When Jenny had a mastectomy after being diagnosed with breast cancer, she believed the major surgery to remove her breast, although traumatic, had saved her life.
She described feeling rage when, at a follow-up appointment three years later, she said to her surgeon: “I would probably be dead by now” if she had not received the surgery, to which he replied: “Probably not.”
It was only then, after she had already undergone invasive and life-changing treatment, that Jenny learned about “overdiagnosis.”
While breast cancer screening programs are essential and save lives, sometimes they also detect lumps that might never go on to cause harm in a woman’s lifetime, leading to overtreatment, along with psychological and financial suffering.
Jenny is one of 12 women from the UK, the US, Canada and Australia whose stories were published in the medical journal BMJ Open on June 2. It is the first study to interview breast cancer patients who believe they might have received unnecessary and harmful treatment, highlighting the effect this has had on their lives.
“The usual story of breast cancer screening is ‘screening saves lives,’” said Alexandra Barratt, one of the study’s authors and a professor of public health at the University of Sydney.
“This study reports the other side of the story — how breast cancer screening can cause harm through overdiagnosis and overtreatment,” she said.
In Jenny’s case, she learned from her surgeon only after her mastectomy that her cancer might not ever have progressed to cause harm or symptoms, and that ongoing monitoring or less-invasive treatments might have been an option.
Overdiagnosis occurs when cancers are correctly diagnosed, but at such an early stage that those cancers are unlikely to ever go on to grow or spread in a person’s lifetime, and are not causing any symptoms. Due to improved medical technology, these are being detected more often.
This early diagnosis can sometimes be useful for ongoing monitoring, but sometimes as a result of the cancer being identified, psychological distress occurs. Treatment is recommended by a specialist or preferred by the patient, including treatments that carry risks and can be invasive. This is known as overtreatment.
Prostate cancer is another example where overdiagnosis and overtreatment is an established issue.
However, there are some cancers, such as ovarian cancer, for which the prognosis can be dire by the time it is diagnosed, and for which early detection is crucial.
Early detection and treatment of ovarian cancer is rare because it is a cancer that can quickly dislodge from the fallopian tube or ovary surface and spread, making it much harder to treat and highly fatal.
REVEALING STUDIES
Estimates of breast cancer overdiagnosis vary from 10 percent to 30 percent, depending on the study methods.
A review of screening mammography from the policy institute Cochrane found that “for every 2,000 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,” it said.
Chris Pyke, vice president of the Royal Australasian College of Surgeons and a past president of Breast Surgeons of Australia and New Zealand, said the paper from Barratt and her colleagues should be “congratulated.”
“We must all get used to the idea that every time you have a screening program for any disease at all, there will be a certain number of people diagnosed with diseases that would never have affected the person,” Pyke said. “I think it’s good to get the issue out there in the open for discussion.”
He said surgeons receive ongoing training about screening, risks and benefits, and how to communicate those well.
“Whether that means every single breast cancer surgeon in Australia has overdiagnosis at the forefront of their mind during advice they give is another matter,” he said.
An independent British review into the issue concluded that for every 10,000 women invited to screening from age 50, about 681 cancers are found, of which 129 represent overdiagnosis, and 43 deaths from breast cancer are prevented.
They estimated that in the UK, about 3,000 women are overdiagnosed with breast cancer every year, and about 1,000 deaths are prevented.
“As a result of the review, for the last 10 years women in the UK have been receiving information about the benefits of screening as well as the harms of overdiagnosis,” Barratt said. “We believe that policy should also be implemented in Australia and other countries with screening programs.”
SCREENING DEBATE
Breast Cancer Network Australia CEO Kirsten Pilatti said the challenge is that many women do not have a way to know if they were overdiagnosed, and “we need to be very careful about the message we send to the public when talking about overdiagnosis.”
The earlier a cancer is found, the better the chances of surviving it, she said, adding that screening programs a part of the reason survival rates from breast cancer have improved significantly.
“We have also seen a reduction in breast cancer screening during the pandemic and as a result we are concerned about how that, combined with ongoing pressures on health systems, might translate into later detection and treatment, and poorer outcomes for women,” Pilatti said.
“But we do need to move to a risk stratification model where we use the latest in research to identify those women at greater risk from breast cancer and tailor screening for them,” she said.
Major cancer organizations worldwide acknowledge the risks of overdiagnosis, and have called for patients to be given greater information about the risks and harms of screening and treatment for a variety of cancers.
Anna Samecki, a general practitioner and medical adviser at NPS MedicineWise, said that while the BMJ Open study interviewed a small number of women, it is nonetheless an “informative qualitative study” that discussed a “small but real” risk of overdiagnosis.
“The study highlights the importance of informed consent and the need to inform patients about the risks of proposed procedures,” she said.
“The study found that women who became aware of overdiagnosis following breast cancer screening experienced negative psychosocial consequences, including feelings of anger, remorse and loneliness,” she said.
PATIENT RIGHTS
Sally, an Australian woman who participated in the study, told the Guardian that when she was diagnosed with the earliest stage of breast cancer, which is non-invasive at this stage, her surgeon told her she would need a mastectomy, even without showing any symptoms.
Sally, who had been successfully treated for a pituitary tumor in the past, brought the possibility of overdiagnosis up with her first surgeon. She said she was left feeling “utterly patronized” with “no autonomy ... no right to have any decision about anything at all.”
The surgeon that she went to for a second opinion also only offered a mastectomy.
However, Sally contacted a third surgeon who advised a mastectomy, although was willing to perform a lumpectomy, a less invasive procedure where the cancer and tissue that surrounds it is removed.
Eight years after later, Sally remains healthy and cancer-free. She firmly believes a mastectomy would have been overtreatment and is relieved she did not undergo the procedure.
She said it was “incredibly difficult” to have a conversation about treatment with clinicians, one who asked what “nonsense” she had been reading because she had decided not to have a mastectomy.
She said she understands why surgeons recommend mastectomy.
“Cancer surgeons often see extremely sick people, and they want to do all they can to prevent that,” she said.
“There is sometimes more ambiguity to deal with when other treatment options are recommended,” Sally said.
“There is that chance it may come back or get worse, but I would like more doctors to be willing to at least have the conversation with their patients,” she added.
Sally and Jenny are pseudonyms to protect the identities of the women interviewed for this article.
A return to power for former US president Donald Trump would pose grave risks to Taiwan’s security, autonomy and the broader stability of the Indo-Pacific region. The stakes have never been higher as China aggressively escalates its pressure on Taiwan, deploying economic, military and psychological tactics aimed at subjugating the nation under Beijing’s control. The US has long acted as Taiwan’s foremost security partner, a bulwark against Chinese expansionism in the region. However, a second Trump presidency could upend decades of US commitments, introducing unpredictability that could embolden Beijing and severely compromise Taiwan’s position. While president, Trump’s foreign policy reflected a transactional
There appears to be a growing view among leaders and leading thinkers in Taiwan that their words and actions have no influence over how China approaches cross-Strait relations. According to this logic, China’s actions toward Taiwan are guided by China’s unwavering ambition to assert control over Taiwan. Many also believe Beijing’s approach is influenced by China’s domestic politics. As the thinking goes, former President Tsai Ing-wen (蔡英文) made a good faith effort to demonstrate her moderation on cross-Strait issues throughout her tenure. During her 2016 inaugural address, Tsai sent several constructive signals, including by acknowledging the historical fact of interactions and
HSBC Holdings successfully fought off a breakup campaign by disgruntled Asian investors in recent years. Now, it has announced a restructuring along almost the same east-west lines. The obvious question is why? It says it is designed to create a simpler, more efficient and dynamic company. However, it looks a lot like the bank is also facing up to the political reality of the growing schism between the US and China. A new structure would not dissolve HSBC’s geopolitical challenges, but it could give the bank better options to respond quickly if things worsen. HSBC spent 2022 battling to convince shareholders of
Chinese President Xi Jinping (習近平) has prioritized modernizing the Chinese People’s Liberation Army (PLA) to rival the US military, with many experts believing he would not act on Taiwan until the PLA is fully prepared to confront US forces. At the Chinese Communist Party’s 20th Party Congress in 2022, Xi emphasized accelerating this modernization, setting 2027 — the PLA’s centennial — as the new target, replacing the previous 2035 goal. US intelligence agencies said that Xi has directed the PLA to be ready for a potential invasion of Taiwan by 2027, although no decision on launching an attack had been made. Whether
RSS