US Preventive Services Task Force Recommends Reduced Screening for Breast Cancer
This topic was selected because of its currency--scientifically, politically, emotionally, and economically--and importance to our State and nation.
The US Preventive Services Task Force (USPSTF) issued new guidelines for breast cancer screening that dramatically reduces mammography for screening and should reduce overdiagnosis and unnecessary discomfort, anxiety, biopsies, other medical procedures, personal financial expense, and potentially, after 30+ years of annual mammograms, radiation-induced cancer, without significantly sacrificing the benefits in breast cancer mortality. The controversy that followed, including allegations of scientific illiteracy and personal affronts, is also covered below. To some extent, the angst is captured by the cartoon (original source: Planet Cancer).
For a runnning account of the prostate cancer screening controversy, click here
For a review of overtreatment in general, click here.
A recent, balanced review of the social and polltical history of screening mammography written by a radiologisit, Handel Reynolds, MD, was puiblished in 2012 by Cornell Univ. Press: The_Big Squeeze
test list item test
Breast Cancer Screening Conflicting Guidelines and Medicolegal Risk Allen Kachalia, MD, JD; Michelle M. Mello, JD, PhD Brigham and Women's Hospital, Harvard Medical School and School of Public Health
JAMA / August 3, 2013 online
Drs. Kachalia and Mello maintain that physicians should not fear medicolegal risk in using the USPSTF guidelines. They point out that presence of the conflicting practice guidelines do not heighten vulnerability to allegations of malpractice. Not only are these types of overt conflicts among guidelines are rare but also physicians should resist the temptation to reflexively follow the more aggressive guideline simply to avoid liability risk—needless cost and harm can result. Rather, they should clearly communicate and document the rationale for the recommended screening strategy. Such communication may also bring to light patient values and preferences that help the physician choose the best screening strategy for each individual patient.
For full report, click title or JAMA
NCI Panel: Stop Calling Low-Risk Lesions 'Cancer' By Nick Mulcahy / Medscape Medical News / July 30, 2013 Ms Mulcahy reviews new proposals to reduce overdiagnosis by Laura Esserman, MD, breast cancer surgeon at UCSF, Ian Thompson, MD, University of Texan Health Science Center at San Antonio and Brian Ried, PhD, at the Fred Hutchinson Cancer Center, that were published online in JAMA. working group sanctioned by the National Cancer Institute. Most dramatically, the NCI commissioned group says that a number of premalignant conditions, including ductal carcinoma in situ and high-grade prostatic intraepithelial neoplasia, should no longer be called "cancer." The preferred term is now "indolent lesion of epithelial origin" (IDLE). For the original report, click here
Biennial Mammograms After Age 65 Offer Same Benefits as Annual Screening For the full report in HemOnc Today on May 10, 2013, click here Source: Braithwaite D et al. J Natl Cancer Inst. 2013;doi:10.1093/jnci/djs645. Biennial mammograms offer older women the same benefits as annual screening while significantly reducing the likelihood of false-positive results, according to findings of a prospective population-based study. ... Dejana Braithwaite, PhD, an assistant professor of epidemiology and biostatistics at the University of California San Francisco, and colleagues questioned whether the benefits and risks of screening are influenced by frequency and comorbidity among older women in the community practice. The researchers collected data from four Breast Cancer Surveillance Consortium (BCSC) mammography registries that ... included 2,993 older women with breast cancer and 137,949 older women without breast cancer who underwent mammography at one of the four BCSC facilities from January 1999 to December 2006. ... “Screening every other year, as opposed to every year, does not increase the probability of late-stage breast cancer in older women,” Braithwaite said in a press release. “Moreover, the presence of other illnesses such as diabetes or heart disease made no difference in the ratio of benefit to harm.” Among women aged 66 to 74 years, researchers found a higher rates of false-positive results (48% vs. 29%) among those who underwent annual screening compared with those who underwent screenings every 2 years, regardless of comorbidity.
Perspective Adam M. Brufsky, MD, PhD, FACP These are interesting data, especially given the recent data from the TEAM study presented at the San Antonio Breast Cancer Symposium. The Braithwaite study suggests that women aged 66 to 89 years have the same rates of advanced cancer incidence whether they are screened or not with mammography. The false-positive rate is also the same as in younger women, suggesting that the harm of screening may be the same in this older population. The suggestion is that we think even harder about whether to continue the practice of screening women older than age 69. ...
Screening Mammography: Value versus Jeopardy The May 2013 meeting of the COMS featured a debate on the merits and risks of disease screening, as exemplified by breast cancer. Heather West, MD, of the Bend Memorial Clinic cautioned against screening women for breast cancer beyond age 70. Cora Calomeni, MD, of the St. Charles Cancer Center, described how complex the problem is and how insufficient are the data to alter current recommendations for screening mammography. Archie Bleyer, MD, reviewed the NEJM report on Thanksgiving Day 2012 he co-authored with H. Gilbert Welch, MD on the magnitude in the U.S. of the overdiagnosis problem associated with screening mammography. To review the slides shown by Drs. West, Calomeni and Bleyer, click here.
Screening Mammography: Value versus Jeopardy Pace LE, Ho Y, Keating NL Harvard Institute of Healthcare Policy Cancer ePub April 2013 METHODS Cross-sectional assessments of mammography screening in 2005, 2008, and 2011 using data from the National Health Interview Survey, a nationally representative, in-person, household survey of the civilian, noninstitutionalized US population. In total, 27,829 women ages ≥40 years responded to the 2005, 2008, or 2011 surveys and reported about their mammography use. The primary outcome assessed was self-reported mammography screening in the past year. RESULTS When adjusted for race, income, education level, insurance, and immigration status, mammography rates increased slightly from 2008 to 2011 (from 51.9% to 53.6%; P = .07) and did not decline within any age group. Among women ages 40 to 49 years, screening rates were 46.1% in 2008 and 47.5% in 2011 (P = 0.38). For women ages 50 to 74, screening rates were 57.2 in 2008 and 59.1 in 2011 (P = 0.09). CONCLUSIONS Mammography rates did not decrease among women aged >40 years after publication of the USPSTF recommendations in 2009, suggesting that the vigorous policy debates and coverage in the media and medical literature have had an impact on the adoption of these recommendations.
Our [Not So] Feel Good War on Breast Cancer By Peggy Orenstein / New York Times / April 25, 2013 Ms. Orenstien, a breast cancer patient at the age of 35, used to credit screening mammography for having "saved her life" [as she previously reported in the NY Times}. Sixteen years later, her thinking has changed.
Biennial Mammography Better Than Annual for Women 50 to 74 By Troy Brown/Medscape/March 18, 2013 For full report, click here Source:Kerlikowske K, Zhu W, Hubbard RA, et al. Outcomes of Screening Mammography by Frequency, Breast Density, and Postmenopausal Hormone Therapy. JAMA Intern Med. 2013;():1-10. doi:10.1001/jamainternmed.2013.307.
Women aged 50 to 74 who undergo biennial mammography have a similar risk for advanced-stage breast cancer and a lower cumulative risk for false-positive results compared with women who undergo annual mammography, according to a prospective cohort study of 934,098 women.
NEJM Poll of Screening Mammography In conjunction with the Clinical Decisions debate on whether and at what age women should undergo breast cancer screening with serial mammography, the New England Journal of Medicine conducted a poll aligned with the three Decision opinions published on November 22, 2012. A total of 1,240 votes were cast from around the world. The results show that North Amerca and Europe have the highest proportion of journal readers who agree with current United State Preventive Services Task Force guidelines to delay starting screening mammography until age 50 (46.9% vs. 45.4%, respectively). More than a quarter of European respondents (26.8%) agree with the opinion that screening mammography should not be routinely performed at all, more than twice the rate in the North America (13.4%), Asia (14.8%), and Central and South America (11.0%). For full report, click here.
Study Results Renew Debate Over Value of Screening Mammography Individuals interviewed and selected quotes: Archie Bleyer, MD, co-author with H. Gilbert Welch, MD, of the NEJM report. “No one is denying that screening mammography doesn’t have some benefit,” William Farrar, MD, Professor of Surgery and Chief of Surgical Oncology, Ohio State University Comprehensive Cancer Center—James Cancer Hospital and Solove Research Institute “Screening is the only way to detect an abnormality in the breast.” Adam M. Brufsky, MD, PhD, HemOnc Today Editorial Board member; Professor of Medicine, University of Pittsburgh School of Medicine; Codirector of the Comprehensive Breast Cancer Center and Medical Director, Women’s Cancer Center at Magee-Womens Hospital of UPMC "This is an incredibly complicated and emotional issue for many in the breast cancer community." Christoph I. Lee, MD, MSHS, Assistant Professor, Department of Radiology, University of Washington School of Medicine, Affiliate investigator, Public Health Sciences, Fred Hutchinson Cancer Research Center "While provocative, the analysis by Bleyer and Welch is flawed and misleading" Debasish “Debu” Tripathy, MD, HemOnc Today Editorial Board member; Professor of Clinical Medicine and Co-leader of the Women’s Cancer Program "Until such estimates are provided to the public, they will rightfully be confused and anxious."
Effect of Screening on Breast Cancer Incidence NEJM correspondence (published on Valentine's Day 2013) re: Thirty Years of Screening Mammography and Effect on Breast Cancer Incidence (published on Thanksgiving, 2012). Three are supportive (two from Europe) and one not (from the Society of Breast Imaging and American College of Radiology Commission on Breast Imaging, both in Reston, Virginia). One questioned stage migration that because of the nature of the original analysis was eliimnated and unlikely given the nature of the incidence flux. Click here for original correspondence.
Historic Breast Ca Incidence Trend Less than Cited by Radiologists The 1%/year rate preferred by radiologists to correct for rates estimates since the screening mammographjy era began was based on an estimate 1) for one geographic area of 1.3% of the US population (Connecticut), 2) inclusive of the 1970s when breast cancer incidence increased due to the onset of screening mammography and the Betty Ford-Happy Rockefelller impact, 3) rounded to the nearest percent, and 4) a linear rather than compounded rate. The incidence of invasive breast cancer in the U.S. was closer to 0.35% per year during 1940-1973 (prior to the Ford-Rockefeller effect) according to data from the 2nd and 3rd National Cancer Surveys of 7 and 9 metropolitan areas, respectively and the entire state of Connecticut. The estimates used by Bleyer and Welch in their NEJM report of 0.25%/year for Best Guess and 0.5%/year for Extreme and Very Extreme assumptions were based on the incidence since 1976 in <40 year-old women who were not screened. These rates are 1) contemporary, 2) consistent with the a rate of 0.35%/year prior to the screening mammography era, and 3) as reported in correspondence rely, probably in excess of the real background rate since there has been no_evidence for an increase since the rate of screening mammography in the U.S. stabilized and after the effect of hormone replacement therapy could be eliminated.
Screening Mammography: Value versus Jeopardy Oregon Health & Science University Medicine Grand Rounds - January 29, 2013 A presentation to the Department of Medicine and Knight Cancer Institute was derived from this slideset. Each frame is bookmarked with topic content.
NEJM Article on Three Decades of Screening Mammography Explained H. Gilbert Welch, MD, of the Dartmouth Institute of Health Policy and Clinical Practice explains the New England Journal of Medicine report* he co-authored with Archie Bleyer, MD, Quality Department, St. Charles Health System and Department of Radiation Medicine, Knight Cancer Institute, Oregon Health & Science University. Click here or on the You Tube icon to view the video. Click here for related interview of Archie Bleyer, MD *Bleyer A, Welch HG: Effect of three decades of screening mammography on the incidence of breast cancer, NEJM367:1998-2005;2012
Screening Harms > Benefits if Treatment-Related Deaths Included By Michael Baum, Professor Emeritus of Surgery at the University College London / BMJ / January 23, 2013 For the full report, click here +BMJ subscription or fee If treatment-related mortatliy is included, most if not all of the reduction in breast-cancer morlality attributed to screening mammography, is negated For responses to his oped, including that by Sir Michael Marmot who led the latest United Kingdom review of the risk:benefit rato of screening, click here. Sir Marmot quotes data from the review that estimated a 1.3% benefit for all-cause mortality in comparison to 20% for breast cancer mortality, substantiating a high other-cause mortality in screened women.
Breast Cancer Study calls for Better Screening Methods, has Critics By Nick Budnick / The Oregonian / November 21, 2012 Click here for full story In the last 30 years, more than a million women have been diagnosed with breast cancer when they didn't have it or had a low-level, non-threatening form, according to a new study. And even though early screening has surged since the 1980s, there has been little decline in late-stage cancer detection. ... The overdiagnosis rate is "larger and more problematic than I had hoped," and calls for better screening methods, said study coauthor Archie Bleyer, an OHSU research professor and oncologist at St. Charles Health System in Bend. "Even if this is partially true, we can't just let it go. Either it should be refuted or we have to rethink some of what we are doing." ... "This addresses the question of how should we be offering screening. It doesn't really contribute to the treatment decision," said Heidi Nelson, an OHSU professor and medical director of the Providence Health System's Women and Children's Program. "We don't have that crystal ball showing who's being over diagnosed and who's being appropriately diagnosed." The study looked at data gathered by a U.S. registry that has tracked cancer rates since 1973. It applied a number of statistical assumptions and estimated that in the last 30 years, 1.3 million women have been over diagnosed. The crux of the study is that with invasive cancer rates holding steady, every case of cancer detected early should mean one less develops into late-stage cancer. "That's the definition of effective screening," said Bleyer, noting that a corresponding decline took place because of colonoscopies. "We hoped we would see that with breast cancer, and it turns out we didn't even come close." While late-stage cancers have declined slowly, the reduction hasn't matched the surge in detection of early breast cancer, the study found. Nelson of OHSU led a team of researchers to conduct the underlying research for the recommendation. She said the new study's estimate of 31 percent over diagnosis is consistent with several studies conducted since the government review, mainly in Europe. While the study relies on a lot of assumptions, "I think it adds to the conversation," she said.
Biennial offer Same Benefits as Annual Screening among Older Women HemOnc Today / February 13, 2013 For the full report, click here Source: Braithwaite D. J Natl Cancer Inst. 2013;doi:10.1093/jnci/djs645.\ Biennial mammograms offer older women the same benefits as annual screening while significantly reducing the likelihood of false-positive results, according to findings of a prospective population-based study. ... Dejana Braithwaite, PhD, an assistant professor of epidemiology and biostatistics at the University of California San Francisco, and colleagues questioned whether the benefits and risks of screening are influenced by frequency and comorbidity among older women in the community practice. The researchers collected data from four Breast Cancer Surveillance Consortium (BCSC) mammography registries that participated in data linkage with Medicare. The national study included 2,993 older women [age 66-89] with breast cancer and 137,949 older women without breast cancer who underwent mammography at one of the four BCSC facilities from January 1999 to December 2006. “Screening every other year, as opposed to every year, does not increase the probability of late-stage breast cancer in older women,” Braithwaite said in a press release. “Moreover, the presence of other illnesses such as diabetes or heart disease made no difference in the ratio of benefit to harm.” ... [The] researchers found a higher rates of false-positive results (48% vs. 29%) among those who underwent annual screening compared with those who underwent screenings every 2 years, regardless of comorbidity. “They get no added benefit from annual screening, and face almost twice the false positives and biopsy recommendations, which may cause anxiety and inconvenience,” researcher Karla Kerlikowske, MD, a professor of medicine at UCSF and a physician at ... San Francisco VA Medical Center, said in a press release. Perspective by Adam M. Brufsky ... [this] study suggests that women aged 66 to 89 years have the same rates of advanced cancer incidence whether they are screened or not with mammography. The false-positive rate is also the same as in younger women, suggesting that the harm of screening may be the same in this older population. The suggestion is that we think even harder about whether to continue the practice of screening women older than age 69.
How Often Should Women Be Screened? By Heidi Hagemeier / The Bulletin / November 21, 2012 The effectiveness of routine mammograms — a simmering debate among experts in recent years — is now being questioned by a Bend oncologist in one of medicine's most prestigious journals. The article examines data gathered nationally about women over the last three decades. It suggests that advances in treatment, rather than screenings, have reduced the number of late-stage breast cancer cases, and that screenings have led instead to the overdiagnosis of more than 1 million women nationally during that same time period. Drs. Gary Frei and Linyee Chang, a surgeon at Bend Memorial Clinic who regularly sees breast cancer patients, and the St. Charles Cancer Center Medical Director comment on the report.
Study Finds Mammograms Lead to Unneeded Treatment Associated Press / The Oregonain / Nov. 21, 2012 Click here for the full story Mammograms have done surprisingly little to catch deadly breast cancers before they spread, a big U.S. study finds. At the same time, more than a million women have been treated for cancers that never would have threatened their lives, researchers estimate. Up to one-third of breast cancers, or 50,000 to 70,000 cases a year, don't need treatment, the study suggests. It's the most detailed look yet at overtreatment of breast cancer, and it adds fresh evidence that screening is not as helpful as many women believe. Mammograms are still worthwhile, because they do catch some deadly cancers and save lives, doctors stress. And some of them disagree with conclusions the new study reached. But it spotlights a reality that is tough for many Americans to accept: Some abnormalities that doctors call "cancer" are not a health threat or truly malignant. There is no good way to tell which ones are, so many women wind up getting treatments like surgery and chemotherapy that they don't really need. Men have heard a similar message about PSA tests to screen for slow-growing prostate cancer, but it's relatively new to the debate over breast cancer screening. "We're coming to learn that some cancers — many cancers, depending on the organ — weren't destined to cause death," said Dr. Barnett Kramer, a National Cancer Institute screening expert. However, "once a woman is diagnosed, it's hard to say treatment is not necessary." He had no role in the study, which was led by Dr. H. Gilbert Welch of Dartmouth Medical School and Dr. Archie Bleyer of St. Charles Health System and Oregon Health & Science University. Results are in Thursday's New England Journal of Medicine. Breast cancer is the leading type of cancer and cause of cancer deaths in women worldwide. Nearly 1.4 million new cases are diagnosed each year. Other countries screen less aggressively than the U.S. does. In Britain, for example, mammograms are usually offered only every three years and a recent review there found similar signs of overtreatment. The dogma has been that screening finds cancer early, when it's most curable. But screening is only worthwhile if it finds cancers destined to cause death, and if treating them early improves survival versus treating when or if they cause symptoms. Mammograms also are an imperfect screening tool — they often give false alarms, spurring biopsies and other tests that ultimately show no cancer was present. The new study looks at a different risk: Overdiagnosis, or finding cancer that is present but does not need treatment. Researchers used federal surveys on mammography and cancer registry statistics from 1976 through 2008 to track how many cancers were found early, while still confined to the breast, versus later, when they had spread to lymph nodes or more widely. ... "This study is important because what it really highlights is that the biology of the cancer is what we need to understand" in order to know which ones to treat and how, said Dr. Julia A. Smith, director of breast cancer screening at NYU Langone Medical Center in New York. Doctors already are debating whether DCIS, a type of early tumor confined to a milk duct, should even be called cancer, she said. Another expert, Dr. Linda Vahdat, director of the breast cancer research program at Weill Cornell Medical College in New York, said the study's leaders made many assumptions to reach a conclusion about overdiagnosis that "may or may not be correct. I don't think it will change how we view screening mammography,
Cancer Survivor or Victim of Overdiagnosis? By H. Gilbert Welch: / New York Times / November 21, 2012 Click here for the full editorial For decades women have been told that one of the most important things they can do to protect their health is to have regular mammograms. But over the past few years, it’s become increasingly clear that these screenings are not all they’re cracked up to be. The latest piece of evidence appears in a study in Wednesday’s New England Journal of Medicine, conducted by the oncologist Archie Bleyer and me. The study looks at the big picture, the effect of three decades of mammography screening in the United States. After correcting for underlying trends and the use of hormone replacement therapy, we found that the introduction of screening has been associated with about 1.5 million additional women receiving a diagnosis of early stage breast cancer. That would be a good thing if it meant that 1.5 million fewer women had gotten a diagnosis of late-stage breast cancer. Then we could say that screening had advanced the time of diagnosis and provided the opportunity of reduced mortality for 1.5 million women. But instead, we found that there were only around 0.1 million fewer women with a diagnosis of late-stage breast cancer. This discrepancy means there was a lot of overdiagnosis: more than a million women who were told they had early stage cancer — most of whom underwent surgery, chemotherapy or radiation — for a “cancer” that was never going to make them sick. Although it’s impossible to know which women these are, that’s some pretty serious harm. But even more damaging is what these data suggest about the benefit of screening. If it does not advance the time of diagnosis of late-stage cancer, it won’t reduce mortality. In fact, we found no change in the number of women with life-threatening metastatic breast cancer. The news on the benefits of screening isn’t any better. Some of the original trials from back in the ’80s suggested that mammography reduced breast cancer mortality by as much as 25 percent. This figure became the conventional wisdom. In the last two years, however, three investigations in Europe came to a radically different conclusion: mammography has either a limited impact on breast cancer mortality (reducing it by less than 10 percent) or none at all. ... One final plea: Can we please stop using screening mammography as measure of how well our health care system is performing? That’s beginning to look like a cruel joke: cruel because it leads doctors to harass women into compliance; a joke because no one can argue this is either a public health imperative or a valid measure of the quality of care. ... Pre-emptive mammography screening .. is, at best, is a very mixed bag — it most likely causes more health problems than it solves. H.Gilbert Welch is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and an author of “Overdiagnosed: Making People Sick in the Pursuit of Health.”
Mammography Benefits Outweigh Harms: New European Data By Zosia Chustecka / Medscape Medical New / September 27, 2012 According to EUROSCREEN, screening mammography in 50- to 69- year-olds in Europe achieves a mortality benefit at least as great as the randomized controlled trials. The authors recommend that these outcomes be communicated to women offered service screening in Europe.
$4 Billion Spent Per Year in the US on Screening Mammograms Between 1994 and 2005, the Breast_Cancer_Surveillance Consortium (BCSC) collected information from 243 radiology facilities that participated through one of the seven BCSC mammography registries. These facilities represent 2.4% of the approximately 10,000 FDA-certified mammography facilities in the United States in 2000. 60% of radiology facilities participating in the BCSC are located in an urban setting. The majority of the participating facilities are non-profit (71%) and are not associated with an academic medical center (89%). 8,354,087 mammograms recorded in the Breast Cancer Surveillance Consortium for the years 1996-2009 inclusive. 94% were screening and 6% diagnostic. Assuming that the BCSC was representative of the U.S.. the average annual number of screening mammograms performed nationwide during the 14 years was (8,354,087/0.024)*0.94/14= 23,371,552. If the average mammogram costs $170, the yearly screening mammogram total in the U.S. is $4B.
How a Charity Oversells Mammography Woloshin S, Schwartz LM / BMJ / 2012;345:e5232 Two professors at Dartmouth's Institute for Health Policy and Clinical Practice point out how Susan B. Komen for the Cure Foundation advocates mammography with misleading and false statements. Their advertisement during the last Beast Awaremess Month (October) states: 1) "What's key to surviving breast cancer? You. Get screened now." Hardly say the authors of this British Medical Journal report. The best evidence indicates that screening decreases the chance that a 50 year-old woman wiill die from breast cancer from 0.53% to 0.46%, a reduction of 0.07% (less than 1 in 1000 chance of having a survival benefit by being screened). The real key is treatment which has improved so much over the years that whatever benefit screening had in the 1980s when the randomized trials were done has all but disappeared. 2) "early detection saves lives. The 5-year survival rate for breast cancer when caught early is 98%. When it's not? 23%." When applied to screening and the associated lead-time bias, thiis statementcould not be further from the truth. Komen is comparing apples with oranges. 3) nothing about the harms of screening.
Breast Screening Advice Updated Amid Controversy Over Tests By James Gallagher / BBC News / October 31, 2012
Women invited for breast cancer screening in the UK are to be given more information about the potential harm of being tested. An independent review was set up to settle a fierce debate about whether the measure did more harm than good. It showed that for every life saved, three women had treatment for a cancer which would never have been fatal.
The information will be included on leaflets to give women an "informed choice", the government said.
Cancer charities said women should still take up the offer of screening.
Screening has been a fixture in diagnosing breast cancer for more than two decades. Women aged between 50 and 70 are invited to have a mammogram every three years. It helps doctors catch cancer early so treatment can be given when it is more likely to save lives. ...
The review, published in the Lancet medical journal, showed that screening saved 1,307 lives every year in the UK, but led to 3,971 women having unnecessary treatment. From the point of view of a single patient they have a 1% chance of being overdiagnosed if they go for screening.
Benefit-to-Harm Ratio Favors Mammography Beginning at Age 40 HemOnc Today / July 10, 2012 Source: van Ravesteyn NT. Ann Intern Med. 2012;156: 609-617. Diana L. Miglioretti, PhD, a senior investigator at Group Health Research Institute in Seattle, and colleagues used four independent, well-established simulation models that were part of the NCI’s Cancer Intervention and Surveillance Modeling Network (CISNET) collaborative (including data from the Breast Cancer Surveillance Consortium) to determine the threshold relative risk (RR) at which the harm–benefit ratio of screening women aged 40 to 49 years equals that of biennial screening for women aged 50 to 74 years. In the absence of screening, the study models estimate that a median of 153 cases of breast cancer would be diagnosed and 25 deaths from breast cancer would occur among 1,000 women aged 40 years followed during their lifetimes. The harm–benefit ratios for adding screening between ages 40 and 49 years are less favorable than those for biennial screening starting at age 50 years, according to study results. In all study models, adding annual to biennial screening led to minor increases in additional life-years gained and breast cancer deaths avoided, but at the cost of greater increases in incremental harm. ... “Our results provide important information toward more individualized, risk-based screening, suggesting that starting biennial screening at age 40 years for women with an increased risk for breast cancer (RR ≥1.9) has a balance of benefits and harms similar to that of biennial screening for average-risk women aged 50 to 74 years,” Miglioretti and colleagues wrote. “For women below this level of risk, the harm–benefit ratio of starting screening at age 40 years is less favorable than that of biennial screening between ages 50 and 74 years. Reducing the false-positive rate is crucial to improving the balance of benefits and harms for screening regimens for women of all ages.” [COMS Web Manager Note: The authors are recommending that a selected group of 40-49-year-olds at higher risk of breast cancer be screened; they continue to recommend that the age group not be screened in general.]
Mammography Declining in All Age Groups According to the NCI Breast Cancer Survillance Consortium (BCSC), the number of screening and diagnostic mammograms performed in the U.S. has steadily desclinied since 2003-2004 in all age groups (chart). In 40- to 49-year-olds, it has decreased by more than half. Some of the reduction is due to the decreased incidence of breast cancer in women since hormone replacement therapy (HRT) was widely abandoned. On the other hand, BSCS data indicates that 94% of the mammograms performed in women 40+ years of age were for screening, suggesting that adherence with screening guidelines was declining before the USPSTF issued their reduction recommendations. Source: NCI-funded BCSC co-operative agreement (U01CA-63740, -86076, -86082, -63736, -70013, -69976, -63731, -70040). Downloaded 5/21/2012 from the BCSC Website.
By Emily P. Walker / MedPage Today / June 19, 2012 CHICAGO -- The American Medical Association's House of Delegates has come out in support of routine screening mammography for women starting at age 40. The House of Delegates stopped short of recommending that "every woman should get routine screening mammograms every year starting at age 40". Strongly debated in Tuesday morning's session, that language was rejected by the delegates in favor of a lighter "should be eligible" phrasing. Click here for report
Mammograms Smart for Some Women in 40s By Markian Hawryluk / The Bulletin / May 10. 2012 Markian reviews the report by Heidi Nelson, MD, MPH and colleagues at OHSU that identifies which 40- to 50-year-old women could benefit from screening mammography. As shown in the chart, those with one and certaionly two first-degree relative (parent, sibling, child) are most likely to benefit. Those with dense breasts (at least for those who know that they have such breast) are next most likely to benefit, at least in densely populated metropolitan area where breast density has been most correlated with an increased risk of breast cancer incidence. For Central Oregon this finding may be therefor less relevant. The findings need not change the USPSTF guideline since the Task Force limited their recommendation to women who are not at increased risk. Also, that women with a prior benign breast biopsy have a higher risk (chart) is not directly relevant to the screening mammography conflict since such women are in follow-up from prior biopsy and not the population addressed by the USPSTF on screening mammography.
Mammograms May Lead To Breast Cancer 'Over-Diagnosis' By Richard Knox / NPR News / April 3, 2012 Norwegian scientists report in the Annals of Internal Medicine that as many as 1 in every 4 cases of breast cancer doesn't need to be found because it would never have caused the woman any problem. It's a startling idea for laypeople (and many doctors) thoroughly indoctrinated with the notion that any breast cancer is medically urgent — and should be found at the earliest possible moment. The report (abstract below in next report) is among an increasing number to suggest that breast cancer is often "over-diagnosed" through mammography screening. This is when a tumor is found that would never have gone on to cause symptoms or death. Click here for a full report from National Public Radio or here for coverage by the Harvard School of Public Health (Routine Mammograms May Result in Significant Overdiagnosis of Invasive Breast Cancer).
'False-Alarm' Mammograms Linked to Increased Breast Cancer Risk By Anna Azvolinsky / LiveScience.com / April 5, 2012 Click here for full article.Source: Euler-Chelpin Mv, et al: JNCI 104(9):682-9, 2012 Eileen Moleski has received mammogram results suggesting she has breast cancer four times, but further testing showed, each time, that she didn't have the disease. Now, she gets anxious each time she's due for another mammogram, said Moleski, 44. "A new study suggests that, for women like Moleski who've had a false-positive mammogram, continuing to be watchful for signs of breast cancer may be a good idea — such women are 67 percent more likely to eventually develop the disease, compared with women who’ve only had negative mammogram results, the findings showed. The findings suggest "that either that the false positive mammograms may not be false at all, or that the false positive mammograms may be representative of a biological process which contributes to elevated risk of developing breast cancer in the future," said Dr. Richard Bleicher, of the Fox Chase Cancer Center, in Philadelphia. A heightened risk Researchers at the University of Copenhagen compiled mammography data from more than 58,000 Danish women. The women in the study were between 50 and 69 years old, and were screened between 1991 and 2005. The findings showed that 339 cases of breast cancer would be expected in one year in a group of 100,000 women who had only negative mammograms, whereas 583 cases would be expected in a year in a group of 100,000 women who'd previously had a false-positive mammogram. The increased risk of breast cancer remained for six years after a false positive mammogram, compared with women who always had a negative mammogram. Still, similar findings have been shown in the United States, said Dr. Jeff Tice, of the Helen Diller Family Comprehensive Cancer Center in San Francisco, who was not involved in the study. The link might be explained by breast density, Tice said. Women with higher-density breast tissue may be more likely to get a false positive mammogram, and studies, including one that Tice worked on, have shown these women also have increased risk of developing breast cancer. Dr. Dana Whaley, an assistant professor of radiology at the Mayo Clinic in Rochester, Minn., agreed that breast density may be the common link: "Breast density is an independent risk factor for breast cancer, and it is more significant than family history most of the time," Whaley said, though he added that why this is the case is not understood. ... Skepticism of a link Some experts raised cautions about the new findings. "We don't know other critical factors about the risk of the patients in the study — family history, genetic mutations, hormone use," Bleicher said. The false-positive test might not, in itself, be the risk factor for cancer— it may be related to something else entirely. The findings would be more convincing if the study researchers had linked the specific location within the breast of the abnormality that caused the false positive with the location of later breast cancer, said Dr. Karla Kerlikowske, also of the Diller Cancer Center. The underlying biology that might increase the risk of breast cancer in these women needs to be explained with follow-up studies, Kerlikowske said. Like Moleski, many patients with previous false-positive mammograms have anxiety, Whaley said. But that anxiety is usually about the detection of cancer, not the false-positive result. "When and how this information is presented to women is very important in preventing unnecessary anxiety," he said.
Specialists May Downplay the Harms of Mammography By Joe Rojas-Burke / The Oregonian / April 30, 2012 Expert recommendations on mammography couldn't be more confusing for women in their 40s.
Some guidelines urge all women 40 or older to get a screening mammogram every year. Others recommend screening once every two years starting at age 50, and tell younger women to make an individualized decision after carefully weighing the pros and cons.
A new study raises the possibility that groups advocating earlier and more frequent mammography may be motivated in part by the financial self-interest of specialists who perform screening and diagnostic imaging. The promotion of earlier screening by radiology and cancer specialists also may reflect their daily exposure to patients ill with cancer, the researchers write in the Journal of Clinical Epidemiology.
Dr. Susan L. Norris, an associate professor at Oregon Health & Science University, and others researchers analyzed the authorship of 12 screening guidelines for women at average risk for breast cancer. (For women in their 40s with above average risk, the benefits of screening are more pronounced; more on that below)
Having radiologists among the authors seemed to guarantee that a guideline would recommend earlier and more frequent screening. Radiologists accounted for 59 of the 125 physician-authors of the eight guidelines calling for routine screening starting at age 40. There were no radiologists among the 53 physician-authors of the four guidelines that recommend individualized decisions for women younger than 50. More than 90 percent of the authors of those guidelines were primary care physicians.
"We don't know why some specialties appear to recommend mammography more than other specialties. Different specialties have different perspectives when looking at the same body of evidence," Norris said. "There is evidence from other studies to suggest that physicians who deliver a particular service or who gain financially from using a particular surgical center, recommend that service more frequently than do physicians without those interests."
Dr. Carol H. Lee, a radiologist in New York and representative of the American College of Radiology, said her organization advocates for annual mammography starting at 40 because studies repeatedly have shown it saves lives.
"To say that it is based on a financial conflict of interest is completely ridiculous," Lee says. "On the scale of harm versus benefit, it's a subjective value judgement. People have different values," she says. "That's what it comes down to."
Mammography screening before age 50 is controversial because it exposes large numbers of healthy women to potential harms. Inevitably, some who are screened will undergo unnecessary cancer treatment because of over-diagnosis: the detection of harmless tumors that are dormant, destined to regress without treatment or growing so slowly the patient dies of other causes before the tumor causes illness.
In younger women, the benefits may not justify the harms. Among women age 40 to 49 getting screened, the rate of breast cancer deaths is about 29 per 10,000, compared with 31 per 10,000 among those not getting screened, based on the combined results of eight clinical trials analyzed for the U.S. Preventive Services Task Force in 2009.
For every 10,000 younger women screened for 10 years, 5 are likely to avoid death from breast cancer. But about 600 to 2,000 women will have a false positive result that requires them to undergo a biopsy, according to a 2009 analysis in the Annals of Internal Medicine. And 10 to 50 healthy women will be overdiagnosed and subjected to unnecessary cancer therapy: they will have either a part of their breast or the whole breast removed, and they will often receive radiotherapy and sometimes chemotherapy.
Rather then declaring a one-size-fits-all recommendation for average-risk women in their forties, primary care groups such as the American College of Physicians say screening mammography decisions should be based on benefits and harms -- and each woman's preferences and breast cancer risk profile.
Risk factors may tip the balance
For women with certain risk factors, starting mammography screening at age 40 may be as beneficial as it is for average risk women after 50. A pair of studies in the Annals of Internal Medicine this week identified two factors that appear to tip the balance in favor of screening because they double the risk of breast cancer: 1) a sibling or parent with breast cancer, and 2) extremely dense breast tissue, as viewed by X-ray mammography.
Having second-degree relatives with cancer increased the risk by 1.5 to 2 times, as did a previous suspicious mammogram that led to a biopsy, and having partially dense breasts.
[ed. note: screening is for persons of average risk; high risk patients are not in the screening population; they undergo early detection evaluation with physical exams, MRI, and other diagnostic and history-taking evaluations]
“We distilled the list down to really just a few factors that are of high enough magnitude to make a difference," said co-author Dr. Heidi Nelson, medical director of cancer prevention and screening for the Providence Cancer Center and research professor at OHSU. "Focusing on those select few might make it a more focused decision.”
Current use of birth control pills, having never given birth, or reaching age 30 before giving birth increased risk by less than 1.5 times or not at all. “They fall pretty far short of that threshold,” Nelson said.
Newer digital mammography is more sensitive than older film-based mammography. But digital equipment is likely to worsen the harm tradeoff in younger women, the studies found, because it produces more false-positives.
The findings are too preliminary to change expert guidelines. But they provide estimates of risk to help younger women weigh screening. A weakness of the new analysis was its assumption mammography works just as well in women with risk factors, which isn't always the case. Dense breast tissue, for instance, worsens the performance of mammography and some studies suggest that mammography isn't sensitive enough to increase detection even if done annually in women with extremely dense breast tissue.
Study Finds Overdiagnosis of Some Early Breast Cancer By Stephanie Nano / The Associated Press / April 3. 2012 Also published in The Bulletin The Annals of Internal Medicine, internationally recognized as the most prestigious internal medicine journal published the latest estimate of overdiagnosis of breast cancer and an accompanying editorial. The primary report comes from Norway where screening mammography was introduced in a programmed staggered schedule over the country's counties from 1996 to 2005 and compared with a decade of national breast cancer incidence and mortality before 1996. The research estimates that between 15 and 25 percent of breast cancers found by mammograms wouldn’t have caused any problems during a woman’s lifetime, but these tumors were being treated anyway. Once detected, early tumors were surgically removed and sometimes treated with radiation, hormones and/or chemotherapy. “When you look for cancer early and you look really hard, you find forms that are ultimately never going to bother the patient,” said Dr. H. Gilbert Welch of the Dartmouth Institute for Health Policy and Clinical Practice,who was not part of the research. “It’s a side effect of early diagnosis.” The study is the latest to explore overdiagnosis from routine mammograms — finding tumors that grow so slowly or not at all and that would not have caused symptoms or death. Previous estimates of the problem have varied.
Cancer Screening Data Often Misunderstood By Doctors By Roxanne Nelson / Medscape Medical News / March 5, 2012 Many primary care physicians appear to be misinterpreting cancer screening data. According to research published in the March 5 issue of the Annals of Internal Medicine, they often mistakenly interpret improved survival and increased detection with screening as evidence that screening can save lives.
No Significant Overdiagnosis in 40-49 Year-Olds in Swedish Study Hellquist BN, Duffy SW, Nyström L, Jonsson H. Overdiagnosis in the population-based service screening programme with mammography for women aged 40 to 49 years in Sweden. J Med Screen. 2012 Mar;19(1):14-9. OBJECTIVES: To estimate the level of overdiagnosis of all breast cancers and of invasive breast cancers in women aged 40-49 invited to the subsequent screening rounds in the Swedish service-screening programme 1986-2005. METHODS: To estimate the level of overdiagnosis in subsequent screening, the rate ratios (RR) of the breast cancer incidence in the study group (women in areas with screening in ages 40-49) and the control group (women in areas with no screening in ages 40-49) were calculated for all breast cancers and for invasive breast cancers. lll RESULTS: The prescreening incidence rate ratio was estimated at 0.92 (95% CI: 0.88-0.97). The number of breast cancer cases and person-years were 6047 and 3.8 million, and 7790 and 5.2 million, in the study group and control group respectively during the study period. The RR estimate for all cancers was 1.01 (95% CI: 0.94-1.08) when adjusted for prescreening difference and a lead time of 1.2 years. The corresponding estimate for invasive breast cancers was 0.95 (95% CI: 0.88-1.02). CONCLUSIONS: We found no significant overdiagnosis for women aged 40-49 in the Swedish service screening programme with mammography.
Cancer Screening Recommendations Must Change as Knowledge Grows By Leah Lawrence / HemOnc Today / January 25, 2012 The onslaught of studies and new updates can hinder informed decision-making. If nearly 90% of adults think routine cancer screening is almost always a good idea, three in every four believe detecting cancer early saved lives most or all of the time, and very few are concerned about false-positive tests leading to unnecessary treatment as a prior survey revealed, education of the public will be needed before recommendations to reduce cancer screening can be implemented. Physicians are also loathe to change habits. it is also important that physicians resist the urge to impose their value system on patients or the public.
Most Screen-Detected Breast Cancers Are Low Risk Should Molecular Testing Be Part of Screening? By Nick Mulcahy / Medscape Medical News / January 13, 2012 There has been a significant increase in "low-risk" and "ultra-low-risk" breast cancers among women 49 to 60 years of age in the era of population-wide mammography screening. Using Netherlands data, the investigators report that because screening mammography has detected much less-aggressive breast cancer, there needs to be an associated increase in less-aggressive treatment and less-aggressive diagnosis. Source: Esserman LJ, Shieh Y, Rutgers EJT. Impact of mammographic screening on the detection of good and poor prognosis breast cancers. Breast Cancer Res Treat. 2011;130:725-34 Abstract We sought to compare the molecular signature of node negative cancers from two cohorts 15 years apart, to determine if there is molecular evidence of increase in low and ultralow risk cancers over time. We studied the impact of age, time period of diagnosis, and mammographic screening on biology of tumors where The Netherlands Cancer Institute 70-gene prognosis signature was generated as part of 2 validation series, one retrospective (1984–1992), Cohort 1, and one prospective (2004–2006), Cohort 2. A total of 866 patients were analyzed. Regardless of time period of diagnosis, the proportion of T1, grade 1, hormone receptor positive (HR) tumors, and good prognosis by 70-gene signature significantly increases as age increases (P < 0.01). In women aged 49–60, the time period of diagnosis significantly affects the proportion of cancers that were NKI 70-gene low risk: 40.6% (67/165) compared with 58% (119/205) for Cohorts 1 and 2, respectively. This is in contrast to the absence of a significant change for women under age 40, where 25% (17/68) and 30% (17/56) were low risk in Cohorts 1 and 2, respectively. In women aged 49–60, using an ultralow risk threshold of the 70-gene signature, 10% of tumors in Cohort 1 were ultralow risk compared with 30% for women with screen-detected cancers in Cohort 2. Older age and method of detection (screening) are associated with a higher likelihood of a biologically low risk tumor. In women over age 50, biologically low risk tumors are frequent and tools that classify risk may minimize overtreatment.
Benefits of Mammography are Explained by Biology, not Dogma By Laura Esserman, MD, MBA* / HemOnc Today / December 25, 2011 *Director, Carol Franc Buck Breast Care Center and co-leader of the Breast Oncology Program at UCSF, Helen Diller Family Comprehensive Cancer Center. “My daughter just had a mammogram and they found a tumor. You can’t tell me her life was not saved. Should we just have waited until it grew and was twice the size the next year?” When a cancer is found on screening, the assumption is that if any more time elapsed between the time of screening and the time it became clinically apparent, a woman’s life would be lost. Turns out that this is rarely true.
Early Breast and Prostate Cancer That is Not Cancer By Gina Kolata / New York Times / November 21, 2011 Illustration by Kelly Blair, NYT 11/21/11 Ms. Kolata pleads for improving the nomenclature of stage 0 breast cancer, D.C.I.S. and low stage Gleason prostate cancer to aovid use of or reference to cancer as was done by the cervial cancer community when they replaced the cancer reference with intraepithleial neoplasm. Click here for full report.
Systematic Review of the Mammography Trials Contradicts Meta-Analysis By Peter Gotzsche / Danish Med J / 2011;58(3):A4246, March, 2011 Prof. Dr. Gotzsche of The Nordic Cochrane Centre reviews all of the randomized trials and finds that he differences in the reported reductions in breast cancer mortality cannot be explained by differences in screening effectiveness. Given that the size of the bias was similar to the estimated screening effect, screening appears ineffective. For full article, click here.
Stop 'Selling' Cancer Screening, Says Critic Publicize Harms and Benefits By Nick Mulcahy / Medscape Oncology / November 21, 2011 Source: J Natl Cancer Inst, Published online November 21, 2011 (abstract immediately below). Medical professional organizations and cancer advocacy groups need to "refocus on educating, rather than persuading," the public about cancer screening, according to a commentary published online November 21 in the Journal of the National Cancer Institute. most important, public information must highlight the "harms and benefits" of cancer screening, writes Michael Edward Stefanek, PhD, associate vice president of collaborative research in the office of the vice president at Indiana University in Bloomington. In the past 30 years, the harms of screening have been largely unmentioned as various organizations have "maintained a focus on establishing who should be screened and promoting recommendations for which age groups should be screened," he says. Organizations have donea dismal job of accurately informing the public. Overall, mainstream organizations have done "a dismal job of accurately informing the public" about cancer screening, he contends. "The public still lacks basic knowledge about the harms and benefits of screening." "It is easy to 'sell' screening," writes Dr. Stefanek. "Just magnify the benefit, minimize the cost, and keep the numbers less than transparent." ... Paternalistic Stance Dr. Stefanek also suggests that paternalism is at play in the United States. Both breast and prostate cancer screening suffer from a "similar ambiguity of evidence," he points out. However, guidelines "have typically recommended that men make informed decisions about prostate cancer screening," whereas women have been summoned to breast cancer screening. "We must...question whether our practice of summoning women to have mammograms, while providing men informed choice for prostate cancer screening, is consistent with a scientific analysis of the relative harms and benefits," he writes.
Sweden's Latest Report Claims Benefit for 40-49 Year-Olds Effectiveness of Population-Based Service Screening With Mammography for Women Ages 40 to 49 Years. Evaluation of the Swedish Mammography Screening in Young Women (SCRY) Cohort Hellquist BN, Duffy SW, Abdsaleh S, et al / Cancer 117:714–22, February 15, 2011 BACKGROUND: The effectiveness of mammography screening for women ages 40 to 49 years still is questioned, and few studies of the effectiveness of service screening for this age group have been conducted. METHODS: Breast cancer mortality was compared between women who were invited to service screening at ages 40 to 49 years (study group) and women in the same age group who were not invited during 1986 to 2005 (control group). Together, these women comprise the Mammography Screening of Young Women (SCRY) cohort, which includes all Swedish counties. A prescreening period was defined to facilitate a comparison of mortality in the absence of screening. The outcome measu e was refined mortality, ie, breast cancer death for women who were diagnosed during follow-up at ages 40 to 49 years. Relative risks (RRs) with 95% confidence intervals (CIs) were estimated. RESULTS: There was no significant difference in breast cancer mortality during the prescreening period. During the study period, there were 803 breast cancer deaths in the study group (7.3 million person-years) and 1238 breast cancer deaths in the control group (8.8 million person-years). The average follow-up was 16 years. The estimated RR for women who were invited to screening was 0.74 (95% CI, 0.66-0.83), and the RR for women who attended screening was 0.71 (95% CI, 0.62- 0.80). CONCLUSIONS: In this comprehensive study, mammography screening for women ages 40 to 49 years was efficient for reducing breast cancer mortality. Commentary: Letter to Editor (LTE) (DOI: 10.1002/cncr.26175): Karsten Jørgensen, MD and Peter Gøtzsche, DrMedSci of The Nordic Cochrane Centre review the dataa from 30 European countries, including Sweden, and rebuke the report with the following conclusion: Screening probably had some effect 30 years ago. However, because of improved treatments and breast awareness, it is questionable whether there is an effect today, in any age group, when the data used do not require assumptions. LTE (DOI: 10.1002/cncr.26163): Harald Weedon-Fekjær, PhD of The Cancer Registry of Norway finds the reported 29% mortality reduction erroneous. His team calculated that it was 24% and the 95% CI was 13-38%. LTE (DOI: 10.1002/cncr.26002): Roger Forsyth, MD, of the Permanente Group (Pasadena CA) estimates that the cost of screening 40-49 year-olds is $1m for each year of life saved COMS Web Manager: 1) Curiously, overall survival was not reported. 2) The 40-44 age group difference was not statistically signficant 3) The screened areas had a 6% lower breast cancer mortality rate before screening implementation, indicating that a) the control and screened regions were not comparable, b) the screened regions had better resources and/or awareness to be diagnosed earlier and receive better therapy independent of a screening effect.
More Informative Screening Mammography Poster By Zosia Chustecka / Medscape Medical News / November 18, 2010 Gilbert Welch, MD, MPH, Professor of Medicine, Dartmouth Institute for Health Policy and Clinical Practice, Geisel Medical School at Dartmouth, Lebanon, New Hampshire, designed a poster for mammography for Medscape Medical News that provides more balanced information than the "Mammography Save Lives ... and One of Them May Be Yours" poster (see next report). That screening mammography can be harmful is stated clearly in the title. The choice is clearer and the guilt feelings that are induced by current (and especially prior) campaigns (see next two reports) are avoided.
Latest Screening Mammography Poster is Deceptive By Zosia Chustecka / Medscape Medical News / November 18, 2010 The current "Mammography Saves Lives" campaign in the United States and previous campaigns promoting screening for breast cancer are not providing balanced information, because they under-report, or don't mention at all, potential harms from the procedure, say critics. This campaign slogan is 1-sided, several critics told Medscape Medical News, and it oversells the benefits of mammography. For the rest of this report, click here. For an alternative poster proposed by H. Gilbert Welch, MD, MPH, Dartmouth, see item immediately above.
Better Than Previous Campaigns, But Still Unbalanced By Zosia Chustecka / Medscape Medical News / November 18, 2010 The current campaign [described above] is better than some of the previous campaigns promoting breast cancer screening, said H. Gilbert Welch, MD, MPH, of Dartmouth. Both he and Dr. Jorgensen were critical of the American Cancer Society's campaign in the 1980s, which declared: "If you haven't had a mammogram, you need more than your breasts examined." This is an example of a 1-sided campaign — it mentions nothing about the harms of screening, Dr. Jorgensen pointed out. "The truth is that mammography screening today has marginal benefits and serious harms, and that a decision not to get screened can be as sensible and responsible as the decision to get screened." Dr. Welch echoed this sentiment in his recent editorial, entitled Screening Mammography — A Long Run for a Short Slide?" (N Engl J Med. 2010;363:1276-1278). It was prompted by new data from Norway that appeared in the same issue (Kalagar et al. N Engl J Med 2010;363:1203-1210), which highlighted the fact that the mortality benefit from mammography is modest.
Shift in Cancer Detection: Where Do We Go from Here? By Gina Kolata / New York Times / October 30, 2011 Also published by The Bulletin A new analysis of mammography concluded that while mammograms find cancer in 138,000 women each year, as many as 120,000 to 134,000 of those women either have cancers that are already lethal or have cancers that grow so slowly they do not need to be treated.
Breast Cancer Mortality Reduction Due to Screen-Detected Tumors Likely to be Less than 10% HemOnc Today / November 25, 2011 Commenting on their report below, renowned Dartmouth investigators report on their analysis of national data: the "probability that a woman with screen-detected breast cancer has, in fact, avoided a breast cancer death because of screening mammography is now likely to be well below 10%." In an accompanying editorial, Timothy J. Wilt, MD, MPH, and Melissa R. Partin, PhD, of the Minneapolis VA Center for Chronic Disease Outcomes Research, and the University of Minnesota, said the study presented convincing evidence that the claim among cancer survivors that screening saved their life is "markedly exaggerated." Leslie Montgomery, MD, Director of the Breast Cancer Program at Montefiore Einstein Center for Cancer Care conuters by stating that "most patients would like to avoid the treatments necessary to achieve a cure associated with stage 1 or stage 2 breast cancer, such as sentinel node biopsy, axillary node dissection, and chemotherapy. Clearly, screening mammogram can detect DCIS or subcentimeter invasive breast cancer and, therefore, the patient avoids the morbidity of the treatments required for the more advanced disease of a clinically palpable tumor." [Website Editor: Dr. Montgomery does not mention that even more women may wish to avoid overtreatment (biopsy, surgery, radiation, years of hormonal therapy) if they knew that half of the screen detected "tumors" do not need to be treated.] [Website Editor: The Dartmouth report indicates that the expected survival benefit attributable to screening is inversely proportional to the age of the woman at the start of screening mammography. For a 40-year-old, the model predicts that the probability that her life will be saved due to the screeningis 4% if screening has a 20% 20-year relative risk reduction of the breast cancer mortallity rate. The 20% relative risk reduction is based on the results of randomized trials conducted more than a quarter century ago, since which the relative reduction has undoubtedly declined as non-screened women are are being diagnosed earlier over time as shown by the continuing reduction in the size of the tumor at diagnosis and the dramatic increase in stage 0 disease in non-screened women. Thus the life-saving capability of screening in a 40-year-old is likely <3%. This rate of beneift can not compare favorably with the considerable higher rate of overdiagnosis and overtreatment.]
From the Radiological Society of North America Is Mammographic Screening Justifiable Considering Its Substantial Overdiagnosis Rate and Minor Effect on Mortality Jørgensen KJ, Keen JD, Gøtzsche PC / Radiology 260:621–7, 2011 Nordic Cochrane Group* Proponents of mammographic screening generally say that the benefit is large and established beyond doubt, that there is little overdiagnosis, and that screening leads to less invasive treatment. The truth is that the benefit is doubtful, that overdiagnosis is substantial and certain, and that screening increases the number of mastectomies performed. In 2003, 7% of U.S. radiologists read more than 5000 mammograms a year, 20% read 2000–4999 mammograms, 18% read 1000–1999 mammograms, and 11% read 480–999 mammograms. Assuming an overdiagnosis rate of 30% and a 15% reduction in breast cancer mortality ( 5,6 ), a breast imaging specialist in the United States who reads 9000 mammograms annually from women in their 50s would prevent two future breast cancer deaths the entire year. Predicted follow-up events include 820 recalls, approximately 68 negative and 42 positive biopsies, and 18 cases of overdiagnosis. A radiologist who reads 1000 mammograms a year from women in their 40s would take 10 years to prolong one life yet burden woman every year with overdiagnosis and overtreatment. *The Cochrane Collaboration, which was established in 1993, is an independent, not-for-profi t, international network of scientists who prepare and update systematic Cochrane reviews, which are published online in the Cochrane Library. The risk of bias in the included randomized trials is evaluated in a standardized fashion on the basis of empirical evidence. The U.S. Cochrane Center is located at the Johns Hopkins Bloomberg School of Public Health, with a branch at the University of California in San Francisco.
Likelihood That a Woman With Screen-Detected Breast Cancer Has Had Her Life Saved by That Procedure Welch HG, Frankel BA / Arch Intern Med / October 24, 2011 [Epub ahead of print] BACKGROUND: Perhaps the most persuasive messages promoting screening mammography come from women who argue that the test "saved my life." Because other possibilities exist, we sought to determine how often lives were actually saved by mammography screening. METHODS: We created a simple method to estimate the probability that a woman with screen-detected breast cancer has had her life saved because of screening. We used DevCan, the National Cancer Institute's software for analyzing Surveillance Epidemiology and End Results (SEER) data, to estimate the 10-year risk of diagnosis and the 20-year risk of death-a time horizon long enough to capture the downstream benefits of screening. Using a range of estimates on the ability of screening mammography to reduce breast cancer mortality (relative risk reduction [RRR], 5%-25%), we estimated the risk of dying from breast cancer in the presence and absence of mammography in women of various ages (ages 40, 50, 60, and 70 years). RESULTS: We found that for a 50-year-old woman, the estimated risk of having a screen-detected breast cancer in the next 10 years is 1910 per 100 000. Her observed 20-year risk of breast cancer death is 990 per 100 000. Assuming that mammography has already reduced this risk by 20%, the risk of death in the absence of screening would be 1240 per 100 000, which suggests that the mortality benefit accrued to 250 per 100 000. Thus, the probability that a woman with screen-detected breast cancer avoids a breast cancer death because of mammography is 13% (250/1910). This number falls to 3% if screening mammography reduces breast cancer mortality by 5%. Similar analyses of women of different ages all yield probability estimates below 25%. CONCLUSIONS: Most women with screen-detected breast cancer have not had their life saved by screening. They are instead either diagnosed early (with no effect on their mortality) or overdiagnosed.
Shift in Cancer Detection: Where Do We Go from Here? By Gina Kolata / New York Times / October 30, 2011 Also published by The Bulletin The veteran New York Times health reporter summarizes the current status of the cancer screening conflict. Two recent clinical trials of prostate cancer screening cast doubt on whether many lives — or any — are saved. And it said screening often leads to what can be disabling treatments for men whose cancer otherwise would never have harmed them. A new analysis of mammography concluded that while mammograms find cancer in 138,000 women each year, as many as 120,000 to 134,000 of those women either have cancers that are already lethal or have cancers that grow so slowly they do not need to be treated. Cancer experts say they cannot ignore a snowballing body of evidence over the past 10 years showing over and over that while early detection through widespread screening can help in some cases, those cases are small in number for most cancers. At the same time, the studies are more clearly defining screening’s harms.
Mammography Questioned Again, British Program Under Review By Zosia Chustecka / Medscape Medical Review / October 25, 2011 Questions about mammography have been circulating for some time across the Atlantic, where the British national breast screening program is currently being reviewed. The national program — which offers mammography every 3 years to women 47 to 73 years of age — has previously come under attack for not representing the harms of screening as adequately as the benefits. Some of these concerns, as well as many others, have resurfaced in a letter published online October 25 in BMJ from Susan Bewley, MB BS, MRCOG, professor of complex obstetrics, division of women's health, at King's College London, United Kingdom. A reply from the UK cancer tsar Mike Richards, CBE, MD, FRCP, DSc(Hon), national clinical director of cancer at the Department of Health, London, accompanies the letter.
Cumulative Probability of False-Positive Recall or Biopsy Recommendation After 10 Years of Screening Mammography: A Cohort Study Hubbard RA, Kerlikowske KK, Flowers CI, et al / Annal Int Med / 155 (8):481-492, October 18, 2011 From Group Health Cooperative and School of Public Health of the University of Washington, Seattle, Washington; University of California, San Francisco; Moffitt Cancer Center and Research Institute, Tampa, Florida; and University of North Carolina at Chapel Hill, North Carolina. Background:False-positive mammography results are common. Biennial screening may decrease the cumulative probability of false-positive results across many years of repeated screening but could also delay cancer diagnosis. Objective: To compare the cumulative probability of false-positive results and the stage distribution of incident breast cancer after 10 years of annual or biennial screening mammography. Design: Prospective cohort study. Setting: 7 mammography registries in the National Cancer Institute–funded Breast Cancer Surveillance Consortium. Participants: 169 456 women who underwent first screening mammography at age 40 to 59 years between 1994 and 2006 and 4492 women with incident invasive breast cancer diagnosed between 1996 and 2006. Measurements: False-positive recalls and biopsy recommendations stage distribution of incident breast cancer. Results: False-positive recall probability was 16.3% at first and 9.6% at subsequent mammography. Probability of false-positive biopsy recommendation was 2.5% at first and 1.0% at subsequent examinations. Availability of comparison mammograms halved the odds of a false-positive recall (adjusted odds ratio, 0.50 [95% CI, 0.45 to 0.56]). When screening began at age 40 years, the cumulative probability of a woman receiving at least 1 false-positive recall after 10 years was 61.3% (CI, 59.4% to 63.1%) with annual and 41.6% (CI, 40.6% to 42.5%) with biennial screening. Cumulative probability of false-positive biopsy recommendation was 7.0% (CI, 6.1% to 7.8%) with annual and 4.8% (CI, 4.4% to 5.2%) with biennial screening. Estimates were similar when screening began at age 50 years. A non–statistically significant increase in the proportion of late-stage cancers was observed with biennial compared with annual screening (absolute increases, 3.3 percentage points [CI, −1.1 to 7.8 percentage points] for women age 40 to 49 years and 2.3 percentage points [CI, −1.0 to 5.7 percentage points] for women age 50 to 59 years) among women with incident breast cancer. Limitations: Few women underwent screening over the entire 10-year period. Radiologist characteristics influence recall rates and were unavailable. Most mammograms were film rather than digital. Incident cancer was analyzed in a small sample of women who developed cancer. Conclusion: After 10 years of annual screening, more than half of women will receive at least 1 false-positive recall, and 7% to 9% will receive a false-positive biopsy recommendation. Biennial screening appears to reduce the cumulative probability of false-positive results after 10 years but may be associated with a small absolute increase in the probability of late-stage cancer diagnosis.
Biennial Mammograms May Reduce False Positive Rate ASCO Communications / October 17, 2011 A number of media sources discussed a new study suggesting that annual mammogram screening may lead to a high false positive rate. The AP (10/18) reports that a study in the Annals of Internal Medicine "finds that more than 60 percent of women who get tested each year for a decade will be called back at least once for extra tests that turn out not to show breast cancer." However, "screening every other year, as a government task force recommends, drops this false alarm rate to 42 percent without a big risk of cancer being found at a late stage." The Los Angeles Times (10/18, Roan) "Booster Shots" blog reports, "In 10 years of annual screening, 61% of...women will be called back for another mammogram screening, because the first reading was inconclusive. About one in 12 women will be referred for a 'false positive' biopsy." If the mammogram is every two years, "42% of women were called back." In addition, "having prior year mammograms available" reduced the false positive rate, which means "women should try to have their mammograms taken at the same place each time or, if they switch sites, order their previous mammograms sent to the new office." The Washington Post (10/18, Huget) "The Checkup" blog reports that the National Cancer Institute-funded study "analyzed data for 169,456 women who had their first screening mammogram in their 40s or 50s and 4,492 women who were diagnosed with invasive breast cancer." MedPage Today (10/18, Phend) reports, "Biennial screening came with a small, nonsignificant increase in the probability of diagnosis at an advanced stage, with an absolute 3.3 percentage points more breast cancers detected among women in their 40s and 2.3 percentage points more cancers detected in their 50s being late stage." However, an accompanying editorial observed that "that didn't necessarily mean a longer screening interval actually led to more late-stage breast cancers," but rather, that "annual screening picks up more small, non-life-threatening cases." Also reporting this story are the Wall Street Journal (10/18, Hobson, Subscription Publication) "Health Blog,"AFP (10/18), Reuters (10/18, Steenhuysen), the National Journal (10/18, Fox, Subscription Publication), HealthDay (10/18, Gardner), and WebMD (10/18, Rubin).
Most Women Who Get Yearly Mammograms Will Face A False Alarm
By MyHealthNewsDaily Staff / MyHealthNewsDaily / October 17, 2011 Click herefor full story Source: Hubbard RA et al: Annals Int Med 155(8):481-92 Of women who get yearly mammograms, 61 percent will have at least one false-positive result over a decade, a new study shows. And because of these 'false alarm' test results — which seem to indicate cancer but further tests reveal not to be tumors —7 to 9 percent of women will be recommended to get a biopsy. If women are instead screened every other year, only 42 percent will have a false positive over a decade, but this lengthened screening interval brings a small increased risk of getting a later-stage cancer diagnosis, the study showed. "We hope that by helping women know what to expect in terms of false-positive results, they'll be less likely to experience anxiety when they are called back for a repeat screening or biopsy," said study researcher Rebecca Hubbard, an assistant investigator at the Group Health Center for Health Studies in Seattle. The study researchers say they recommend that women and their doctors develop a screening plan based on the patient's individual risk factors for breast cancer and her tolerance for dealing with such false alarms. Mammogram recommendations ... The new findings emphasized the importance of radiologists being able to review a patient's previous mammograms because it "may halve the odds of a false-positive recall,'' the researchers wrote. Though recommendations for for further testing — fine-needle aspiration or surgical biopsy — are less common than false positives, they can lead to unnecessary pain and scarring. The additional testing also contributes to rising medical costs. "We conducted these studies to help women understand that having a false-positive result is part of the process for mammography screening," Hubbard said. The researchers used data from seven mammography registries in the Breast Cancer Surveillance Consortium, a comprehensive breast cancer registry. They looked at data from nearly 170,000 women from seven regions around the United States, and almost 4,500 women with invasive breast cancer. Mammograms are going digital A second study compared digital mammograms with the older technology, film mammograms. Digital mammograms are increasingly being used, the researchers said. That study included data nearly 330,000 women between the ages of 40 and 79, also from the Breast Cancer Surveillance Consortium. The researchers found that digital and film mammography were equally effective for women over age 50, but for women ages 40 to 49 — especially those with dense breast tissue— digital mammograms were slightly more likely to find a cancer. However there was also an increased risk for false positive results for these younger women. The researchers found that for every 10,000 women 40 to 49 who are given digital mammograms, two more cases of cancer will be identified for every 170 additional false-positive examinations.
Data Proves that Screening Mammograms Save Lives Linyee Chang / In My View / The Bulleitin / October 8. 2011 The clinical director of the Cancer Center of Care at St. Charles reviews why seven major health care agencies oppose the US Preventive Services Task Force recommendations to reduce the use of routine screening mammography.
Can Cancer Ever Be Ignored? By Shannnon Brownlee and Jeanne Lenzer / New York Times / October 5, 2011 Otis Webb Brawley, MD, Chief Medical and Scientific Officer of the American Cancer Society and Professor of Ocology and Epidemiology at Emory University has become the target of attacks because of his blunt and very public skepticism about the routine use of the PSA test to screen men for early. “I’m not against prostate-cancer screening,” Brawley says. “I’m against lying to men. I’m against exaggerating the evidence to get men to get screened. We should tell people what we know, what we don’t know and what we simply believe. Click here for the report
Organizations Weigh In on Breast Cancer Screening Guidelines A total of 20 national organizations have lined up for or against the new USPSTF guidlelines: For - 12 organizations (in alphabetical order): American Academy of Family Physicians, American Academy of Nurse Practitioners, American Academy of Physician Assistants, American College of Physicians, American College of Obstetricians and Gynecologists. American College of Preventive Medicine, American Public Health Association, Breast Cancer Action, National Association of County and City Health Officials, National Breast Cancer Coalition, National Women's Health Network, Partnership for Prevention Public Health and the Institute Trust for America’s Health. The 11 are characterized by their general medicine representativeness in health and prevention and do not have a financial investment per se in screening mammography. Against - 8 organizations: All are specialty groups representing radiolgists (ACR, SBI), oncologists (NCI, NCCN, ASCO, ACoS) or cancer support foundations (ACS, Komen). The organizations that defend the USPSTF point out that in contrary to the criticisms, the guidelines do not "recommend that women aged 40 to 49 not receive mammograms", that their "recommendations were intended to reduce costs by reducing the number of mammograms women will receive", that USPSTF members are "not qualified to make scientific recommendations or have other agendas," or that " no breast oncologists or radiologists were on the USPSTF." Diana Pettiti, MD, MPH, Vice Chair of the Task Force said at the House Energy and Commerce Subcommittee on Health hearing that radiologists were "consulted and reviewed the recommendations and had input." The OHSU team that participated in updating the USPSTF Guidelines included a breast cancer surgeon.
Mammography Continues to be Beneficial in Younger Women HemOnc Today / September 25, 2011 Source: ASCO Breast Cancer Symposium Caughran J. #1. Presented Sept. 8-10; San Francisco. SAN FRANCISCO - Mammography and self-breast exams continue to be an important tool to detect breast cancer, even among women aged 40 to 49 years, the age range in which the benefit of mammography has been called into question by the US Preventive Services Task Force. Jamie Caughran, MD, medical director of the Comprehensive Breast Center at the Lacks Cancer Center in Grand Rapids, Mich., and colleagues used data from Michigan's breast cancer registry to examine how the 2009 US Preventive Services Task Force breast cancer screening recommendations could affect future breast cancer detection. They analyzed data on breast cancer diagnosis and treatment in 5,903 women between 2006 and 2009. They found that 65.5% of breast cancers were detected by mammography, 29.8% were detected by palpation and 4.7% were detected by other methods. Most women with breast cancers detected by mammography were aged older than 50 years. Among women whose tumors were found by palpation, 40% were aged younger than 50 years. Among women aged younger than 50 years, cancers were detected by mammography in 48.3% of the women vs. 41.6% detected by palpation. Patients with palpable presentations were younger than those diagnosed by mammography: 55.8 years vs. 61.2 years (P<.001). Patients also presented at later stages in the palpation group, and mastectomy was performed more often in the palpation group. Chemotherapy was also given more frequently to women in the palpation group. "Women who have mammographically detected cancer present at earlier stages are more likely to undergo breast conservation and not require chemotherapy," Caughran said. "Annual screening mammograms and evaluation of palpable masses are important tools in breast cancer detection." Commentary by Andrew D. Seidman, MD / Memorial Sloan-Kettering Cancer Center This is a very important work for a number of reasons. There has been controversy regarding the screening of breast cancer using mammography in younger women. We certainly know that younger women have denser breast tissue, which can reduce the sensitivity of mammography compared to older women. But it doesn't negate the utility of mammography as a screening tool. A lot of the debate of the utility of mammography has been its impact on OS and breast cancer-specific survival. These are the most important endpoints. But this study raises another important issue, and that is the use of screening in younger populations has led to a lower rate of mastectomy because of the earlier detection of cancers, and also the lower likelihood of needing to use adjuvant chemotherapy. As a medical oncologist, this is a very important gain, independent of any potential survival benefit. Having less disfiguring surgery and the ability to deliver less chemotherapy based on the stage at diagnosis is a step forward. Undoubtedly, this area will continue to be an area of controversy for some, but certainly women in this age group would be well served to know about this data.Counter Commentary Missing from the original report and above commentary is the other side of screening mammography, particularly in young women who have had a dramatic increase in ductal carcinoma in situ (DCIS) cancer, many of whom, currently estimated as high as one-half of the cases, do not need therapy. Because which half need therapy is not yet determinable, are all treated with mastectomy or lumpectomy and radiotherapy, and hormonal therapy if receptor positive. This is the problem of overdiagnosis and overtreatment that is not discussed by the authors or commentators. So, the conclusion that screening mammography in young women can save them from patients from mastectory or chemotherapy may be countered by saving them from the same therapy, as well as radiotherapy and years of hormonal therapy, if screening mammography is delayed until age 50.
To Mammogram or Not to Mammogram? Bend oncologist says treatment, not screening, is primary reason for U.S. breast cancer mortality reduction By Betsy Cliff / The Bulletin / September 15, 2011 U.S. data support the observation in the Autier_Report from northern Europe and Ireland, including Sweden, the home of a randomized trial the showed a benefit from screening mammography, that the country-to-country improvement in breast cancer mortality reduction has been remarkably similar despite a high degree of variability in national screening programs. The U.S. and the composite analysis lends further support to conclusion that treatment and not screening has been the primary reason for mortality reduction. Screening mammography not only has had a minor role in the progress gained, it also has created the problem of overdiagnosis (unnecessary turmoil, tests and treatments), societal (financial) cost, and controversy that will continue until a more effective screening method replaces what we are struggling to use and increasingly defend.
Click chart to enlarge in separate window
Screening Has Little Impact on Breast Cancer Deaths By Fran Lowry / Medscape Medical News / August 3, 2011 The Autier Report on Lack of Screening Mammography is reviewed and debated by three U.S. physicians. Carol Lee, MD, rebuts the article but John Leen, MD, radiologist at John Stroger Hospital at the University of Illinois criticizes Lee in supporting the report.
Breast Cancer Mortality Reduction in Europe Not due to Screening Mammography Autier P, et al / BMJ. 2011;343:d4411 doi: 10.1136/bmj.d4411 / August 3, 2011 Screening has been successful in reducing deaths from cervical and colorectal cancer, but not breast cancer, according to the authors of a new European study. Better treatment and improved healthcare-delivery systems are more likely to have led to reduced deaths from breast cancer than routine screening with mammography, according to lead author Philippe Autier, MD, of the International Prevention Research Institute. "Deaths from breast cancer are decreasing in North America, Australia, and most Nordic and western European countries, but it is difficult to tell whether this decrease is due to early detection from screening and early treatment, or whether it is due to better healthcare, he said. "We think it's due to better care."
Screen Evaluation without Evaluating Screening? Harry J. de Koning, Professor of Screening Evaluation Dept of Public Health, Erasmus MC, The Netherlands Professor Koning describes the weaknesses of the Autier report and adds that Berry et al. calculated that some 50% of the decline in U.S. BC mortality between 1975-2000 was due to treatment and the remaining 50% due to screening (Berry D.A., et al. Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med 2005 Oct. 27;353(17):1784-92).
A Bit More Humility Please Neville W Goodman, Retired Anaesthetist, Bristol, UK / BMJ / Rapid_Response / August 17, 2011 (in response to Autier_report) In 2002, I quoted the editor of the Lancet, Richard Horton, deriding the view that "women cannot decide for themselves whether the available evidence supports or refutes the case for mammography." (1) In the intervening nine years, the complex statistical arguments about the value of mammography have continued, and arguments between the statistically knowledgeable cannot be understood by most women considering mammography. What little clarity that has emerged, however, seems to suggest that mammography is less effective than was previously thought, which makes it disappointing that the only consistency we have observed over that time is the insistence by those who run breast screening programmes that the programmes are effective. 1. Goodman NW. Screening mammography: but how do women decide? Lancet 2002;360:171.
U.S. Breast Cancer Incidence since 1975 Inconsistent with Screening Mammography Benefit Since more than a million women have been diagnosed with breast cancer in the U.S. during the past 30 years via screening mammography, the country's incidence data should by now provide some evidence for the benefit of screening mammography. From this perspective, the nation's breast cancer incidence trends since 1975 (obtained from the SEER database which now covers 26% of the country) show no such evidence for benefit in women below age 55, weak evidence for benefit in 55-59 year-olds, and some evidence in 60-74 year-olds.
One Word Can Save Your Life: No! New research shows how some common tests and procedures aren’t just expensive, but can do more harm than good. Sharon Begley / Dr. Stephen Smith, Professor emeritus of family medicine at Brown University School of Medicine, tells his physician not to order a PSA blood test for prostate cancer or an annual electrocardiogram to screen for heart irregularities, since neither test has been shown to save lives. Rather, both tests frequently find innocuous quirks that can lead to a dangerous odyssey of tests and procedures. Dr. Rita Redberg, professor of medicine at the University of California, San Francisco, and editor of the prestigious Archives of Internal Medicine, has no intention of having a screening mammogram even though her 50th birthday has come and gone. That’s the age at which women are advised to get one. But, says Redberg, they detect too many false positives (suspicious spots that turn out, upon biopsy, to be nothing) and tumors that might regress on their own, and there is little if any evidence that they save lives. ... “There are many areas of medicine where not testing, not imaging, and not treating actually result in better health outcomes,” Redberg says. In other words, “less is more.” Archives, which is owned by the American Medical Association, has been publishing study after study about tests and treatments that do more harm than good. In fact, for many otherwise healthy people, tests often lead to more tests, which can lead to interventions based on a possible problem that may have gone away on its own or ultimately proved harmless. Patients can easily be fooled when a screening test detects, or an intervention treats, an abnormality, and their health improves, says cardiologist Michael Lauer of the National Heart, Lung, and Blood Institute. In fact, says Lauer, that abnormality may not have been the cause of the problem or a threat to future health: “All you’ve done is misclassify someone with no disease as having disease.” From PSA tests for prostate cancer (which more than 20 million U.S. men undergo every year) to surgery for chronic back pain to simple antiobiotics for sinus infection, a remarkable number and variety of tests and treatments are now proving either harmful or only as helpful as a placebo. This realization comes at a time when Medicare has emerged as a fat target in the debate over taming the deficit, with politicians proposing to slash costs by raising the age of eligibility or even eliminating the program. Experts estimate that the U.S. spends hundreds of billions of dollars every year on medical procedures that provide no benefit or a substantial risk of harm, suggesting that Medicare could save both money and lives if it stopped paying for some common treatments. “There’s a reason we spend almost twice as much per capita on health care [as other developed countries] with no gain in health or longevity,” argues Dr. Steven Nissen, the noted cardiologist at the Cleveland Clinic. “We spend money like a drunken sailor on shore leave.”
Mammography Advice Conflicts By Markian Hawryluk / The Bulletin / August 11. 2011 Screenings detect breast cancer earlier, but outcomes questioned
Breast-Cancer Screening - Clinical Practice Ellen Warner / NEJM / 365(11):1025-32, September 15, 2011 Division of Medical Oncology, Sunnybrook Health Sciences Centre, University of Toronto A healthy, 42-year-old white woman wants to discuss breast-cancer screening. She has no breast symptoms, had menarche at the age of 14 years, gave birth to her first child at the age of 26 years, is moderately overweight, drinks two glasses of wine most evenings, and has no family history of breast or ovarian cancer. She has never undergone mammography. She notes that a friend who maintained the “healthiest lifestyle possible” is now being treated for metastatic breast cancer, and she wants to avoid the same fate. What would you advise? Dr. Warner discusses the pros and cons of screening women at high and average risk of breast cancer and decides to recommmend mammography to the patient.
Lessons from Mammography in Older Women Keen JD / N Engl J Med 363(13),1288 / Sept. 13, 2010 A Cook County physician makes that point that the benefit-to-harm ratio for screening mammography peaks in the 60-69-year age group and that screening for both younger and older women has debatable net benefit. Hyman Muss, University of North Carolina and colleagues at the Massachushetts Generall Hospital reply that age alone should not be used as a criterion for screening recommendations.
Effectiveness of Mammography Screening in Reducing Breast Cancer Mortality in Young Women Magnus MC et al., J Womens Health (Larchmt). 2011 Jun;20(6):845-52 Source: Department of Epidemiology, Tulane School of Public Health and Tropical Medicine, New Orleans Background Mammographyscreening of women >50 years of age significantly reduces breast cancer mortality in randomized controlled trials (RCTs). We sought to evaluate the effectiveness of mammographyscreening in women aged 39-49 years in reducing breast cancer mortality and to discuss previously published meta-analyses. Methods PubMed/MEDLINE, OVID, COCHRANE, and Educational Resources Information Center (ERIC) databases were searched, and extracted references were reviewed. Dissertation abstracts and clinical trials databases available online were assessed to identify unpublished works. All assessments were independently done by two reviewers. All trials included were RCTs, published in English, included data on women aged 39-49, and reported relative risk (RR)/odds ratio (OR) or frequency data. Results Nine studies were identified: the Kopparberg, Ostergotland (The Two-County study), Health Insurance Plan (HIP), Canada, Stockholm, Gothenburg, Edinburgh, Age, and Malmo trials. The individual trials were quality assessed, and the data were extracted using predefined forms. Using the DerSimonian and Laird random effects model, the results from the seven RCTs with the highest quality score were combined, and a significant pooled RR estimate of 0.83 (95% confidence interval [CI] 0.72-0.97) was calculated. Post hoc sensitivity analyses excluding studies with randomization before 1980 caused a loss of statistical significance (RR 0.87, 95% CI: 0.56, 1.13). Conclusions Mammography screenings are effective and generate a 17% reduction in breast cancer mortality in women 39-49 years of age. The quality of the trials varies, and providers should inform women in this age group about the positive and negative aspects of mammography screenings.
Screening for Breast Cancer with Mammography Gøtzsche PC, Nielsen M Cochrane Database Syst Rev / 2011 Jan 19;(1):CD001877 Source: The Nordic Cochrane Centre, Rigshospitalet, Blegdamsvej 9, 3343, Copenhagen, Denmark, DK-2100. Background A variety of estimates of the benefits and harms of mammographic screening for breast cancer have been published and national policies vary. Objectives To assess the effect of screening for breast cancer with mammography on mortality and morbidity. Search Strategy We searched PubMed (November 2008). Selection Criteris Randomised trials comparing mammographic screening with no mammographic screening. Data Collection and Analysis Both authors independently extracted data. Study authors were contacted for additional information. Results Eight eligible trials were identified. We excluded a biased trial and included 600,000 women in the analyses. Three trials with adequate randomisation did not show a significant reduction in breast cancer mortality at 13 years (relative risk (RR) 0.90, 95% confidence interval (CI) 0.79 to 1.02); four trials with suboptimal randomisation showed a significant reduction in breast cancer mortality with an RR of 0.75 (95% CI 0.67 to 0.83). The RR for all seven trials combined was 0.81 (95% CI 0.74 to 0.87). We found that breast cancer mortality was an unreliable outcome that was biased in favour of screening, mainly because of differential misclassification of cause of death. The trials with adequate randomisation did not find an effect of screening on cancer mortality, including breast cancer, after 10 years (RR 1.02, 95% CI 0.95 to 1.10) or on all-cause mortality after 13 years (RR 0.99, 95% CI 0.95 to 1.03).Numbers of lumpectomies and mastectomies were significantly larger in the screened groups (RR 1.31, 95% CI 1.22 to 1.42) for the two adequately randomised trials that measured this outcome; the use of radiotherapy was similarly increased. Conclusions Screening is likely to reduce breast cancer mortality. As the effect was lowest in the adequately randomised trials, a reasonable estimate is a 15% reduction corresponding to an absolute risk reduction of 0.05%. Screening led to 30% overdiagnosis and overtreatment, or an absolute risk increase of 0.5%. This means that for every 2000 women invited for screening throughout 10 years, one will have her life prolonged and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress for many months because of false positive findings. It is thus not clear whether screening does more good than harm. To help ensure that the women are fully informed of both benefits and harms before they decide whether or not to attend screening, we have written an evidence-based leaflet for lay people that is available in several languages on www.cochrane.dk.
NEJM Letters to Editor Support USPSTF Guideline Revisions N Engl J Med / 364(3):281-6 / January 20, 2011 On January 20, 2011, the New England Journal of Medicine published seven letters to the editor from Ireland, the Netherlands, Denmark, Norway, Italy, Harvard Medical School, and University of Washington about the screening mammography report from Norway that supported (6 letters) or challenged (1 letter) the USPSTF guideline revisions.
Mammography Wars - Followup N Engl J Med / 363(26):2569-70 / December 23, 2010 The New England Journal published three letters to the editor re: Quanstrum and Hayward's editorial on Mammography Wars. 1) Who will set the thresholds for the lower and upper limit of the gray zone recommended by original authors? (Harry B. Burke, MD, PhD, George Washington University School of Medicine) 2) The Cochrane Collaboration in Europe should be used by the U.S. to help set screening mammography guidelines since they were the first to quantify overdiagnosis and overtreatment and are obviously the most widely regarded evidence-based medicine program worldwide. The author pointed out that the Cochrane conclusiosn support the U.S. Preventive Services Task Force reviews on screening mammography of 2002 and 2009. This recommendation would avoid having the new Centered Outcomes Research Institute mandated by the Affordable Care Act undertake duplication of work and be more in concert with the rest of the world. (Peter C. Gotzsche, DrMedSci, Nordic Cochrane Center) 3) Informed consent be mandated for women before screening mammography is performed in order to provide better information to the patient and eliminate many of the controversies and concerns that the current, non-consent process that is utilized. (Ismail Jatoi, MD, PhD, University of Texas Health Science Center at San Antonio) The original authors replied that 1) educated, discerning physicians on an independent panel of research and clinical generalists can assure a more nuanced selection fo the threshold criteria, 2) the Cochrane Collaboration should be applauded for the work they have done and conclusions reached, but that a national or regional overview is needed to account for differing value systems and resource constraints, and 3) informed consents alone could not fix our profession's tendency to overtreat [of interest, they did not refute the partial solution that informed consent could offer].
All-Cause Mortality Nullfies Alleged Benefit of Breast and Prostate Cancer Screening Newman DH / JNCI / 102:1008-11,2010 A Mt. Sinai School of Medicine faculty member points out that all-cause mortality is the primary endpoint of cancer screening and yet has not be widely used due to the much larger number of subjects required to evaluate this metric. Yet, the available evidence suggests that the reported benefits of both screening mammography and PSA screening are negated of most of the alleged benefits when all-cause mortality is assessed.
Harms are Underreported, if Mentioned At All By Zosia Chustecka / Medscape Medical News / November 18, 2011 Another critic of the promotional campaign is John D. Keen, MD, MBA, from the Cook County John H. Stroger Jr. Hospital in Chicago, Illinois. Explaining to Medscape Medical News that he is a diagnostic radiographer and breast imager with no conflicts of interest and no axe to grind, he said he is very concerned about physicians getting a balanced picture of mammography screening for breast cancer. In a recent communication in the Journal of the American Board of Family Medicine(2010;23:775-782), Dr. Keen writes that "the premise of a near universal life-saving benefit from finding presymptomatic breast cancer through mammography is false." Statistically, there is only a 5% chance that a mammogram will save a woman's life, he points out. And that chance has to be balanced against potential harms, which vary with age, Dr. Keen continues. For instance, women who are 40 to 50 years of age are "10 times more likely to experience overdiagnosis and overtreatment than to have their lives saved by mammography," he writes. Dr. Keen told Medscape Medical News that he is concerned that much of the ongoing debate about mammography has been dominated by screening advocates, but pointed out that many of these experts have professional and financial interests in mammography. He is concerned that they are promoting screening without presenting the whole story.
Lessons from the Mammography Wars Quanstrum KH, Hayward RA, N Engl J Med 363(11, Sept 9):1076-8, 2010 Surgeon and internist at the University of Michigan and VA, and clinical scholars of the Robert Wood Johnson Foundation, criticize the self-interest of the pro-mammography forces: "... it is a fool's dream to expect the guild of any service industry to harness its self-interest and to act accordingn to beneficience alone -- to compare on true value when the opportunity to inflate perceived value is readily available." "We can work to prevent vested interests from being granted the loudest voices in health care ..." They quote Adam Smith in The Wealth of Nations, publised in 1776: People of the same trade seldom meet together ... [without] the conversation end[ing] in a conspiracy against the public. They conclude: .. when a prudent application of the evidence threatens the profitability and stature of our own specialty, ... we conduct our own version of the mammography wars.
Harms are Under-Reported, if Mentioned at All By Zosia Chustecka / Medscape Medical News / November 18, 2010 The current Mammography Saves Lives campaign in the United States and previous campaigns promoting screening for breast cancer are not providing balanced information, because they underreport, or don't mention at all, potential harms from the procedure, say critics. This campaign slogan is 1-sided, several critics told Medscape Medical News, and it oversells the benefits of mammography. When asked for a more accurate headline, H. Gilbert Welch MD, MPH, from the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Lebanon, New Hampshire, had the following tongue-in-cheek suggestions: "Mammography could save your life, but it's a long shot" and "Chances are it won't, but mammography could save your life." [Also criticizing the Mammography Saves Live ad in the Medscape News report are John D. Keen, MD, MBA, from the Cook County John H. Stroger Jr. Hospital in Chicago, Illinois, and Karsten Juhl Jorgensen, MD, from the Nordic Cochrane Center in Copenhagen, Denmark.]
Screening Mammography — A Long Run for a Short Slide? N Engl J Med / 363(13):1276-8 / September 23, 2010 Based on his analysis of the NEJM report of decreasing benefit of screening mammography in Norway [see next two news item], Gilbert Welch, MD, MPH, Dartmouth Institute for Health Policy and Clinical Practice, summarizes the benefits and harms associated with a 10-year course of screening mammography for 2500 Women who are 50 years of age: Benefit: One woman will avoid dying from breast cancer. Harm: Up to 1000 women will have at least one “false alarm" about half of whom will undergo biopsy. Harm: Breast cancer will be overdiagnosed in 5 to 15 women, who will be treated needlessly with surgery, radiation, chemotherapy, or a combination.
Backlash of Mistrust and Some Tone-Deaf Advice Ellen Goodman / Boston Globe and The Bulletin / November 29, 2009 Ellen describes the US Preventive Services Task Force report on new breast cancer screening guidelines as communication malpractice
Breast Cancer Screening Recommendations are More Widely Accepted than Reported Ann Partridge, MD, MPH, Eric Winer, MD / N Engl J Med / November 25, 2009 Well known breast cancer experts at the Dana Farber Cancer Institute maintain that the recent screening recommendations are not as different (more like modifications) as reported
Clinically Occult Breast Cancer Has a 98+% Survival Rate Nonpalpable Breast Carcinomas: Long-Term Evaluation of 1,258 Cases Veronesi U, et al; The Oncologist 2010;15:1248-52 IEO European Institute of Oncology, Milan, Italy Introduction. In recent decades, a steady improvement in imaging diagnostics has been observed together with a rising adherence to regular clinical breast examinations. As a result, the detection of small clinically occult (nonpalpable) lesions has progressively increased. At present in our institution some 20% of the cases are treated when nonpalpable. The aim of the present study is to analyze the characteristics and prognosis of such tumors treated in a single institution. Methods. The analysis focused on 1,258 women who presented at the European Institute of Oncology with a primary clinically occult carcinoma between 2000 and 2006. All patients underwent radioguided occult lesion localization (ROLL), axillary dissection when appropriate, whole breast radiotherapy, or partial breast intraoperative irradiation and received tailored adjuvant systemic treatment. Results. Median age was 56 years. Imaging showed a breast nodule in half of the cases and a breast nodule accompanied by microcalcifications in 9%. Microcalcifications alone were present in 17.1% of the cases, whereas suspicious opacity, distortion, or thickening represented the remaining 24.6%. Most tumors were characterized by low proliferative rates (68.9%), positive estrogen receptors (92.3%), and non-overexpressed Her2/neu (91.3%). After a median follow-up of 60 months, we observed 19 local events (1.5%), 12 regional events (1%), and 20 distant metastases (1.6%). Five-year overall survival was 98.6%. Conclusions. Clinically occult (nonpalpable) carcinomas show very favorable prognostic features and high survival rates, showing the important role of modern imaging techniques. Additional Conclusions [per COMS website editor]. Many of the occult cancers detected in this screening-mammography and ultrasound-based study may be examples of "overdiagnosed cancers", especially given the low proliferation rate and grade of the majority of the lesions and the fact that 21% were DCIS.
Beast Cancer Screening and the 'R' Word: Controversy That Must Abate Robert Truog, MD / N Engl J Med / November 25, 2009 Rationing of healthcare has become unavoidable, as exemplified by breast cancer screening: for an average "woman inher 40s, a decade’s worth of mammograms would increase her lifespanby an average of 5 days — and this survival advantagewould be lost if she rode a bicycle for 15 hours without a helmet(or 50 hours with a helmet).
Treatment Advances Suppress Value of Screening Mammography Mammography Appears To Be Associated With Modest Reduction In Mortality Rate In the News / American Society of Clinical Oncology Cancer (ASCO) / September 23, 2010 In a front-page article, the New York Times (9/23, A1, Kolata, see next report) reports, "Previous studies of mammograms, done decades ago, found they reduced the breast cancer death rate by 15 to 25 percent, a meaningful amount" that may have influenced "most women in" the US, "starting in their 40s or 50s," to "faithfully get a mammogram every year." Now, however, the report written by Harvard and Norwegian researchers "suggests that increased awareness and improved treatments rather than mammograms are the main force in reducing the breast cancer death rate."
25% Reduction in Breast Cancer Mortality Attributed to Screening Mammography Disappears Jorgensen KJ, Zahl PH, Gotzche P / BMJ / 2010;340:c1241 / March 23, 2010 Summary The often-cited 25% reduction in breast cancer mortality attributed to screening mammography derives from European studies, particularly from Denmark and Sweden, and not from the U.S. With larger, better-controlled studies and longer follow-up, however, the Danes are now reporting they no longer have evidence for benefit of screening mammography. In the age group expected to have the greatest benefit (age 55-74), there was actually a trend toward higher breast cancer mortality rates in the screened population and the reversal in breast cancer death rates was less (both p< 0.05). ______________ A preliminary study in Denmark suggested a 25% reduction in breast cancer mortality in Copenhagen where screening was introduced in 1991 compared with non-screened areas in Denmark. To determine if their findings were indeed due to screening, the Danish researchers subsequently compared the annual % change in breast cancer mortality in areas where screening was used with that of areas where it was not used for 10 years before the introduction of screening and for 10 years after screening practice. The research plan was more carefully constructed by prospectively dividing participants into those most likely to benefit from screening (age 55-74 years), too young likely to benefit (35-54 years), and those who would be largely unaffected by screening (age 75-84 years). Among 55- to 74-year-olds considered most likely to benefit, breast cancer mortality declined by 1% per year in screened areas (95% CI= 0.96-1.01, p=NS) and by 2% per year in non-screened areas (95% CI=0.97-0.99, p<.05), suggesting that the breast cancer death rate was significantly greater in the non-screened areas in the age group who were supposed to have the greatest benefit. Before the introduction of screening, breast cancer mortality rates increased 1% per year in screened areas (95% CI=0.99-1.03, p=NS) and by 2% per year in non-screened areas (95% CI=1.01-1.03, p<.05), suggesting that the non-screened patients had a significantly greater reversal of death rate (from 2%/year increase to a 2%/year decrease, both rates of which were statistically significant, whereas the screened patients has a less reversal that was not statistically significant. Among women aged 35-54 years, death rates decreased 6%/year in non-screened areas (95% CI=0.92-0.95) and 5%/year in screened areas (95% CI=0,95-0,98), again consistent with a slightly greater reduction in women who were not screened. There were no significant differences for women 75-84 years of age, as expected. The researchers, who had previously reported the 25% benefit, concluded that “it is time to question whether screening has delivered the promised effect on breast cancer mortality.” ____________ *similar to the strategy the Japanese used to study neuroblastoma screening in children, which later was found to be faulty and ultimately led, after more than a decade of debate, to abandonment of the screening
Yearly Mammography Cuts Mastectomy Risk in Half Yearly Mammograms Starting at Age 40 Cut Mastectomy Risk in Half By Fran Lowry / Medscape Medical News / December 6, 2010 Radiological Society of North America Annual Meeting - December 2, 2010 - Chicago, Illinois A lead Radiologist and Director of the Princess Grace Breast Unit and of Breast Cancer Insitute in London found that 74% of 184 women 40 to 50 years of age with breast cancer at his center had never had a mammogram, 26% had previously had a mammogram, 18 in the previous year and 30 some time in the past. The mastectomy rate in the women who were screened in the previous year was 22%. The rate in the women who had had a mastectomy [sic: mammogram] at some point in the past was 47%; if they had never had a mammogram, it was 53%. [COMS Ed. Note: There are multiple flaws is this study: 1) the study design selected for patients in the mammography group who would have smaller, less aggressive tumors, and thereby require less mastectomy and not because screening mammography was or was not performed (e.g. as in a randomized trial), 2) no consideration is given to the fact that screening mammography detects more women whose breast cancer does not need treatment (overdiagnosis and overtreatment) than those who are not screened, 3) the study was retrospective and thereby plagued with confounding variables that a prospective study can control, and 4) even if an assumption is made that all of the women detected on mammography required therapy, none of the differences are statistically significant.]
Healthcare Reform Law Requires Insurers to Follow USPSTF Recommendations The 2010 Healthcare Reform Law (Affordable Care Act) requires health insurers to pay fully for services that get an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF). Thus the USPSTF could become a political lightning rod. If it doesn't recommend a service, insurers don't have to pay for it, and advocates might argue the decision is a barrier to care. If the panel does back a service, it might increase patients' access, as well as create new business opportunities. For the whole report in the Washington Post, click here
Mammograms’ Value in Cancer Fight at Issue By Gina Kolata / New York Times / September 22, 2010 A new study suggests that increased awareness and improved treatments rather than mammograms are the main force in reducing the breast cancer death rate. Starting in their 40s or 50s, most women in this country faithfully get a mammogram every year, as recommended by health officials. But the study suggests that the decision about whether to have the screening test may now be a close call. The study, medical experts say, is the first to assess the benefit of mammography in the context of the modern era of breast cancer treatment. ... it indicates that improved treatments with hormonal therapy and other targeted drugs may have, in a way, washed out most of mammography’s benefits by making it less important to find cancers when they are too small to feel. Previous studies of mammograms, done decades ago, found they reduced the breast cancer death rate by 15 to 25 percent, a meaningful amount. But that was when treatment was much less effective. In the new study, mammograms, combined with modern treatment, reduced the death rate by 10 percent, but the study data indicated that the effect of mammograms alone could be as low as 2 percent or even zero. A 10 percent reduction would mean that if 1,000 50-year-old women were screened over a decade, 996 women rather than 995.6 would not die from the cancer — an effect so tiny it may have occurred by chance. The study, published in The New England Journal of Medicine, looked at what happened in Norway before and after 1996, when the country began rolling out mammograms for women ages 50 to 69 along with special breast cancer teams to treat all women with breast cancer. The study is not perfect. The ideal study would randomly assign women to have mammograms or not. But, cancer experts said, no one would do such a study today when mammograms are generally agreed to prevent breast cancer deaths. In the study, which is continuing, women were followed for a maximum of 8.9 years. It is possible that benefits may emerge later. Nonetheless, the new study is “very credible,” said Dr. Barnett Kramer, associate director for disease prevention at the National Institutes of Health. “This is the first time researchers used real populations to compare the effects of treatment and mammography in the modern era of treatment,” Dr. Kramer said. “It shows the relative impacts of screening versus therapy in an era in which therapy has been improving.” Dr. Otis Brawley of the American Cancer Society said in a statement that the investigators used “careful methodology.” The society, Dr. Brawley said, “believes that the total body of the science supports the fact that regular mammography is an important part of a woman’s preventive health care.” Dr. Carol Lee, a radiologist at Memorial Sloan-Kettering Cancer Centerand chairwoman of the breast imaging commission of the American College of Radiology, said the new study affirmed that mammography saves lives. “Mortality from breast cancer is decreasing, and I have to believe that screening mammography has played a part,” Dr. Lee said. In their study, the investigators analyzed data from all 40,075 Norwegian women who had received a diagnosis of breast cancer from 1986 to 2005, a time when treatment was changing markedly. In that period, 4,791 women died. And, starting in 1996, Norway began offering mammograms to women ages 50 to 69 and assigning multidisciplinary treatment teams to all women with breast cancer, similar to the teams at many major medical centers in the United States. The question was, Did the program of mammograms and optimal new treatment with coordinated teams of surgeons, pathologists, oncologists, radiologists and nurses lower the breast cancer death rate? The investigators found that women 50 to 69 who had mammograms and were treated by the special teams had a 10 percent lower breast cancer death rate than similar women who had had neither. They also found, though, that the death rate fell by 8 percent in women over 70 who had the new treatment teams but had not been invited to have mammograms. And Dr. Kramer said he knew of no evidence that breast cancer was more easily treated in women over 70 than in women ages 50 to 69. That means, Dr. H. Gilbert Welch of Dartmouth wrote in an additional analysis in an accompanying editorial [see preceding news item], that mammography could have reduced the breast cancer death rate by as little as 2 percent, an amount so small that it is not really different from zero. Two percent is an estimate, Dr. Welch said. But, he said, whatever the effect of mammograms is, “all the signals here are that it is much smaller than we believed.” Dr. Laura Esserman, a professor of surgery and radiology at the University of California in San Francisco, said it tells her that “if you get the same treatment and the outcome is the same if you find it earlier or later, then you don’t make a difference when you find it early.” And screening has a cost, Dr. Welch said. Screening 2,500 50-year-olds for a decade would identify 1,000 women with at least one suspicious mammogram resulting in follow-up tests. Five hundred would have biopsies. And 5 to 15 of those women would be treated for cancers that, if left alone, would have grown so slowly they would never have been noticed. When the study was planned, the scientists expected that screening would be even more effective than it was in studies from decades ago. After all, mammography had improved and, in Norway, each mammogram was independently read by two radiologists, which should make it less likely that cancers would be missed. The researchers expected mammograms to reduce the breast cancer death rate by a third. “We were surprised,” said Dr. Mette Kalager, the lead author of the paper who is a breast surgeon at Oslo University and a visiting scientist at the Harvard School of Public Health. Marvin Zelen, a statistician at the Harvard School of Public Health and the Dana-Farber Cancer Institute, who was a member of the research team said even though the mammography benefit is small, if he were a woman he would get screened. “It all depends on how you approach risk,” Dr. Zelen said. His approach, he says, is “minimax” — he wants to minimize the maximum risk — which, in this case, is dying of a cancer. Dr. Kalager came to the opposite conclusion. She worries about the small chance of benefit in light of the larger chance of finding and treating a cancer that did not need to be treated. “Since I’m a breast cancer surgeon, I know what being treated is like,” she says. The decision to be screened, she says, “is a matter of personal preference. Is it worth it to risk becoming a patient without it being necessary?” Many women may still want mammograms, she says, and that is fine. “I think we have to respect what women want to do.”
Observational Study in Norway Reduces Screening Mammography Benefit to Less Than 10% Kalager M, Zelen M, Langmark F, Adami H-O / N Engl J Med 363(13):1203-10, 2010 Norwegian investigators and Frontier Science in the U.S. (Marvin Zelen, Harvard) conclude, in a non-randomized but prospective study, that much of the putative screening mammography benefit is due to population awareness of breast cancer than to the screening. For comment on the report see the above report by Gina Kolata of the New York Times.
Not So Pretty Pink: The Uproar Over New Breast Cancer Screening Guidelines By Barbara Ehrenreich Breast cancer survivor and author of "Bright-Sided: How the relentless promotion of positive thinking has undermined America". Excerpted below from Barbara's Blog Copyright 2009 Barbara Ehrenreich, December 02, 2009 Click here for full article Has feminism been replaced by the pink-ribbon breast cancer cult? ... Welcome to the Women’s Movement 2.0: Instead of the proud female symbol -- a circle on top of a cross -- we have a droopy ribbon. Instead of embracing the full spectrum of human colors -- black, brown, red, yellow, and white -- we stick to princess pink. While we used to march in protest against sexist laws and practices, now we race or walk “for the cure.” And while we once sought full “consciousness” of all that oppresses us, now we’re content to achieve “awareness,” which has come to mean one thing -- dutifully baring our breasts for the annual mammogram. Look, the issue here isn’t health-care costs. If the current levels of screening mammography demonstrably saved lives, I would say go for it, and damn the expense. But the numbers are increasingly insistent: Routine mammographic screening of women under 50 does not reduce breast cancer mortality in that group, nor do older women necessarily need an annual mammogram. In fact, the whole dogma about “early detection” is shaky, as Susan Love reminds us: the idea has been to catch cancers early, when they’re still small, but some tiny cancers are viciously aggressive, and some large ones aren’t going anywhere. One response to the new guidelines has been that numbers don’t matter -- only individuals do -- and if just one life is saved, that’s good enough. So OK, let me cite my own individual experience. In 2000, at the age of 59, I was diagnosed with Stage II breast cancer on the basis of one dubious mammogram followed by a really bad one, followed by a biopsy. Maybe I should be grateful that the cancer was detected in time, but the truth is, I’m not sure whether these mammograms detected the tumor or, along with many earlier ones, contributed to it: One known environmental cause of breast cancer is radiation, in amounts easily accumulated through regular mammography. And why was I bothering with this mammogram in the first place? I had long ago made the decision not to spend my golden years undergoing cancer surveillance, but I wanted to get my Hormone Replacement Therapy (HRT) prescription renewed, and the nurse practitioner wouldn’t do that without a fresh mammogram. ... what’s at stake here: Not only the possibility that some women may die because their cancers go undetected, but that many others will lose months or years of their lives to debilitating and possibly unnecessary treatments. You don’t have to be suffering from “chemobrain” to discern evil, iatrogenic, profit-driven forces at work here. In a recent column on the new guidelines, patient-advocate Naomi Freundlich raises the possibility that “entrenched interests -- in screening, surgery, chemotherapy and other treatments associated with diagnosing more and more cancers -- are impeding scientific evidence.” I am particularly suspicious of the oncologists, who saw their incomes soar starting in the late 80s when they began administering and selling chemotherapy drugs themselves in their ghastly, pink-themed, “chemotherapy suites.” Mammograms recruit women into chemotherapy, and of course, the pink-ribbon cult recruits women into mammography.
Sreening Conundrum Why Guidelines for Screening May Not Necessarily Apply to You Markian Hawryluk / The Bulletin / January 21, 2010 The Bulletin health reporter reviews his interviews with the lead author of the original USPSTF report, Heidi Nelson, MD, PhD, Evidence-Based Practice Center, Oregon Health & Science University, Miriam Alexander, MD, President Elect of the American Society for Preventive Medicine and two local physicians (Brundage and Bleyer) for their take on the revised guidelines.
WSJ Reporter Finds Conflicts of Interest Among Screening Mammography Proponents By Alicia Mundy / Wall Street Journal / January 12, 2010 Ms. Mundy points to multiple conflicts of interest among the organizations protesting the USPSTF breast cancer screening guideline modifications: The two major manufacturers of mammography equipment (GE, Siemens) gave at least $1 million each to the American College of Radiology, the organzation that claimed the recommendations to be "incredibly flawed" and would result in "countless deaths.” Several other medical device manufacturers contributed at leaast $100,000. One of the companies helped the Susan B. Komen for the Cure Foundation light up the Great Pyramids in Egypt in pink to help launch mammography screening in the Middle East. A mammography van bought for the Dana Farber Cancer Institute by the America Cancer Society and the Komen Foundation touts a company's new mammography system. The Komen Foundation Chief Executive Officer received a public service award from the company and has touted company's system at events at the nation's Capitol.
US Women's Attitudes to False+ Mammography Results and Detection of DCIS: : Cross Sectiona Lisa M Schwartz, Steven Woloshin, Harold C Sox, Joseph M Huber, Baruch Fischhoff, H Gilbert Welch, BMJ. 2000 Jun 17;320(7250):1635-40 A Veterans Administration Outcomes Group (111B), Veterans Administration Medical Center, White River Junction, VT Department of Medicine, Dartmouth-Hitchock Medical Center, Lebanon, NH Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA Objective: To determine women's attitudes to and knowledge of both false positive mammography results and the detection of ductal carcinoma in situ after screening mammograph. Participants: 479 women aged 18–97 years who did not report a history of breast cancer. ,br>Main outcome measures: Attitudes to and knowledge of false positive results and the detection of ductal carcinoma in situ after screening mammography. Results: Women were aware that false positive results do occur. Their median estimate of the false positive rate for 10 years of annual screening was 20% (25th percentile estimate, 10%; 75th percentile estimate, 45%). The women were highly tolerant of false positives: 63% thought that 500 or more false positives per life saved was reasonable and 37% would tolerate 10 000 or more. Women who had had a false positive result (n=76) expressed the same high tolerance: 39% would tolerate 10 000 or more false positives. 62% of women did not want to take false positive results into account when deciding about screening. Only 8% of women thought that mammography could harm a woman without breast cancer, and 94% doubted the possibility of non-progressive breast cancers. Few had heard about ductal carcinoma in situ, a cancer that may not progress, but when informed, 60% of women wanted to take into account the possibility of it being detected when deciding about screening. Conclusions: Women are aware of false positives and seem to view them as an acceptable consequence of screening mammography. In contrast, most women are unaware that screening can detect cancers that may never progress but feel that such information would be relevant. Education should perhaps focus less on false positives and more on the less familiar outcome of detection of ductal carcinoma in situ.
JAMA Review of the Breast Cancer Screening Controversy On January 11, 2010, the Journal of the American Medical Association (JAMA), at the top of the list as one of most discriminating jounals, published four Commentaries on breast cancer screening and the controversy over the November 2009 update by the U.S. Preventive Services Task Force. JAMA's Editor-in-Chief, Catherine DeAngelis, MD, MPH, and the Deputy Executive Editor, Phil Fontanarsosa, MD, MPH, summarize the commentaries:
With increased attention from the medical community and increased awareness in the public, the U.S. now has more than 20 years experience with screening mammography.
Despite this, the incidence of regional and more aggresively growing cancers has not decreased commensurate with the increase in the relative fraction of early cancers detected that would be expected from effective screening [this statement appears to be that of the editors since it's not obviously made by the Commentators; click here for data to support this conclusion.]
The instant professional and public reaction that occurred should be considered as entering "the murky area between mathematics and psychology."
Independent panels such as the USPSTF are essential to provide objective appraisals, reports and guidelines without concern about special interests, politics, or ideology or fear of repercussions for seeking the truth in providing evidence-based recommendations.
The USPSTF did fulfuil its mandate to provide guidance and evidence that will help physicians and patients make informed, individualtized decisions about screening for bresat cancer.
Understanting the Trade-Offs JAMA Commentary 1: Steve Woloshin, MD, MS and Lisa Schwartz, MD, MS, of the Dartmouth Institute for Health Policy Research and Clinical Practice and the VA Outcomes Research Group provide a quantitiative summary of the risks:benefit ratio of mammography screening for U.S. women screened between 40 and 50 years of age and between 50 and 60 (Table). The top line, literally and figuratively, is that mammography screening every 1 to 2 year between age 40 and 50 reduces the chance of dying from breast cancer from about 3.5 per 1000 to about 3 per 1000. The corollary in the age group is that without screening, approximately 9,965 of 10,000 women would not die of breast cancer and with screening the number increases to approximately 9970 (of 10,000). The discussion of overdiagnosis is usually met with disbelief, as indicated by a survey that found only 7% of women believe that breast cancer could grow so slowly so as to never cause them symptoms or affect their health. Yet, the randomized trials lead to estimates of two to ten women are overdiagosed (did not need to be diagnosed) for every cancer death avoided. For the bottom line, Woloshin and Schwartz emphasize in interpreting the data that most women screening does not change the ultimate outcome since the cancer is usually just as treatable or as deadly regardless of screening and that it is essential to remember that the harms are just as real as the benefits.
Radiologist Defends Screening Mammography in 40- to 49-Year-Olds JAMA Commentary 2: Wendie Berg, MD, PhD, a radiologist and mammography screening advocate at Johns Hopkins Green Village in Lutherville, Maryland defends screening mammography before age 50 "provided the woman is willing to accept the downsides of false positive results, including additional imaging, needle biopsies for findings that prove not to be cancer" (DeAngelis CD, Fontanarosa PB, JAMA reprint above). Overdiagnosis (Woloshin S and Schwartz L, JAMA reprint above), increased anxieties, and the risks of open biopsies should be added, the latter being used in some places in the U.S. more than in the United Kingdom (Murphy A, JAMA reprint below).
Critical Evaluation and Lessos Learned from the USPSTF Breast Cancer Screening Guidelines JAMA Commentary 3: Steve Woolf, MD, MPH, Professor of Family Medicine, Epidemiology and Community Health at Virginia Commonweatlh University, former member of the USPSTF and author of their 2002 breast cancer screening recommendations reviews the "harms to publc enlightenment" that occurred and what we, our government, and academia can learn from the aftermath.
Breast Cancer Survivor and Mammography Screening Advocate Sides with Guidelines Update JAMA Commentary 4: Anne Murphy, MD, a breast cancer survivor and screening advocate and pediatrician at Johns Hopkins, views both "worlds" of the issue, sides with the recent screening recommendations, and offers advice to physicians as to how to identify in their offiice which women at higher risk of breast cancer and more likely to benefit from screening mammmography before the age of 50.
President Elect of American Society of Preventive Medicine Defend Guidelines By Linda Brookes Good, MSc / Medscape Medical News / January 8, 2010 Medscape summarizes the current status of mammography debate and interviewed Miriam Alexander, MD, MPH, President Elect, American Society of Preventive Medicine. Dr. Alexander points out that "when science and evidence flies in the face of people's desires or health beliefs, they get angry," that the new guidelines are more consistent with what is being done in Europe the rest of the world, and that the guidelines do not say what most opponents have claimed.
Mammography Experts Decry Breast Cancer Screening Guidelines On December 2, 2009, a panel of mammography experts held a news conference in Chicago to condemn the United States Preventive Services Task Force updated guidelines for breast cancer screening that were published in the Annals of Internal Medicine on November 17. At least one of the panelists was personally offended by the USPSTF. Alternative views of the press conference content are provided by the current COMS President.
US Preventive Services Task Force Recommends Reducing Breast Cancer Screening Annals Int Med / November 17, 2009 This is the third of the five articles. In this report investigators at the University of Texas M.D. Anderson Cancer Center, Dana Farber Cancer Institute, Stanford University, University of Wisconsin, Harvard University, Rotterdam University (Netherlands) and Georgetown University summarize the basis for their recommendations for reducing the use of mammography for breast cancer screening.
US Preventive Services Task Force Recommends Reducing Breast Cancer Screening Annals Int Med / November 17, 2009 This is the second of five articles published in the issue on Breast Cancer Screening. In this report Heidi Nelson, MD, MPH, and her colleagues at the Oregon Health and Science University and the VA Hospital and Women & Children’s Research Center in Portland updated and analyzed all of the randomized clinical trials of breast cancer screening and present evidence for their recommendations to reduce the use of mammography, self-breast examination, and clinical breast examination for breast cancer screening.
One in Four Cancers Detected by Mammography are Pseudocancers Welch HG, Schwartz LM, Woloshin S / BMJ / March 23, 2006 Ramifications of screening for breast cancer: 1 in 4 cancers detected by mammography are pseudocancers. BMJ 2006;332:727.