Breast With Cancer

>> mr. chairman, ladies andgentlemen, first of all, welcome from our founder. this is jeremy benthamwhose embalmed body is just up the road for everyone to see. he's head has got rather rotten, so the head you see here'sbrought out on special occasions which allows me to imaginewhat they're saying, would i tell a lie, that'sthe plaster of paris head. his will has probably andthat's the kind of relationship

that i have with the departmentof health over the issue of breast cancer screening. this is the miracle ofsan carlos borromeo, a mid 17th century painting bygiovanni crustini [phonetic] and it refers to the miraculoushealing of a breast cancer. this is mid-17th centuryand you can see the terror on this woman's face. so the diagnosisof the suspicion of breast cancer generatesterror in the heart of a woman.

my family has experiencedthis terror. this is me as a little boy andthat is my beloved mother mary who died tragically youngand in uncontrolled pain. and her experienceleft me with anger. this disease is upfrontand personal. and then about 15 years ago mybaby sister linda who was then in her early 50s, shedeveloped breast cancer. but things had moved onagain a lot since then and thank god she's aliveand well 15 years later.

but it's in the family. i've got two daughters andmy sister has four daughters. [ pause ] >> sorry about that. women invited to screeningreceived these leaflets, breast cancer: the facts. the object of mytalk to you today is to say this should be retitledbreast cancer: the fibs. and it's not just me, somemaverick saying this stuff.

there was a lead article inthe british medical journal in february last yearbreast screening, what the leafletsdon't tell you. i'm not alone. and over the last year or two,the evidence has got worse. the journal of the royal societyof medicine the beginning of this year, has breastscreening save lives, a question mark. the bmj then published areview on the experience

in denmark demonstrating breastcancer did not save lives. last month, there was a majorarticle and an editorial in the new englandjournal of medicine, the most prestigious medicaljournal with the title, screening mammography: along run for a short slide. and then also recently thebritish medical journal commissioned professorklim mcpherson to independently review thedata and he concluded the same as the new england journalof medicine and fiona godlee

in her editorialsupported the fact that this subjectseriously needs attention from the department of health. i want to highlight a tablefrom the new england journal of medicine editorial. now, read this carefully,estimated benefits and harms associated with10 years of screening for 2,500 women aged 50 or more. you avoid one womandying from breast cancer

for every 2,500 screened for10 years, that is the benefit. against that, a thousandwomen will have at least one false alarm andwill undergo unnecessary biopsy and breast cancer will be overdiagnosed in 5 to 15 women who will then be treatedunnecessarily for a disease that would neverthreaten her life. how can you understand this? this is so counter to the culture you'vebeen brought up in.

catch it early, save your life. my answer to the question, has breast cancer savelives is a categorical no. let us go back to theunderlying hypothetical model which drives thescreening industry. you start off with a lesionwhich we call ductal carcinoma in situ, which is assumed to be a precursorlesion for breast cancer. then that progresses to an earlybreast cancer which progresses

to a late breast cancer. so very simple, simplisticlinear dynamic. so screening theory would haveyou believe, catch it early, save a life and save a breast. this is based on thepremise that detection early, by that i mean smallcancers leads to a fall in the incidenceof late cancers. the detection of in situ diseasewill prevent the development of invasive disease, smallercancers, fewer mastectomies,

fewer advanced cases,lower mortality. none of that is true. it is the assumption yetthe scientific data refuse that very seductive hypothesis. to understand this, you need to understand the biasesassociated with screening. there are three biases:lead-time bias where you're simply prolongingthe period of observation, length bias where you aresimply picking up good cancers

and the bad cancers slipthrough, and attendance bias which is a social class effect. let me explain that. here we have a timeframefrom clinical detection of breast cancer toeither death or from cancer or death from old age. if you increase the timeframeto the left and pick the disease up at screening, then survivalis prolonged even though the long-term outcome is the same.

and that's calledlead-time bias. length bias is illustratedby this cartoon [inaudible], the cancers, but[inaudible] intervals, the moment that's3-year intervals. we catch the slow swimmingfish in these intervals. but the really nasty fish, the sharks that are gonnakill you slip through the net. and those are calledinterval cancers. and even if you shorten theinterval to a year instead

of 3 years, you get the same. attendance bias means attenders who accept the invitation aredifferent to those who fail to accept the invitation. non-attenders, we know are lowersocial class and we know stage for stage, lower social classwomen do worse with the outcome of breast cancer forreasons we're not quite sure. and there's nothing to dowith access to treatment. we don't yet understand that.

because of thesebiases, the only way to assess whether screeningsaves lives is randomized control trials comparinga screened population with an unscreened population where the primary outcomeis cost specific mortality, not survival. you count the number ofwomen dying of breast cancer in the screened againstthe unscreened. but at the same timeit is just possible

that all this activity mightbe detrimental for other causes of death and therefore, a secondary endpointis all cause mortality. >> the national healthservice screening program was established in 1998following the forrest report. this is sir patrick forrestwho was a good friend of mine and i respected him enormously. and it was predicatedon the outcome of seven randomizedcontrol trials which started

in the early '70s and werereported in the mid-'80s, and that's very importantthing to mote. and the outcome of a summation of those trials was arelative risk reduction of breast cancer mortality of25 percent which is another way of saying a hazardratio of 0.75. i don't expect anyof you to understand that unless there are fewstatisticians in the audience. but that 25 percentis what the women get.

none of them canreally understand it because it's framing of a resultwhich i will explain shortly. i was given the task of setting up the first nationalscreening center in the uk when i was professorof surgery at kings and i chose camberwell greenand we set up this clinic. we were given a year fromthe forrest report to get up and running and starttraining everybody to do screening in 1998.

i know about screening. i started it in thesoutheast of england. within 8 to 10 years,it all went pear-shaped. there were 2 sets ofreports that looked at the more mature followupof these clinical trials and also looked at the probityof these clinical trials. and reports started to come out in all the top journalsdemonstrating the initial estimate of a 25 percentrelative risk reduction was a

gross overestimate. so, the nhs screening programwas predicated on 25 percent. the united states preventativeservices task force both in 2002 and again in 2009 saidit's not, it's 15 percent and the cochran report, cochranis an independent group based in denmark who take onsubjects for overview analyses and they derive thesame percentage. so screening is associated with a 15 percentrelative risk reduction

but these are the oldtrials that were started in the mid-'70s andreported in the mid-'80s since when treatmenthas improved. here is one illustration ofhow treatment has improved. at the time these trialswere being conducted, the 5-year survival forbreast cancer in the over '50s was about 70 percent. in 1984, '85, we had thefirst overview of trials of adjuvant tamoxifenand immediately,

the 5-year survivalshowed up to 85 percent. and now with newer drugs, and i won't botheryou with the details. we now expect a 90 percent5-year survival compared with the 70 percent5-year survival at the time the trialswere being done. so, in other words thewindow for improvement from screening getsnarrower and narrower. now this is tough, atough table but it's

to give you an idea how wetranslate these relative risk reductions in toabsolute numbers. don't be embarrassedif you can't follow it. trust me or turn to aneighbor who happens to be a mathematician. so, we take 10,000women, age 50, and we screen them for 10 years. the incidence of breastcancer in this age group of women is 2,000 per year.

so, this group of women willgenerate 200 breast cancers. with modern treatment,over 10 years, this is a mediumfollowup of 5 years. so it's a medium follow up of5 years for this group of women with modern treatment whowould expect 20 deaths. the relative risk reductionis of the number 20. so a 25 percent reduction of the number 20 meansthe absolute benefit is 5. five breast cancer deathsavoided over 10 years

when you screen 10,000 women. but if the figure isnearer to 15 percent, it is 3 breast cancerdeaths avoided by screening 10,000women for 10 years. this leads to the issue ofthe framing of the result where we now justgot numbers needed to screen to save one life. if we take the initialnhs estimates, it works out at 1,000women for 10 years

to avoid one breastcancer death. if we take the morerecent estimates, based on the same trial data,you have to screen close on 1,500 women for 10 years toavoid 1 breast cancer death. but if you take the modern era and this is what the new englandjournal of medicine referred to where treatments are so muchbetter then you have to screen about 3,000 women, two and ahalf to 3,000 women for 10 years to avoid 1 breast cancer death.

and that's calledframing the results. how can you expect womeninvited for screening being told that that is the case to understand howdisingenuous that invitation is? muir gray was the director ofthe national screening program, an honorable man and he wroteall screening programs do harm. some can do well, too goodas well as an afterthought. and that is the issue. the downside of screening arefalse alarms, over diagnosis,

unnecessary surgery, an increase in mastectomy rates,not decrease. i want to say a littlebit about over diagnosis. here is a histopathologicalpicture of ductal carcinoma in situ and it is assumed thatit will inevitably progress to invasive breast cancer ifyou don't adequately treat it. well, that is simply not true. and the estimates fromthe cochran report are that for every breast cancerdeath avoided, 10 women are

over diagnosed and over treated for something labeledbreast cancer which does not behavelike breast cancer. shocked, horror, becausei dare say that in public, people use ad hominemattacks, he must hate women. he's a misogynist,he murders women. and yet, the sameis exactly similar for prostate screening trials. again, in the new englandjournal of medicine last year,

the outcome of theprostate screening trials that for every prostate cancerdeath avoided by psa screening, 50 men are over diagnosedand over treated. everyone accepts that. i don't know why. is it double standard here? they accept that men areover diagnosed by screening but they are resistant tothe notion that women are over diagnosed as aresult of screening.

in the year 2000, michael douek,a surgical colleague of mine and myself, we lookedat the cancer registries and plotted the incidenceof ductal carcinoma in situ since the introduction ofscreening in the london area. the blues and the yellowsare the group not screened. this is the groupthat is screened. this is the increased incidencein ductal carcinoma in situ from less than 500 a yearto nearly 2,000 cases a year in the london district.

what we assume basedon screening theory, the knock-on effects of thatwould be the invasive cancer would stop fully. well, this is what wesaw for invasive cancer, the unscreened blocks,the screened blocks, and it wasn't the case. the incidence of invasivecancer also goes up. so in situ cancer, uninvasivecancer go up in parallel when you start screeninga population.

and that is over diagnosis. and it's not just us mavericks,these was a separate analysis by joregensen published inthe british medical journal. >> this shows the incidence ofbreast cancer in those too old to be screened and the green,too young to be screened, and this group in themiddle, this was the incidence of breast cancerbefore screening, and this is invasivebreast cancer. note, it shoots up to the sameincidence as the elderly women

and remains up once youintroduced screening and that's when they introducedscreening for the 50 plus, and then if you follow thatdown to go to another 10 years and here we look at the olderage group who've been invited to the screening, the same thinghappens, and this is repeated in every country in the world. the introduction of screeningincreases the incidence of breast cancer by closed on 50percent increase and 20 percent of those are in-situ cancer.

this is what we discoveredlooking at mastectomy rates. mastectomy rate shot upsince screening started. this is the ductalcarcinoma in situ and that was 10 yearsago, those results. michael dixon in breast cancerresearch last year has looked to the last 10 years,again, showing the incidence of in-situ cancer shootingup and the incidence of mastectomy shooting up. in every country in the worldthat introduces screening,

mastectomy rates go up. here is a summary slideof what i have said, and note it was published5 years ago by barrett in the bmj 2005. working up from the bottom,this is breast cancer deaths, caused specific deaths in thescreened and in the unscreened. this is breast cancerincidents in the unscreened, this is the breast cancerincidents in the screened, and this, these two lines

that are superimposed aretotal mortality, and again, in all the slides-- all thetrials, all the summation of all the trials, there is noeffect on all-cause mortality, and yet the women are coercedto attend the screening without informed consent even tothe point that they coerce women with learning difficulties,i find this disgusting. it's meant to be a cartoonof a woman with down syndrome and when you open the page, youwill see a cartoon strip trying to persuade this womento come for screening,

and the irony here is the women with down syndrome almostnever get breast cancer, and then you come back tobreast screening: the facts, and this is the leaflet my wifegot two to three weeks ago. breast cancer, thespin, look at this. around half the cancersthat are found on screening arestill smaller enough to be removed from the breast. this means the whole breast doesnot have to be removed, hurray,

only 50 percent mastectomy rate. and yet, for clinicalbreast cancer found in the normal way is only25 percent mastectomy rate. you have twice the riskof having a mastectomy. if your cancer isscreen detected but we mustn't tellthe little women. it might frighten themoff, and then they come up with this figure, breast screening saves1400 lives a year.

i don't know where thatnumber comes from, honestly. hand on heart, again andagain, myself and my colleague, where and how do youderive that number. we get no answerto that question. as far as i am concerned,it's a made-up number. on the basis of this, i resigned for the national healthservice screening committee just over 10 years ago and i wrote aletter to the lancet explaining to the medical establishmentwhat i had explained to you.

and what happened, every doctor in the country got aglossy leaflet like this. this is a photograph of it,ridiculing me and worst of all, this chart here,let me magnify it. they published thistable to demonstrate that breast cancer mortalitywas going up and up and up, and then screening kicksin and it fell down. that is scientific fraud. if i published that, i would be

up before the generalmedical council. it is fraudulent. this is the truth andthis comes from cruk, nothing to do with me. breast cancer mortalityreached the peak in all age groups in about 1987. 1986-'87 was the time adjuvantsystemic therapy was rolled out for all women. tamoxifen, chemotherapy whichhas had an effect on mortality

of 30 or 40 percentreduction but note, this fall in mortalityis in all age groups, not just the agegroup being screened. so any fall in mortalitywe're seeing is due to improved treatmentnot due to screening. i am not suggestingwe shutdown screening. first of all, it wouldbe political suicide for any government to dothat but i have been invited. i was invited last yearto speak to the science

and technology committeeat the house of commons to explain what iwould do about this, and i had a very warm reception. what i recommend is thatinstead of blanket screening for the whole female population, we should have arisk assessment, risk management campaignrather than one size fits all. this is just the picture of one of the modern algorithms howwe can accurately predict risk

of developing breast cancerboth from family history, demography, and so on. and as a result ofthat, it is possible to carry out the triage. if we look at thelow-risk group, these women have somethinglike 50 times the risk of dying of cardiovasculardisease and breast cancer. why are we obsessedby one issue? perhaps this groupcould be advised on how

to avoid cardiovascular disease,stop smoking, healthy diet, avoid alcohol, which incidentally might reducethe risk of breast cancer. this group at the top end-- genetic counselingand genetic testing. maybe if we just screenthe middle risk group, we might have more bangsfor the buck and talking about buck we're talking70 million pounds a year on this thing, who knows.

so maybe it would be rational toadopt a program like this rather than continue to coerceinnocent women with half truths to tick boxes andfulfill targets. if nothing else, you willagree with me it is shameful and disgusting that womenare denied the opportunity to learn the truthabout screening. so my conclusion istreat women like adults, offer informed choicerather than political spin, and i think the message mightbe getting through because i saw

in the evening standarda couple of weeks ago, the london clinic is offeringmammography at a reduced price. they can no longersell it, damage goods. thank you very much. [ applause ] >> thank you professor baum. that was thought-provokingand fantastic. can we please start tohave lots of questions? okay. we have a microphonecoming in so

if you could use themicrophone please. >> you did say earlyon that detected early, the new treatments will havea greater chance of success. [ inaudible remark ] >> what-- sorry? >> i didn't say that. i'm sorry. >> i thought you did. >> no, i said that was atheory, catch it early.

it is a theory. my problem is the catch it earlymantra is something of a cliche. what people are sayingis catch it small, and the way i teach mymedical students on this is if you are a woman and youhave a 1 centimeter cancer, would you rather it was sixweeks old or six years old and the answer is you'drather it was six years old. >> right. what sort of-- idon't know how i'd ask this now. what sort of detectionshould someone

in my age group, 70now and getting-- >> you don't look 70, come on. >> i am. thank you. [ laughter ] >> you don't look oldenough to be screened even. >> but i'm in an age group where it is theoreticallyincreasing even on your charts there. what should i do?

>> right. that is a verysensible, excellent question, and i'm often asked that, and the answer is youdon't do anything. and the reason youdon't do anything, the results you'll see fantasticimprovements with treatment. these are women who by chancedetect the breast cancer. having detected it by chancethen they're aware they should go and have it attended to, but you don't live your lifeworrying about breast cancer.

if you want to worry about themost likely cause of your death, worry about cardiovasculardisease. do not obsess aboutbreast cancer. [inaudible] more likely todie of cardiovascular disease. i hope you don't smoke. >> michael, as you knowbecause we consulted you, my wife recently had a breastcancer, and the biopsy showed that it wasn't [inaudible]but invasive lobular so, and 2 centimeters and that's--

despite the fact that i'vesigned the letter with you about the inaccuracyof the nhs information which is undoubtedly the case. i think [inaudible]the thought i must say. would you like to comment? >> yes. yes. that is often the killerquestion because you do not want to be unkind when you answer it. now, i don't have to be unkindin answering your question

because it's-- themessage is good news. it's all good news. there are two possibilities:left undetected that might not progressor it would not progress in the woman's lifetime, the woman's normalexpectation of life. i left out a whole sectionon the natural history of breast cancer whereuntreated many breast cancers, clinical breast cancersdon't do any harm

so that's one possibility, the other possibility mighteven regress spontaneously, or the third possibility, she--we're talking about your wife. >> i know. the other possibility shemay be that 1 in 2500 women. so whichever way you lookat it it's good news. >> diane [phonetic], ithink there were two people with their hands up here, okay. here. alright.

>> late in your presentationyou were talking about risk assessment triageand your slide suggested that there were somesoftware that did that. what is that softwarecalled please? >> well, that is-- thereare several versions of that software. that's the ibis 2software, which was developed in saint bartholomew'sdepartment, professor jack cuzick'sdepartment is ibis 2.

there are others that arecoming online all the time. we are working towardshaving an ipad technique where the patients, ornot patients, the clients, where the clients can fillin all the data on an ipad which is instantaneous, translated into a risk beforecoming in to see the doctor. so, the technology exists,in fact that technology for risk assessment, theipad or touchpad actually sat in a clinic, massachusettsgeneral recently

and they've alreadygot that going and i like to get that into london. >> we have a gentleman here. >> okay. suppose you had anextra hour of teaching available for medical students, wouldyou teach them about cancer or would you teach them aboutnumbers needed to treat? >> that is a very easy question. what i have described to you is of generic issueillustrated by breast cancer.

it applies across the board. the first thing our medicalstudents must learn is a degree of numeracy and anunderstanding of risks, and i wish they'd learnthis in their first year. is that the right answer, sir? >> thank you. >> we have a gentlemandown there. >> yes. you have spokenalways with reference to mortality rate, death rate.

would any of your conclusionsbe different if you're concerned about quality of years lived? >> quality adjusted life. well, i mean, that isan excellent question. quality adjusted lifehere is you cannot supply in health economics unlessyou can demonstrate years of life per se. quality of life though isa real important issue. now some of thesewomen, i've written a lot

on the natural historyof breast cancer and i've collecteda large series of clinically avertuntreated breast cancers, and they're pretty grotesque. what happens to them even ifthey're not killing the woman, they're horrible and theyimpair quality of life so there is an argument forthe local treatment in any case to maintain a good quality oflife but that isn't an issue with screening because if youallow the minority screened

detected lesions to progress tobecome clinically detectable, these days they'revery easily treated. local treatment now isadorable, it's minimalistic, and it's getting more andmore minimalistic as we go. >> we have a lady in there. given that the governmentis now even more committed to saving money whereit can in the nhs, i wonder is it too optimistic tothink that the logical proposal from you presented, which isthe government could save money

by doing much less screening,use a fraction of that savings to set up the screeningand prevention trials for the intermediate riskgroup and put some of-- the rest of the savings intoimproving access treatment to the new drugs, and icould imagine that might go down quite well andno one would have to lose too muchface about screening. >> you are absolutely right, andi have been battling this one for a number of years.

i do not want toembarrass the department of health whichevergovernment here. i don't wanna embarrassthem or humiliate them but they won't listen. i've been banging onabout this for 10 years and suggesting alternativeways of spending. they simply will not listen. we have a letter in the times; in fact hazel thorpe[phonetic] was the first author

of that letter in the times. was it last week, hazel? a letter in the bmj drawingattention to the fact that in february 2009,we publically described in the times and the bmj that the leafletswere misleading, frankly disingenuous. mike richards, the cancer czar,responded two days later saying that they are already working onan update, more honest report.

we haven't seen it yet, so wepublished a letter in the times to last week saying whereis it, what's happened. meanwhile, 3 millionwomen are being invited. is that the right number? three million women arebeing invited to screen without informed concern. so, i don't know what to do. i'm just hoping apublic lecture like this which may cause ripplesand get out to a lot

of audience may justembarrass the government into doing something. we have time for one lastquestion from the lady at the back and justto reassure you, the lecture is being recorded and it does reach avery wide audience, so we thank you for this. >> so i can kiss my[inaudible] goodbye. >> i have a more fundamentalquestion, i am not very familiar

on how is this breast screening. so, how safe is it like if yousay that the breast is a system and you disturb it byirradiating or something like that, you mayactually produce cancer with over screening? >> you mean by the x-rays? >> yes. >> yeah. the dose of x-rays for mammographicscreening is incredibly low

and less than the chest x-ray. it's used to be a concern inthe early days of mammography. it isn't really a concern that mammographic screeningwill induce new breast cancers. by putting it anotherway, the "commonest cause" of breast cancer screening" because once you startscreening the incidence goes up by 50 percent. that is, of course, it isn'tcausing directly the breast

cancer, it's exposing latentdisease 'cause i don't think you need to worry aboutthe dose of radiation. >> okay, i thinkthat we need to close because there is aclass coming here. thank you all verymuch for coming. remember to come back for nexttuesday, and this is fantastic. this is exactly what thelunchtime lectures are all about, free debateon interesting and controversial subjects.

thank you, bye.