Efficacy Of Screening Mammography Research Articles

Characteristics of breast cancers detected by screening mammography in Taiwan: a single institute’s experience

Background/aimBreast cancer is the most common female malignancy in the world. Nearly ninety percent of screening-detected breast cancers were diagnosed with earlier stages of 0 to II in Taiwan. It’s widely acknowledged that mammography screening of breast cancer can achieve the goal of early diagnosis and treatment in terms of preventive task while neglected interval cancers are associated with unfavorable tumor characteristics and worse outcomes. The purpose of this study was to explore the characteristics of screening-detected breast cancers in Taiwan.Materials and methodsBoth screening and diagnostic mammography examinations with accompanied BI-RADS (breast imaging-reporting and data system) classification were extracted from the health information system and linked to cancer registry in Taiwan. Enrolled population included those attending their first mammography between 2012 and 2016, excluding subjects with previous breast cancer, or with missing or incomplete data. We compared treatment outcomes between breast cancers with either initial screening or diagnostic mammography (control group), and investigated the compositions of breast cancers detected by screening mammography through direct chart reviews.ResultsA total of 84,246 screening and 61,230 diagnostic mammography sessions were performed from 2010 to 2020. More positive results (BI-RADS 0, 3, 4 and 5) were observed for those attending the first diagnostic than the first screening mammography (43.58% versus 16.12%, p < 0.001). Earlier stages (0 and I) distribution (92% versus 81%, p < 0.0001), better survivorship (overall survival: 96.91% versus 92.17%, p = 0.007) and a lower HER2 (human epidermal growth factor receptor II) positive status and lower tumor grade were noted in breast cancers with initial screening rather than diagnostic mammography. Among 26,103 mammography screening invitees between 2012 and 2016, 325 breast cancers were ascertained from cancer registry. Of these, 234 had one, 72 had two and 19 had three episodes of mammography before cancer diagnosis. Extensive chart reviews revealed that women with and without breast symptoms constituted 29.9 and 70.1% of the 325 screening-detected breast cancers, with the latter further divided into false negative results (interval cancer), diagnosed at the first mammography, diagnostic at the secondary or subsequent mammography and those with a delayed biopsy or confirmatory imaging constituted (5.2, 47, 10.5 and 7.4%).ConclusionScreening-detected breast cancers were a mixture of women with and without symptoms, those with a false negative result, true negative results with cancer detected at subsequent mammography and non-adherers. Despite this, efficacy of mammography screening was ascertained in Taiwan from this study. To further enhance earlier detection and decrease false negativity, the impact of repeated mammography, and additional sonography for symptomatic women, compliance following a positive screening mammography should not be overemphasized.

Effectiveness of Mammography Screening on Breast Cancer Mortality - A Study Protocol for Emulation of Target Trials Using German Health Claims Data.

The efficacy of mammography screening in reducing breast cancer mortality has been demonstrated in randomized trials. However, treatment options - and hence prognosis - for advanced tumor stages as well as mammography techniques have considerably improved since completion of these trials. Consequently, the effectiveness of mammography screening under current conditions is unclear and controversial. The German mammography screening program (MSP), an organized population-based screening program, was gradually introduced between 2005 and 2008 and achieved nation-wide coverage in 2009. We describe in detail a study protocol for investigating the effectiveness of the German MSP in reducing breast cancer mortality in women aged 50 to 69 years based on health claims data. Specifically, the proposed study aims at estimating per-protocol effects of several screening strategies on cumulative breast cancer mortality. The first analysis will be conducted once 10-year follow-up data are available. We will use claims data from five statutory health insurance providers in Germany, covering approximately 37.6 million individuals. To estimate the effectiveness of the MSP, hypothetical target trials will be emulated across time, an approach that has been demonstrated to minimize design-related biases. Specifically, the primary contrast will be in terms of the cumulative breast cancer mortality comparing the screening strategies of "never screen" versus "regular screening as intended by the MSP". In Germany, the utilization of data from health insurances for scientific research is regulated by the Code of Social Law. All involved health insurance providers as well as the responsible authorities approved the use of the health claims data for this study. The Ethics Committee of the University of Bremen determined that studies based on claims data are exempt from institutional review. The findings of the proposed study will be published in peer-reviewed journals.

Effectiveness of mammography screening for women aged 40–49

The aim of the work was to review randomized controlled trials regarding the efficacy of screening mammography in women aged 40–49 years.Google Scholar and PubMed databases were searched for English-language publications for randomized controlled trials. Inclusion criteria were studies evaluating the possible benefit/harm of mammographic screening in women 40–49 years old, a follow-up period of at least 10 years, primary breast cancer, regarding as primary outcomes reduction of breast cancer mortality, and side effects screening mammography.A search for the specified keywords found 2453 sources in electronic databases, of which only 83 studies were published as articles. After analyzing these studies, only 5 studies met the inclusion criteria. An analysis of these studies according to the inclusion criteria is subsequently presented in the article.Based on the available data from randomized trials, no definitive conclusion about the effectiveness of mammographic screening in women 40–49 years of age can yet be drawn. Therefore, it is too early to draw a line in the debate about the appropriateness of mammography in the 40–49 age group.

Offline: The Donald Trump Promise

Evidence-based medicine (EBM) has been a powerful influence on clinical practice. But one book should make even the most ardent EBM advocates pause. That book is How Doctors Think, by Jerome Groopman (Houghton Mifflin, 2007). Groopman, an oncologist, drew on the work of Daniel Kahneman and Amos Tversky (before both were made famous by Kahneman's own bestseller, Thinking, Fast and Slow). Groopman used his clinical experience to show how easy it was, despite the very best evidence, to be misled by multiple personal biases—most notably the bias of “availability”. Clinicians will often make diagnoses or decisions based on the mental availability of particular pieces of knowledge, including what might be considered as “best evidence”. Groopman punctures easy assumptions that high-quality evidence alone can improve the quality of medical care. Unless doctors are aware of their own informational biases, the possibility of false reliance on “evidence” is not only conceivable, but likely. How Doctors Think should be required reading before any prospective physician is allowed to lay a hand on a patient. Last week, at the annual Rambam Summit in Haifa, Israel, Groopman, together with Pamela Hartzband, deepened the scepticism with which we should approach EBM. Doctors are educated to believe in their scientific appreciation of evidence. But we may not have educated ourselves to appreciate the mindsets that interpose themselves between evidence and our interpretations of that evidence. Based on extensive interviews with physician colleagues, Groopman and Hartzband identified three dimensions of the medical mindset that any doctor (and patient) should be self-consciously aware of as they make clinical decisions. The three mindsets each have two extremes—maximalist/minimalist, naturalist/technologist, believer/doubter. Ask yourself. Are you the kind of doctor who wants to go as far as you can with the latest technology and who believes in the power of that technology to make a difference to the patient? Or are you the type of doctor who thinks that less is more and who is inherently sceptical about claims for new discoveries? Groopman readily admitted to being a maximalist-believer, which probably influenced his decision in the 1970s to choose haematology as a career when bone-marrow transplantation became popular. Hartzband, by contrast, is a self-confessed minimalist-doubter. Their point was that most clinical decisions lie in a grey zone—there is no single right answer for everyone. The important step is less to adhere to some abstract notion of EBM, but rather to think hard about what kind of medical mindset you have. Whether you are a maximalist-believer or a minimalist-doubter will have a larger effect on your clinical decisions than the result of any single systematic review or randomised trial. We see these mindsets at play all the time in today's scientific, evidence-informed medicine. There have been at least four US expert committees ruling on the safety and efficacy of screening mammography—with four different sets of recommendations. There have been three expert committees reviewing the evidence on screening for prostate cancer using PSA—with three different conclusions. So much for science. So much for evidence. What matters more are the mindsets of those “experts” reviewing the scientific evidence. Here is The Donald Trump Promise, according to Groopman and Hartzband. Modern scientific medicine promises the right doctor prescribing the right treatment and the right procedure for the right outcome. It's just impossible. A final word regarding Joel D Kaufman and colleagues from the University of Washington in Seattle, USA. The International Society for Environmental Epidemiology (ISEE) has awarded its prize for the Best Environmental Epidemiology Paper published in 2016 to Kaufman and coauthors' Lancet Article “Association between air pollution and coronary artery calcification within six metropolitan areas in the USA”. The multicentre team, funded by the US Environmental Protection Agency and National Institutes of Health (both targeted for cuts by President Trump), concluded that, “Increased concentrations of PM2·5 and traffic-related air pollution…in ranges commonly encountered worldwide, are associated with progression in coronary calcification, consistent with acceleration of atherosclerosis. This study supports the case for global efforts of pollution reduction in prevention of cardiovascular diseases.” Congratulations.

Breast Cancer Screening: Past, Present and Future

Future OncologyVol. 11, No. 19 EditorialBreast cancer screening: past, present and futureIsmail JatoiIsmail Jatoi*Author for correspondence: E-mail Address: jatoi@uthscsa.edu Division of Surgical Oncology & Endocrine Surgery, University of Texas Health Science Center, 7703 Floyd Curl Drive, Mail Code 7738, San Antonio, TX 78229, USASearch for more papers by this authorPublished Online:4 Sep 2015https://doi.org/10.2217/fon.15.209AboutSectionsView ArticleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInRedditEmail View articleKeywords: mammographymortalityoverdiagnosisscreeningtherapyReferences1 Jatoi I, Anderson WF. Cancer screening. Curr. Probl. Surg. 42(9), 620–682 (2005).Crossref, Medline, Google Scholar2 Force USPST. Screening for breast cancer: US Preventive Services Task Force recommendation statement. Ann. Intern. Med. 151(10), 716–726 (2009).Crossref, Medline, Google Scholar3 Lauby-Secretan B, Scoccianti C, Loomis D et al. Breast-cancer screening – viewpoint of the IARC Working Group. N. Engl. J. Med. 372(24), 2353–2358 (2015).Crossref, Medline, CAS, Google Scholar4 Shapiro S, Venet W, Strax P, Venet L, Roeser R. Ten- to fourteen-year effect of screening on breast cancer mortality. J. Natl Cancer Inst. 69(2), 349–355 (1982).Medline, CAS, Google Scholar5 Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ 348, g366 (2014).Crossref, Medline, Google Scholar6 Moss SM, Wale C, Smith R, Evans A, Cuckle H, Duffy SW. Effect of mammographic screening from age 40 years on breast cancer mortality in the UK Age trial at 17 years' follow-up: a randomised controlled trial. Lancet Oncol. doi:10.1016/S1470-2045(15)00128-X (2015) (Epub ahead of print).Crossref, Medline, Google Scholar7 Jatoi I. The impact of advances in treatment on the efficacy of mammography screening. Prev. Med. 53(3), 103–104 (2011).Crossref, Medline, Google Scholar8 Jatoi I, Miller AB. Why is breast-cancer mortality declining? Lancet Oncol. 4(4), 251–254 (2003).Crossref, Medline, Google Scholar9 Holloway CM, Easson A, Escallon J et al. Technology as a force for improved diagnosis and treatment of breast disease. Can. J. Surg. 53(4), 268–277 (2010).Medline, Google Scholar10 Jatoi I, Anderson WF. Breast cancer overdiagnosis with screening mammography. Arch. Intern. Med. 169(10), 999–1000 (2009).Medline, Google Scholar11 Jatoi I. Breast cancer screening. Am. J. Surg. 177(6), 518–524 (1999).Crossref, Medline, CAS, Google Scholar12 Black WC, Haggstrom DA, Welch HG. All-cause mortality in randomized trials of cancer screening. J. Natl Cancer Inst. 94(3), 167–173 (2002).Crossref, Medline, Google Scholar13 Miller AB, Yurgalevitch S, Weissfeld JL, Prostate LC, Ovarian Cancer Screening Trial Project T. Death review process in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. Control Clin. Trials. 21(6 Suppl.), S400–S406 (2000).Crossref, Google Scholar14 Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N. Engl. J. Med. 367(21), 1998–2005 (2012).Crossref, Medline, CAS, Google Scholar15 Jatoi I. Screening clinical breast examination. Surg. Clin. North Am. 83(4), 789–801 (2003).Crossref, Medline, Google ScholarFiguresReferencesRelatedDetailsCited BySurgical management of the axilla in early breast cancerCurrent Problems in Surgery, Vol. 55, No. 2Targeting breast cancer outcomes-what about the primary relatives?31 May 2017 | Molecular Genetics & Genomic Medicine, Vol. 5, No. 4Future Oncology: a 10-year anniversary issueNicholas J Ward & Gemma Westcott7 October 2015 | Future Oncology, Vol. 11, No. 19 Vol. 11, No. 19 eToC Sign up Follow us on social media for the latest updates Metrics Downloaded 117 times History Published online 4 September 2015 Published in print October 2015 Information© Future Medicine LtdKeywordsmammographymortalityoverdiagnosisscreeningtherapyFinancial & competing interests disclosureThe author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.PDF download

Breast cancer mortality in relation to receipt of screening mammography: a case-control study in Saskatchewan, Canada.

The efficacy of screening mammography in reducing breast cancer mortality continues to be controversial. In addition, few data exist on the efficacy of screening mammography in women 70years of age or older. An organized screening mammogram program has existed in Saskatchewan since the mid-1990s. It offers mammography every 2years to women ≥50years of age. We conducted a population-based case-control study to evaluate the efficacy of screening mammography, as practiced in Saskatchewan, Canada. Cases (n=501) were women who died of breast cancer during 1995-2008 and were at least 52years of age at the time of their diagnosis. Controls (n=5,009) were matched to cases on birth year and duration of healthcare coverage prior to the cases' breast cancer diagnosis date. In cases and controls, receipt of screening mammography during the several years up to and including the date of the case's diagnosis of breast cancer was ascertained from the records of the screening program. Receipt of a screening mammogram in the preceding 2years was more common among controls (53%) than cases (37%), OR 0.51 (95% CI 0.42-0.62). A decreased risk was observed among women in all age groups, including those 70-79years (OR 0.40; 95% CI 0.27-0.60). Our findings suggest that receipt of screening mammography among women in Saskatchewan has been associated with a decreased risk of death from breast cancer.

Mammography for Older Women?

Mammography for Older Women?

Mammographic surveillance in women aged 35–39 at enhanced familial risk of breast cancer (FH02)

Although there have been encouraging recent studies showing a potential benefit from annual mammography in women aged 40-49 years of age with an elevated breast cancer risk due to family history there is little evidence of efficacy in women aged <40 years of age. A prospective study (FH02) has been developed to assess the efficacy of mammography screening in women aged 35-39 years of age with a lifetime breast cancer risk of ≥ 17 % who are not receiving MRI screening. Retrospective analyses from five centres with robust recall systems identified 47 breast cancers (n = 12 in situ) with an interval cancer rate of 15/47 (32%). Invasive tumour size, lymph node status and current vital status were all significantly better than in two control groups of unscreened women (including those with a family history) recruited to the POSH study. Further evaluation of the prospective arm of FH02 is required to assess the potential added value of digital mammography and the cancer incidence rates in moderate and high risk women in order to inform cost effectiveness analyses.

Harms of screening mammography for breast cancer in Japanese women

The US Preventative Services Task Force assesses the efficacy of breast cancer screening by the sum of its benefits and harms, and recommends against routine screening mammography because of its relatively great harms for women aged 40-49years. Assessment of the efficacy of screening mammography should take into consideration not only its benefits but also its harms, but data regarding those harms are lacking for Japanese women. In 2008 we collected screening mammography data from 144,848 participants from five Japanese prefectures by age bracket to assess the harms [false-positive results, performance of unnecessary additional imaging, fine-needle aspiration cytology (FNA), and biopsy and its procedures]. The rate of cancer detected in women aged 40-49years was 0.28%. The false-positive rate (9.6%) and rates of additional imaging by mammography (5.8%) and ultrasound (7.3%) were higher in women aged 40-49years than in the other age brackets. The rates of FNA (1.6%) and biopsy (0.7%) were also highest in women aged 40-49years. However, they seemed to be lower than the rates reported by the Breast Cancer Surveillance Consortium (BCSC) and other studies in the US. The results, although preliminary, indicate the possibility that the harms of screening mammography for Japanese women are less than those for American women.

Mammography Screening and Risk of Breast Cancer Death: A Population-Based Case–Control Study

Because the efficacy of mammography screening had been shown in randomized controlled trials, the focus has turned on its effectiveness within the daily practice. Using individual data of women invited to screening, we conducted a case-control study to assess the effectiveness of the Dutch population-based program of mammography screening. Cases were women who died from breast cancer between 1995 and 2003 and were closely matched to five controls on year of birth, year of first invitation, and number of invitations before case's diagnosis. ORs and 95% confidence intervals (CI) for the association between attending either of three screening examinations prior to diagnosis and the risk of breast cancer death were calculated using conditional logistic regression and corrected for self-selection bias. We included 755 cases and 3,739 matched controls. Among the cases, 29.8% was screen-detected, 34.3% interval-detected, and 35.9% never-screened. About 29.5% of the never-screened cases had stage IV tumor compared with 5.3% of the screen-detected and 15.1% of the interval-detected cases. The OR (95% CIs), all ages (49-75 years), was 0.51 (0.40-0.66) and for the age groups 50-69, 50-75, and 70-75 years were 0.61 (0.47-0.79), 0.52 (CI 0.41-0.67), and 0.16 (0.09-0.29), respectively. The study provides evidence for a beneficial effect of early detection by mammography screening in reducing the risk of breast cancer death among women invited to and who attended the screening. This is the first case-control study that accurately accounts for equal screening opportunity for both cases and matched controls by number of invitations before case's diagnosis.

Reaching Underserved Women with Mammography: 15 month experience with a Mobile Prevention Unit and Prevention Program

Abstract Objective: There is much debate regarding the efficacy of mammography screening in women &amp;lt;50. No cost and low cost service providers may be required to target screening to the population at highest risk in order to maximize utility of resources. We sought to describe outcomes of women &amp;gt;40 undergoing mammography screening in underserved areas through a mobile unit and prevention program affiliated with a large network cancer program in Louisville, Kentucky. Methods: We conducted a retrospective review of women undergoing mammography during the period 3/08-6/09. Locations determined to be high risk by GIS analysis, income and cancer incidence. Analyses included: descriptive analyses, calculation of odds ratios and confidence intervals and regression analyses. Results: Of the 1702 women, 735 (43%) were white, 884 (52%) were African American, 54 (3%) other and 236 (14%) Hispanic/Latina. The mean age was 54 (std.dev. 9.4). Twenty-eight percent of the women (471/1702) had either never had a mammogram or not had one in 5 years. Fifty-one percent were uninsured. Of the 1702 women, 662(39%) were between the ages of 40-49 (Group A) and 1040 (61%) were &amp;gt;49 (Group B). The majority of women resided in high risk areas (74% Group A, 51% Group B). Twelve percent (206/1702) of the mammograms were abnormal and required follow up. Women in Group A were 1.4 times more likely than women in Group B to have a screening mammogram classified as abnormal (OR 1.4 95% CI 1.05-1.88). Four women were diagnosed with cancer in group A (0.6%) and 9 in group B (0.8%), P = ns. The median age of women with cancer was 52, mean = 58, range 42-83, (std. dev. 12.5). The overall follow up rate was 92%. All women with cancer received treatment. Logistic regression analysis demonstrated women of African American race and women who had never been screened were more likely to have abnormal results (P &amp;lt; 0.0001 and P = 0.03 respectively). Conclusion: Our targeted approach of community based screening was successful in identifying a subpopulation of women who are not regularly screened and are at risk for abnormal screening mammograms and breast cancer. Further studies are needed to determine if recommendations for screening should be based on factors other than age.

TU-C-210A-03: Molecular Imaging of the Breast

Recent controversy over the efficacy of screening mammography highlights the need for more effective breast imaging techniques. While the sensitivity of mass breast cancer screening with mammography is in the range 60% – 90%, numerous studies have demonstrated that this sensitivity is reduced to less than 50% in radiographically dense breasts. Hence there is need for an alternative screening technique, particularly in women with radiographically dense breasts. A recent ACRIN trial shows that whole breast ultrasound had comparable performance to mammography. Breast MRI performs very well in this population, but high cost and variable specificity limit its application. Conventional scintimammography has a high overall sensitivity and specificity for the detection of breast cancer. However sensitivity drops to ∼50% for the detection of breast lesions less than 15 mm in diameter, making it unsuitable as a diagnostic or screening tool. Molecular Breast Imaging (MBI) refers to a new technique that employs small field of view gamma cameras specifically designed for breast imaging. These cameras utilize either multi‐crystal arrays of Sodium Iodide (NaI) or more recently, use semiconductor materials such as Cadmium‐Zinc‐Telluride (CZT). Using Tc‐99m sestamibi as the primary radiopharmaceutical, MBI has been shown to have a high sensitivity (∼90%) for the detection of breast lesions < 10 mm in diameter. Hence, MBI may be a valuable screening tool, particularly for women in whom the sensitivity of conventional mammography is reduced by the density of the breast parenchyma. This presentation will review the basic principles of molecular breast imaging, and present current clinical results. It will also present details of prototype systems currently under development and future plans for this technology. Learning Objectives: 1. Understand the limitations of current imaging techniques of the breast, including mammography,ultrasound,MRI and scintimammography. 2. Understand the basic concept of multi‐crystal and semiconductor‐based gamma cameras. 3. Describe the relative advantages and disadvantages of scintimammography and molecular breast imaging. 4. Understand the potential advantages/disadvantages and future applications for this technology in the detection and understanding of breast cancer.

Mammography Reduces Breast Cancer Mortality: More Evidence

Randomized trials demonstrating the efficacy of screening mammography in reducing breast cancer mortality were performed in the U.S. decades ago, and

Protection of mammography screening against death from breast cancer in women aged 40–64 years

This study assessed the efficacy of community-based screening mammography in protecting against breast cancer death, asking whether age differences in efficacy persisted in the 1990s. In a case-control study with follow-up, odds ratios (OR) were used to estimate the relative mortality rates from invasive breast cancer among women with at least one screening mammogram in the two years prior to a baseline reference date compared to non-screened women, adjusting for potential confounding. The multicenter population-based study included 553 black and white women diagnosed during 1994-1998 who died in the following five years, and 4016 controls without breast cancer. Efficacy for reducing the rate of breast cancer death within five years after diagnosis was greater at ages 50-64 years (OR = 0.47, 95% confidence interval (CI) 0.35-0.63) than at ages 40-49 (OR = 0.89, 95% CI 0.65-1.23), and greater among postmenopausal (OR = 0.45, 95% CI 0.33-0.62) than premenopausal women (OR = 0.74, 95% CI 0.53-1.04). Estimates of efficacy were conservative, as shown by sensitivity analyses addressing whether cancer was discovered by a screening mammogram, age at which screening was received, the length of the screening observation window, and years of follow-up after diagnosis. Despite the persistence of age differences in efficacy of mammography screening, with greater observed benefit for women aged 50-64 years, these findings support current screening recommendations for women 40-64 years old.

To Screen or Not to Screen Older Women for Breast Cancer: A New Twist on an Old Question or Will We Ever Invest in Getting the Answers?

Women 65 or older (hereinafter referred to as older women) constitute one half of new breast cancer patients each year. With the graying of America, the absolute number of patients in this age group will double by the year 2030. The efficacy of screening mammography for improving survival of this growing older population has never been demonstrated in a randomized trial, leading most groups to qualify their screening recommendations for older women, especially women older than age 74 or 79. However, annual mammography is recommended for breast cancer screening surveillance for all women after treatment for breast cancer, despite the absence of clinical trial evidence for effectiveness in older women (or any other age group). Filling this evidence gap was the goal of the study in this issue of the Journal of Clinical Oncology by Lash and colleagues. Lash et al used data from a large cohort of older breast cancer survivors with stage I and II disease receiving care in managed care settings to examine the protective effect of mammography on breast cancer and all cause mortality. They found that there was a striking 31% (95% CI, 18% to 48%) reduction in the odds of death for each additional surveillance mammogram, after considering tumor characteristics, comorbidity, surgery, and other covariates. Unfortunately, even with guaranteed access in the managed care environment, use of mammography among survivors fell well below the recommended annual recommendation, with 40% of decedents having no mammograms, 32% having only one, and only 41% of survivors having four or more mammograms in the 5-year follow-up period. Given these rates of surveillance and an estimated prevalence of older breast cancer survivors of 2.3 million, the results of Lash and colleagues suggest that as many as 500,000 older women will die of their breast cancers due to suboptimal mammography surveillance. One assumes that the survival advantage afforded to older breast cancer survivors by surveillance mammography is a result of the detection of curable new primaries in the contralateral breast. There is also growing evidence that survival is improved when surveillance detects early locoregional recurrences of the primary breast cancer. The fact that overall nonbreast cancer–specific survival was greater among women who underwent surveillance mammography in the Lash et al study also suggests that part of the benefit observed may have been due to observational bias (eg, unobservable or unmeasured selection of healthier women to mammography). However, the authors did conduct statistical analyses to try to correct for any such bias (propensity scoring), and the results of a strong survival benefit were robust. Randomized trials can avoid potential observational biases, but we are left with the persistent dilemma that older women have not been included in trials in sufficient numbers to provide the necessary evidence base. Moreover, as new technology evolves, this situation is being perpetuated. For example, a recent high-profile article from the American College of Radiology Imaging Network (ACRIN) trial demonstrated that magnetic resonance imaging (MRI) can detect new breast cancers in survivors that were not seen on clinical examination or mammography. The average age in the MRI study was 53.3 11.4 years; therefore, there were no women 65 or older included, leaving us to wonder if MRI should be applied in older patients. With continued gains in life expectancy, improvements in survival from breast cancer (and other major cancer sites), and increases in incidence with age, clinicians will be caring for an ever-increasing number of older breast cancer patients and survivors. Without a major shift in emphasis in clinical trials and new investments in understanding the impact of therapy and technology on older populations, we will continue to practice with limited trial evidence. In this situation, as demonstrated by the study by Lash et al, well-designed observational studies can provide a reasonable level of evidence. This high-quality observational research was facilitated by the development of the Cancer Research Network, a National Cancer Institute (NCI) –funded collaboration between 12 large, mature, managed care systems, including Group Health Cooperative, the Harvard Pilgrim Health Plan, Henry Ford Health Systems, Fallon Community Health Plan, and Kaiser Permanente in six regions. Managed care research networks have several potential advantages for studying questions about cancer care in older women. First, access is removed from the equation in survival outcomes. Second, they include large proportions of the population from almost all regions of the United States, providing an alternative universe for population-based studies. Third, the availability of computerized administrative databases linked to laboratory and pathology data and often electronic medical records allows careful delineation of disease and interventions and comprehensive, cost-efficient long-term follow-up. Thus, this network JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 25 NUMBER 21 JULY 2

Screening for breast cancer.

Mammographic screening for breast cancer commenced in the UK in 1988 following the recommendations of the Forrest Committee and is now well established. This article reviews the evidence for efficacy of mammographic screening, the mode of delivery of the service including the assessment of mammographic abnormalities and the role of needle biopsy in diagnosis. Despite the established position of breast screening in the UK there are continuing challenges, not least workforce issues and the recent extension of the programme. There is increasing interest in the use of digital mammography and research continues into the possibility of computer-assisted detection (CAD) of mammographic abnormalities.

Mammographic breast cancer screening: after the dust has settled

Breast cancer is still a major public health issue worldwide; according to present estimates, 1 million women will be diagnosed with breast cancer this year. There are no longer any countries in which the incidence is truly low. In the European Union, there are 1 million women alive today with breast cancer and over 100 000 deaths each year. Death can frequently occur at an age when a woman has maximal social responsibility. It is a common cause of cancer and cancer death and can frequently be a dreadful disease. Progress in breast cancer control is slow but steady with recent proof-ofconcept in Tamoxifen intervention giving a cause for hope for the future. Clinical and pathological considerations clearly demonstrate that survival following the diagnosis and treatment of breast cancer at an ‘early’ stage is much better than when the disease is locally advanced or metastatic. Mammography can detect tumours at a clinically undetectable stage; such tumours have a very good prognosis and many can be cured by appropriate treatment. Since the publication of the results of the Greater New York Trial and the Swedish Two-County Trial in the 1970s and 1980s, there has been a general consensus that screening for breast cancer with mammography reduces mortality from the disease. The results of these pioneering trials have for the most part been subsequently confirmed by later trials in Sweden, Canada and the United Kingdom. Although some debated issues endure, most notably issues of costeffectiveness of screening in particular age groups, the evidence that screening reduces deaths from breast cancer has grown and the consensus has remained. Results from trials were adequately promising that routine, population screening was either recommended or introduced as Public Health Policy in a number of populations. Questions about the quality of the trial data were raised by G tzsche and Olsen and vigorously debated. This challenge was renewed when The Lancet published a research letter by Olsen and G tzsche describing their overview of the mammographic screening trials and reaching a startling conclusion. It was asserted that ‘y the reliable evidence does not indicate any survival benefit of mass screening for breast cancer,’ and maintain that screening leads to more aggressive treatment. The publication has not prompted any major rethinking of screening policy in the United Kingdom, Sweden, the Netherlands or the United States, and most of the scientific community remains unconvinced by the arguments. To see why, consider the figure (Fig. 1) showing the published results of the mammographic screening trials. Overwhelmingly, the results indicate a substantial and significant reduction in breast cancer mortality with invitation to screening. The data in these trials have undergone repeated independent scrutiny and recent evidence suggests that in organised service screening programmes, the benefit may be greater than that observed in the trials. The situation was in striking contrast to the views of the media and the general public, where frequently major concerns were raised that screening was doing no good and may even be doing harm. The temperature was further raised when the PDQ Committee in the United States, in a highly publicised meeting, then down-graded their position on the quality of the evidence on mammographic screening. The controversy regarding the efficacy of mammographic screening is clearly one of the most important issues in cancer control at the present time. If recent conclusions questioning the efficacy of mammography ARTICLE IN PRESS

Validation of self-reported screening mammography histories among women with and without breast cancer.

As part of a case-control study of the efficacy of screening mammography, the authors validated the mammography histories of 2,495 women aged 40-64 years with incident breast cancer diagnosed in 1994-1998 and a 25% random sample of 615 controls never diagnosed with breast cancer, all reporting a mammogram in the past 5 years. Subjects from five metropolitan areas of the United States were cross-classified by facility records ("gold standard") and self-report according to history of a recent screening mammogram (within 1 year or within 2 years). Sensitivity and specificity of self-reported screening at 1 year were 0.93 and 0.82, respectively, for cases and 0.92 and 0.80 for controls. At 2 years, sensitivity and specificity were 0.97 and 0.78 for both cases and controls. Confidence intervals for the differences in sensitivity and specificity were narrow and included zero. Scant evidence was found of telescoping (recollection of events as more recent than actual). Findings suggest that, in an interview-based case-control study of the efficacy of screening mammography, 1) estimated true prevalences of recent screening mammography adjusted for sensitivity and specificity will be slightly lower than self-reported prevalences, and 2) differential misclassification of exposure status is slight. Therefore, odds ratios will likely be biased toward the null, underestimating screening efficacy.

Field trial of mobile digital telemammography: Phase I—installation and testing of equipment

This report on the first phase of an evaluation and demonstration project to provide high quality mammography services to women in remote and underserved areas appears at a time of considerable controversy regarding the efficacy of screening mammography. The objectives of the first phase were focused on the technical feasibility of utilizing digital mammography in a mobile setting, transmitting the images via satellite for immediate interpretation at centers of excellence, and providing the results to the patient before she left the examination site. The next phase, a field trial on a Native American reservation, will include baseline data and operational measures to address patient participation, compliance with follow-up recommendations, and the costs and benefits of the program. With the support of the Komen Foundation, the project team was able to complete the initial phase of the project to evaluate a new method of providing real-time, expert mammography interpretations to rural and underserved women. In this phase, the project team tested the feasibility of using a mobile breast care center, equipped with a digital mammography unit, and a satellite telecommunication link to medical centers for image interpretation on an electronic review workstation. The satisfactory completion of this first phase supports the recommendation that a field trial using the methods described in this report be conducted with a remote rural population to determine the clinical efficacy and economic viability of this concept in delivering breast cancer detection services.

Breast cancer screening controversies.

The Cochrane Collaborative, a respected independent review body, recently published a meta-analysis of the effectiveness of screening mammography in decreasing breast cancer mortality. Based on the results of two controlled trials they judged to be of medium validity, they concluded that screening mammography was unjustified. In contrast, the US Preventive Services Task Force recently updated their screening recommendations, and based on a meta-analysis of the same randomized controlled trials, they recommended screening mammography for all women starting at age 40 years. Additionally the Canadian Task Force on Preventive Health Care no longer recommends breast self-examination (BSE). This article reviews the controversies regarding breast cancer screening. We performed a systematic review of the literature using keywords and cross-referencing articles. We also used automated data from the Breast Cancer Screening Program at Group Health Cooperative to determine the sensitivity of the clinical breast examination (CBE) at our institution. For the latter we included all cancers diagnosed within 1 year of a screening examination and then determined which of those had been found by CBE. Although most screening studies have shown that mammography decreases breast cancer death, there are controversies about the validity of some of the randomized controlled screening mammography trials. These controversies have led to different conclusions about the efficacy of screening mammography. Evidence is limited about the optimal interval for screening mammography. No studies have directly tested the efficacy of the CBE in decreasing breast cancer mortality. At Group Health Cooperative, 8% of all diagnosed breast cancers were found by the CBE alone (negative mammogram). Whether this 8% incremental increase in case finding leads to decreased breast cancer deaths is unknown. There is good evidence that training women to perform BSE does not increase breast cancer diagnoses or decrease breast cancer deaths. There are limitations to randomized controlled trials and meta-analyses. The balance of the evidence still favors screening mammography in women aged 40 years and older at least every 2 years. The independent incremental benefit of the CBE, when added to mammography, in decreasing breast cancer mortality is unknown. Population-based education and training to do BSE are unlikely to lead to decreased breast cancer deaths. Many women find their own breast cancers, so women need to pay attention to symptoms or changes in their breasts.