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Guide to Breast Cancer Screening Decisions

Fifty years of international breast cancer screening research data was recently assessed by US researchers to assess the benefits and risks of mammography. They determined that the benefits of mammography are modest, and the harms are significant, making it very important that women make informed decisions about screening.

A systematic assessment of benefits and risks to guide breast cancer screening decisions.

Breast cancer is the second leading cause of cancer deaths among US women. Mammography screening may be associated with reduced breast cancer mortality but can also cause harm. Guidelines recommend individualising screening decisions, particularly for younger women.

The researchers reviewed the evidence on the mortality benefit and chief harms of mammography screening and what is known about how to individualise mammography screening decisions, including communicating risks and benefits to patients.

They searched MEDLINE from 1960-2014 to describe

(1) benefits of mammography,

(2) harms of mammography, and

(3) individualising screening decisions and promoting informed decision making.

They also manually searched reference lists of key articles retrieved, selected reviews, meta-analyses, and practice recommendations. We rated the level of evidence using the American Heart Association guidelines.

Mammography screening is associated with a 19% overall reduction of breast cancer mortality (approximately 15% for women in their 40s and 32% for women in their 60s).

For a 40-50-year-old woman undergoing 10 years of annual mammograms, the cumulative risk of a false-positive result is about 61%. About 19% of the cancers diagnosed during that 10-year period would not have become clinically apparent without screening (overdiagnosis), although there is uncertainty about this estimate.

The net benefit of screening depends greatly on baseline breast cancer risk, which should be incorporated into screening decisions.

Decision aids have the potential to help patients integrate information about risks and benefits with their own values and priorities, although they are not yet widely available for use in clinical practice.

The researchers concluded that to maximise the benefit of mammography screening, decisions should be individualised based on patients' risk profiles and preferences. Risk models and decision aids are useful tools, but more research is needed to optimise these and to further quantify overdiagnosis. Research should also explore other breast cancer screening strategies. 

Reference

Pace LE, Keating NL. A systematic assessment of benefits and risks to guide breast cancer screening decisions. JAMA. 2014 Apr 2;311(13):1327-35. doi: 10.1001/jama.2014.1398.   

Content updated 28 May 2014

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