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David Plaut: Off the Cuff

Mammography Screening: To Screen or Not to Screen?

Published May 8, 2014 1:29 PM by David Plaut

Recently, the Swiss Medical Board proposed discontinuing screening of women for breast cancer using mammography. The report did not suggest an alternate. The board included a medical ethicist, a clinical epidemiologist, a clinical pharma-cologist, an oncologic surgeon, a nurse scientist, a lawyer and a health economist. Two of the board, the ethicist and epidemiologist, have written about the report, pointing out four particular concerns they had (none of the four argued for screening). In both this and the next blog, I want to quote extensively from their report (the entire report and the text from the two members are available) (1,2).

The first point addressed the fact “that the ongoing debate [over screening with mammograms] was based on a series of re-analyses of the same, predominantly outdated trials. The first trial started more than 50 years ago in New York City and the last trial in 1991 in the United Kingdom. None of these trials were initiated in the era of modern breast-cancer treatment, which has dramatically improved the prognosis of women with breast cancer.”

In 2011, a study from the UK showed an increasing effectiveness -- from a 28% reduction in breast cancer mortality in the period 1975-1991 to 65% in the period 1992-2008. The article did not report on the mortality in the population at large (3). It was this that led to the second issue the board raised – “over diagnosis.” The two members of the board said that they “were struck by how non-obvious it was that the benefits of mammography screening outweighed the harms. The relative risk reduction of approximately 20% in breast-cancer mortality associated with mammography that is currently described by most expert panels came at the price of a considerable diagnostic cascade, with repeat mammography, subsequent biopsies and over diagnosis of breast cancers — cancers that would never have become clinically apparent. The recently published extended follow-up of the Canadian National Breast Screening Study is likely to provide reliable estimates of the extent of over-diagnosis. chemotherapy or some combination of these therapies.”

In my next blog, I will discuss the third and fourth comments that the ethicist and epidemiologist brought to our attention.

References:

1.            N Engl J Med. 2014 Apr 16.

2.            www.medical-board.ch

3.            Br J Cancer. 2011 Mar 15;104(6):910-4.

posted by David Plaut

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