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Tipping the balance of benefits and harms to favor screening mammography starting at age 40 years: a comparative modeling study of risk.

ABSTRACT: Timing of initiation of screening for breast cancer is controversial in the United States.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.Comparative modeling study.Surveillance, Epidemiology, and End Results program, Breast Cancer Surveillance Consortium, and medical literature.A contemporary cohort of women eligible for routine screening.Lifetime.Societal.Mammography screening starting at age 40 versus 50 years with different screening methods (film, digital) and screening intervals (annual, biennial).life-years gained, breast cancer deaths averted; harms: false-positive mammography findings; harm-benefit ratios: false-positive findings/life-years gained, false-positive findings/deaths averted.Screening average-risk women aged 50 to 74 years biennially yields the same false-positive findings/life-years gained as biennial screening with digital mammography starting at age 40 years for women with a 2-fold increased risk above average (median threshold RR, 1.9 [range across models, 1.5 to 4.4]). The threshold RRs are higher for annual screening with digital mammography (median, 4.3 [range, 3.3 to 10]) and when false-positive findings/deaths averted is used as an outcome measure instead of false-positive findings/life-years gained. The harm-benefit ratio for film mammography is more favorable than for digital mammography because film has a lower false-positive rate.The threshold RRs changed slightly when a more comprehensive measure of harm was used and were relatively insensitive to lower adherence assumptions.Risk was assumed to influence onset of disease without influencing screening performance.Women aged 40 to 49 years with a 2-fold increased risk have similar harm-benefit ratios for biennial screening mammography as average-risk women aged 50 to 74 years. Threshold RRs required for favorable harm-benefit ratios vary by screening method, interval, and outcome measure.National Cancer Institute.

SUBMITTER: van Ravesteyn NT

PROVIDER: S-EPMC3520058 | biostudies-literature | 2012 May

REPOSITORIES: biostudies-literature

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Tipping the balance of benefits and harms to favor screening mammography starting at age 40 years: a comparative modeling study of risk.

van Ravesteyn Nicolien T NT Miglioretti Diana L DL Stout Natasha K NK Lee Sandra J SJ Schechter Clyde B CB Buist Diana S M DS Huang Hui H Heijnsdijk Eveline A M EA Trentham-Dietz Amy A Alagoz Oguzhan O Near Aimee M AM Kerlikowske Karla K Nelson Heidi D HD Mandelblatt Jeanne S JS de Koning Harry J HJ

Annals of internal medicine 20120501 9

<h4>Background</h4>Timing of initiation of screening for breast cancer is controversial in the United States.<h4>Objective</h4>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.<h4>Design</h4>Comparative modeling study.<h4>Data sources</h4>Surveillance, Epidemiology, and End Results program, Breast Cancer Surveillance Consortium, and medical literature.<h4>Target pop ...[more]

PMID: 22547470

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Project description:BACKGROUND:Women with Down syndrome have a lower breast cancer risk and significantly lower life expectancies than women without Down syndrome. Therefore, it is not clear whether mammography screening strategies used for women without Down syndrome would benefit women with Down syndrome in the same way. OBJECTIVE:To determine the benefits and harms of various mammography screening strategies for women with Down syndrome using collaborative simulation modeling. DESIGN:Two established Cancer Intervention and Surveillance Modeling Network (CISNET) simulation models estimated the benefits and harms of various screening strategies for women with Down syndrome over a lifetime horizon. PARTICIPANTS:We modeled a hypothetical cohort of US women with Down syndrome who were born in 1970. INTERVENTIONS:Annual, biennial, triennial, and one-time digital mammography screenings during the ages 40-74. MAIN MEASURES:The models estimated numbers of mammograms, false-positives, benign biopsies, breast cancer deaths prevented, and life-years gained per 1000 screened women when compared with no screening. KEY RESULTS:In average-risk women 50-74, biennial screening incurred 122 mammograms, 10 false-positive mammograms, and 1.4 benign biopsies per one life-year gained compared with no screening. In women with Down syndrome, the same screening strategy incurred 2752 mammograms, 242 false-positive mammograms, and 34 benign biopsies per one life-year gained compared with no screening. The harm/benefit ratio varied for other screening strategies, and was most favorable for one-time screening at age 50, which incurred 1629 mammograms, 144 false-positive mammograms, and 20 benign biopsies per one life-year gained compared with no screening. CONCLUSIONS:The harm/benefit ratios for various mammography screening strategies in women with Down syndrome are not as favorable as those for average-risk women. The benefit of screening mammography for women with Down syndrome is less pronounced due to lower breast cancer risk and shorter life expectancy.

Project description:BackgroundThe CONSORT statement specifies the need for a balanced presentation of both benefits and harms of medical interventions in trial reports. However, invitations to screening and newspaper articles often emphasize benefits and downplay or omit harms, and it is known that scientific articles can be influenced by conflicts of interest. We wanted to determine if a similar imbalance occurs in scientific articles on mammography screening and if it is related to author affiliation.MethodsWe searched PubMed in April 2005 for articles on mammography screening that mentioned a benefit or a harm and that were published in 2004 in English. Data extraction was performed by three independent investigators, two unblinded and one blinded for article contents, and author names and affiliation, as appropriate. The extracted data were compared and discrepancies resolved by two investigators in a combined analysis. We defined three groups of authors: (1) authors in specialties unrelated to mammography screening, (2) authors in screening-affiliated specialties (radiology or breast cancer surgery) who were not working with screening, or authors funded by cancer charities, and (3) authors (at least one) working directly with mammography screening programmes. We used a data extraction sheet with 17 items described as important benefits and harms in the 2002 WHO/IARC-report on breast cancer screening.ResultsWe identified 854 articles, and 143 were eligible for the study. Most were original research. Benefits were mentioned more often than harms (96% vs 62%, P < 0.001). Fifty-five (38%) articles mentioned only benefits, whereas seven (5%) mentioned only harms (P < 0.001). Overdiagnosis was mentioned in 35 articles (24%), but was more often downplayed or rejected in articles that had authors working with screening, (6/15; 40%) compared with authors affiliated by specialty or funding (1/6; 17%), or authors unrelated with screening (1/14; 7%) (P = 0.03). Benefits in terms of reduced breast cancer mortality were mentioned in 109 (76%) articles, and was more often provided as a relative risk reduction than an absolute risk reduction, where quantified (45 articles (31%) versus 6 articles (3%) (P < 0.001)).ConclusionScientific articles tend to emphasize the major benefits of mammography screening over its major harms. This imbalance is related to the authors' affiliation.

Project description:BACKGROUND:In Spain, women invited to breast screening are not usually informed about potential harms of screening. The objective of the InforMa study is to assess the effect of receiving information about the benefits and harms of breast screening on informed choice and other decision-making outcomes, in women approaching the age of invitation to mammography screening. METHODS:Two-stage randomised controlled trial. In the first stage, 40 elementary territorial units of the public healthcare system were selected and randomised to intervention or control. In the second stage, women aged 49-50 years were randomly selected. The target sample size was 400 women. Women in the intervention arm received a decision aid (DA) with detailed information on the benefits and harms of screening. Women in the control arm received a standard leaflet that did not mention harms and recommended accepting the invitation to participate in the Breast Cancer Screening Program (BCSP). The primary outcome was informed choice, defined as adequate knowledge and intentions consistent with attitudes. Secondary outcomes included decisional conflict, worry about breast cancer, time perspective, opinions about the DA or the leaflet, and participation in the BCSP. RESULTS:In the intervention group, 23.2% of 203 women made an informed choice compared to only 0.5% of 197 women in the control group (p < 0.001). Attitudes and intentions were similar in both study groups with a high frequency of women intending to be screened, 82.8% vs 82.2% (p = 0.893). Decisional conflict was significantly lower in the intervention group. No differences were observed in confidence in the decision, anxiety, and participation in BCSP. CONCLUSIONS:Women in Spain lack knowledge on the benefits and harms of breast screening. Providing quantitative information on benefits and harms has produced a considerable increase in knowledge and informed choice, with a high acceptance of the informative materials. TRIAL REGISTRATION:Trial identifier NCT03046004 at ClinicalTrials.gov registry. Registered on February 4 2017. Trial name: InforMa study.

Project description:PurposeTo analyze trends in detection method related to breast cancer stage at diagnosis, treatments, and outcomes over time among 40-49-year-old women.Materials and methodsi This study was institutional review board approved, with a waiver of informed consent, and HIPAA compliant. A longitudinal prospective cohort study was conducted of women aged 40-49 years who had primary breast cancer, during 1990-2008, and were identified and tracked by a dedicated registry database (n = 1977). Method of detection--patient detected (PtD), physician detected (PhysD), or mammography detected (MamD)--was chart abstracted. Disease-specific survival and relapse-free survival statistics were calculated by using the Kaplan-Meier method for stage I-IV breast cancer.ResultsA significant increase in the percentage of MamD breast cancer over time (28%-58%) and a concurrent decline in patient and physician detected (Pt/PhysD) breast cancer (73%-42%) (Pearson x(2) = 72.72, P < .001) were observed over time from 1990 to 2008, with an overall increase in lower-stage disease detection and a decrease in higher-stage disease. MamD breast cancer patients were more likely to undergo lumpectomy (67% vs 48% of Pt/PhysD breast cancer patients) and less likely to undergo modified radical mastectomy (25% vs 47% of the Pt/PhysD breast cancer patients) (P < .001). Uncorrected for stage, 13% of MamD breast cancer patients underwent surgery and chemotherapy versus 22% of Pt/PhysD breast cancer patients (P < .001), and 31% of MamD breast cancer patients underwent surgery, radiation therapy, and chemotherapy versus 59% of Pt/PhysD breast cancer patients (x(2) = 305.13, P < .001). Analyzing invasive cancers only, 5-year relapse-free survival for MamD breast cancer patients was 92% versus 88% for Pt/PhysD patients (log-rank test, 12.47; P < .001).ConclusionIncreased mammography-detected breast cancer over time coincided with lower-stage disease detection resulting in reduced treatment and lower rates of recurrence, adding factors to consider when evaluating the benefits of mammography screening of women aged 40-49 years.

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Tipping the balance of benefits and harms to favor screening mammography starting at age 40 years: a comparative modeling study of risk.

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Tipping the balance of benefits and harms to favor screening mammography starting at age 40 years: a comparative modeling study of risk.

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