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Analysing the ethics of breast cancer overdiagnosis: a pathogenic vulnerability

Abstract

Breast cancer screening aims to help women by early identification and treatment of cancers that might otherwise be life-threatening. However, breast cancer screening also leads to the detection of some cancers that, if left undetected and untreated, would not have damaged the health of the women concerned. At the time of diagnosis, harmless cancers cannot be identified as non-threatening, therefore women are offered invasive breast cancer treatment. This phenomenon of identifying (and treating) non-harmful cancers is called overdiagnosis. Overdiagnosis is morally problematic as it leads to overall patient harm rather than benefit. Further, breast cancer screening is offered in a context that exaggerates cancer risk and screening benefit, minimises risk of harm and impedes informed choice. These factors combine to create pathogenic vulnerability. That is, breast cancer screening exacerbates rather than reduces women’s vulnerability and undermines women’s agency. This paper provides an original way of conceptualising agency-supporting responses to the harms of breast cancer overdiagnosis through application of the concept of pathogenic vulnerability.

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Notes

  1. Scholars differ in formal definitions of overdiagnosis (see e.g., Hofmann 2014; Carter et al. 2016; Rogers and Mintzker 2016). However, all of these authors would include breast cancer overdiagnosis as described here within their definitions of overdiagnosis.

  2. Note that overdiagnoses differ from false positives which occur when an initial positive test is found to be incorrect on further testing.

  3. The rate of overdiagnosis may be expressed in relation to numbers of women invited to be screened, women actually screened, or cancers detected by screening. The number of overdiagnosed cancers may be presented as a percentage of the cancers diagnosed in the screening group or as the percentage of excess cancers found in screened women versus the numbers of cancers in unscreened women (Marmot 2012, p 41).

  4. I thank an anonymous reviewer for noting that all of these are iatrogenic harms. The harms of ODx are a subset of these.

  5. These incorrect beliefs about screening included:

    • screening prevents or reduces the risk of contracting breast cancer (68% believed this but screening has no effect on this risk);

    • screening at least halves breast cancer mortality (62% believed this but even the most optimistic estimates are a reduction of no more than 31% rather than 50% [Paci 2012]);

    • 10 years of regular screening will prevent 10 or more breast cancer deaths per 1000 women (75% of women believed this, whereas the real figure is thought to be between 0.3 and 3.2 per 1000 [Welch and Passow 2014]).

  6. These include methodological and contextual features that preclude meaningful comparisons of trials, ever-evolving diagnostic technologies, improvements in breast cancer treatment outcomes that change the baseline by reducing the anticipated benefit conferred by early diagnosis, and uncertainty about the most effective treatment for DCIS, which is detected almost exclusively through screening (Carter et al. 2015).

  7. This is not a carte blanche for any level of ODx: Australian women’s stated willingness to be screened is sensitive to potential rates of overdiagnosis. Rates of up to 30% ODx had little impact on intentions and attitudes to screening. Rates of 50% prompted some women to decline screening altogether although others retained an unchanged commitment to participate (Hersch et al. 2013).

  8. The percentages rose to 50 and 19% respectively regarding ‘conceptual information’ only (i.e., general understanding of the issues rather than recall of specific numerical information).

  9. These authors defined informed choice in terms of adequate knowledge about the benefits and harms of screening including overdiagnosis and intentions consistent with attitudes.

  10. I am indebted to my colleagues Stacy Carter, Bjorn Hofmann and Lynette Reid for this term, ‘epistemic burden’.

  11. The Swiss Medical Board is notable here for shouldering the epistemic burden. After 12 months of deliberation, the Board decided to time limit existing screening mammography programs and not introduce any new ones (Biller-Andorno and Jüni 2014).

  12. For example, screening for cervical cancer is generally accepted to have made a major contribution to the decrease in deaths from this disease, although this belief has never been tested in a randomized controlled trial.

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Acknowledgements

Work on this paper was funded by Australian Research Council FT130100346, awarded to Professor Wendy Rogers. An earlier version was presented as part of a panel at the 2016 Feminist Approaches to Bioethics World Congress in Edinburgh. Thanks to my co-panellists Stacy Carter and Lynette Reid, members of the audience, and also to Mary Walker for helpful comments on earlier drafts.

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Rogers, W.A. Analysing the ethics of breast cancer overdiagnosis: a pathogenic vulnerability. Med Health Care and Philos 22, 129–140 (2019). https://doi.org/10.1007/s11019-018-9852-z

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Keywords

  • Overdiagnosis
  • Breast cancer
  • Vulnerability
  • Screening
  • Harm
  • Pathogenic vulnerability
  • Ethics