The Mammography Screening Debate in Germany: Yes or No?

After living in the United States for 19 years I moved back to my native Germany last year. Shortly after my arrival, I received an invitation to be screened for breast cancer. The standard letter I got in the mail described Germany’s FREE screening program and conveniently came with an automatic appointment that was set at the next available date and time at a screening center nearby. I didn’t feel that it was my choice to go or not because of the already scheduled date. It felt more like an obligation, and I am not the only woman who feels this way.

Germany’s nationwide mammography screening program did not come into existence until 2002, largely as the result of fervent discussions in the United States and other European countries about the tool’s potential benefit for saving women’s lives. Since Germany was, in a sense, behind other countries in screening for breast cancer, German women who were concerned about the disease would go to anyone offering mammograms, without knowing whether the physicians or staff were adequately trained or the machines up to standards. This so-called “gray-screening” went out of favor after a national program established quality measures to ensure that all women officially residing in Germany had access to the same, best available options.

Is the Program Really the Best Choice for Women in Germany?

In June 2014, the political TV journal MONITOR, known for its critical voice and reporting on issues generally out of favor with many politicians and businesses, took on the breast cancer screening issue. MONITOR airs every five weeks in Germany and this episode investigated Germany’s mammography screening program. The following is a description of the TV report.

MONITOR Screen Shot 2014-08-11 at 2.34.47 PMThe anchor explained that Germany’s national mammography screening program has been in existence since 2002 and that German women between the ages of 50 to 69 are invited every two years to participate. Even though there were critical voices from the onset that screening could do more harm than good, Germany’s political parties agreed to and supported the program. Now, after 12 years there are new doubts about how effective the program really is.

The cost of Germany’s mammography screening program to healthcare providers is 220 Million Euros every year. Mobile screening buses drive to the smallest corners of Germany to make the screening available to as many women as possible. The scientific adviser of the national program, Professor Alexander Katalinic, says that 18,000 women die of breast cancer every year in Germany, and screening helps 7 to 9 women to survive over a 20-year period. Is that really accurate?

German women generally trust the program and too believe mammograms save lives. One woman featured in the MONITOR had participated in Germany’s screening program since its inception. She believed it was her duty to enroll in the program to ensure that, should she get breast cancer, she would have done everything she could to find it as early as possible. Unfortunately, despite her routine screenings, she was diagnosed with breast cancer and treated with surgery and radiation.

The report also introduced recent discussions in Switzerland calling for an end to that country’s national screening program. The Swiss Medical Board reviewed results of existing studies of mammography screening worldwide and found no effect of screening on overall mortality. The Swiss researchers found that 4 out of 1000 women in the screening programs eventually died of breast cancer, compared to 5 out of 1000 women who had not been screened. When taking into account treatment-related deaths (such as heart attacks or the development of other cancers) the overall death rate was exactly the same between the two groups, 5 and 5.


Figure 1: Summary of the Swiss Medical Board’s Findings (In German)

The Swiss Medical Board also found an increased likelihood of harm from overdiagnosis and overtreatment. (See BCC’s Research Brief on the View from the Swiss Medical Board).

Of particular concern to those questioning screening programs is the overdiagnosis of nonlethal cancers that, while they may meet the pathological criteria for cancer, are not likely to become symptomatic in a person’s lifetime. When women receive treatment for these conditions, they face physical and emotional consequences even though large randomized trials show that for most women the treatment will do little to nothing to impact their overall survival.

Woman Screen Shot 2014-08-11 at 4.10.36 PMThe woman who started to tell her story in the early part of the MONITOR segment had been diagnosed with carcinoma in situ, one of those collections of abnormal cells that mostly (about 85 percent of the time) don’t go anywhere or do anything. These are the indolent cancers many leading researchers now question as to whether or not they should be classified as carcinomas. The woman now knows this, and she wishes someone would have explained the uncertainties surrounding the in situ conditions so she could have made more informed treatment decisions. With the knowledge she has now, she doubts she would have agreed to treatment that left her sick and fatigued for two years.

Mette Kalager, a former director of Norway’s Mammography Screening Program, said in the report that, like in Germany, the Norwegian program was established with the goal of finding breast cancers “early,” especially the dangerous ones. After 15 years, Norway’s program still has not witnessed a reduction in the number of breast cancers that spread quickly and metastasize. If we’re detecting cancers “early,” why are there still so many of the “late” variety? Now a critic of screening, Kalager left the program she once directed. “We are misusing trust,” says Kalager, “telling women to do something that could harm them.”

Despite international concerns about mammography screening, says MONITOR, the federal ministry of health in Germany has been a strong supporter of the national program from the beginning, and the German minister of health seems to have no interest in discussing the topic. Likewise, the organization that administers Germany’s program does not consider the critical studies. The ministry did, however, initiate an evaluation of Germany’s national program by a research institute in Münster whose director of research, Professor Hans-Werner Hense, has already expressed doubt about the efficacy of the program.

The segment ended with the president of the German Medical Association, (Bundesärztekammer) Dr. Frank Ulrich Montgomery, advising German officials to pay close attention to the Swiss findings and researchers to validate the numbers. If the German situation is similar (in that screening does not reduce overall mortality and potential harms outweigh potential benefits), Montgomery argues that we will have to ask seriously whether Germany’s mammography screening is meeting our expectations.

The German Response

The MONITOR report generated intense discussion about mammography screening among experts and the public. On July 23rd the online journal of clinical medicine Deutsches Ärzteblatt reported that Tatjana Heinen-Kammerer, director of Cooperation Mammography (a division of the German mammography program responsible for quality control and program evaluation), believes Germany has had reliable nationwide screening since 2009. It took seven years to put the program in place, and longer-term mortality statistics are expected by 2019 to 2021. Since the program began, the rate of screen-detected DCIS (Ductal Carcinoma In Situ, stage zero) is reported to have increased from seven to 19 percent, and the detection of invasive tumors (up to ten millimeters in size) increased from 14 to 35 percent. Based on these data Ms. Heinen-Kamerer has no doubt that Germany’s national screening program is the way to go. In 2010, 53.7 percent of German women used the program.

Professor Dr. Hense MD who was featured in the MONITOR program agreed to an interview with the German Medical Association regarding his evaluation of Germany’s program. He explained in Deutsches Ärzteblatt (July 24, 2014) that the public’s expectations of screening are unrealistic and far too high, and that program materials should therefore focus on uncertainties and limitations. At the same time, he is concerned that if the German program ended women would rely, once again, on “gray-screening” with no quality assurance. For this reason, he believes it is important to remind women that the national screening program offers the best quality mammography screening in Germany.

mammografie-100~_v-videoweblThe news program Tagesschau reported a study by Bertelsmann Stiftung that asked women about screening (July 29, 2014). Alarmingly, one-third of those surveyed thought they could protect themselves from breast cancer just by getting screened. Many also overestimated the impact of screening on mortality. Thirty percent of participants believed screening mammograms prevent breast cancer, and there was an overall belief that the reduction in mortality due to screening was much higher than it is.

The survey question was: “In your opinion, how many breast cancer deaths can be prevented if 1000 women participate in mammography screening every two years for twenty years in Germany?” The answer options went from zero to 999. The average number selected was 237 (with a median of 100). The correct answer is five. Just four percent of participants selected the correct answer, and only 48.5 percent answered the question at all. German women clearly do not have accurate information about the topic, yet there is a high level of uncertainty about this screening tool.

Big campaigns in favor of mammography perpetuate the idea that by participating in the national program women don’t have to worry about breast cancer: cancer will be found early enough that it will be cured. But that is only part of the story. When I went to the website of the German national screening program, I found a public statement that essentially referred to critiques of mammography screening as nonsense. The official statement declared that critics of screening cite studies that are based on questionable samples and results, suggesting that there are, in effect, no valid studies calling screening into question.

This conclusion contradicts the eight randomized, controlled trials that together show the benefits of screening to be far smaller than early evidence suggested, and the harms far greater. The website asserts that there are “no other appropriate screening methods” and boasts that Germany’s mastectomy rates have not (unlike other countries such as the U.S.) been on the rise, with breast conserving therapies fairly standard. It does claim that screening “cannot prevent breast cancer” but also that participation in the program can “prevent women from dying of breast cancer.” There is no information about why, despite increased detection of smaller, “earlier” tumors, there has been no equivalent decline in more advanced disease as would be expected. By simply listing the basic pros and cons of screening, the materials dismiss overdiagnosis as an unavoidable effect, but one that is neither foreseeable nor measurable.

Using esoteric language that would be incomprehensible to persons with no background in academic or medical fields, those who rely on the program website would be left with little evidence-based information to make informed decisions. Moreover, the scientific jargon is paired with simple messaging that critics of screening are just wrong because they allegedly cite false studies yet women should make informed decisions (by enrolling in the program without question and listening to their doctors.)

My Conclusion

Breast cancer treatment in Germany is state of the art in many ways, but the problem of overtreatment still exists for those with early-stage and indolent disease. Unfortunately, it doesn’t appear that protocols will change unless, in 2021 or ‘22 when that first reliable nationwide mortality data is finally available, the evidence steers the policy. But with 220 million Euros spent every year on screening, many more women with tumors that are not life threatening will be treated with the same “slash and burn” techniques for years to come. Until that day, making an “informed decision” will be a tall order for German women. And the monies that could be spent on finding better therapies for the breast cancers that kill will continue to be diverted into finding more of the ones that don’t.

Astrid Eich-Krohm is a research associate in the Institute of General Medicine at Otto-von-Guericke University. She received her training as a registered nurse in Germany and then became a nursing educator. After her move to the United States she went back to school and received her BA, MA, and PhD in sociology from University at Albany (SUNY). Astrid’s research is informed by both careers. Her thesis focused on infertility and how couples make decisions about childlessness, and her dissertation investigated how German highly skilled families determine whether to stay permanently in the United States or return to their home country. She served as an associate professor of sociology at Southern Connecticut State University for five years and had the opportunity to combine her medical and sociological interests in her courses on the sociology of aging, medical sociology, migration, and other subjects. Since collaborating with Gayle Sulik on a variety of projects, Astrid has shifted her interests toward breast cancer in Germany particularly in terms of its newly emerging status as a “chronic disease.”

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