* (There’s) always something new (coming) out of
The Swiss are famously independent minded. They recently demonstrated this again by challenging orthodoxy on breast screening. This raises wider questions about health policy.
Switzerland has never been shy of taking a different line to the rest of the world. They didn’t join the United Nations until 2002 and only did so after a referendum. In February this year they voted to introduce curbs on immigration, despite the risk to their complex reciprocal arrangements with the European Union. Now they have set their sights on breast screening.
Earlier this year the Swiss Medical Board reviewed the case for mammographic breast screening. They concluded that there were several flaws in the rationale for screening and that the programme should be wound down; no new programmes should be started; and that women should be given better information on the pros and cons of screening. How did they reach these conclusions? They observed that evidence for the effectiveness of screening is weak. All of the clinical trials date is from decades ago, when breast cancer treatment was much less effective. Some of the clinical trials have flaws. There may not be any reduction in all-cause mortality. There is substantial evidence that screening causes harms: overtreatment with surgery, chemotherapy and radiotherapy. Alongside this are greatly exaggerated perceptions of the effectiveness of screening.
The outcry was predictable. One clue to their conclusions is the fact that they had not previously been involved with mammographic screening and therefore reached their conclusions untainted by provider influence. The case for screening appeared not to persuade the dispassionate.
The issue of provider influence is a variant of government failure. Those providing a service tend to believe it is a good thing. That may be why they chose their line of work. Or as Festinger observed half a century ago, beliefs follow behaviour. Institutions operate to their own internal agendas, the most obvious of which is survival. So an institution providing a service is staffed by enthusiasts and organisationally incapable of deciding when it has outlived its purpose.
What should we conclude from this? The last people we should ask about the value of a service are the providers. Yet when it comes to health care they have a privileged voice. And finally, beware of self-justifying narratives. We have a lot to learn from the independent minded Swiss.
- Biller-Andorno N, Peter Jüni P. Abolishing Mammography Screening Programs? A View from the Swiss Medical Board. NEJM. 2014. [Online].
- Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database Syst Rev. 2013;6:CD001877.
- Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ. 2014; 348: g366.
- Domenighetti G, D’Avanzo B, Egger M, et al. Women’s perception of the benefits of mammography screening: population based survey in four countries. Int J Epidemiol. 2003; 32: 816-21.
- Festinger L. A theory of cognitive dissonance. Evanston, IL: Row, Peterson and Company. 1957.