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Ethics of Screening

Scott Pilla with Joseph Carrese

Framework for Public Health Ethics


1. What are the goals of the program? 2. How effective is the program at achieving those goals? 3. What are the burdens of the program? 4. How can the benefits and burdens of the programs be balanced?

Adapted from An Ethics Framework for Public Health by NE Kass.1

1. Goals of Breast Cancer Screening


Reduce breast cancer deaths Decrease the financial burden of illness / improve cost effective care???
Not a stated goal by expert panels.2,3,4 Cost effectiveness not reviewed by them.2,3,4 Analyses of large-scale cost effectiveness are scarce, tend to be equivocal at best.5,6,7

2. Efficacy of Breast Cancer Screening


Reduce breast cancer deaths
1 per 1000 screened will have life saved from breast cancer over 10 years. This is the ballpark estimate from large metaanalyses.2,8,9 Proportion of mortality reduction due to screening vs. improved treatment is debated.

3. Burdens of Breast Cancer Screening


False-Positives Overdiagnosis Discomfort / shame of testing Financial cost to uninsured Time taken from other medical issues

3. Burdens of Breast Cancer Screening


False Positive finding a suspicious lesion that is not
cancer by tissue diagnosis. Causes unnecessary procedures (typically needle or excisional biopsy) and psychological hardship.
200 per 1000 screened will have FP over 10 years.2,8,9

Overdiagnosis finding breast cancer that would never


have caused harm in the absence of treatment (i.e. would have regressed spontaneously, or stopped growing on its own). Causes unnecessary cancer dx / treatment. 10 per 1000 screened will have overdiagnosis over 10 years.2,8,9

Benefits

Burdens

Public Perception of Screening


Screening is seen as confirming good health.10 Screening is assumed to be the right decision.10

Mammography rates did not change in response to change in USPSTF guidelines.11

Citations
1. Kass NE. An ethics framework for public health. Am J Public Health 2001; 91:1776-1782. 2. Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L. Screening for breast cancer: an update for the U.S. preventive services task force. Ann Intern Med 2009; 151(10):7 27-737. 3. Smith RA, Saslow D, Sawyer KA, Burke W, Costanza ME, Evans WP, Foster RS, Hendrick E, Eyre HJ, Sener S. American cancer society guidelines for breast cancer screening: update 2003. CA Cancer J Clin 2003; 53:141-169. 4. ACOG practice panel. Breast cancer Screening. Obstegrics & Gynecology 2011; 118(2):372-382. 5. Lebovic GS, Hollingsworth A, Feig SA. Risk assessment, screening and prevention of breast cancer: A look at cost-effectiveness. The Breast 2010; 19:260-267. 6. Gross CP, Long JB, Ross JS, Abu-Khalaf MM, Wang R, Killelea BK, Gold HT, Chagpar AB, Ma X. The cost of breast cancer screening in the medicare population. JAMA Intern Med 2013; 173(3):220-226. 7. Pharoah PDP, Sewell B, Fitzsimmons D, Bennett HS, Pashayan N. Cost effectiveness of the NHS breast screening programme: life table model. BMJ 2013; 346:f2618. 8. Gtzsche PC, Jrgensen KJ. Screening for breast cancer with mammography. Cochrane library; 2013: Issue 6. 9. Bleyer A and Welch HG. Effects of three decades of screening mammography on breast-cancer incidence. NEJM 2012; 367:21. 10. Osterlie W, Solbjor M, Skolbekken J-A, Hofvind S, Saetnan AR, Forsmo S. Challenges of informed choice in organized screening. J Med Ethics 2008; 34:e5. 11. Pace LE, He Y, Keating NL. Trends in mammography screening rates after publication of the 2009 US preventive services task for recommendations. Cancer 2013; 119:2518-23.