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‘Overdiagnosis’: some breast cancer treatments may have been unnecessary, study suggests | Breast cancer

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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 may never go on to cause harm in a woman’s lifetime, leading to overtreatment, and psychological and financial suffering.

Jenny is one of 12 women from the UK, US, Canada and Australia whose stories were published in the medical journal BMJ Open on Thursday. It is the first study to interview breast cancer patients who believe they may 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’,” an author of the study and a professor of public health at the University of Sydney in Australia, Alexandra Barratt, said.

“This study reports the other side of the story – how breast cancer screening can cause harm through overdiagnosis and overtreatment.”

In Jenny’s case, she learned from her surgeon only after her mastectomy that her cancer may not ever have progressed to cause harm or symptoms, and that ongoing monitoring or less invasive treatments may 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, and treatment is nonetheless 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.

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Estimates of breast cancer overdiagnosis vary from 10% to 30%, depending on the study methods. A Cochrane review of screening mammography 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.”

Prof 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 do 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.”

An independent UK review into the issue concluded that for every 10,000 women invited to screening from age 50, about 681 cancers will be found, of which 129 will represent overdiagnosis, and 43 deaths from breast cancer will be 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.”

The screening debate

Kirsten Pilatti, the chief executive of the Breast Cancer Network Australia, said the challenge is many women will never know for sure 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, with 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.”

Major cancer organisations worldwide now 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.

Dr Anna Samecki, a general practitioner and medical adviser at NPS MedicineWise, said while the BMJ Open study interviewed a small number of women, it is nonetheless an “informative qualitative study” that highlighted 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.”

One study participant was advised by two surgeons to get a mastectomy but a third was willing to perform a less invasive lumpectomy.
One study participant was advised by two surgeons to get a mastectomy but a third was willing to perform a less invasive lumpectomy. Photograph: Mango Productions/Getty Images

Sally*, an Australian woman who participated in the study, told the Guardian that when she was diagnosed with ductal carcinoma in situ, considered the earliest stage of breast cancer and non-invasive at this stage, her surgeon told her she would need a mastectomy. Sally had no symptoms.

Sally, who had been successfully treated for a pituitary tumour in the past, brought the possibility of overdiagnosis up with her first surgeon. She said she was left feeling “utterly patronised” 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 mastectomy, but she contacted a third surgeon who advised a mastectomy but was willing to perform a lumpectomy, a less invasive procedure where the cancer and tissue that surrounds it is removed. Eight years after the lumpectomy, Sally is still 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. 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.”

*Names changed to protect identity

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WHO estimates 90% of world have some resistance to Covid | Coronavirus

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The World Health Organization estimates that 90% of the world population now has some resistance to Covid-19, but warned that a troubling new variant could still emerge.

Gaps in vigilance were leaving the door open for a new virus variant to appear and overtake the globally dominant Omicron, the WHO director general, Tedros Adhanom Ghebreyesus, said.

“WHO estimates that at least 90% of the world’s population now has some level of immunity to Sars-CoV-2, due to prior infection or vaccination,” said Tedros, referring to the virus that causes the Covid-19 disease.

“We are much closer to being able to say that the emergency phase of the pandemic is over – but we’re not there yet,” he told reporters.

“Gaps in surveillance, testing, sequencing and vaccination are continuing to create the perfect conditions for a new variant of concern to emerge that could cause significant mortality.”

Last weekend marked one year since the organisation announced Omicron as a new variant of concern in the Covid-19 pandemic, Tedros noted.

It has since swept round the world, proving significantly more transmissible than its predecessor, Delta.

Last week, the latest real-world study of updated Covid boosters showed that new vaccines by Pfizer/BioNTech and Moderna are likely to provide better protection compared with the original shots.

The study of more than 360,000 people indicated that the boosters offer increased protection against new variants in people who have previously received up to four doses of the older vaccine.

Since their introduction to the US in September, the vaccine boosters, which contain both original and Omicron BA.4/5 coronavirus strain, provided greater benefit to younger adults aged 18-49 years that those in the older age group.

Tedros said there were now more than 500 highly transmissible Omicron sub-lineages circulating – all able to get around built-up immunity more easily, even if they tended to be less severe than previous variants.

Around the world, 6.6 million Covid deaths have been reported to the WHO, from nearly 640 million registered cases. But the UN health agency says this will be a massive undercount and unreflective of the true toll.

Tedros said more than 8,500 people were recorded as having lost their lives to Covid last week, “which is not acceptable three years into the pandemic, when we have so many tools to prevent infections and save lives”.

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Kevin Durant, Nets beat Raptors to tally fourth win in a row

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Make it four in a row and seven of their last nine.

The Nets are one of the hottest teams in basketball and moved two games above .500 with a 114-105 victory over the Toronto Raptors in front of a sellout 17,732 fans at Barclays Center on Friday night.

They led by as many as 36 points before letting the Raptors creep back into the game late in the fourth quarter.

After digging a 2-6 hole to start the season, the Nets (13-11) have pulled a complete 180. They are inching closer toward contender status, though they still have tremendous ground to cover separating themselves from the cream of the NBA crop.

And it both looks and feels different when the Nets aren’t leaning too heavily on Kevin Durant — or Kyrie Irving, as they did for unending stretches last season.

Durant’s minutes have become a point of contention in Brooklyn, as they were last year. He entered Friday’s matchup as the league’s leader in minutes, points and field goals. At age 34 and in year 15, the Nets star is averaging 37 minutes per game for the second consecutive season.

“We’ve had to play Kevin more minutes than we’ve wanted to,” head coach Jacque Vaughn said ahead of tipoff. “That’s just kind of where we are. He understands that.”

It hits different, though, when Durant has help, and it reflects on the scoreboard.

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Sharpshooter Joe Harris got hot early, scoring 11 points in the first quarter alone. After breaking out of his shooting slump to hit four out of six threes in Wednesday’s win over the Washington Wizards, Harris, who is starting in place of the injured Ben Simmons (calf strain), hit another five threes for 17 points against the Raptors on Friday.

Royce O’Neale hit a trio of timely threes, and Kyrie Irving shouldered a large chunk of the scoring load, scoring 27 points on 17 shot attempts. Veteran forward TJ Warren, in his Nets debut after missing two-plus seasons with consecutive stress fractures in his left foot, scored 10 points on 5-of-11 shooting off the bench.

And Nic Claxton added 15 points and nine rebounds, sealing the game with a putback dunk, then offensive rebound and finish that extended the Nets’ lead back to 16.

He forced Raptors coach Nick Nurse to call his second to last timeout with four minutes left in the fourth.

It was Durant’s lightest workload of the season. He still played 38 minutes but they were low impact. He only took 10 shots and finished with 17 points, nine rebounds and seven assists.

The Nets built a lead as large as 36 and watched the Raptors whittle the deficit down to as little as seven in the final minute of the fourth quarter. It wasn’t a pretty finish but nothing has come easy for the Nets this season.

They have a chance to make it five in a row on Sunday, though they’ll have to go through last year’s Eastern Conference champion Boston Celtics to get there.

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Fourth child dies in UK after contracting Strep A infection | UK news

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A fourth child has died in the UK after contracting Strep A, as health officials issued warnings to parents and school staff about signs and symptoms of infection.

These include a sore throat, fever and minor skin infections. In rare incidences, it can become a severe illness, and anyone with high fever, severe muscle aches, pain in one area of the body and unexplained vomiting or diarrhoea should seek urgent medical help.

On Friday, the UK Health Security Agency (UKHSA) confirmed that a child who attended St John’s primary school in Ealing, west London, had died from the bacterial infection, while it also emerged that the parents of a four-year-old boy from Buckinghamshire have said he has died from Strep A.

Shabana Kousar, the mother of Muhammad Ibrahim Ali, who attended the Oakridge school and nursery in High Wycombe, told the Bucks Free Press: “The loss is great and nothing will replace that. He was very helpful around the house and quite adventurous, he loved exploring and enjoyed the forest school, his best day was a Monday and [he] said how Monday was the best day of the week.

“He also had a very close bond with his dad. He was his best friend and went everywhere with him. He just wanted to be with him.”

A pupil from Victoria primary school in Penarth, four miles south of Cardiff, has also died from the infection. A six-year-old died last week after an outbreak of the same infection at a school in Surrey.

Health officials are understood to have reported a slight rise recently in cases of Strep A, which can cause scarlet fever, although deaths and serious complications from the infection are rare.

Dr Yimmy Chow, a health protection consultant at UKHSA, said of the Ealing case: “We are extremely saddened to hear about the death of a child at St John’s primary school, and our thoughts are with their family, friends and the school community. Working with Ealing council public health team, we have provided precautionary advice to the school community to help prevent further cases and we continue to monitor the situation closely.

“Group A streptococcal infections usually result in mild illness, and information has been shared with parents and staff about the signs and symptoms. These include a sore throat, fever and minor skin infections and can be treated with a full course of antibiotics from the GP.

“In rare incidences, it can be a severe illness and anyone with high fever, severe muscle aches, pain in one area of the body and unexplained vomiting or diarrhoea should call NHS 111 and seek medical help immediately.”

Group A streptococcal bacteria can cause many different infections, ranging from minor illnesses to deadly diseases. Scarlet fever is caused by Strep A and mostly affects young children but is easily treated with antibiotics.

According to the NHS, the first signs of scarlet fever can be flu-like symptoms including a high temperature, sore throat and swollen neck glands. A rash appears 12 to 48 hours later that starts on the chest and stomach and then spreads. A white coating appears on the tongue, which peels, leaving the tongue red, swollen and covered in small bumps (often called “strawberry tongue”).

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