Key Elements of Mammography Shared Decision-Making: a Scoping Review of the Literature.

The United States Preventive Services Task Force recommends individualized breast cancer screening for average-risk women before age 50, advised by risk assessment and shared decision-making (SDM). However, the foundational principles of this recommendation that would inform decision support tools for patients and primary care physicians at the point of care have not been codified. Determining the core elements of SDM for breast cancer screening as valued by patients and primary care providers (PCPs) is necessary for implementing effective SDM tools. The aim of this study is to affirm core elements of SDM in the context of clinical interactions, through a Delphi consensus process. A Delphi was conducted with 30 participants (10 women aged 40-49, 10 PCPs, and 10 healthcare decision scientists), to codify core elements of breast cancer screening SDM. The criterion for establishing consensus was a threshold of 80% agreement. The Delphi concluded with an 83% response rate. Of 48 items fielded, 44 met the threshold on the high-importance end of the response scale and were accepted as core elements. Core elements across three thematic categories-information delivery and patient education, interpersonal clinician-patient communication, and framework of the decision-received panelists' support in nearly equal measure. Panelists unanimously agreed that SDM should include provision of clearly understandable information, including that of personal breast cancer risk factors, and benefits and harms of mammography screening, and that PCPs should convey they are listening, knowledgeable, and demonstrate cultural sensitivity. This research codifies the core elements of SDM for mammography in women 40-49, augmenting the evidence to inform discussions between patients and physicians. These core elements of SDM have the potential to operationalize SDM for breast cancer screening in an effort to improve public health outcomes.

Background: National health organizations offer contrasting guidelines for women aged 40–49 regarding when to begin and how often to use mammography screening for breast cancer. The ACS recommends average risk women aged 40–44 receive annual screening “if they wish to do so” and annual screening for women aged 45–54. The United States Preventive Services Task Force recommends individualized screening for average-risk women before age 50 advised by risk assessment and shared decision-making (SDM). Clinicians lack guidance on how to conduct and what elements to include in mammography SDM. Our prior work identified core elements via scoping review applied to a modified Delphi consensus process involving patients, primary care physicians (PCP), and healthcare decision scientists (HDS). This study examines stakeholder group differences in endorsing core SDM elements. Methods: The Delphi consensus included 10 patients, 10 PCP, and 10 HDS and fielded 48 items to codify core elements of mammography SDM. A threshold of 80% agreement across all participants was set to establish consensus for retaining or dropping an item. In this study, separate stakeholder groups’ endorsement rates for each item were calculated. Items were deemed to have stakeholder discrepancy if one group differed from the 2 others in either meeting or not meeting the 80% threshold criteria. Results: 16 items (13 retained, 3 dropped in Delphi) had a discrepant group. For all retained items, the discrepant group fell below 80% criteria for retaining. For 2 of the dropped items, discrepant groups achieved threshold for retaining the item. One item was dropped despite most participants voting to retain it (>80%) due to the discrepant group’s rating <80%. Patients rated less importance to educating women about risks and recommendations. PCPs rated lower importance to training PCPs and women for discussions about mammograms and having discussions on a regular basis. HDSs rated greater importance to considering mammogram procedures and costs in SDM. Discussion: Leading healthcare organizations are increasingly recommending SDM in breast cancer screening, among other decisions. Guidelines enumerating core elements of SDM are needed to effectively direct clinicians. This study, by illuminating differences between stakeholder group perspectives, highlights the importance of eliciting varied perspectives in identifying core elements of SDM when informing healthcare practices and policy.

The objective of this review is to identify and synthesize the best available evidence related to the meaningfulness of internal and external influences on shared-decision making for adult patients and health care providers in all health care settings.The specific questions to be answered are: BACKGROUND: Patient-centered care is emphasized in today's healthcare arena. This emphasis is seen in the works of the International Alliance of Patients' Organizations (IAOP) who describe patient-centered healthcare as care that is aimed at addressing the needs and preferences of patients. The IAOP presents five principles which are foundational to the achievement of patient-centered healthcare: respect, choice, policy, access and support, as well as information. These five principles are further described as:Within the description of these five principles the idea of shared decision-making is clearly evident.The concept of shared decision-making began to appear in the literature in the 1990s. It is defined as a "process jointly shared by patients and their health care provider. It aims at helping patients play an active role in decisions concerning their health, which is the ultimate goal of patient-centered care." The details of the shared decision-making process are complex and consist of a series of steps including:Three overall representative decision-making models are noted in contemporary literature. These three models include: paternalistic, informed decision-making, and shared decision-making. The paternalistic model is an autocratic style of decision-making where the healthcare provider carries out the care from the perspective of knowing what is best for the patient and therefore makes all decisions. The informed decision-making model takes place as the information needed to make decisions is conveyed to the patient and the patient makes the decisions without the healthcare provider involvement. Finally, the shared decision-making model is representative of a sharing and a negotiation towards treatment decisions. Thus, these models represent a range with patient non-participation at one end of the continuum to informed decision making or a high level of patient power at the other end. Several shared decision-making models focus on the process of shared decision-making previously noted. A discussion of several process models follows below.Charles et al. depicts a process model of shared decision-making that identifies key characteristics that must be in evidence. The patient shares in the responsibility with the healthcare provider in this model. The key characteristics included:This model illustrates that there must be at least two individuals participating, however, family and friends may be involved in a variety of roles such as the collector of information, the interpreter of this information, coach, advisor, negotiator, and caretaker. This model also depicts the need to take steps to participate in the shared decision-making process. To take steps means that there is an agreement between and among all involved that shared decision-making is necessary and preferred. Research about patient preferences, however, offers divergent views. The link between patient preferences for shared decision-making and the actuality of shared decision-making in practice is not strong. Research concerning patients and patient preferences on shared decision-making points to variations depending on age, education, socio-economic status, culture, and diagnosis. Healthcare providers may also hold preferences for shared decision-making; however, research in this area is not as comprehensive as is patient focused research. Elwyn et al. explored the views of general practice providers on involving patients in decisions. Both positive and negative views were identified ranging from receptive, noting potential benefits, to concern for the unrealistic nature of participation and sharing in the decision-making process. An example of this potential difficulty, from a healthcare provider perspective, is identifying the potential conflict that may develop when a patient's preference is different from clinical practice guidelines. This is further exemplified in healthcare encounters when a situation may not yield itself to a clear answer but rather lies in a grey area. These situations are challenging for healthcare providers.The notion of information sharing as a prerequisite to shared decision-making offers insight into another process. The healthcare provider must provide the patient the information that they need to know and understand in order to even consider and participate in the shared decision-making process. This information may include the disease, potential treatments, consequences of those treatments, and any alternatives, which may include the decision to do nothing. Without knowing this information the patient will not be able to participate in the shared decision-making process. The complexity of this step is realized if one considers what the healthcare provider needs to know in order to first assess what the patient knows and does not know, the readiness of the patient to participate in this educational process and learn the information, as well as, the individual learning styles of the patient taking into consideration the patient's ideas, values, beliefs, education, culture, literacy, and age. Depending on the results of this assessment the health care provider then must communicate the information to the patient. This is also a complex process that must take into consideration the relationship, comfort level, and trust between the healthcare provider and the patient.Finally, the treatment decision is reached between both the healthcare provider and the patient. Charles et al. portrays shared decision-making as a process with the end product, the shared decision, as the outcome. This outcome may be a decision as to the agreement of a treatment decision, no agreement reached as to a treatment decision, and disagreement as to a treatment decision. Negotiation is a part of the process as the "test of a shared decision (as distinct from the decision-making process) is if both parties agree on the treatment option."Towle and Godolphin developed a process model that further exemplifies the role of the healthcare provider and the patient in the shared decision-making process as mutual partners with mutual responsibilities. The capacity to engage in this shared decision-making rests, therefore, on competencies including knowledge, skills, and abilities for both the healthcare provider and the patient. This mutual partnership and the corresponding competencies are presented for both the healthcare provider and the patient in this model. The competencies noted for the healthcare provider for shared decision making include:Patient competencies include:This model illustrates the shared decision-making process with emphasis on the role of the healthcare provider and the patient very similar to the prior model. This model, however, gives greater emphasis to the process of the co-participation of the healthcare provider and the patient. The co-participation depicts a mutual partnership with mutual responsibilities that can be seen as "reciprocal relationships of dialogue." For this to take place the relationship between and among the participants of the shared decision-making process is important along with other internal and external influences such as communication, trust, mutual respect, honesty, time, continuity, and commitment. Cultural, social, and age group differences; evidence; and team and family are considered within this model.Elwyn et al. presents yet another model that depicts the shared decision-making process; however, this model offers a view where the healthcare provider holds greater responsibility in this process. In this particular model the process focuses on the healthcare provider and the essential skills needed to engage the patient in shard decisions. The competencies outlined in this model include:The healthcare provider must demonstrate knowledge, competencies, and skills as a communicator. The skills for communication competency require the healthcare provider to be able to elicit the patient's thoughts and input regarding treatment management throughout the consultation. The healthcare provider must also demonstrate competencies in assessment skills beyond physical assessment that includes the ability to assess the patient's perceptions and readiness to participate. In addition, the healthcare provider must be able to assess the patient's readiness to learn the information that the patient needs to know in order to fully engage in the shared decision-making process, assess what the patient already knows, what the patient does not know, and whether or not the information that the patient knows is accurate. Once this assessment is completed the healthcare provider then must draw on his/her knowledge, competencies, and skills necessary to teach the patient what the patient needs to know to be informed. This facilitates the notion of the tailor-made information noted previously. The healthcare provider also requires competencies in how to check and evaluate the entire process to ensure that the patient does understand and accept with comfort not only the plan being negotiated but the entire process of sharing in decision-making. In addition to the above, there are further competencies such as competence in working with groups and teams, competencies in terms of cultural knowledge, competencies with regard to negotiation skills, as well as, competencies when faced with ethical challenges.Shared decision-making has been associated with autonomy, empowerment, and effectiveness and efficiency. Both patients and health care providers have noted improvement in relationships and improved interactions when shared decision-making is in evidence. Along with this improved relationship and interaction enhanced complianc

Mammography is one of the most technically challenging areas of radiography, required high spatial resolution, excellent soft tissue contrast and low radiation dose. Mammography screening for breast cancer is worldwide available. Early detection of breast cancer through screening can lower breast cancer mortality rate and reduce the burden of this disease in the population, the benefits and harms of mammography screening have been debated in the past years. This review discuss the benefits and harms of mammography screening in light of findings from randomized trials and more recent observational studies performed in the era of modern diagnosis. The main benefit for mammography screening is reduces the risk of dying from breast cancer. Reduction vary from 15 to 20% in randomized trials to more recent estimates of 13 to 17% in analyses of observational studies. UK data of 2007 shows that for 1,000 women invited to biennial mammography screening for 20years to 50years age, 2-3 women’s are prevented from breast cancer. Main harm of mammography screening is the over diagnosis of breast cancer. 15 women’s over diagnosis for every 1000 women invited to biennial screening for 20 years from 50 years age. In an era of limiting health care services, screening services need to scrutinized and compared with each other regard to effectiveness, cost effectiveness and harms.

<h3>Objective:</h3> To characterize and quantify SDM in GOC meetings To identify factors associated with higher SDM score <h3>Background:</h3> Shared decision making (SDM) is recommended by experts to improve difficult decisions in ICUs; yet for the most difficult decision of all, the goals-of-care (GOC) decision, empirical research in medical-surgical ICUs demonstrated that only 2% of clinician-family meetings contained all SDM elements. Little is known about the extent and predictors of SDM in critically-ill neurological patients (CINPs). <h3>Design/Methods:</h3> Two qualitative coders applied a validated 10-element SDM instrument to 63 GOC clinician-family meetings for CINPs, audio-recorded at seven U.S. medical centers. Clinicians and families completed post-meeting questionnaires assessing their own prognostic estimates. We defined the Clinician-Family-Prognostic-Discordance-Score as the difference between both estimates and prognostic discordance as ≥20% difference. We applied univariate and multivariable longitudinal regression to identify predictors of more SDM. <h3>Results:</h3> The median SDM score (total number of unique SDM elements per meeting) was 7 (range 1–10; IQR 5–8). Only 6% of meetings contained all 10 SDM elements. The most common SDM elements were “<i>discussing uncertainty”</i>(89%) and <i>“assessing family understanding”</i>(86%); the least frequent elements were <i>“assessing the need for input from others”</i>(40%) and <i>“eliciting the context of the decision”</i>(32%). Prognostic discordance was 60% and 45% for hospital-survival and 6-month independent functioning, respectively. In univariate analyses, more SDM was associated with female clinicians, and Cohort 2. Meetings with less clinician-surrogate survival discordance approached significance. After adjustment, there was a trend towards clinician gender being an independent predictor of more SDM(p=0.11), but none of the variables were independent predictors. <h3>Conclusions:</h3> Few clinician-family GOC-meetings for CINPs contained all SDM elements. We uncovered modifiable gaps as opportunities for improvement. While our sample was too small to find independent predictors of SDM, our data supports the urgent need to continue our mixed-method of examination of clinician-family GOC-meetings in larger cohorts. <b>Disclosure:</b> Miss Fleming has nothing to disclose. Mr. Prasad has nothing to disclose. Ms. Ge has nothing to disclose. Mr. Meraj has nothing to disclose. Miss Franco has received personal compensation for serving as an employee of Umass Medical School. The institution of Catherine Hough has received research support from NIH. Bernard Lo has nothing to disclose. Shannon Carson has nothing to disclose. The institution of Jay Steingrub has received research support from NHLBI. Douglas White has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for uptodate. Douglas White has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Journal of Respiratory and Critical Care Medicine. The institution of Dr. Muehlschlegel has received research support from NIH. The institution of Dr. Muehlschlegel has received research support from NIH. The institution of an immediate family member of Dr. Muehlschlegel has received research support from NIH. Dr. Muehlschlegel has a non-compensated relationship as a Member of Board of Directors with Neurocritical Care Society that is relevant to AAN interests or activities.

Both the practice of medicine and the expectations of patients regarding their care are changing. A point of confluence is in the need for medicine to be more patient centered, and in the need for patients to be more involved in their care.(1,2) This confluence is particularly pertinent when more than one reasonable approach is available to manage the patient's situation, and when those approaches differ in ways that matter to patients.(3) In shared decision-making (SDM), clinicians and patients work together to understand the patient's situation and to determine how best to address it. Emergency medicine is not exempt from these trends. In this paper we seek to define SDM and its role in contemporary healthcare. Our goal is to set the stage for the active exploration of SDM in the care of patients in the emergency department. This article is protected by copyright. All rights reserved

IntroductionIt has been difficult to implement Shared Decision-Making (SDM) in routine practice for patients with cardiovascular disease (CVD) in the Netherlands. In CVD care, the multidisciplinary heart team plays an...

The uptake of shared decision making (SDM) for lung cancer screening (LCS) as required by the Centers for Medicare & Medicaid Services (CMS) is suboptimal. Alternative models for delivering SDM are needed, such as decision coaching in the low-dose computed tomography (LDCT) setting. The Replicating Effective Programs framework guided our implementation of decision coaching, which included a patient-facilitated component before screening followed by in-person coaching that addressed the required elements for the SDM visit from CMS. We surveyed two LCS patient cohorts (pre-implementation and implementation of decision coaching) about their knowledge of LCS and perception of the SDM process. We conducted time-motion studies to assess the feasibility of implementing decision coaching and audio recorded clinical encounters from the implementation cohort to assess fidelity of the SDM conversation to the CMS requirements. Compared with the pre-implementation cohort (n = 51), the implementation cohort (n = 30) had greater knowledge of LCS (P < .01) and reported a better SDM process (P = .01). Coaching took 7.6 ± 4.1 minutes and did not increase visit time (P = .72). Coaches addressed an average of 6.4 of 7 SDM elements required by CMS. Decision coaching in the LDCT setting provides an opportunity for patients to confirm their screening decision by ensuring that patients are truly informed about the potential harms and benefits of LCS. The decision coaching had excellent fidelity in addressing the required SDM elements from CMS and is feasible.

Background. There is a growing need for valid shared decision-making (SDM) measures. We aimed to determine whether the items of extant SDM observer-based coding schemes assess the 4 key elements of SDM. Methods. Items of SDM coding schemes were extracted and categorized. Except for the 4 key elements of SDM (fostering choice awareness, informing about options, discussing patient preferences, and making a decision), (sub)categories were created inductively. Two researchers categorized items independently and in duplicate. Results. Five of 12 coding schemes assessed all 4 SDM elements. Seven schemes did not measure “fostering choice awareness,” and 3 did not measure “discussing patient preferences.” Seventy of 194 items (36%) could not be classified into one of the key SDM elements. Items assessing key SDM elements most often assessed “informing about options” (n = 57/124, 46%). Conclusion. Extant SDM coding schemes often do not assess all key SDM elements and have a strong focus on information provision while other crucial elements of SDM are underrepresented. Caution is therefore needed in reporting and interpreting the resulting SDM scores.

The purpose of this article is to review clinical computed tomography (CT) lung screening program elements essential to safely and effectively manage the millions of Americans at high risk for lung cancer expected to enroll in lung cancer screening programs over the next 3 to 5 years. To optimize the potential net benefit of CT lung screening and facilitate medical audits benchmarked to national quality standards, radiologists should interpret these examinations using a validated structured reporting system such as Lung-RADS. Patient and physician educational outreach should be enacted to support an informed and shared decision-making process without creating barriers to screening access. Programs must integrate smoking cessation interventions to maximize the clinical efficacy and cost-effectiveness of screening. At an institutional level, budgets should account for the necessary expense of hiring and/or training qualified support staff and equipping them with information technology resources adequate to enroll and track patients accurately over decades of future screening evaluation. At a national level, planning should begin on ways to accommodate the upcoming increased demand for physician services in fields critical to the success of CT lung screening such as diagnostic radiology and thoracic surgery. Institutions with programs that follow these specifications will be well equipped to meet the significant oncoming demand for CT lung screening services and bestow clinical benefits on their patients equal to or beyond what was observed in the National Lung Screening Trial.

BackgroundEffective shared decision making (SDM) in health care involves thorough discussions of options, pros, cons, and patient preferences. While SDM is recommended for engaging adults aged 76 to 85 y in colorectal cancer (CRC) screening decisions, the extent of SDM documentation in clinical notes remains unclear.ObjectiveThis study aimed to evaluate the current state of SDM documentation in clinical notes regarding CRC screening discussions for adults aged 76 to 85 y. It also sought to assess the impact of an SDM training intervention on documentation quality and compare documented SDM elements with physician- and patient-reported SDM.MethodsData from 465 patient participants and 58 primary care physicians in a multisite cluster randomized trial were analyzed. Physicians in the intervention arm underwent a 2-h SDM skills training and received support tools, including an electronic health record SmartPhrase. Coders analyzed clinical notes using content analysis to identify SDM elements. Linear multilevel models and multilevel partial correlations were used for analysis.ResultsOverall, SDM Note scores were low ( = 0.80, s = 0.99). The intervention arm exhibited higher SDM Note scores than the comparator arm did (adjusted mean 1.02 v. 0.66; P = 0.006), with more frequent documentation of stool-based tests (52% v. 33%; P = 0.02) and colonoscopy cons (28% v. 8%; P = 0.001). No significant differences were observed in patient preference documentation. SDM Note scores correlated moderately with patient- and physician-reported SDM.ConclusionDocumentation of CRC screening discussions with older adults lacks comprehensive SDM elements. The intervention improved SDM documentation, particularly regarding alternative screening options and potential cons. Given the limited documentation of SDM even after a training intervention, attention to more robust SDM documentation, including patient preferences and discussion of stopping CRC screening, is needed.HighlightsShared decision-making (SDM) documentation in clinical notes is limited for discussions on colon cancer screening among older adults.SDM training improves SDM documentation of screening options for colorectal cancer, specifically documentation of stool-based testing and the downsides of screening options.SDM documentation in clinical notes is related to patient and provider reports of SDM.

MMpowerment: Empowering patients with multiple myeloma for shared decision-making by developing an intervention to integrate personal preferences into digital care pathways

Background: Breast cancer patients are faced with treatment choices that can involve complex preference-sensitive decisions. The National Quality Forum initiated a “Call to Action” to integrate shared decision-making (SDM) processes into practice where clinicians and patients work together to make healthcare decisions that align with what matters most to patients. Projects In Knowledge, @Point of Care, Dartmouth and Yale collaborated to develop a pilot educational initiative to address and improve patient-centered care and SDM processes in the institutional cancer care setting. Methods: Training materials co-developed for the Yale Breast Cancer multidisciplinary team (N=11: oncologists, nurses/NPs, pharmacist) address SDM, CDK4/6 Inhibitor treatment of metastatic HR+ HER2- breast cancer, and clinician-patient role play methods implementing SDM in treatment discussions/decisions with patients. Reinforcement training, based on interim interview and case role play assessments, was customized to meet specific needs of the team. Qualitative semi-structured interviews and simulation case role play observational methods, using a two-rater system, were used to assess improved SDM performance. Baseline pre-intervention interviews and case role play assessments were compared to interim post-intervention and end of pilot (EOP) post-reinforcement training intervention interviews and case role play assessments (using a Likert scale 0-4 rating score: 0=0%; 1=25%, 2=50%; 3=75%; 4=100%). Following the training and assessments, a focus group of team members provided insights into the performance of the group, assessed the acceptability, feasibility, and repeatability of the program, and informed future education. Results: Semi-structured interview findings revealed that clinicians learned about nuances of CDK 4/6 inhibitors, crystallized their understanding of SDM through reinforcement training (customized in real time), and felt they were better able to implement SDM as a result of their case role play assessments. Training empowered the Yale Breast Cancer team to show pre- to post-education improvement in SDM case role play scenarios, ranging from 16% to 39%. Areas of greatest improvement: 1) determining decision style preference (+36%); 2) determining patients’ risk/burden tolerance (+32%); 3) determining patients’ activation, engagement, and self-efficacy (+34%), 4) determining trade-off decisions with patients (+39%), and 5) determining patients’ readiness to make a decision (+32%). Future research should explore how best to integrate SDM into the real world time restricted clinical practice. Conclusions: Educational training improved SDM skills for the multidisciplinary Yale Breast Cancer team, which can lead to improved clinician-patient decision-making and patient-centric care. The training process also facilitated team building and encouraged ongoing participation in SDM. Overall Yale Breast Cancer SDM Pilot Case Study Role-Play Assessments (Data reflect findings for 11 participants who completed their case role play) Citation Format: Elaine Rudell, Tarjani Agrawal, Patty Peterson, Michele Fallon Ingram, Brant Oliver, Kerin Adelson. Standard of Care for HR+/HER2- Breast Cancer: Integrating The “Yale Model Shared Decision-Making Multidisciplinary Team Solution” into the Practice Setting [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-15.

The U.S. Department of Veterans Affairs (VA)/Department of Defense (DoD) Clinical Practice Guideline (CPG) for the Management of Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder strives to advance the VA's practice of recovery-oriented, evidence-based, patient-centered care (PCC) for veterans with PTSD. A core foundation of PCC is that care is individually tailored to meet the needs and preferences of each patient. Accordingly, the 2017 update to the CPG specifically recommends the use of shared decision making (SDM), an individualized collaborative approach to treatment planning, in the PTSD treatment planning process. Although SDM has been promoted by the CPG throughout the VA and SDM training is being developed, no systemic training was available at the time the guidelines were updated. Additionally, while early research has studied the impact and experience of SDM for the patient, no work has explored provider experiences with SDM for those who work with trauma populations. This project bridges this gap by examining survey data collected 6 months following a formal SDM training to staff and trainees working with veterans who have experienced trauma within a trauma clinic at a large VA hospital. After the training, clinicians understood SDM and were engaging in SDM with their patients. Patients indicated that they were satisfied with and felt like an active participant in the treatment planning process. Clinician assumptions about the SDM process and barriers to SDM shown in previous research were also demonstrated. Implications for future research and practice, such as using decision aids in PTSD treatment planning and targeting clinician beliefs about SDM, are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Mammography screening for breast cancer is widely available in many countries. Initially praised as a universal achievement to improve women's health and to reduce the burden of breast cancer, the benefits and harms of mammography screening have been debated heatedly in the past years. This review discusses the benefits and harms of mammography screening in light of findings from randomized trials and from more recent observational studies performed in the era of modern diagnostics and treatment. The main benefit of mammography screening is reduction of breast-cancer related death. Relative reductions vary from about 15 to 25% in randomized trials to more recent estimates of 13 to 17% in meta-analyses of observational studies. Using UK population data of 2007, for 1,000 women invited to biennial mammography screening for 20 years from age 50, 2 to 3 women are prevented from dying of breast cancer. All-cause mortality is unchanged. Overdiagnosis of breast cancer is the main harm of mammography screening. Based on recent estimates from the United States, the relative amount of overdiagnosis (including ductal carcinoma in situ and invasive cancer) is 31%. This results in 15 women overdiagnosed for every 1,000 women invited to biennial mammography screening for 20 years from age 50. Women should be unpassionately informed about the benefits and harms of mammography screening using absolute effect sizes in a comprehensible fashion. In an era of limited health care resources, screening services need to be scrutinized and compared with each other with regard to effectiveness, cost-effectiveness and harms.