Mario Saliba's correspondence against a regulated breast screening programme (The Sunday Times, July 20) is misleading and scientifically unfounded. Although mammography may not prevent the vast majority of breast cancer deaths, it is wrong to glibly declare that a regulated breast screening programme for the Maltese islands cannot be justified or cost-effective. Mammography is the best screening tool available.
Discussion on improving methods of risk prediction, communication, disease detection, and treatment is currently of more public health benefit than resurrecting a debate about mammography.
Dr Saliba should mention slightly more recent publications, such as the Copenhagen 2005 report showing a reduction in breast cancer mortality of 25 per cent for women screened or the 2002 overview from Sweden (21 per cent) with a breast cancer mortality reduction in the region of 25 per cent for the 55-69 age range (2003).
In that year, a breast cancer mortality reduction of approximately eight per cent among the entire UK female population was attributed directly to the UK screening programme - little wonder that two-view mammography (which incidentally detects 24 per cent more women with breast cancer) was soon introduced, with added extension for older age groups.
Evidence on the benefits of screening takes time to emerge - at least five or 10 years, and the full impact even longer. In a remarkable 20-year follow-up in Sweden published in 2003, mammography screening is contributing to substantial reductions in breast cancer mortality even after taking account of potential biases such as changes in clinical practice and changes in the incidence of breast cancer.
Ever more powerful arguments for a regulated screening programme are now emerging. Research from Finland published in the last three or four years indicated that those women whose cancer is detected by screening have half the chance of a cancer recurrence than those detected because of their symptoms.
The UK Cancer Intelligence Unit recently observed that women with screen-detected breast cancer have a substantial survival advantage over those with symptomatic breast cancer. Screening has been shown to result in a significant 'stage shift' - cancers are treated earlier with lesser side-effects. The benefits to patients and cost-savings to the entire community are substantial.
One can be slightly more tolerant of some of the remaining sweeping statements made in Dr Saliba's letter. He is presumably unaware that detailed internal reviews of the gains and costs of introducing such a screening programme for the Maltese islands have been carefully undertaken by local health offices. The need for introducing quality assurance benchmarks is wholly recognised and work is underway to ensure compliance with the requirements of European Guidance, a document some 400 pages long.
This exhaustive set of standards for quality control and assurance detail medical, organisational and technical aspects of breast screening, covering service delivery, timeliness of service, quality and outcome measures and user satisfaction.
They are now the firm basis which governs screening practice. Most of Europe (in line with the strong EC recommendations) has now moved towards a regulated breast screening programme, a path the Maltese authorities find obliged to follow.
At their implementation stage, several European fellow countries found (as in Malta) a mix of inefficient opportunistic screening and public symptomatic services.
Increasingly, Malta is obliged to reconsider its hesitant approach to breast screening. We should consider that screening programmes exist to target those who are least likely to seek help or who cannot afford regular mammography.
It is tempting to suggest that this very Christian need to care for the most vulnerable (rather than vote-catching aspirations) can be a potent incentive even for those who guide us.