aged 50 to 69 years in 2007, we know that for every death from breast cancer prevented, 15 healthy women, who wouldn’t have been diagnosed if they hadn’t been screened, will be diagnosed as having invasive breast cancer and will be treated unnecessarily.</p>
<p>Although there’s considerable argument about the exact extent of over-diagnosis, most estimates find the balance of lives saved to cases over-diagnosed and treated unnecessarily unfavourable, with more women over-diagnosed than saved.</p>
<p>We believe that the decision to invite women for screening should be reviewed with the aim of ceasing the standard invitation for screening. As women aged 50 to 69 years have been invited for screening for 20 years now, a change in policy may take some time to work through. </p>
<p>In the meantime, women need to be made aware of the issue of over-diagnosis and the information provided to those invited for mammographic screening needs to be better balanced between benefits and harms so they can make up their own minds about whether to be screened.</p>
<p><em>Have you or someone you know been over-diagnosed? Share your story below or <a href="mailto:reema.rattan@theconversation.edu.au">email</a> the series editor.</em></p>
<p><em>This is part two of our series on over-diagnosis, click on the links below to read other articles:</em></p>
<p><em><strong>Part one:</strong> <a href="https://theconversation.com/preventing-over-diagnosis-how-to-stop-harming-the-healthy-8569">Preventing over-diagnosis: how to stop harming the healthy</a></em></p>
<p><em><strong>Part three:</strong> <a href="https://theconversation.com/the-perils-of-pre-diseases-forgetfulness-mild-cognitive-impairment-and-pre-dementia-8702">The perils of pre-diseases: forgetfulness, mild cognitive impairment and pre-dementia</a></em></p>
<p><em><strong>Part four:</strong> <a href="https://theconversation.com/how-genetic-testing-is-swelling-the-ranks-of-the-worried-well-9080">How genetic testing is swelling the ranks of the ‘worried well’</a></em></p>
<p><em><strong>Part five:</strong> <a href="https://theconversation.com/psa-screening-and-prostate-cancer-over-diagnosis-8568">PSA screening and prostate cancer over-diagnosis</a></em></p>
<p><em><strong>Part six:</strong> <a href="https://theconversation.com/over-diagnosis-the-view-from-inside-primary-care-8889">Over-diagnosis: the view from inside primary care</a></em></p>
<p><em><strong>Part seven:</strong> <a href="https://theconversation.com/moving-the-diagnostic-goalposts-medicalising-adhd-8675">Moving the diagnostic goalposts: medicalising ADHD</a></em></p>
<p><em><strong>Part eight:</strong> <a href="https://theconversation.com/the-ethics-of-over-diagnosis-risk-and-responsibility-in-medicine-9054">The ethics of over-diagnosis: risk and responsibility in medicine</a></em></p>
<p><em><strong>Part nine:</strong> <a href="https://theconversation.com/ending-over-diagnosis-how-to-help-without-harming-9633">Ending over-diagnosis: how to help without harming</a></em></p><img src="https://counter.theconversation.com/content/7396/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robin Bell receives funding from the Victorian Cancer Agency, the BUPA Health Foundation and the National Health and Medical Research Council of Australia.</span></em></p><p class="fine-print"><em><span>Robert Burton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>OVER-DIAGNOSIS EPIDEMIC – Today Robin Bell and Robert Burton examine breast cancer to evaluate the role of population-wide screening in over-diagnosis. Since the national screening mammography program…Robin Bell, Professor & Deputy Director, Women's Health Program, School of Public Health and Preventive Medicine, Monash UniversityRobert Burton, Professor School of Public Health and Preventive Medicine, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.