Germany will penalise cancer patients who do not undergo regular screening
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7574.877-c (Published 26 October 2006) Cite this as: BMJ 2006;333:877All rapid responses
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Sirs:
My colleagues and I have published a number of papers in the past few
years that discuss our findings regarding breast cancer growth (1-6). Our
results suggest that temporary dormancy is common in breast cancer.
Sometimes, surgery to remove a primary breast tumor apparently can kick-
off growth of dormant distant micrometastatic disease resulting in
acceleration of relapse. Our findings indicate that this occurs in over
half of all relapses in breast cancer. This is probably a major reason why
early detection has only produced moderate mortality reduction in clinical
trials for postmenopausal women and why there is excess mortality for
premenopausal women during the first few years after screening trials
start.
If authorities feel compelled to force their citizens to undergo
early detection of cancer, I suggest they channel their efforts into early
detection of colon cancer instead of breast cancer. There is little if any
indication that colon cancer undergoes temporary dormancy, the disease
claims more lives than breast cancer and it affects both sexes.
Michael Retsky, Ph.D.
Lecturer in Surgery - Harvard Medical School and
Board of Directors – Colon Cancer Alliance
www.ccalliance.org
1. M Retsky, R Demicheli and W Hrushesky. Breast cancer screening:
controversies and future directions. Current Opinion in Obstetrics and
Gynecology. 15:1-8, 2003.
2. R Demicheli, G Bonadonna, WJM Hrushesky, MW Retsky, P Valagussa.
Menopausal status dependence of the early mortality reduction due to
diagnosing smaller breast cancers (T1 versus T2-T3): relevance to
screening. J Clin Oncol. 22(1): 102-7, Jan. 1, 2004.
3. R Demicheli, G Bonadonna, WJM Hrushesky, MW Retsky. P Valagussa.
Menopausal status dependence of the timing of breast cancer recurrence
following primary tumour surgical removal. Breast Cancer Research 2004,
6:R689-R696 . http://breast-cancer-research.com/content/6/6/R689
4. M Baum, R Demicheli, W Hrushesky and M Retsky. Does surgery
unfavorably perturb the “natural history” of early breast cancer by
accelerating the appearance of distant metastases? European Journal of
Cancer 2005 Mar;41(4):508-15. Epub 2005 Jan 18.
5. R Demicheli, A Moliterni, M Zambetti, WJM Hrushesky, MW Retsky, P
Valagussa, G Bonadonna, Breast cancer recurrence dynamics following
adjuvant CMF is consistent with tumour dormancy and mastectomy-driven
acceleration of the metastatic process. 2005 Ann Oncol. 2005
Sep;16(9):1449-57. Epub 2005 Jun 14.
6. Retsky M, Demicheli R and Hrushesky WJM. Does surgery induce
angiogenesis in breast cancer? Indirect evidence from relapse pattern and
mammography paradox. International Journal of Surgery 2005;3(3):179-187.
Competing interests:
Board of Directors - Colon Cancer Alliance (www.ccalliance.org)
Competing interests: No competing interests
It is of interest that in Germany an element of compulsion is being
used to persuade women to undergo screening tests.
In 1864, with the aim of protecting the health of the army, the UK
parliament introduced the Contagious Diseases Act. This required women who
were prostitutes in garrison towns to undergo compulsory medical
examinations. It also empowered the police to detain women they suspected
of prostitution and to compel them to undergo such examination. In
practice this meant that any working-class woman in a garrison town was at
risk.
The measures were wholeheartedly supported by the medical profession,
including Dr Elizabeth Garret Anderson the UK's first and leading woman
doctor of the time. She saw the measure as helping protect innocent women
from venereal disease. It took the efforts of such women as Josephine
Butler and Elizabeth Wolstenholme to eventually repeal the act in 1886.
It appears to be easy for health professionals to allow their
enthusiasm for the greater good to override concern for womens' rights
over their own bodies.
Competing interests:
None declared
Competing interests: No competing interests
Sir,
Annette Tuffs hits the point in saying "penalise", where government
insists on
"setting incentives" for people who undergo cancer screening. Tuffs is
also
right in mentioning the disagreement among experts about the usefulness of
screening tests. But there are not just "some doctors" who say that Pap
smears could be carried out every three to five years.
Compared to the international recommendations of the European Cancer
Code and the United States Preventive Services Task Force, the German
Screening Programme must urgently be reworked. Besides the annually
screening for cervical cancer (instead of every three to five years), the
digital
examination of breast, prostate and colon are rather historically than
clinically justified.
One major point in the international recommendations is neglected
totally
in the plans of the German government: People should be informed about
pros and cons of screening so they can make an informed decision. If you
penalise people, you let them no real choice.
Competing interests:
Author of "Mythos
Krebsvorsorge"
Competing interests: No competing interests
The gap between policy and evidence identified by Jefferson [1] with
respect to public health programmes recommending the flu vaccine is not
the only example of this transgression. His report summary indicates that
“evidence from systematic reviews shows that inactivated vaccines have
little or no effect on the effects measured”. On 18th October 2006 a
systematic review of screening for breast cancer with mammography [2]
concluded: “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.”
Yet proposals are afoot for German citizens to be financially
penalised if they do not subject themselves to a variety of screening
tests, including mammography every two years from age 50 to 69. [3] This
proposed state imposition “setting incentives for healthy behaviour”
intrudes on an individual`s right to refuse an imperfect intervention that
can result in false negative and false positive diagnoses; can lead to
gross over-treatment; to psychological harm and false categorisation as
`cancer patient`. Citizens and doctors who value their freedom to make
evidence-based decisions should vigorously oppose this proposal. The
imposition of potentially damaging interventions on healthy individuals
with financial penalties if they resist should be identified as an
infringement of civil liberty and resisted at all costs.
This imposition, coupled with current government and peer pressure on
doctors to adhere to guidelines recommending over-treatment for `early`
(pseudo-) latent cancers [4] is a recipe for inflicting more harm than
benefit on unsuspecting, misinformed citizens [5] and a further step along
the road to loss of liberty.
Hazel Thornton
Independent Advocate for Quality in Research and Healthcare.
[1] Tom Jefferson. Influenza vaccination: policy versus evidence. BMJ
2006; 333:912-915
[2] Gøtzsche PC, Nielsen M. Screening for breast cancer with
mammography. Cochrane Database of Systematic Reviews 2006. Issue 4. Art
No. CD001877. DOI: 10.1002/14651858. CD001977.pub2.
[3] Annette Tuffs. Germany will penalise cancer patients who do not
undergo regular screening. BMJ 2006; 333:877
[4] H. Gilbert Welch. Should I be tested for cancer? Maybe not and
here`s why. University of California Press, California. 2004.
[5] Hazel Thornton, Adrian Edwards, Michael Baum. Women need better
information about routine mammography. BMJ 2003; 327:101-103
Competing interests:
None declared
Competing interests: No competing interests
Compulsory screening participation is judicially questionable
Annette Tuffs reports in the 28 October 2006 issue of BMJ that the
German government is planning to “penalise” cancer patients who do not
undergo regular screening, and that cancer specialists, politicians and
health insurance companies have responded with anger and surprise (1).
However, in our view it is important to underline that this attempt will
fail not only because of the broad opposition of experts, but also for
obvious legal and ethical reasons. In Germany, an organised screening
programme according to European Guidelines is in status nascendi for
breast cancer, but for other cancer sites the policy consists only of
reimbursement of opportunistic annual examinations. They include clinical
breast examination for women older than 30, and DRE for the early
detection of prostate cancer, in spite of lack of evidence of efficacy.
The annual Pap smear starting at 20, generates enormous costs without
guarantee of more life-years gained compared to adequate cytology screening
at three year intervals (4).
In the third version of the European Code of Cancer, authorities were
warned not to recommend this types of screening and they were not included
in the European Council recommondation on cancer screening of 2 December
2003, which was also endorsed by the German minister of health (2,3). It
is unlikely that a patient with advanced prostate cancer, who did not
comply with yearly DRE, will be obligated to pay an increased part of his
treatment costs, when, in the court, the following arguments or brought
about: lack of scientific proof of utility for the proposed screening, the
risk of serious side-effects, and the unavailability of a properly
designed screening programme.
Hopefully, the current discussion will stimulate the German health
authorities to move forward in the direction of organised programmes,
based on scientifically based proof of effectiveness and cost-
effectiveness, including quality assurance and monitoring of the
attendance of the target population and the management of those with a
positive screen test result.
Prof. Nikolaus Becker
Division of Cancer Epidemiology,
German Cancer Research Center,
Im Neuenheimer Feld 280,
69121 Heidelberg,
Germany
Prof. Marc Arbýn
Unit of Cancer Epidemiology,
Scientific Institute of Public Health,
J. Wytsmanstreet 14,
B1050 Brussels
Belgium
REFERENCES
(1) Tuffs A. Germany will penalise cancer patients who do not undergo
regular screening. BMJ 2006; 333: 877.
(2) The Council of the European Union. Council Recommendation of 2
December on Cancer Screening. Off J Eur Union 2003; 878: 34-8.
(3) Boyle P, Autier P, Bartelink H, Baselga J, Boffetta P, Burn J et al.
European Code Against Cancer and scientific justification: third version
(2003). Ann Oncol 2003; 14: 973-1005.
(4) van Ballegooijen M, van den Akker van Marle ME, Patnick J, Lynge E,
Arbyn M, Anttila A et al. Overview of important cervical cancer screening
process values in EU-countries, and tentative predictions of the
corresponding effectiveness and cost-effectiveness. Eur J Cancer 2000; 36:
2177-88.
Competing interests:
None declared
Competing interests: No competing interests