This topic was selected because of its currency--scientifically, politically, emotionally, and economically--and importance to our State and nation.
It was also selected because according to Medicare data, Deschutes County has
1) the highest screening mammography rate of all 36 counties in Oregon
2) the 5th highest of the 148 counties in the 4 states in the West with the highest proportions (Washington, Oregon, California, Arizona)
3) the 2nd highest of 67 counties in the West with greater than 42,000 pop.
[ Robert Wood Johnson County Health Ratings and Roadmaps; click here ]
The US Preventive Services Task Force (USPSTF) issued new guidelines for breast cancer screening that reduces mammography for screening and should reduce overdiagnosis, false positivies, 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).
A recent, balanced review of the social and polltical history of screening mammography written by a radiologist, Handel Reynolds, MD, was puiblished in 2012 by Cornell Univ. Press: The Big Squeeze [click]
By H. Gilbert Welch, M.D., M.P.H. (who gave the Pease Symposium presentation in Bend in 2014) and Elliott S. Fisher, M.D., M.P.H.
Dartmouth Institute for Health Policy and Clinical Practice and Geisel School of Medicine
N Engl J Med 2017; 376:2208-2209 | June 8, 2017
The authors found that high-income counties have experienced markedly greater increases than low-income counties breast, prostate and thyroid cancer, and melanoma. What explains this pattern? They hypothesize that the proximal cause is that wealthier people are exposed to increased observational intensity: they are likely to be screened more often and by means of tests (such as magnetic resonance imaging) that can detect smaller abnormalities, undergo more follow-up testing, and undergo more biopsies, and they may be served by health systems that have a lower threshold for labeling results as abnormal. More cancers are therefore found. Thus overdiagnosis is more problematic in higher income communities, like Bend.
To read the full report, click the title.
The recent article by Welch et al.1 in the Journal showed clearly that since the adoption of widespread screening mammography, small breast cancers have increased in incidence over three times more than large cancers have decreased. This implies that many small cancers are not destined to progress to large cancers; instead, their detection results in overdiagnosis. This study characterizes groups of tumors that are likely to contain a large portion of overdiagnosed cancers and to explain the mechanism that may have led to their overdiagnosis.
"Breast Cancer Screening's Triple O: Overdiagnosis, Overtreatment, Overutilization"
A presentation to the medical staff than included a 3-year update of the NEJM report on 3 decades of experience with screening mammography in the U.S.
What If I Decide to Do Nothing?
The October 8, 2015 issue summarized the controversy.
To listen to the interview, click title
Anthony B. Miller,* Professor Emeritus, University of Toronto and lead author of the BMJ report of the Canadian randomized controlled trial that found no breast cancer or all-cause mortality benefit of annual mammograms in 45,000 women between the ages of 40 and 59 explains how criticism of the study by the American College of Radiology and the Society of Breast Imaging are "totally wrong".
*Distinguished Achievement Award, American Society for Preventive Oncology, 1994, Medal of Honour, International Agency for Research on Cancer, Lyon, 2003
Source: BMJ 2014;348:g1403 February 11, 2014
The editorial accompanying the Canadian National Breast Cancer Screening Trial report in the BMJ was written by Mette Kalager, Dept. of Epidemiology, Harvard Medical School, and colleagues in Norway and Sweden concludes that long-term follow-up does not support screening women under 60. They also observe that the benefit of screening mammography is, in the long run, comparable to PSA screening for prostate cancer, and yet cessation of prostate cancer screening, generally accepted, is not matched with similar action for breast cancer.
By Gina Kolata / New York Times / February 11, 2014
Also in Bend Bulletin / February 13, 2014
For full report, click title For the original report in the BMJ, click here
Source: Miller AB, et al. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ. Online February 11, 2014
One of the largest and most meticulous studies of mammography ever done, involving 90,000 women and lasting a quarter-century, has added powerful new doubts about the value of the screening test for women of any age. It found that the death rates from breast cancer and from all causes were the same in women who got mammograms and those who did not. And the screening had harms: One in five cancers found with mammography and treated was not a threat to the woman's health and did not need treatment such as chemotherapy, surgery or radiation. The study ... is one of the few rigorous evaluations of mammograms conducted in the modern era of more effective breast cancer treatments. ...
On December 20, 2013, Ferqus Coakley, MD, Chair, Department of Radiology and Karen Oh, MD, Chief of Breast Cancer Imaging in the Department debated Archie Bleyer, MD on the benefits and harms of screening mammography. The handout that was distributed is available here. The video recording will be available on the St. Charles website: https://www.stcharleshealthcare.org/For-Professionals/Continuing-Medical-Education/Grand-Rounds-Archive/2013-Archive.
Rosenbaum L. "Misfearing"--Culture, Identity and Our Perceptions of Health. NEJM. February 13, 2014
Lisa Rosenbaum, MD, an Oregonian who is currently a cardiologist at the Philadelphia VA Medical Center and the Robert Wood Johnson Foundation Clinical Scholars Program at the University of Pennsylvania, describes how women ignore hard evidence when asked "what is the #1 killer of women?". Many answer "breast cancer" when that is far from the truth. Her report compared the prevalence and mortality of breast cancer with heart disease that shows the latter to be 4 and 10 times greater, respectively. She states that "we pick and choose evidence that reinforces our sense of who we are or our allegiances to our 'tribes.'" "Have pink ribbons and Races for the Cure so permeated our culture that the resulting female solidarity lends mammography a sacred status? Is the issue that breast cancer attacks a body part that is so fundamental to female identity that, to be a woman, one must join the war on this disease? In an era when women's reproductive rights remain under assault, is reduced screening inevitably viewed as an attempt to take something away? Or is the issue one of a tragic story we have all heard "a young woman's life destroyed, the children who watch her suffer and are then left behind?"
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
For full report, click title or JAMA
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.
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
Triple O: Overdiagnosis, Overtreatment, Overutilization - May 18, 2013
This topic was featured at the Spring meeting of the Society in Ashland Oregon. Click here to view the presentation; each frame is bookmarked with topic content.
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.
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.
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.
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.
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 Centerï¿½James 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."
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.
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.
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.
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, NEJM 367:1998-2005;2012
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.
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.
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.
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,
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."
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.
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 statement could not be further from the truth. Komen is comparing apples with oranges.
3) nothing about the harms of screening.
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.
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 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.
NEW BOOK: Mammography screening: truth, lies and controversy.
By Peter Gotzche / Nordic Cochrane Centre
London: Radcliffe Publishing; January 2012. Click here or book cover (right) for more information
Featured in The Guardian, JAMA (16 May 2012) and BMJ (17 May 2012)
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.
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.
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.
Stefanek MS* / J Natl Cancer Inst / doi: 10.1093/jnci/djr474 published online: November 21, 2011
*Office of the Vice President for Research, Indiana University
Needed Shift in our Our Approach to Cancer Screening
It has been more than 30 years since the first consensus development meeting was held to deal with guidelines of mammography screening. Although the National Cancer Institute has wisely focused on the science of screening and of screening benefits vs harm, many professional organizations, advocacy groups, and the media have maintained a focus on establishing who should be screened and promoting recommendations for which age groups should be screened. Guidelines have been developed not only for mammography but also for screening at virtually all major cancer sites, especially for prostate cancer, and most recently, with the preliminary results of the National Lung Screening Trial, for lung cancer. It seems clear that we have done an inadequate job of educating screening candidates about the harms and benefits of cancer screening, including the extent to which screening can reduce cancer mortality. We must also 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. We have spent a staggering amount of time and energy over the past several decades developing, discussing, and debating guidelines. Professional and advocacy groups have spent much time aggressively advocating the adoption of guidelines supported by their respective groups. It seems that it would be much more productive to devote such energy to educating screening candidates about the harms and benefits of screening and to engaging in shared decision making. ï¿½ The Author 2011. Published by Oxford University Press.
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 done a 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." ...
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.
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.
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.
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.
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.
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 screening is 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.]
Is Mammographic Screening Justifiable Considering Its Substantial Overdiagnosis Rate and Minor Effect on Mortality
Jorgensen KJ, Keen JD, Gotzsche PC / Radiology 260:621ï¿½7, 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.
Has Had Her Life Saved by That Procedure
Welch HG, Frankel BA / Arch Intern Med / October 24, 2011:171(22):2043-2046.
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.
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).
By MyHealthNewsDaily Staff / MyHealthNewsDaily / October 17, 2011
Click here for 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.
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.
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
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 Americaï¿½s 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.
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
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.
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."
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.
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.
New research shows how some common tests and procedures arenï¿½t 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."
By Markian Hawryluk / The Bulletin / August 11. 2011
Screenings detect breast cancer earlier, but outcomes questioned
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 ï¿½healthiest lifestyle possibleï¿½ 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.
Gotzsche 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.
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.
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].
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.
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.
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.
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.
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 in her 40s, a decadeï¿½s worth of mammograms would increase her lifespan by an average of 5 days ï¿½ and this survival advantage would be lost if she rode a bicycle for 15 hours without a helmet (or 50 hours with a helmet).
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."
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
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 "
*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
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.
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,
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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.
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.
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.
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.
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:
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.
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.
Annals Int Med / November 17, 2009
This is the fifth of the five articles. In this article the US Preventive Services Task Force provides a summary of the new guidelines for breast cancer screening for the public and individuals interested in how the guidelines may or should apply to them.
Annals Int Med / November 17, 2009
This is the fourth of five articles. In this editorial, Dr. Kerlikowske of the San Francisco Veterans Affair Medical Center emphasizes the need for application of the new breast cancer screening guidlelines on an individual subject basis.
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.
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 & Childrenï¿½s 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.
Annals Int Med / November 17, 2009
This is the first of five articles published in the issue on Breast Cancer Screening. In this report the US Preventive Services Task Force summarizes their recommendations for reducing the use of mammography for breast cancer screening.
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.