Overtreatment Of Breast Cancer Research Articles

Breast Cancer Screening Trials: Endpoints and Overdiagnosis.

Screening mammography was assessed in 9 randomized trials initiated between 1963 and 1990, with breast cancer-specific mortality as the primary endpoint. In contrast, breast cancer detection has been the primary endpoint in most screening trials initiated during the past decade. These trials have evaluated digital breast tomosynthesis, magnetic resonance imaging, and ultrasound, and novel screening strategies have been recommended solely on the basis of improvements in breast cancer detection rates. Yet, the assumption that increases in tumor detection produce reductions in cancer mortality has not been validated, and tumor-detection endpoints may exacerbate the problem of overdiagnosis. Indeed, the detection of greater numbers of early stage breast cancers in the absence of a subsequent decline in rates of metastatic cancers and cancer-related mortality is the hallmark of overdiagnosis. There is now evidence to suggest that both ductal carcinoma in situ and invasive cancers are overdiagnosed as a consequence of screening. For each patient who is overdiagnosed with breast cancer, the adverse consequences include unnecessary anxiety, financial hardships, and a small risk of morbidity and mortality from unnecessary treatments. Moreover, the overtreatment of breast cancer, as a consequence of overdiagnosis, is costly and contributes to waste in health-care spending. In this article, we argue that there is a need to establish better endpoints in breast cancer screening trials, including quality of life and composite endpoints. Tumor-detection endpoints should be abandoned, because they may lead to the implementation of screening strategies that increase the risk of overdiagnosis.

Trends in Breast Cancer Treatment De-Implementation in Older Patients with Hormone Receptor-Positive Breast Cancer: A Mixed Methods Study.

Guidelines allow for the omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy in women ≥ 70years of age with hormone receptor-positive (HR +) breast cancer. Despite this, national data suggest these procedures have not been widely de-implemented. Our objectives were to evaluate trends in SLNB and post-lumpectomy radiotherapy utilization in patients who are eligible for omission, and evaluate patient preferences as a target for de-implementation of low-value care. We performed a sequential explanatory mixed-methods study by first analyzing an institutional database of patients ≥ 70years of age with HR + breast cancer who received surgical treatment from 2014 to 2018. Based on the quantitative data, we conducted semi-structured interviews with women identified as high or low utilizers of breast cancer treatments to elicit patient perspectives on de-implementation. SLNB and post-lumpectomy radiotherapy were performed in 68% and 43% of patients, respectively, who met the criteria for omission. There was a significant decrease in SLNB rates from 2014 to 2018. Forty-nine percent of patients were classified as high utilizers and 26% were classified as low utilizers. Qualitative analysis found that the most important factors influencing decision making regarding SLNB and post-lumpectomy radiotherapy omission for both high and low utilizers were trust in their provider and a desire for peace of mind. Despite efforts to de-implement low-value care, older women with HR + breast cancer remain at risk of overtreatment. Patient perspectives suggest that multi-level de-implementation strategies will need to target provider practice patterns and patient-provider communication to promote high-quality decision making and reduction in breast cancer overtreatment.

Individualizing Local-Regional Therapy of Breast Cancer in the Elderly

The treatment of breast cancer in the elderly population requires a tailored approach. We summarize the current best evidence for personalized local-regional therapy in breast cancer patients older than 70. Breast cancer treatment in older adults incorporates the use of geriatric assessment tools to best evaluate functional status and treatment tolerability while accounting for the biologic profile of the disease. Surgical resection of the primary tumor with lymph node evaluation remains the cornerstone of local-regional control. Recent clinical trials demonstrate that surgery and radiation therapy may, however, be safely omitted in selected patients who are eligible for primary endocrine therapy. In patients with high-risk node-positive disease, DFS can be improved by systemic chemotherapy, but potential toxicity should be carefully considered in this population. Patient-specific evaluation of the risks of both under- and over-treatment of breast cancer in the older adult is essential for delivering optimal care in this population.

Recent Trends in Chemotherapy Use and Oncologists' Treatment Recommendations for Early-Stage Breast Cancer.

There is growing concern about overtreatment of breast cancer as outcomes have improved over time. However, little is known about how chemotherapy use and oncologists' recommendations have changed in recent years. We surveyed 5080 women (70% response rate) diagnosed with breast cancer between 2013 and 2015 and accrued through two Surveillance, Epidemiology, and End Results registries (Georgia and Los Angeles) about chemotherapy receipt and their oncologists' chemotherapy recommendations. We surveyed 504 attending oncologists (60.3% response rate ) about chemotherapy recommendations in node-negative and node-positive case scenarios. We conducted descriptive statistics of chemotherapy use and patients' report of oncologists' recommendations and used a generalized linear mixed model of chemotherapy use according to time and clinical factors. All statistical tests were two-sided. The analytic sample was 2926 patients with stage I-II, estrogen receptor-positive, human epidermal growth factor receptor 2-negative breast cancer. From 2013 to 2015, keeping other factors constant, chemotherapy use was estimated to decline from 34.5% (95% confidence interval [CI] = 30.8% to 38.3%) to 21.3% (95% CI = 19.0% to 23.7%, P < .001). Estimated decline in chemotherapy use was from 26.6% (95% CI = 23.0% to 30.7%) to 14.1% (95% CI = 12.0% to 16.3%) for node-negative/micrometastasis patients and from 81.1% (95% CI = 76.6% to 85.0%) to 64.2% (95% CI = 58.6% to 69.6%) for node-positive patients. Use of the 21-gene recurrence score (RS) did not change among node-negative/micrometastasis patients, and increasing RS use in node-positive patients accounted for one-third of the chemotherapy decline. Patients' report of oncologists' recommendations for chemotherapy declined from 44.9% (95% CI = 40.2% to 49.7%) to 31.6% (95% CI = 25.9% to 37.9%), controlling for other factors. Oncologists were much more likely to order RS if patient preferences were discordant with their recommendations (67.4%, 95% CI = 61.7% to 73.0%, vs 17.5%, 95% CI = 13.1% to 22.0%, concordant), and they adjusted recommendations based on patient preferences and RS results. For both node-negative/micrometastasis and node-positive patients, chemotherapy receipt and oncologists' recommendations for chemotherapy declined markedly over time, without substantial change in practice guidelines. Results of ongoing trials will be essential to confirm the quality of this approach to breast cancer care.

Current Issues in the Overdiagnosis and Overtreatment of Breast Cancer.

The discovery of breast cancer at earlier stages with screening brings the risk that some cancers will be overdiagnosed or overtreated. Reasonable estimates show the overdiagnosis rate due to screening mammography to be low, 1-10%. Overdiagnosis should not be used as a reason to delay the onset or decrease the frequency of screening, because neither strategy will decrease overdiagnosis. Improvements in personalized treatment will diminish the morbidity of treatment and, therefore, the significance of overdiagnosis.

Mammography screening — a recognised standard

Breast cancer is the most common global malignancy found in women and likewise so in Poland; newly diagnosed cases being respectively ≈ 1.7 million and 17 thousand annually. For the last 30 years, population screening has been adopted in the developed world. In Poland, breast screening attendance is however around 45%, what is still lower than in highly developed countries (above 70%). Breast cancer mortality has also declined more slowly in Poland. Following the introduction of breast screening, the rapid decreases in mortality demonstrated in Western Europe and the USA prove its effectiveness. Observations and data accumulated over many years through screening have nevertheless generated debate regarding overdiagnosis and overtreatment of breast cancer. This issue has been summarised in the WHO Position Paper that recommends continuing breast screening whilst also ensuring that patients are able to make informed decisions.

The effect of information about overdetection of breast cancer on women's decision-making about mammography screening: study protocol for a randomised controlled trial

IntroductionWomen 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...

In Response

In Response

Overdiagnosis and Overtreatment of Breast Cancer: How Can We Promote Informed Patient Choice?

Stemming from closer examination of breast cancer incidence treads, there has been growing concern about the issues of overdiagnosis and overtreatment of breast cancer. As incidence trends showing a limited decline in later stage cancers shed doubt on the extent of benefit screening mammography holds, women need to be informed accordingly. However, it is apparent that women often do not fully understand the risks and benefits they face when undergoing screening mammography. Further, treatment decisions for women diagnosed with breast cancer are equally, if not more challenging, and studies suggest women are ill-informed here too. As the science improves and allows us to better differentiate bad acting cancers from those with no or limited risk, improved communication tools such as decision aids and shared decision making will be imperative as a means to promote informed patient choice.

Screening mammography in older women: the balance between appropriate use and overuse

263 ISSN 1758-1923 10.2217/BMT.13.24 © 2013 Future Medicine Ltd Breast Cancer Manage. (2013) 2(4), 263–265 The incidence of female breast cancer gen‐ erally increases with age, with a median age of 61 years at the time of diagnosis. Women aged 65 years and older comprise approximately 35% of incident breast can‐ cer cases and 57% of breast cancer deaths [1]. The likelihood of death from breast cancer increases with advanced stage and larger tumor size at diagnosis. An impor‐ tant strategy to reduce such deaths is to screen asymptomatic women with mam‐ mography in order to detect and treat breast cancer in its preclinical stage and improve survival. However, ubiquitous mammographic screening among older women may not confer the expected ben‐ efit, but instead may result in unintended harms. For example, there is at least a 4‐year lag between screen‐detected breast cancer and onset of clinical symptoms for women aged 65–74 years [2]. Mammo‐ graphy trials found no survival difference between screened and unscreened women before 7 years of follow‐up for women aged 65–74 years [3]. In older women with lim‐ ited life expectancy, the delayed screening benefit does not have sufficient time to emerge because of competing risks. In fact, such women may be exposed to immediate physical and psychological harms caused by false‐positive results, invasive diagnostic tests, and overdiagnosis and overtreatment of breast cancer that otherwise would not have been diagnosed and treated in their lifetime [4,5]. High‐quality screening mam‐ mography services need to strike a balance between appropriate use and overuse; that is, they must screen older women who have a long enough life expectancy to benefit and avoid screening those with limited life expectancy. Both underuse and overuse of screen‐ ing mammography are evident among older women. Current cancer screening guidelines generally set age limits in their recommendations. For example, the US Preventive Services Task Force recom‐ mends regular screening mammography for women aged 50–74 years and individu‐ alized screening decisions for those aged 75 years and older [6]. It was estimated that, among women aged 75–90 years, approxi‐ mately 80% had an estimated life expec‐ tancy of 7 or more years and 60% had a life expectancy of 10 or more years [7,8]. With the rapid growth of the aging population, the proportion of such healthy, very old persons is expected to increase accordingly.

Costs, Evidence, and Value in the Medicare Program

Costs, Evidence, and Value in the Medicare Program

Overdiagnosis and Overtreatment of Breast Cancer

Breast cancer is the most common cancer in women. Through greater awareness, mammographic screening, and aggressive biopsy of calcifications, the proportion of low-grade, early stage cancers and in situ lesions among all breast cancers has risen substantially. The introduction of molecular testing has increased the recognition of lower risk subtypes, and less aggressive treatments are more commonly recommended for these subtypes. Mammographically detected breast cancers are much more likely to have low-risk biology than symptomatic tumors found between screenings (interval cancers) or that present as clinical masses. Recognizing the lower risk associated with these lesions and the ability to confirm the risk with molecular tests should safely enable the use of less aggressive treatments. Importantly, ductal carcinoma in situ (DCIS) lesions, or what have been called stage I cancers, in and of themselves are not life-threatening. In situ lesions have been treated in a manner similar to that of invasive cancer, but there is little evidence to support that this practice has improved mortality. It is also being recognized that DCIS lesions are heterogeneous, and a substantial proportion of them may in fact be precursors of more indolent invasive cancers. Increasing evidence suggests that these lesions are being overtreated. The introduction of molecular tests should be able to help usher in a change in approach to these lesions. Reclassifying these lesions as part of the spectrum of high-risk lesions enables the use of a prevention approach. Learning from the experience with active surveillance in prostate cancer should empower the introduction of new approaches, with a focus on preventing invasive cancer, especially given that there are effective, United States Food and Drug Administration (FDA)-approved breast cancer preventive interventions.

Overdiagnostikk av brystkreft etter 14 år med mammografiscreening

In 2004 we wrote in Tidsskriftet that mammography screening resulted in massive over-diagnosis and over-treatment of breast cancer. Our study was criticised because we had only five years of follow-up time and did not take account of the fact that increased use of hormone replacement therapy could lead to more breast cancer. We have now been screening women for 14 years, and during a period when the use of hormones has fallen by 70 %. Age-specific incidence rates, detection rates and interval rates for breast cancer in the period 1991-2009 have been computed for 40-79 year-old women. Incidence trends have been calculated using Poisson regression. The incidence of breast cancer in the age group 40-49 was stable throughout the period, but rose by 50 % in the age group 50-69 years immediately after the start of screening. There was no significant reduction in the incidence of breast cancer in the age group 70-74. The number of new cases of breast cancer in the period increased from around 2000 to 2750. About 300 cases of ductal carcinoma in situ (DCIS) were also diagnosed. Today a total of some 1050 more women have been diagnosed than before screening started. Our calculations indicate that in the absence of screening, around 800 of these women would never have become breast cancer patients. The figures from 14 years of mammography screening indicate that all increase in the incidence of breast cancer is due to over-diagnosis: findings of tumours that in the absence of screening would never have given rise to clinical illness.

Overdiagnosis and Overtreatment of Breast Cancer

Overview: Breast cancer is the most common cancer in women. Through greater awareness, mammographic screening, and aggressive biopsy of calcifications, the proportion of low-grade, early stage cancers and in situ lesions among all breast cancers has risen substantially. The introduction of molecular testing has increased the recognition of lower risk subtypes, and less aggressive treatments are more commonly recommended for these subtypes. Mammographically detected breast cancers are much more likely to have low-risk biology than symptomatic tumors found between screenings (interval cancers) or that present as clinical masses. Recognizing the lower risk associated with these lesions and the ability to confirm the risk with molecular tests should safely enable the use of less aggressive treatments. Importantly, ductal carcinoma in situ (DCIS) lesions, or what have been called stage I cancers, in and of themselves are not life-threatening. In situ lesions have been treated in a manner similar to that of invasive cancer, but there is little evidence to support that this practice has improved mortality. It is also being recognized that DCIS lesions are heterogeneous, and a substantial proportion of them may in fact be precursors of more indolent invasive cancers. Increasing evidence suggests that these lesions are being overtreated. The introduction of molecular tests should be able to help usher in a change in approach to these lesions. Reclassifying these lesions as part of the spectrum of high-risk lesions enables the use of a prevention approach. Learning from the experience with active surveillance in prostate cancer should empower the introduction of new approaches, with a focus on preventing invasive cancer, especially given that there are effective, United States Food and Drug Administration (FDA)-approved breast cancer preventive interventions.

Request for Complementary Medicine After Brain Death

2008;247(3):597-601. 2. Habbema JD, Tan SY, Cronin KA. Impact of mammography on US breast cancer mortality, 1975-2000: are intermediate outcome measures informative? J Natl Cancer Inst Monogr. 2006;(36):105-111. 3. Duffy SW, Agbaje O, Tabar L, et al. Overdiagnosis and overtreatment of breast cancer: estimates of overdiagnosis from two trials of mammographic screening for breast cancer. Breast Cancer Res. 2005;7(6):258-265. 4. Ganott MA, Sumkin JH, King JL, et al. Screening mammography: do women prefer a higher recall rate given the possibility of earlier detection of cancer? Radiology. 2006;238(3):793-800. 5. Berry DA, Cronin KA, Plevritis SK, et al; Cancer Intervention and Surveillance Modeling Network (CISNET) Collaborators. Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med. 2005;353(17):1784-1792.

Maximizing Informed Cancer Screening Decisions

Maximizing Informed Cancer Screening Decisions

Overdiagnosis and overtreatment of breast cancer: Is overdiagnosis an issue for radiologists?

Overdiagnosis is diagnosis of cancers that would not present within the life of the patient and is one of the downsides of screening. This applies to low-grade ductal carcinoma in situ and some small grade 1 invasive cancers. Radiologists are responsible for cancer diagnosis, but at the time of diagnosis they cannot determine whether a particular low-grade diagnosis is one to which the definition of overdiagnosis applies. Overdiagnosis is likely to be driven by technological developments, including digital mammography, computer-aided detection and improved biopsy techniques. It is also driven by the patient's fear that cancer will be missed and the doctor's fear of litigation. It is therefore an issue of importance for radiologists, presenting them with difficult fine-tuned decisions in every assessment clinic that are ultimately counted later by those who evaluate their screening.

Overdiagnosis and overtreatment of breast cancer: Progression of ductal carcinoma in situ: the pathological perspective

Ductal carcinoma in situ (DCIS) is encountered much more frequently in the screening population compared to the symptomatic setting. The behaviour of DCIS is highly variable and this presents difficulties in choosing appropriate treatment strategies for individual cases. This review discusses the current data on the frequency and rate of progression of DCIS, the value and limitations of clinicopathological and biological variables in predicting disease behaviour and suggests strategies to develop more robust means of predicting progression of DCIS.

Overdiagnosis and overtreatment of breast cancer: Rates of ductal carcinoma in situ: a US perspective

The incidence of breast ductal carcinoma in situ (DCIS) in the USA exceeds that of other countries. This cannot be explained entirely by the frequency of mammographic screening in the USA and may result from differences in the interpretation of mammograms and/or the frequency with which biopsies are obtained. Although the percentage of DCIS patients treated with mastectomy has decreased, the absolute number is unchanged and the use of lumpectomy with whole-breast radiotherapy has increased in inverse proportion to the decrease in mastectomy. Treatment of DCIS with tamoxifen is still limited.

Overdiagnosis and overtreatment of breast cancer: Overdiagnosis and overtreatment in service screening

Screening mammography has been shown to be effective for reducing breast cancer mortality. According to screening theory, the first expected consequence of mammography screening is the detection of the disease at earlier stages and this diagnostic anticipation changes the population incidence curve, with an observed increase in incidence rates at earlier ages. It is unreasonable to expect that the age-specific incidence will ever return to pre-screening levels or to anticipate a significant reduction of incidence at older ages immediately after the first screening round. The interpretation of incidence trends, especially in the short term, is difficult. Methodology for quantification of overdiagnosis and statistical modelling based on service screening data is not well developed and few population-based studies are available. The overtreatment issue is discussed in terms of appropriateness of effective treatment considering the question of chemotherapy in very early stages and the use of breast conserving surgery.