The 33% overdiagnosis we found means that one in four breast cancers diagnosed in a screened population is over- diagnosed. This is lower than the 52% we have previously estimated for other mammographyscreening pro- grammes, likely because the Danish programme has low uptake, a deliberately conservative attitude towards microcalcifications, and low recall rates. Despite these precautions, the level of overdiagnosis is still disturbingly high and it leads to overtreatment and great physical and psychological harms for those who experience it. It is therefore important that women receive balanced infor- mation that makes is possible for them to decide on a rational basis whether screening is right for them. Unfor- tunately, the official information leaflets women receive when they are invited to screening do not tell them about overdiagnosis and overtreatment . We have therefore published an evidence-based leaflet  that has been translated into several languages, and which conveys the message that it is not clear whether breast screening does more good than harm .
Evidence shows that mammographyscreening is of optimal benefit to women from 47 years to 73 years, as periodic screening within this age range reduces the women’s chances of dying as a result of breast cancer 22 . More breast cancers were found in women within this age group, and the breast tissues are better visualised on mammograms, as it changes from being glandular to fatty tissue in older women 1 . Currently, the United Kingdom invites women from 50-70 years of age to attend the program; but they are in the process of extending screening to women between 47 and 73 years by 2016, due to the potential benefits of screening at these ages 17 . The Australian screening program invites women within 50-74 years to participate in their
The main effect of screening is to reduce mortality from breast cancer by allowing a stage shift from later cancers to early cancers at detection. With this stage shift toward earlier and more treatable cancer forms, the survival of affected women is increased. In some cases, though, mammographic screening is not sensitive enough to find all treatable cancers and, in other cases, positive results turn out to be false results. False-positive results are included using age- and breast density-dependent specificity rates, as reported by Carney et al (33). These false-positive screening results have both cost and utility consequences, in the form of unnecessary diagnostic work up and utility decrements of 0.013 quality-adjusted life years (QALY), which reflects a QALY loss of 0.156 over the duration of 2 months for 50% of the women receiving false-positive results (13). In some events, mammographyscreening may, however, also identify either in situ cancers, which never progress to an invasive form, or invasive cancers, which would never progress fast enough to be harmful. Once detected though, these cancers are being treated. Breast cancer screening may thus lead to overdiagnosis. Overdiagnosis is defined as the number of screening- detected cancer cases that would have never have been detected or treated if the woman had not been screened (15, 34).
Mammographic screening programs are essential in timely detection and ef- fective treatment of breast cancer. Since 2006, Croatia implemented a national MSP which asks for a regular biannual mammography for all women 50 - 69 years of age. First-visit screening attendance in the country is estimated at 58.3% with the trend of gradually decreasing re-attendance rates. Since patient satisfaction with the screening procedure may influence subsequent adhe- rence, this study aimed to assess patient satisfaction in order to predict and improve patient re-attendance rate, a first-time effort of such kind in Croatia. 201 random patients undergoing mammographyscreening procedure at four facilities in Croatia were asked to complete an anonymous questionnaire which specifically evaluated the following aspects of patient experience: pa- tient attitude, facility surroundings, staff attitude and pre-examination infor- mation transfer, associated physical pain, psychological discomfort, and final- ly overall patient impressions and satisfaction. The majority of our examinees expressed high satisfaction with MSP and an intention to re-screen; patient attitude, facility environment and staff attitude were deemed overly positive, whereas the majority of patients estimated the physical and psychological pain associated tolerable. These results suggest that patient satisfaction is not a critical factor influencing future adherence rate in MSP, and other compo- nents of the program should be evaluated and improved.
10 programme as reported by the literature are: affordability, geographic access, acceptance of mammographyscreening within a community (Lor et al., 2013). In countries with a high level of poverty, organising a free mammographyscreening programme might be a very important facilitator to encourage women to participate in regular breast screening. In rural areas, geographic accessibility of the mammographyscreening units by providing a mobile mammography van might be an important facilitator, as women might not be willing to travel far to have a mammogram (the cost and time of travel being prohibitive). Klug et al. (2005) mentioned that w o e s k o ledge of the e efits a d risks of a ograph screening, and experience of previous mammography examination (that is satisfaction or dissatisfaction) might influence their decision on whether or not to participate in
method. BCSS was computed from the date of the diag- nosis until death due to breast cancer. The logrank test was used to compare survival between subgroups. Multi- variate survival analyses were performed using a Cox proportional hazards model by entering the following covariates: method of tumor detection (mammographyscreening = 0, outside screening = 1), grade (well-differ- entiated = 0, moderately or poorly differentiated = 1), ER and progesterone receptor (PR) status (positive = 0, negative = 1), histological type (lobular or special = 0, ductal = 1), and age at detection grouped to account for the nonlinear risk associated with age. The tumor size in centimeters and the number of metastatic axillary lymph nodes were entered into the multivariate model as continuous variables. Multivariate analysis of the risk of later contralateral breast cancer was performed using logistic regression by entering the same covariates into the model as were entered into the Cox proportional hazards model. A P- value of 0.05 was adopted as the limit for inclusion of a covariate. All P -values are two- sided. STATA version 10 statistical software (StataCorp, College Station, TX, USA) was used for the analyses.
We included all articles on mammographyscreening that described a benefit or a harm, or both, that were pub- lished in English in 2004 and were identified in a compre- hensive PubMed search; (exp breast neoplasm/all OR "breast cancer" OR exp mammography/all OR mammo- graph*) AND (exp mass screening/all OR screen*). We excluded articles on mammographic techniques, assess- ments of methodological approaches to evaluate screen- ing, letters, and articles written by ourselves. The PubMed search was performed in April 2005 and was limited to articles published in 2004 to obtain a manageable sample size that was as up to date as possible. Two investigators read titles and abstracts independently. Potentially eligi- ble articles were collected in hardcopy and read in full. Data extraction was performed in parallel and independ- ently by the three authors. One author (PG) was blinded to author affiliation when evaluating contents, and blinded to contents when evaluating author affiliation. The other two authors (KJJ and AK) were not blinded. Blinding was obtained by cutting out all information from the article on author names, affiliation and funding, and presenting this information separately from the con- tents. The blinded author noted all instances where he thought he could guess who the authors were or to which conflict of interest category they belonged (see below). Extracted data from the two unblinded authors were com- pared and consensus reached where there was disagree- ment ("unblinded consensus"). Subsequently, unblinded consensus data and data from the blinded extraction were compared and conflicts resolved by two of the authors (KJJ and PG) using the blinded material for reference. We analyzed our data in three ways: (1) data extracted by the blinded author, (2) data extracted by unblinded authors, (3) data combined from all three authors. This analysis will be referred to as the "combined analysis".
thus less advanced than those detected clinically. In gen- eral, smaller tumors are more likely to be resected by lumpectomy, and with less node-positive disease, less adjuvant therapy is needed. Based on the randomized mammographyscreening trials, however, this is not the case; screening was associated with an increase in the number of mastectomies of about 20% . The reason is that mammography increased both the number of women diagnosed with invasive breast cancer and the number found to have multiple microscopic cancers dis- tributed throughout the breast, for which mastectomy is recommended. Further, in the National Health Service breast screening program in the UK, 30% of DCIS and 24% of invasive breast cancers were treated with mastec- tomy, so earlier detection does not necessarily mean less aggressive treatment . As mentioned above, another benefit of mammographyscreening could be less aggres- sive adjuvant therapy, due to smaller and less aggressive tumors. As seen in the stage distribution in screening and non-screening groups in Norway , screening led to the diagnosis of 58% more stage I (localized cancer) and 22% more stage II (regional cancer or cancer involv- ing the lymph nodes) cancers, without any reduction in advanced stage disease (stages III and IV). Since all these
The intention to run the program as 2-year screening rounds is affected by the following screening program decisions: (1) The invitation process takes into account the timing of the last mammography regardless of whether it was a screening mammogram or a clinical mammogram taken outside the screening program. The timing of the next screening invitation is calculated from the date of the last mammography. Clinical mammography outside the screening program can thus prolong the timing between formal invitations for screening; (2) Due to the fact that mammographyscreening is a combined service screening for both cervical and breast cancer, the women are allowed to attend screening from 18–23 months after the last mammography. Attendance in the 18–23 month period,
After a nine year period of stable incidence in women aged 70-74 similar to that in women aged 75 or more, invitation to screening in 1998 led to a sudden increase in rates followed by further increases until the advent of digital mammography, which prompted new noticeable rate increases. Overall, during the 23 year period, a sixfold increase in the incidence of in situ cancers occurred among women aged 50-74. The incidence of stage 1 cancers increased by threefold in women aged 50-69 and by 3.5-fold in women aged 70-74. During the same period, rates in women aged less than 50 or more than 75 increased by 2.6-fold for in situ cancer and by 1.3-fold for stage 1 cancers. Of note, among women aged 75 or more, joinpoint analyses for the incidence of in situ and stage 1 cancers combined found two successive periods of increasing annual percentage changes, 6.4% per year (95% confidence interval 1.3% to 11.8% per year) from 1989 to 1993, and 0.7% per year (95% confidence interval 0.2% to 1.1% per year) from 1993 to 2012. Hence, the extra in situ and stage 1 cancers diagnosed in women invited to screening were not followed by a downward inflexion in trends among older women not invited to screening, which could suggest the presence of a compensatory decrease at any moment between 1989 and 2012.
Main variables: The DKMS consists of data retrieved from the five regional invitation systems, the National Pathology Registry, and the National Registry of Patients. The DKMS covers the entire screening process and includes variables required to determine the following eleven indi- cators: 1) radiation exposure, 2) participation among invited women and participation within the target population, 3) time between screening and result, 4) screening interval, 5) recall for further diagnostics, 6) interval cancers consisting of women diagnosed with breast cancer between screening rounds, 7) invasive breast tumors, 8) node-negative cancers, 9) invasive tumors ≤10 mm, 10) ratio of surgery for benign vs malignant lesions, and 11) breast-conserving therapy. Descriptive data: As of August 10, 2015, the database included data from 888,151 unique women who have been invited to one or more screenings. In the first three screening rounds, 641,835 (round I), 580,452 (round II), and 641,938 (round III) women were invited, and par- ticipation increased from 79% to 84%. In the third round, 79% of the screened women received their result within ten working days, 2.7% of the screened women were recalled for further diagnostics, 82% of the women operated for invasive carcinomas were node negative, and 40% of the women had the tumor size of ≤10 mm.
The reviews’ conclusions on any of the screening approaches were not seen to evolve with time, although some recent updates of the guidelines reported lower importance of mammographyscreening for younger women compared to earlier versions. 12,50 We also did not observe a difference in the conclusions of the narrative and systematic reviews. The reviews with high AMSTAR scores and close publication or search date could reach contradictory conclusions on the benefit-to-harm ratio of mammographyscreening and the justification for its imple- mentation. We found no evidence that variability in the reviews’ conclusions was related to objective reasons (search date, rigorousness of inclusion criteria, choice of an outcome, source of evidence). The reviews of more rigorous evidence generally reported both lower benefits and lower harms. We did not see major additive value from the new reviews or updates of the previous reviews on BCS. We conclude that until new high-quality cohort or RCT results are published,
Inconsistencies in the conclusions produced across systematic reviews may reflect the manner in which the reviews were designed and undertaken, or may be related to the expertise and competing interests held by the reviewers. Analyses in other domains have found that financial conflicts of interest can be associated with differences in the interpretation of the results when drawing conclusions and making recommenda- tions [10 – 12]. Specific to mammography, an analysis of mostly primary studies showed that authors who worked directly in mammographyscreening were more likely to downplay or reject over-diagnosis than other authors . Another study examining 12 clinical practice guidelines showed that guidelines authored by ra- diologists or where lead authors had recent publications on diagnosis and treatment were more likely to recom- mend routine screening .
Apart from chosen parameters the choice of the communicated health endpoints is also important. For example, at regular mammographyscreening the mortality from breast cancer is claimed to be reduced from 5 to 4 per 1000 women. However, it could be demonstrated that screening did not change women’s overall mortality. This puzzling fact is explained by unintended side-effects causing one casualty per 1000 women such as due to triggered unnecessary therapy, carcinogenic X-ray exposure, medication and/or risks from unnecessary surgery. The reason is that up to a quarter (15 – 25%) of detected tumours would not have caused any problems if they would have remained undetected and, hence untreated [3,11-13].
Mammographyscreening for breast cancer reduces mortality from breast cancer when women receive timely follow-up and appropriate treatment (7, 15). Mammogram results are interpreted by radiologists using the American College of Radiologist Breast Imaging Reporting and Data System (BIRADS TM ) categories: 0 – “incomplete”; 1- “Negative”; 2-“Probably benign”; 3-“Suspicious”; 4-“Suspicious abnormality”; 5-Highly suspicious of malignancy”; and 6-“Known biopsy proven malignancy” (37). A category of 3, 4, and 5 will require additional diagnostic procedures to determine the presence or absence of the disease (37). About 9%-15% of women who receive mammographyscreening have abnormal finding that require further testing (38), and approximately 30%-50% never return for follow-up testing (39, 40). Incomplete screening and delayed abnormal follow-up can negate the potential benefits of identifying breast cancer at an early stage, where treatment is more effective and cure is more likely. Though many factors predicting incomplete and delayed abnormal breast cancer screening follow-up have been examined (26, 39-50), none has looked at distance to mammography facilities and completion of abnormal breast cancer screening follow-up.
The study focuses on three medical interventions focused on women at midlife: breast screening with mammography, screening for risk of osteoporosis (brittle bones) using bone densitometry and hormone replacement therapy (HRT), used for the relief of symptoms of the menopause and, until recently, widely used for the prevention of osteoporosis. The medicalisation of women’s bodies at midlife, at least in part through the use of these technologies, has been debated over the past 20 or more years. It has long been argued that HRT can be seen as a form of social control imposed on women to keep their pathological bodies under control and to conform to societal expectations which value women in terms of youth and beauty (Oakley 1984 Martin 1987 Greer Klein & Dumble, 1994). However, more recently it has also been argued that women engage with medicalisation (Denny 1996, Griffiths, 1999; Williams & Calnan, 1996) and may even see HRT as a lifestyle choice to help cope with the effects of ageing and to reinvent themselves (Fairhurst, 1998). Roberts argues that sociological theory needs to allow for the possibility of HRT working to the benefit of some women (Roberts, 2002:). However, the literature has not examined the discourse used by health professionals about the medical interventions they use and about medical uncertainty, a missing element in understanding the dynamics of the power relationship between midlife women and health professionals.
The field work for this paper was undertaken in the UK which has a publicly funded mammographyscreening programme inviting all women aged 50-70 years for mammography every three years (Advisory committee on Breast Cancer Screening, 2006). This population screening programme is run independently of responsive health care, such as general practice, with the letters of invitation and results going direct to women. A similar system is found in a number of other countries e.g. Denmark, Canada and Australia (Jørgensen and Gøtzsche, 2006). In the UK, the programme was established in 1987 following a national report demonstrating that early detection and treatment would reduce the rate of early death from breast cancer (Forrest, 1986). Three quarters of women invited for mammographyscreening take up the invitation (Cancer Research UK, 2004; Advisory committee on Breast Cancer Screening, 2006) and the national screening programme estimates that the programme saves 1400 lives each year in England. This means ‘for every 400 women screened regularly over a 10 year period, one woman fewer will die from beast cancer than would have died without screening’ (Advisory committee on Breast Cancer Screening, 2006: 1).
Recently pilot work in one mammographyscreening centre 6 identified a surprising variability in the amount of compression force applied for similar breast types, with practitioners aligned with consistently low, intermediate or high compression force categories. An extension of this study 7 assessed compression values over three consecutive analogue screeningmammography invitations (500 clients). Individual client compression force over the three screens varied significantly, and was highly dependent upon the practitioner who performed the mammogram, rather than the client. Individual practitioners are assumed to be setting their own compression force tolerance levels, regardless of the client’s breast type, and this will likely have implications for the patient experience, their mean glandular radiation dose, and image quality consistency across subsequent screens. This is despite attempts made by manufacturers to reduce
Use of DBT as a mammographyscreening modality substan- tially reduces the need for follow-up diagnostic services and improves detection of invasive cancers, allowing for earlier, less costly treatment. Results from our value analysis of DBT demonstrate that these beneficial attributes could translate into meaningful cost savings for US commercial health insurers. With approximately one in seven women receiving additional diagnostic imaging following digital screeningmammography at an average cost of over $1,200, and with the costs of breast cancer ranging with increasing stage from $35,000 to $224,000, wider adoption of DBT mammography presents a significant opportunity to deliver value-based care in the US health care system. Future research should evaluate the potential impact of DBT from the perspective of patients and/or other types of payers. Investigation of longer-term outcomes is also warranted to better understand the broader clinical and economic implications of adoption of DBT.