Comments on John D . Keen and James E . Keen , What is the point : will screening mammography save my life ? BMC Medical

This paper by John D. Keen and James E. Keen addresses a thorny subject. The numerical findings and commentaries in their paper will be disturbing to some readers and seem to defy logic and well established viewpoints. It may well generate angry letters to the editor. However such numerical analysis and reporting including civil discussion should be welcomed and are the basis for informed decision making – something that is highly needed in this field. Keen and Keen find that, depending on the particular population subset, of the order of a thousand persons need to be screened for early detection of breast cancer in order to save one additional life [1]. The remainder who do not benefit from early detection can have side effects of which they name anxiety, loss of time, unnecessary procedures, and radiation. The numbers are somewhat worse for younger women. They also comment and imply that early detection of cancer is a business with a large market and we should keep that in mind when we read papers and when women are urged to have mammographic screening to improve the mortality and morbidity from breast cancer. As Keen and Keen note, benefits are often exaggerated and side effects are often minimized. I have studied this field for a number of years from a far distant vantage point. My opinions in this subject are mostly in agreement with Keen and Keen. That is, their comments and numerical results are consistent with my knowledge and experience. However, the situation is far more scientifically complex and politically charged than as they describe. I hope readers will become interested in this fascinating subject and study the literature. Early detection of breast cancer is scientifically most interesting but unfortunately this is often lost in the arguing that has taken place. Consider that we had a cancer paradigm consisting of detection of cancer by no special means and subsequent treatment by surgery and possible adjuvant therapy. Now we perturb or probe the system by introducing routine early detection. Do the new results on outcome agree with our expectations? If they do, then we gain confidence that we understand the disease and how it progresses. If they do not, then perhaps our understanding of the disease process was faulty and needs to be reconsidered. Such experimental opportunities are rare in cancer care so we need to fully exploit the scientific situation. It has long been known that the probability of cure with just surgical removal of the primary tumor after diagnosis of breast cancer is highest for patients with the smallest primary tumors and no invasion of the axillary lymph nodes. The probability of cure decreases as the tumor size and the number of lymph nodes with cancer cells increases. It was eminently logical that early detection Published: 2 April 2009 BMC Medical Informatics and Decision Making 2009, 9:20 doi:10.1186/1472-6947-9-20 Received: 18 February 2009 Accepted: 2 April 2009 This article is available from: http://www.biomedcentral.com/1472-6947/9/20 © 2009 Retsky; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.