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Why mammography screening has not lived up to expectations from the randomised trials

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Abstract

We analysed the relation between tumour sizes and stages and the reported effects on breast cancer mortality with and without screening in trials and observational studies. The average tumour sizes in all the trials suggest only a 12% reduction in breast cancer mortality, which agrees with the 10% reported in the most reliable trials. Recent studies of tumour sizes and tumour stages show that screening has not lowered the rate of advanced cancers. In agreement with this, recent observational studies of breast cancer mortality have failed to find an effect of screening. In contrast, screening leads to serious harms in healthy women through overdiagnosis with subsequent overtreatment and false-positive mammograms. We suggest that the rationale for breast screening be urgently reassessed by policy-makers. The observed decline in breast cancer mortality in many countries seems to be caused by improved adjuvant therapy and breast cancer awareness, not screening. We also believe it is more important to reduce the incidence of cancer than to detect it ‘early.’ Avoiding getting screening mammograms reduces the risk of becoming a breast cancer patient by one-third.

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References

  1. Forrest P (ed) (1986) Breast cancer screening. Report to the health ministers of England, Wales, Scotland & Northern Ireland. Department of Health and Social Science

  2. Nyström L, Rutqvist LE, Wall S et al (1993) Breast cancer screening with mammography: overview of Swedish randomised trials. Lancet 341:973–978

    Article  PubMed  Google Scholar 

  3. Austoker J (1994) Screening and self examination for breast cancer. BMJ 309:168–174

    Article  PubMed  CAS  Google Scholar 

  4. Department of Health (1992) The health of the nation: a strategy for health in England. HMSO, London

  5. Byers T, Mouchawar J, Marks J et al (1999) The American Cancer Society challenge goals. How far can cancer rates decline in the U.S. by the year 2015? Cancer 86:715–727

    Article  PubMed  CAS  Google Scholar 

  6. Gøtzsche PC, Olsen O (2000) Is screening for breast cancer with mammography justifiable? Lancet 355:129–134

    Article  PubMed  Google Scholar 

  7. Olsen O, Gøtzsche PC (2001) Screening for breast cancer with mammography (Cochrane Review). In: The Cochrane Library, Issue 4. Update Software, Oxford

  8. Humphrey LL, Helfand M, Chan BK, Woolf SH (2002) Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 137(5 Part 1):347–360

    Google Scholar 

  9. Gøtzsche PC, Nielsen M (2009) Screening for breast cancer with mammography. Cochrane Database Syst Rev (4). Art. No.: CD001877

  10. Jørgensen KJ, Zahl P-H, Gøtzsche PC (2010) Breast cancer mortality in organised mammography screening in Denmark: comparative study. BMJ 340:c1241

    Article  PubMed  Google Scholar 

  11. Autier P, Boniol M, LaVecchia C et al (2010) Disparities in breast cancer mortality trends between 30 European countries: retrospective trend analysis of WHO mortality database. BMJ 341:c3620

    Google Scholar 

  12. Kalager M, Zelen M, Langmark F, Adami HO (2010) Effect of screening mammography on breast-cancer mortality in Norway. N Engl J Med 363:1203–1210

    Article  PubMed  CAS  Google Scholar 

  13. Berry DA, Cronin KA, Plevritis SK et al (2005) Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med 353:1784–1792

    Article  PubMed  CAS  Google Scholar 

  14. Correspondences and author reply (2006) Screening and breast cancer. N Engl J Med 354:767–769

    Article  Google Scholar 

  15. Spratt JS, Meyer JS, Spratt JA (1996) Rates of growth of human neoplasms: part II. J Surg Oncol 61:68–83

    Article  PubMed  CAS  Google Scholar 

  16. Friberg S (2005) On the growth rates of human malignant tumors: implications for medical decision making. J Oncol 55:1–22

    Google Scholar 

  17. Zahl PH, Gøtzsche PC, Mæhlen J (2011) Natural history of breast cancers detected in the Swedish mammography screening program; a cohort study. Lancet Oncol. doi:10.1016/S1470-2045(11)70250-9

  18. Skrabanek P (1985) False premises and false promises of breast cancer screening. Lancet 2:316–320

    Article  PubMed  CAS  Google Scholar 

  19. Fournier Dv, Weber E, Hoeffken W et al (1980) Growth rate of 147 mammary carcinomas. Cancer 45:2198–2207

    Article  Google Scholar 

  20. Narod SA (1997) On being the right size: a reappraisal of mammography trials in Canada and Sweden. Lancet 349:1869

    Article  Google Scholar 

  21. Andersson I, Aspegren K, Janzon L et al (1988) Mammographic screening and mortality from breast cancer: the Malmö mammographic screening trial. BMJ 297:943–948

    Article  PubMed  CAS  Google Scholar 

  22. Frisell J, Eklund G, Hellstrom L, Somell A (1987) Analysis of interval breast carcinomas in a randomized screening trial in Stockholm. Breast Cancer Res Treat 9:219–225

    Article  PubMed  CAS  Google Scholar 

  23. Tabar L, Fagerberg G, Chen HH et al (1996) Tumour development, histology and grade of breast cancers: prognosis and progression. Int J Cancer 66:413–419

    Article  PubMed  CAS  Google Scholar 

  24. Engel J, Eckel R, Kerr J et al (2003) The process of metastasisation for breast cancer. Eur J Cancer 39:1794–1806

    Article  PubMed  CAS  Google Scholar 

  25. Carter CL, Allen C, Henson DE (1989) Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer 63:181–187

    Article  PubMed  CAS  Google Scholar 

  26. Cuzick J, Sestak I, Pinder SE et al (2011) Effect of tamoxifen and radiotherapy in women with locally excised ductal carcinoma in situ: long-term results from the UK/ANZ DCIS trial. Lancet Oncol 12:21–29

    Article  PubMed  CAS  Google Scholar 

  27. Boer R, Warmerdam P, de Koning H, van Oortmarssen G (1994) Extra incidence caused by mammographic screening. Lancet 343:979

    Article  PubMed  CAS  Google Scholar 

  28. Tabár L, Duffy SW, Yen M-F et al (2002) All-cause mortality among breast cancer patients in a screening trial: support for breast cancer mortality as an end point. J Med Screen 9:159–162

    Article  PubMed  Google Scholar 

  29. Jørgensen KJ, Gøtzsche PC (2009) Overdiagnosis in publicly organised mammography screening programmes: systematic review of incidence trends. BMJ 339:b2587

    Article  PubMed  Google Scholar 

  30. Morrell S, Barratt A, Irwig L et al (2010) Estimates of overdiagnosis of invasive breast cancer associated with screening mammography. Cancer Causes Control 21:275–282

    Article  PubMed  Google Scholar 

  31. Weedon-Fekjaer H, Lindqvist BH, Vatten LJ, Aalen OO, Tretli S (2008) Estimating mean sojourn time and screening sensitivity using questionnaire data on time since previous screening. J Med Screen 15:83–90

    Article  PubMed  Google Scholar 

  32. Zahl PH, Strand BH, Maehlen J (2004) Incidence of breast cancer in Norway and Sweden during introduction of nationwide screening: prospective cohort study. BMJ 328:921–924

    Article  PubMed  Google Scholar 

  33. Jørgensen KJ, Zahl P-H, Gøtzsche PC (2009) Overdiagnosis in organised mammography screening in Denmark: a comparative study. BMC Women’s Health 9:36

    Article  PubMed  Google Scholar 

  34. Nielsen M, Thomsen JL, Primdahl S et al (1987) Breast cancer atypia among young and middle-aged women: a study of 110 medicolegal autopsies. Br J Cancer 56:814–819

    Article  PubMed  CAS  Google Scholar 

  35. Welch HG, Black WC (1997) Using autopsy series to estimate the disease “reservoir” for ductal carcinoma in situ of the breast. Ann Intern Med 127:1023–1028

    PubMed  CAS  Google Scholar 

  36. Yen MF, Tabar L, Vitak B et al (2003) Quantifying the potential problem of overdiagnosis of ductal carcinoma in situ in breast cancer screening. Eur J Cancer 39:1746–1754

    Article  PubMed  Google Scholar 

  37. Smith RA, Duffy SW, Gabe R et al (2004) The randomized trials of breast cancer screening: what have we learned? Radiol Clin N Am 42:793–806

    Article  PubMed  Google Scholar 

  38. Paci E, Warwick J, Falini P, Duffy SW (2004) Overdiagnosis in screening: is the increase in breast cancer incidence rates a cause for concern? J Med Screen 11:23–27

    Article  PubMed  CAS  Google Scholar 

  39. Duffy SW, Agbaje O, Tabar L et al (2005) Overdiagnosis and overtreatment of breast cancer: estimates of overdiagnosis from two trials of mammographic screening for breast cancer. Breast Cancer Res 7:258–265

    Article  PubMed  Google Scholar 

  40. Olsen AH, Agbaje OF, Myles JP et al (2006) Overdiagnosis, sojourn time, and sensitivity in the Copenhagen mammography screening program. Breast J 12:338–342

    Article  PubMed  Google Scholar 

  41. Tabar L, Fagerberg CJG, Gad A et al (1985) Reduction in mortality from breast cancer after mass screening with mammography. Randomised trial from the Breast Cancer Screening Working Group of the Swedish National Board of Health and Welfare. Lancet 1:829–832

    Article  PubMed  CAS  Google Scholar 

  42. Tabar L, Fagerberg G, Duffy SW et al (1992) Update of the Swedish two-county program of mammographic screening for breast cancer. Radiol Clin N Am 30:187–210

    PubMed  CAS  Google Scholar 

  43. Tabar L, Fagerberg CJG, Day NE (1988) The results of periodic one-view mammographic screening in Sweden. Part 2: evaluation of the results. Hans Huber, Toronto, pp 39–44

  44. Tabar L, Fagerberg G, Chen HH et al (1995) Efficacy of breast cancer screening by age. New results from the Swedish Two-County Trial. Cancer 75:2507–2517

    Article  PubMed  CAS  Google Scholar 

  45. Zahl PH, Kopjar B, Mæhlen J (2001) Norske tall for brystkreftdødelighet og validititet i svenske mammografistudier. Tidsskr Nor Laegeforen 121:1928–1931

    Google Scholar 

  46. Gøtzsche PC (2004) On the benefits and harms of screening for breast cancer. Int J Epidemiol 33:56–64

    Article  PubMed  Google Scholar 

  47. Zahl P-H, Gøtzsche PC, Andersen JM, Mæhlen J (2006) Results of the Two-County trial of mammography screening are not compatible with contemporaneous official Swedish breast cancer statistics. Dan Med Bull 53:438–440

    PubMed  Google Scholar 

  48. Tabár L, Smith RA, Duffy SW (2002) Update on effects of screening mammography. Lancet 360:337

    Article  PubMed  Google Scholar 

  49. Gøtzsche PC (2011) Relation between breast cancer mortality and screening effectiveness: systematic review of the mammography trials. Dan Med Bull 58:A4246

    PubMed  Google Scholar 

  50. Fletcher SW, Elmore JG (2003) Mammographic screening for breast cancer. N Engl J Med 348:1672–1680

    Article  PubMed  Google Scholar 

  51. Esserman L, Shieh Y, Thompson I (2009) Rethinking screening for breast cancer and prostate cancer. JAMA 302:1685–1692

    Article  PubMed  CAS  Google Scholar 

  52. Jørgensen KJ, Keen JD, Gøtzsche PC (2011) Is mammographic screening justifiable considering its substantial overdiagnosis rate and minor effect on mortality? Radiology 260:621–626

    Article  PubMed  Google Scholar 

  53. Hofvind S, Sorum R, Thoresen S (2008) Incidence and tumor characteristics of breast cancer diagnosed before and after implementation of a population-based screening-program. Acta Oncol 47:225–231

    Article  PubMed  Google Scholar 

  54. Fracheboud J, Otto SJ, van Dijck JA, Broeders MJ, Verbeek AL, de Koning HJ (2004) Decreased rates of advanced breast cancer due to mammography screening in The Netherlands. Br J Cancer 91:861–867

    PubMed  CAS  Google Scholar 

  55. Autier P, Boniol M, Middleton R et al (2011) Advanced breast cancer incidence following population based mammographic screening. Ann Oncol 20 Jan (Epub ahead of print)

  56. Autier P, Boniol M, Gavin A, Vatten LJ (2011) Breast cancer mortality in neighbouring European countries with different levels of screening but similar access to treatment: trend analysis of WHO mortality database. BMJ 343:d4411

    Article  PubMed  Google Scholar 

  57. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) (2005) Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 365:1687–1717

    Google Scholar 

  58. Rostgaard K, Vaeth M, Rootzén H, Lynge E (2010) Why did the breast cancer lymph node status distribution improve in Denmark in the pre-mammography screening period of 1978–1994? Acta Oncol 49:313–321

    Article  PubMed  Google Scholar 

  59. Kerlikowske K, Grady D, Barclay J et al (1998) Variability and accuracy in mammographic interpretation using the American College of Radiology Breast Imaging Reporting and Data System. J Natl Cancer Inst 90:1801–1809

    Article  PubMed  CAS  Google Scholar 

  60. Beam CA, Layde PM, Sullivan DC (1996) Variability in the interpretation of screening mammograms by US radiologists. Findings from a national sample. Arch Intern Med 156:209–213

    Article  PubMed  CAS  Google Scholar 

  61. Poplack SP, Tosteson AN, Grove MR et al (2000) Mammography in 53,803 women from the New Hampshire mammography network. Radiology 217:832–840

    PubMed  CAS  Google Scholar 

  62. Sickles EA, Wolverton DE, Dee KE (2002) Performance parameters for screening and diagnostic mammography: specialist and general radiologists. Radiology 224:861–869

    Article  PubMed  Google Scholar 

  63. Moss M (2002) Spotting breast cancer: doctors are weak link. New York Times 27 June

  64. Napoli M (2009) Reduce your risk of breast cancer: avoid mammograms. July 14, 2009. http://medicalconsumers.org/2009/07/14/cut-your-risk-of-breast-cancer-avoid-mammograms/

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Authors and Affiliations

  1. The Nordic Cochrane Centre, Rigshospitalet, Dept. 3343, Blegdamsvej 9, 2100, Copenhagen, Denmark

    Peter C. Gøtzsche & Karsten Juhl Jørgensen

  2. Norwegian Institute of Public Health, PO Box 4404, Nydalen, 0405, Oslo, Norway

    Per-Henrik Zahl

  3. Department of Pathology, Ullevål University Hospital, 0407, Oslo, Norway

    Jan Mæhlen

Authors
  1. Peter C. Gøtzsche
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  2. Karsten Juhl Jørgensen
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  3. Per-Henrik Zahl
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  4. Jan Mæhlen
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Correspondence to Peter C. Gøtzsche.

Additional information

Peter C. Gøtzsche wrote the first draft, all authors contributed to revisions.

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Gøtzsche, P.C., Jørgensen, K.J., Zahl, PH. et al. Why mammography screening has not lived up to expectations from the randomised trials. Cancer Causes Control 23, 15–21 (2012). https://doi.org/10.1007/s10552-011-9867-8

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