Atypia detected during breast screening and subsequent development of cancer: observational analysis of the Sloane atypia prospective cohort in England
BMJ 2024; 384 doi: https://doi.org/10.1136/bmj-2023-077039 (Published 01 February 2024) Cite this as: BMJ 2024;384:e077039
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Dear Editor
In response to the observational analysis titled "Atypia detected during breast screening and subsequent development of cancer: observational analysis of the Sloane atypia prospective cohort in England" published in the BMJ, I would like to commend the authors Freeman et al., for their comprehensive examination of breast cancer development following atypia detection during breast screenings. The study's insights into the impact of digital mammography on atypia detection rates and the subsequent cancer diagnoses provide crucial data for evaluating current breast screening practices.
The significant increase in atypia detection following the adoption of digital mammography, as reported in the study, raises important questions about the balance between early detection and the potential for overdiagnosis. The observed decrease in subsequent cancer diagnoses within three years of atypia detection in more recent years may indicate an evolution in mammography and biopsy techniques, potentially leading to the identification of less aggressive forms of atypia.
Furthermore, this study underscores the necessity of re-evaluating the follow-up protocols for women diagnosed with atypia. The findings suggest that annual mammography in the short term after an atypia diagnosis may not be beneficial for all women, highlighting the need for personalized follow-up strategies based on the latest evidence and technological advancements.
It is also worth noting the study's contribution to the ongoing discussion about the management of atypia detected during breast screening. By providing a detailed analysis of the incidence and outcomes of breast cancer following atypia detection, Freeman et al. contribute to refining screening protocols and recommendations, ultimately aiming to enhance patient care within the NHS breast screening program.
In conclusion, the Sloane atypia prospective cohort study offers valuable insights that could inform future guidelines on the management of atypia in breast screening. It emphasizes the importance of continuous research and adaptation of screening practices to incorporate technological advancements and emerging evidence. Further research on long-term risks associated with atypia and the development of more precise risk stratification models would be beneficial in optimizing breast cancer screening and management strategies.
Competing interests: No competing interests
Re: Atypia detected during breast screening and subsequent development of cancer: observational analysis of the Sloane atypia prospective cohort in England
Dear Editor,
The authors of this report [1] rightly remind us that before we all enthusiastically engaged in screening women for breast cancer, DCIS was seldom diagnosed. They conclude their report by stating that epithelial atypia could be considered as a risk factor for the subsequent diagnosis of invasive breast cancer rather than as being a `non-invasive `cancer`` as DCIS is defined. A cynical comment, taking it to ad absurdum, might be to suggest that the next step, perhaps using MRI for all women being screened, would be to say that that method might determine which of these women is at risk of having a risk factor!
However, mammographic screening has reliably been shown to result in causing certain wide-ranging harms but conferring vanishingly small potential for benefit.[2] But this study could result in yet more women being harmed, confer no additional benefit, and have no effect overall on survival.
It is fashionable to decry so called `U-turns`. But I would like to suggest, as others have before me, that “if you cannot change your mind, you cannot change anything”. When are we going to decide where we should be prioritising our efforts in the NHS? A series of well-run, adequately informed Citizens Deliberations could constitute a first step in the right direction.
The cost of all this screening activity, both in the clinics and in research, is huge. Additionally, turning these citizens unnecessarily into patients causes unnecessary energy use, more road traffic, vehicular air pollution, environmental damage, time wastage. And this is at a time of crisis in the NHS: a National Health Service that is failing millions of patients who are sick and suffering.[3]
It is said that Nero fiddled while Rome burned: when are we going to wake up to properly consider the interlinked crises we are all currently facing?
Hazel Thornton
Independent Citizen Advocate for Quality in Research and Healthcare
[1] Freeman K, Jenkinson D, Clements K, Wallis M.G., Pinder S.E., et al. Atypia detected during breast screening and subsequent development of cancer: observational analysis of the Sloane atypia prospective cohort in England. BMJ 2024;384:e077039
[2] Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD001877. DOI: 10.1002/14651858.CD001877.pub5. Accessed 10 February 2024.
[3] Crisp N, Bamrah H.M., Morely J, Augst C, Patel K. The NHS principles are still appropriate today and provide a strong foundation for the future. BMJ 2024;384:e078903
Competing interests: No competing interests