Mammography Screening SlideShare Presentation

Why was screening implemented? What is overdiagnosis?

  • Why was screening implemented?
  • What is overdiagnosis?
  • The evidence for overdiagnosis
  • Available data
  • Facts from recent studies
  • Risks of screening
  • The illusion of early detection
  • Harms due to overdiagnosis
  • Benefit-risk balance
  • So, what to do?
Sources:

Should I Get a Mammogram?

Understanding the Harms and Benefits of Routine Breast Cancer Screening

Should-I-Have-A-Mammogram
Download and print a PDF – Understanding the Harms and Benefits of Routine Breast Cancer Screening.

The banner statement (…screening to prevent…) is also misguiding because a screening cannot prevent anything, but only detect.
In order to prevent breast cancer to happen, steps must be taken before a screening detects anything… or it’s another story…

BC Action brochure – ©2014 – provides information about routine screening mammography for women at average risk of breast cancer who do not have a significant family history of breast cancer, have not been diagnosed with breast cancer, and have no other known risk factors.

  • USES OF MAMMOGRAPHY
  • THE FALSE PROMISE OF EARLY DETECTION
  • RISK ASSESSMENT
  • UNDERSTANDING THE HARMS OF SCREENING MAMMOGRAPHY
  • WHAT CAN YOU DO?

Should I Get a Mammogram? Understanding the Harms and Benefits of Routine Breast Cancer Screening: download and print a PDF.

Related posts

Breast Cancer Screening for Women at Average Risk – 2015 Guidelines

American Cancer Society, in a Shift, Recommends Fewer Mammograms

Despite the substantial interest and investment in research on breast cancer screening, there is uncertainty about the magnitude of mammography’s benefits and harms and how to select patients and screening strategies to optimize the balance between benefits and harms.
Despite the substantial interest and investment in research on breast cancer screening, there is uncertainty about the magnitude of mammography’s benefits and harms and how to select patients and screening strategies to optimize the balance between benefits and harms. The American Cancer Society, which has for years taken the most aggressive approach to screening, issued new guidelines, recommending that women should begin mammograms later and have them less frequently than it had long advocated.
Breast Cancer Awareness, A Touch Of Pink by bellasdolls.

2015 Study Abstract

Importance
Breast cancer is a leading cause of premature mortality among US women. Early detection has been shown to be associated with reduced breast cancer morbidity and mortality.

Objective
To update the American Cancer Society (ACS) 2003 breast cancer screening guideline for women at average risk for breast cancer.

Process
The ACS commissioned a systematic evidence review of the breast cancer screening literature to inform the update and a supplemental analysis of mammography registry data to address questions related to the screening interval. Formulation of recommendations was based on the quality of the evidence and judgment (incorporating values and preferences) about the balance of benefits and harms.

Evidence Synthesis
Screening mammography in women aged 40 to 69 years is associated with a reduction in breast cancer deaths across a range of study designs, and inferential evidence supports breast cancer screening for women 70 years and older who are in good health. Estimates of the cumulative lifetime risk of false-positive examination results are greater if screening begins at younger ages because of the greater number of mammograms, as well as the higher recall rate in younger women. The quality of the evidence for overdiagnosis is not sufficient to estimate a lifetime risk with confidence. Analysis examining the screening interval demonstrates more favorable tumor characteristics when premenopausal women are screened annually vs biennially. Evidence does not support routine clinical breast examination as a screening method for women at average risk.

Recommendations
The ACS recommends that women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years (strong recommendation). Women aged 45 to 54 years should be screened annually (qualified recommendation). Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually (qualified recommendation). Women should have the opportunity to begin annual screening between the ages of 40 and 44 years (qualified recommendation). Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer (qualified recommendation). The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (qualified recommendation).

Conclusions and Relevance
These updated ACS guidelines provide evidence-based recommendations for breast cancer screening for women at average risk of breast cancer. These recommendations should be considered by physicians and women in discussions about breast cancer screening.

Sources and more information – October 2015
  • Breast Cancer Screening for Women at Average Risk 2015 Guideline Update From the American Cancer Society, JAMA. articleid=2463262 2015;314(15):1599-1614. doi:10.1001/jama.2015.12783, October 20, 2015.
  • New Guidelines for Breast Cancer Screening in US Women, JAMA. articleid=2463237 2015;314(15):1569-1571. doi:10.1001/jama.2015.13086, October 20, 2015.
  • Benefits and Harms of Breast Cancer Screening A Systematic Review, JAMA. articleid=2463261 2015;314(15):1615-1634. doi:10.1001/jama.2015.13183, October 20, 2015.
  • Measuring the Effectiveness of Mammography, JAMA Oncol. articleid=2456189#ced150019r1 Published online October 20, 2015. doi:10.1001/jamaoncol.2015.3286.
  • Breast Tumor Prognostic Characteristics and Biennial vs Annual Mammography, Age, and Menopausal Status, JAMA Oncol. articleid=2456190 Published online October 20, 2015. doi:10.1001/jamaoncol.2015.3084, October 20, 2015.
  • American Cancer Society, in a Shift, Recommends Fewer Mammograms, nytimes, OCTOBER 20, 2015.

Questioning the Entire Breast Cancer Industry

Laurie Becklund: Treat me like a statistic and save my life

Laurie Becklund, Senior Fellow, USC Annenberg, presents at Stanford Medicine X at Stanford University on Sunday, September 7, 2014.

More info and videos
  • Video published on 25 Nov 2014 by Stanford Medicine X channel.
  • Read As I lay dying, latimes, Oct 18, 2015.
  • Read “As I Lay Dying..” LA Times Writer’s Last Words Will Make You Question Entire Breast Cancer Industry, eatlocalgrown, Oct 18, 2015.
  • More research videos on our YT channel.

Mammography associated to breast cancer incidence increase with no reduction in mortality

Mammography does not “reduce breast cancer deaths”

Image of a mammography-plate
Mammography for detection of breast cancer does not reduce the number of deaths from the disease and may actually lead to overdiagnosis, according to a new study published in JAMA Internal Medicine. Image by Grant Hutchinson.

2015 Study Abstract

Importance
Screening mammography rates vary considerably by location in the United States, providing a natural opportunity to investigate the associations of screening with breast cancer incidence and mortality, which are subjects of debate.

Objective
To examine the associations between rates of modern screening mammography and the incidence of breast cancer, mortality from breast cancer, and tumor size.

Design, Setting, and Participants
An ecological study of 16 million women 40 years or older who resided in 547 counties reporting to the Surveillance, Epidemiology, and End Results cancer registries during the year 2000. Of these women, 53 207 were diagnosed with breast cancer that year and followed up for the next 10 years. The study covered the period January 1, 2000, to December 31, 2010, and the analysis was performed between April 2013 and March 2015.

Exposures
Extent of screening in each county, assessed as the percentage of included women who received a screening mammogram in the prior 2 years.

Main Outcomes and Measures
Breast cancer incidence in 2000 and incidence-based breast cancer mortality during the 10-year follow-up. Incidence and mortality were calculated for each county and age adjusted to the US population.

Results
Across US counties, there was a positive correlation between the extent of screening and breast cancer incidence (weighted r = 0.54; P < .001) but not with breast cancer mortality (weighted r = 0.00; P = .98). An absolute increase of 10 percentage points in the extent of screening was accompanied by 16% more breast cancer diagnoses (relative rate [RR], 1.16; 95% CI, 1.13-1.19) but no significant change in breast cancer deaths (RR, 1.01; 95% CI, 0.96-1.06). In an analysis stratified by tumor size, we found that more screening was strongly associated with an increased incidence of small breast cancers (≤2 cm) but not with a decreased incidence of larger breast cancers (>2 cm). An increase of 10 percentage points in screening was associated with a 25% increase in the incidence of small breast cancers (RR, 1.25; 95% CI, 1.18-1.32) and a 7% increase in the incidence of larger breast cancers (RR, 1.07; 95% CI, 1.02-1.12).

Conclusions and Relevance
When analyzed at the county level, the clearest result of mammography screening is the diagnosis of additional small cancers. Furthermore, there is no concomitant decline in the detection of larger cancers, which might explain the absence of any significant difference in the overall rate of death from the disease. Together, these findings suggest widespread overdiagnosis.

Sources and more information

Breast cancer overdiagnosis costs $4 billion a year to the U.S.

Breast cancer misdiagnoses costs $4 billion/year

The costs from false diagnoses of breast cancer are “much higher” than previously documented, according to a new study published online on April 7, 2015.

Betty-Ford-Breast-Care
About $4 billion is spent ever year in the United States because of false-positive mammography results and breast cancer overdiagnosis, according to a new study. Betty Ford Breast Care image via Spectrum Health.

2015 Study Abstract

Populationwide mammography screening has been associated with a substantial rise in false-positive mammography findings and breast cancer overdiagnosis. However, there is a lack of current data on the associated costs in the United States. We present costs due to false-positive mammograms and breast cancer overdiagnoses among women ages 40–59, based on expenditure data from a major US health care insurance plan for 702,154 women in the years 2011–13. The average expenditures for each false-positive mammogram, invasive breast cancer, and ductal carcinoma in situ in the twelve months following diagnosis were $852, $51,837 and $12,369, respectively. This translates to a national cost of $4 billion each year. The costs associated with false-positive mammograms and breast cancer overdiagnoses appear to be much higher than previously documented. Screening has the potential to save lives. However, the economic impact of false-positive mammography results and breast cancer overdiagnoses must be considered in the debate about the appropriate populations for screening.

Sources and more information
  • Breast Cancer Overdiagnosis Costs $4 Billion, Says Studymedscape, April 08, 2015
  • National Expenditure For False-Positive Mammograms And Breast Cancer Overdiagnoses Estimated At $4 Billion A Year, Health Affairs, doi: 10.1377/hlthaff.2014.1087,  April 2015 vol. 34 no. 4 576-583, April 7, 2015.
  • Breast cancer misdiagnoses cost $4 billion: Study, cnbc, 6 Apr 2015.

Regional factors driving inappropriate, unnecessary breast cancer imaging

Regional factors may drive inappropriate breast, prostate cancer imaging

A new study has identified a regional-level link between inappropriate low-risk prostate cancer and breast cancer imaging, which suggests the presence of certain regional factors that may be driving this association.

mammography
According to the researchers, higher rates of inappropriate breast cancer imaging may be down to regions’ infrastructure (i.e., access to PET) or culture promoting imaging.

2015 Study Abstract

Importance
The association between regional norms of clinical practice and appropriateness of care is incompletely understood. Understanding regional patterns of care across diseases might optimize implementation of programs like Choosing Wisely, an ongoing campaign to decrease wasteful medical expenditures.

Objective
To determine whether regional rates of inappropriate prostate and breast cancer imaging were associated.

Design, Setting, and Participants
Retrospective cohort study using the the Surveillance, Epidemiology, and End Results–Medicare linked database. We identified patients diagnosed from 2004 to 2007 with low-risk prostate (clinical stage T1c/T2a; Gleason score, ≤6; and prostate-specific antigen level,

Main Outcomes and Measures In a hospital referral region (HRR)-level analysis, our dependent variable was HRR-level imaging rate among patients with low-risk prostate cancer. Our independent variable was HRR-level imaging rate among patients with low-risk breast cancer. In a subsequent patient-level analysis we used multivariable logistic regression to model prostate cancer imaging as a function of regional breast cancer imaging and vice versa.

Results
We identified 9219 men with prostate cancer and 30 398 women with breast cancer residing in 84 HRRs. We found high rates of inappropriate imaging for both prostate cancer (44.4%) and breast cancer (41.8%). In the first, second, third, and fourth quartiles of breast cancer imaging, inappropriate prostate cancer imaging was 34.2%, 44.6%, 41.1%, and 56.4%, respectively. In the first, second, third, and fourth quartiles of prostate cancer imaging, inappropriate breast cancer imaging was 38.1%, 38.4%, 43.8%, and 45.7%, respectively. At the HRR level, inappropriate prostate cancer imaging rates were associated with inappropriate breast cancer imaging rates (ρ = 0.35; P < .01). At the patient level, a man with low-risk prostate cancer had odds ratios (95% CIs) of 1.72 (1.12-2.65), 1.19 (0.78-1.81), or 1.76 (1.15-2.70) for undergoing inappropriate prostate imaging if he lived in an HRR in the fourth, third, or second quartiles, respectively, of inappropriate breast cancer imaging, compared with the lowest quartile.

Conclusions and Relevance
At a regional level, there is an association between inappropriate prostate and breast cancer imaging rates. This finding suggests the existence of a regional-level propensity for inappropriate imaging utilization, which may be considered by policymakers seeking to improve quality of care and reduce health care spending in high-utilization areas.

Sources and more information

Overdiagnosis triggers overtreatment, and all of our treatments carry some harm

Overdiagnosis: Bad for You, Good for Business

Boston-University in the snow image
The decision about whether or not to look for something to be wrong is not a “no-brainer.” Early detection has two sides: while it may help you, it may also hurt you.

Likelihood that a woman with screen-detected breast cancer has had her “life saved” by that screening

2011 Study Abstract

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.

  • What is overdiagnosis?
  • What’s the problem with wanting to know if there’s a cancer or disease lurking in our bodies?
  • What’s the harm?
  • Can you give an example of testing that leads to overdiagnosis and overtreatment?
  • You’ve talked about health conditions defined by numbers, or benchmarks—like high blood pressure, high cholesterol, diabetes, and osteoporosis—numbers that distinguish between who’s healthy and who’s sick. Aren’t those numbers based on sound science?
  • Who benefits from overdiagnosis?
  • Why has there been so much emphasis on screening? Do you think it’s been driven by what the public wants—early warnings—or what the medical profession has imposed?
  • Would you advise patients who are offered testing for various conditions, based on family history or other indicators, to refuse the tests?

Read Overdiagnosis: Bad for You, Good for Business, BU Today, 10.26.2011
with H. G. Welch, professor of medicine, lecturer in Public Health, author of Overdiagnosed: Making People Sick in the Pursuit of Health.

Sources: Likelihood that a woman with screen-detected breast cancer has had her “life saved” by that screening, NCBI PMID: 22025097, 2011 Dec, full study PDF.

Women less likely to choose mammography screening when informed about overdiagnosis risk

Women should be informed, not only of the benefits of mammography, but also of the shortcomings of the test

breast-aware image
Educating women about the possibility of “overdiagnosis” from mammography screening may make some of them less likely to get the test, a new study says. Women should be informed, not only of the benefits of mammography, but also of the shortcomings of the test.

Background
Women are largely unaware that mammography screening can cause overdetection of inconsequential disease, leading to overdiagnosis and overtreatment of breast cancer. Evidence is lacking about how information on overdetection affects women’s breast screening decisions and experiences. A study investigated the consequences of providing information about overdetection of breast cancer to women approaching the age of invitation to mammography screening.

Interpretation
Information on overdetection of breast cancer provided within a decision aid increased the number of women making an informed choice about breast screening. Becoming better informed might mean women are less likely to choose screening.

Sources and more information

  • Mammogram Rates May Fall When Women Learn of ‘Overdiagnosis’ Risk,
    health, February 19, 2015.
  • Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial,
    lancet, 17 February 2015.
  • Overdetection in breast cancer screening: development and preliminary evaluation of a decision aid, BMJ Open, 5 September 2014.
  • The effect of information about overdetection of breast cancer on women’s decision-making about mammography screening:study protocol for a randomised controlled trial, BMJ Open, May 25, 2014.

How to Measure a Medical Treatment’s Potential for Harm

Sometimes, the chance of a medical treatment’s harm can be greater than the potential for benefit…

man walking drawing
Knowing a medical therapy’s potential for benefit is not enough., we must also consider potential harms.

Not every person who takes a medication will suffer a side effect, just as not every person will see a benefit. And sometimes, the chance of harm can be greater than the potential for benefit…

For instance, for about every 1,500 women assigned to get mammography screening for 10 years, one might be spared a death from breast cancer (though she’d most likely die of some other cause). But about five more women would undergo surgery and about four more would undergo radiation, both of which can have dangerous, even life-threatening, side effects…

Continue reading How to Measure a Medical Treatment’s Potential for Harm,
nytimes, FEB. 2, 2015.

Related post: Can This Treatment Help Me? There’s a Statistic for That,
nytimes, JAN. 26, 2015.