April 24, 2014

The Swiss Medical Board has recommended that Switzerland stop introducing new mammography screening programs and phase out existing programs, according to an essay published online April 16 in the New England Journal of Medicine.

The group recommends that systematic screening programs be replaced with systematic screening information and that women make individual choices.

“We were struck by how nonobvious it was that the benefits of mammography screening outweighed the harms,” write essayists Nikola Biller-Andorno, MD, PhD, and Peter Jüni, MD, who are part of the 7-member board.

The Swiss Medical Board is an independent health technology assessment initiative that is sanctioned by a number of the country’s major medical bodies. Its recommendations are “not legally binding.”

The board actually made these recommendations public in Switzerland in February, which caused “an uproar,” and they were “emphatically rejected” by various Swiss cancer experts, write Drs. Biller-Andorno and Jüni.

At that time, the recommendations were criticized as “unethical” and as contradicting “the global consensus of leading experts in the field,” the pair notes.

The essayists say that they and their fellow board members were “unprejudiced” precisely because they were not part of past consensus-building efforts by specialists in breast cancer screening.

Dr. Biller-Andorno is a medical ethicist at the University of Zurich and is a member of the Department of Global Health and Social Medicine at Harvard Medical School in Boston. Dr. Jüni is an epidemiologist in the Department of Clinical Research at the University of Bern.

The other board members are a clinical pharmacologist, oncologic surgeon, nurse scientist, lawyer, and health economist.

The Swiss Medical Board is appointed and sanctioned by the Conference of Health Ministers of the Swiss Cantons (the country’s states), the Swiss Medical Association, and the Swiss Academy of Medical Sciences, Drs. Biller-Andorno and Jüni explain.

The constitution of the board is a big problem, according to an American radiologist asked to comment on the essay.

“Folks with no expertise,” Daniel Kopans, MD, professor of radiology at Harvard Medical School, called them in an email to Medscape Medical News. To avoid conflicts of interest, such boards have to exclude experts in a field and are thereby weakened. “Why would you want me on a panel setting guidelines on brain surgery?” Dr. Kopans asked.

“This is just part of a major medical scandal,” he added.

This is just part of a major medical scandal.

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He said the medical board’s work is part of steady and “coordinated” stream of “scientifically unsupportable analyses” of screening mammography published in major medical journals.

However, 2 other Americans, who recently published asystematic review of 50 years of mammography data in JAMAthat concluded screening should be individualized, believe the Swiss Medical Board’s analysis is praise worthy.

“This group appears to have done a thorough assessment of the benefits and harms,” said Nancy Keating, MD, MPH, from the Department of Health Care Policy at Harvard Medical School.

“The authors’ (and the board’s) concerns about the modest benefit of mammography screening, relative to the frequency of harms, is well-founded,” said Lydia Pace, MD, MPH, from the Department of Internal Medicine at Brigham and Women’s Hospital in Boston.

Both researchers emailed comments to Medscape Medical News after being asked to comment the essay.

However, Dr. Pace also said the Swiss Medical Board has gone too far.

I don’t think that the answer is to reject mammography screening entirely.

“I don’t think that the answer is to reject mammography screening entirely (and not recommend that any women do it),” she said. “Instead, I feel that the data should compel us toward an individualized approach to screening.”

“I do think that all women aged 40 and over should discuss their breast cancer risk, and the benefits and risks of screening, with their doctor, and that holding that discussion should be universal,” Dr. Pace added.

The Swiss Medical Board, in their final report that rejected widespread systematic screening, also recommended that when mammography screening is offered to individual women, a balanced review of harms and benefits be presented.

The American College of Radiology (ACR) and Society of Breast Imaging (SBI) issued a joint statement about the essay.

“The deadly consequences of the authors’ breast cancer screening recommendations to the Swiss government may take years to become evident,” they stated, citing studies that indicate screening has a mortality benefit.

Both the groups and Dr. Kopans expressed disappointment that the journalpublished the essay without a counterpoint piece. “The lack of a counterbalancing perspective, in such a major scientific journal, is surprising and concerning,” reads the ACR/SBI statement.

The ACR and SBI do not agree with the proposal to reduce or eliminate systematic mammography screening. The groups also disagree with the recent proposal for risk-based screening made by Drs. Keating and Pace at the conclusion of their recent analysis. The danger is that such a scheme would miss a majority of breast cancers, the societies warned.

The ACR and SBI also sounded a somewhat ominous alarm about the evolving screening debate and related proposals. “American women should pay close attention to the breast cancer screening policies that may be considered for them,” the statement reads.

Drs. Biller-Andorno and Jüni are not confident that the Swiss Medical Board’s recommendations will be game changers there. “It is unclear whether the report will have any effect on the policies of our country,” they write.

Their proposal is a call for a unified approach to mammography screening in a country where its use is fractured and culturally complicated, the pair suggests.

They explain that Switzerland is a quilt-like country in terms of its cultures, languages, and the uptake of systematic screening.

The French- and Italian-speaking cantons are “much more in favor of screening programs” than the German-speaking cantons.

Notably, only 11 of the 26 Swiss cantons have systematic mammography screening programs for women 50 years and older. Two of those programs were only started in 2013, and 1 of these is now being reconsidered (in the German-speaking canton of Uri).

3 Major Concerns

In January 2013, the Swiss Medical Board was mandated by its abovementioned sponsors to review and report on “the available evidence” on mammography screening.

The process left the board “increasingly concerned” about the implications of such screening. They had 3 major concerns.

First, they observed that the debate about screening “was based on a series of reanalyses of the same, predominantly outdated trials.”

They were concerned that the “modest” benefit of screening might not even be found today because modern breast cancer treatment has “dramatically improved” the prognosis of breast cancer patients.

Second, they were concerned that the relative risk reduction of 20% in breast cancer mortality that is cited by “most expert panels” comes at the “price of a considerable diagnostic cascade.” Namely, they worried that the harms incurred by women who do not have any disease or significant disease outweigh the benefits for those who do.

Third, they were “disconcerted by the discrepancy between women’s perceptions of the benefits of mammography screening and the benefits to be expected in reality.”

The essayists cite research that reveals the “overly optimistic” expectations of the public about screening, which, in turn, injure women’s ability to make “informed decisions.”

In the end, Dr. Biller-Andorno, Dr. Jüni, and the rest of the panel concluded that the benefits of screening do not clearly outweigh the harms, citing a recent quantification from Gilbert Welch, MD, from Dartmouth College in Hanover, New Hampshire (JAMA Intern Med. 2014;174:448-454).

The Swiss Medical Board’s use of research from Dr. Welch for their clinching argument did not surprise Dr. Kopans.

“There is an effort being led by Drs. Peter Gotzsche in Denmark and Gilbert Welch at Dartmouth to end breast cancer screening,” he said. “They and a few associates have managed to get pseudoscientific articles like this one published (even in reputable journals).”

Dr. Biller-Andorno, Dr. Jüni, Dr. Keating, and Dr. Pace have disclosed no relevant financial relationships. Dr. Kopans reports receiving research support from GE Healthcare.

N Engl J Med.Published online April 16, 2014. Abstract


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