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Screening for breast cancer

Yet again we have a discussion about whether screening for cancer, this time of the breast, is necessarily a good thing. Peter Gotzsche, director of the Nordic Cochrane Centre in Copenhagen, has renewed his criticism of screening programmes. Together with Karsten Jorgensen he has reviewed breast cancer trends in the UK, Canada, Australia, Sweden, and Norway. Similar levels of over-diagnosis were found in all the countries.

These researchers say that for every woman whose life is saved by screening, up to 10 will be over-diagnosed and up to 500 will have at least one false alarm, leading to biopsy in half the cases.

This does not of course mean that women should not go forward for screening, but it does mean that the decision not to do so is not irrational. As with the PSA test for prostate cancer, there is a balance to be struck. Yes, the test may show up a cancer that can be treated successfully, but it may also produce a false positive and even when a cancer is found it does not always need to be treated; it may regress spontaneously or may never become aggressive in the course of the patient's natural life span.

As so often in medicine, uncertainty about the best course to follow exists. Women who are perplexed about whether to go for screening should discuss it with their GP. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy in the USA, is quoted in the Independent as saying: 'Mammography is one of medicine's close calls - a delicate balance between benefits and harms.'


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I personally read ~6-8,000 mammograms a year, and have spent much of the past two decades trying to do it well. I would agree that it is a close call as to the benefits, and would add that bad mammography, usually done by less than full-time dedicated breast imagers, is likely worse than no mammography.

On another health care issue, there is increasing use of epidural steroid injection for back pain across the developed world, and I see the national health is trying to controll this procedure ( Would like to know your thoughts. - JLF

Anonymous on :

The value of epidurals for back pain seems to be still unproven. There is a dearth of good studies for the treatment. A number of people, including me, think that much of the effects of corticosteroid injection in general is really an acupuncture effect. Corticosteroid injection can be done only a limited number of times, whereas acupuncture can be repeated as often as necessary.

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