Nicolien T. van Ravesteyn, MSc; Diana L. Miglioretti, PhD; Natasha K. Stout, PhD; Sandra J. Lee, DSc; Clyde B. Schechter, MD, MA; Diana S.M. Buist, PhD, MPH; Hui Huang, MS; Eveline A.M. Heijnsdijk, PhD; Amy Trentham-Dietz, PhD; Oguzhan Alagoz, PhD; Aimee M. Near, MPH; Karla Kerlikowske, MD, MS; Heidi D. Nelson, MD, MPH; Jeanne S. Mandelblatt, MD, MPH; Harry J. de Koning, MD, PhD
Note: Both Jeanne S. Mandelblatt, MD, MPH, and Harry J. de Koning, MD, PhD, served as the senior authors for this manuscript.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health.
Acknowledgment: The authors thank Drs. Kathleen Cronin and Brian Sprague for their valuable advice and consultation on this project. They also thank the BCSC investigators, participating women, mammography facilities, and radiologists for the data they have provided for this study. The BCSC investigators and procedures for requesting BCSC data for research purposes are listed at http://breastscreening.cancer.gov/.
Grant Support: The collection of BCSC cancer data used in this study was supported in part by several state public health departments and cancer registries throughout the United States. For a full description of these sources, please see www.breastscreening.cancer.gov/work/acknowledgement.html. This research was supported by a National Cancer Institute Activities to Promote Research Collaboration supplement (U01CA086076-10S1), and, in part, by National Cancer Institute grants U01CA88283, U01CA152958, and KO5CA96940. Data collection was supported by the BCSC funded by the National Cancer Institute cooperative agreements U01CA63740, U01CA86076, U01CA86082, U01CA63736, U01CA70013, U01CA69976, U01CA63731, and U01CA70040.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-2358.
Reproducible Research Statement:Study protocol: Available from Ms. van Ravesteyn (e-mail, mailto:firstname.lastname@example.org). Statistical code: Not available; model profiles are available at http://cisnet.cancer.gov/breast/profiles.html. Data set: Procedures for requesting BCSC data for research purposes are provided at http://breastscreening.cancer.gov/work/proposal_data.html.
Requests for Single Reprints: Nicolien van Ravesteyn, MSc, Department of Public Health, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, the Netherlands; e-mail, mailto:email@example.com.
Current Author Addresses: Ms. van Ravesteyn and Drs. Heijnsdijk and de Koning: Department of Public Health, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, the Netherlands.
Drs. Miglioretti and Buist: Group Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101.
Dr. Stout: Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, 6th Floor, Boston, MA 02215.
Dr. Lee: Dana-Farber Cancer Institute, 3 Blackfan Circle, Boston, MA 02115.
Dr. Schechter: Department of Family & Social Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Mazer Building 406, Bronx, NY 10461.
Ms. Huang: Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 01720.
Dr. Trentham-Dietz: University of Wisconsin-Madison, 610 Walnut Street, WARF Room 307, Madison, WI 53726.
Dr. Alagoz: University of Wisconsin-Madison, 3242 Mechanical Engineering Building, 1513 University Avenue, Madison, WI 53706.
Ms. Near and Dr. Mandelblatt: Lombardi Comprehensive Cancer Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC 20007.
Dr. Kerlikowske: University of California, San Francisco, 4150 Clement Street, Veterans Affairs Medical Center (111A1), San Francisco, CA 94121.
Dr. Nelson: Oregon Evidence-based Practice Center, Oregon Health & Science University, Mailcode BICC, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098.
Author Contributions: Conception and design: N.T. van Ravesteyn, D.L. Miglioretti, N.K. Stout, C.B. Schechter, D.S.M. Buist, A. Trentham-Dietz, H.D. Nelson, J.S. Mandelblatt, H.J. de Koning.
Analysis and interpretation of the data: N.T. van Ravesteyn, N.K. Stout, S.J. Lee, C.B. Schechter, D.S.M. Buist, E.A.M. Heijnsdijk, O. Alagoz, H.D. Nelson, J.S. Mandelblatt, H.J. de Koning.
Drafting of the article: N.T. van Ravesteyn, S.J. Lee, D.S.M. Buist, J.S. Mandelblatt.
Critical revision of the article for important intellectual content: N.T. van Ravesteyn, D.L. Miglioretti, N.K. Stout, C.B. Schechter, D.S.M. Buist, E.A.M. Heijnsdijk, A. Trentham-Dietz, H.D. Nelson, J.S. Mandelblatt, H.J. de Koning.
Final approval of the article: N.T. van Ravesteyn, D.L. Miglioretti, N.K. Stout, S.J. Lee, C.B. Schechter, D.S.M. Buist, E.A.M. Heijnsdijk, A. Trentham-Dietz, O. Alagoz, A.M. Near, H.D. Nelson, J.S. Mandelblatt, H.J. de Koning.
Provision of study materials or patients: D.S.M. Buist.
Statistical expertise: D.L. Miglioretti, N.K. Stout, C.B. Schechter, O. Alagoz.
Obtaining of funding: D.L. Miglioretti, C.B. Schechter, D.S.M. Buist, A. Trentham-Dietz, H.D. Nelson, J.S. Mandelblatt, H.J. de Koning.
Administrative, technical, or logistic support: D.S.M. Buist, J.S. Mandelblatt, H.J. de Koning.
Collection and assembly of data: N.T. van Ravesteyn, D.L. Miglioretti, N.K. Stout, C.B. Schechter, D.S.M. Buist, A.M. Near.
Timing of initiation of screening for breast cancer is controversial in the United States.
To determine the threshold relative risk (RR) at which the harm–benefit ratio of screening women aged 40 to 49 years equals that of biennial screening for women aged 50 to 74 years.
Comparative modeling study.
Surveillance, Epidemiology, and End Results program, Breast Cancer Surveillance Consortium, and medical literature.
A contemporary cohort of women eligible for routine screening.
Mammography screening starting at age 40 versus 50 years with different screening methods (film, digital) and screening intervals (annual, biennial).
Benefits: life-years gained, breast cancer deaths averted; harms: false-positive mammography findings; harm–benefit ratios: false-positive findings/life-years gained, false-positive findings/deaths averted.
Screening average-risk women aged 50 to 74 years biennially yields the same false-positive findings/life-years gained as biennial screening with digital mammography starting at age 40 years for women with a 2-fold increased risk above average (median threshold RR, 1.9 [range across models, 1.5 to 4.4]). The threshold RRs are higher for annual screening with digital mammography (median, 4.3 [range, 3.3 to 10]) and when false-positive findings/deaths averted is used as an outcome measure instead of false-positive findings/life-years gained. The harm–benefit ratio for film mammography is more favorable than for digital mammography because film has a lower false-positive rate.
The threshold RRs changed slightly when a more comprehensive measure of harm was used and were relatively insensitive to lower adherence assumptions.
Risk was assumed to influence onset of disease without influencing screening performance.
Women aged 40 to 49 years with a 2-fold increased risk have similar harm–benefit ratios for biennial screening mammography as average-risk women aged 50 to 74 years. Threshold RRs required for favorable harm–benefit ratios vary by screening method, interval, and outcome measure.
National Cancer Institute.
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van Ravesteyn NT, Miglioretti DL, Stout NK, Lee SJ, Schechter CB, Buist DS, et al. Tipping the Balance of Benefits and Harms to Favor Screening Mammography Starting at Age 40 Years: A Comparative Modeling Study of Risk. Ann Intern Med. 2012;156:609-617. doi: 10.7326/0003-4819-156-9-201205010-00002
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Published: Ann Intern Med. 2012;156(9):609-617.
Breast Cancer, Cancer Screening/Prevention, Hematology/Oncology, Prevention/Screening.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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