| Mammography and the politics of randomised controlled trials, BMJ (1998) |
The debate over the necessity of screening for breast cancer
among women in their 40s has assumed an importance out of
proportion to its potential impact on public health. Even
among women over 50, for whom screening significantly reduces
mortality, the actual number of deaths involved is comparatively
small. Some commentators (for example, the Center for Medical
Consumers and the National Breast Cancer Coalition) feel
that the controversy over mammography has diverted attention
from the more pressing problem of our ignorance about how
to prevent breast cancer.36 Why has this issue become so
important, and why do feelings run so high among the public,
politicians, and health professionals? Thirty five years
of randomised trials of mammography have not produced a
universally acceptable answer to the question of its efficacy
in younger women; in fact, different experts have often
drawn opposite conclusions after analysing the same data.
The mammography story illustrates some of the many obstacles
to putting research findings into clinical practice. When
trials do not give an unequivocal answer, when politicians
and interest groups become involved, and when the professionals
responsible for promoting the public's best interest fail
to do so, objectivity is likely to suffer.
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