Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Katherine Sherif, MD; Mark Aronson, MD; Kevin B. Weiss, MD, MPH; Douglas K. Owens, MD, MS; for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians*
Note: Clinical practice guidelines are guides only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.
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Potential Financial Conflicts of Interest:Grants received: V. Snow (Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Atlantic Philanthropies).
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, email@example.com.
Current Author Addresses: Drs. Qaseem and Snow: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Sherif: 219 North Broad Street, 6th Floor, Philadelphia, PA 19107.
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Dr. Owens: 117 Encina Commons, Stanford, CA 94305.
Breast cancer is one of the most common causes of death for women in their 40s in the United States. Individualized risk assessment plays an important role when making decisions about screening mammography, especially for women 49 years of age or younger. The purpose of this guideline is to present the available evidence for screening mammography in women 40 to 49 years of age and to increase clinicians' understanding of the benefits and risks of screening mammography.
*This paper, written by Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Katherine Sherif, MD; Mark Aronson, MD; Kevin B. Weiss, MD, MPH; and Douglas K. Owens, MD, MS, was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians (ACP): Douglas K. Owens, MD, MS (Chair); Mark Aronson, MD; Patricia Barry, MD, MPH; Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Nick Fitterman, MD; E. Rodney Hornbake, MD; Katherine D. Sherif, MD; and Kevin B. Weiss, MD, MPH (Immediate Past Chair). Approved by the ACP Board of Regents on 15 July 2006.
Table. Family History Patterns Associated with an Increased Risk for BRCA1 or BRCA2Gene Mutations*
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Daniel B. Kopans
Harvard Medical School
April 14, 2007
You can Lead Committees to Publications, but You Can't Make Them Read and Understand!
You Can Lead Committees to Publications, but You Can't Make Them Read!
In their stated goal of providing women with facts so that they can make informed decisions about mammography screening, the Clinical Efficacy Assessment Subcommittee of the American College of Physicians has actually done just the opposite and provided dangerously misleading and scientifically unjustified misinformation on the subject. They are clearly uniformed about the topic of mammography screening. There is a clear, significant decrease in breast cancer deaths, for screening women beginning by the age of 40 both from randomized, controlled trials as well as when screening is introduced into the general population.
1. The age of 50 has no relevance for mammography screening. None of the parameters of screening changes abruptly at age 50 or any other age (1,2). Anyone claiming that age 50 has any relevance should be required to provide ungrouped data that support this.
2. The randomized, controlled trials of screening were trials by "invitation" so that they underestimate the benefit from screening (3).
3. The RCT were not designed to evaluate women ages 40-49 separately. The unplanned subgroup analyses of women ages 40-49 that have misled physicians and women were using data that lacked any statistical power (4). Nevertheless, with longer follow-up they show a, statistically significant, decrease in cancer deaths for these women of as high as 44% (actually higher than for women age s 50 and over).
4. The National Breast Screening Study of Canada (the only trial with more deaths among the screened women than among the controls, and whose data drop the benefit from 26% to 15%) violated the basic rules of randomized, controlled trials. The unblinded study design would never be allowed today since it permitted compromise of the trial's integrity, and the data clearly show it was compromised (1,5,6).
5. The author of the concept that screening saved lives for women in their forties because they reached the age of 50 has recanted his conclusion and now agrees that most of the benefit was due to screening before the age of 50 (1).
6. In Sweden, where accurate data are collected, the death rate has dropped by almost 50% for women in their forties, primarily due to screening.
7. The death rate from breast cancer has declined in the United States since 1990 primarily as a result of mammography screening and this includes women in their forties.
8. There are no data to prove a benefit if women are screened based on their personal risk for breast cancer.
9. Screening only women at increased risk for breast cancer will miss 75-80% of cancers.
10. All women (not just those in their forties) should be informed of the risks and benefits of any medical intervention.
Anyone who wishes to review the data on mammography screening should be required to understand the issues outlined in the accompanying reference list so that women get accurate information and not dangerous misinformation.
Daniel B. Kopans, M.D.
Professor of Radiology - Harvard Medical School Senior Radiologist "“ Breast Imaging Division "“ Massachusetts General Hospital
1. Kopans DB. Bias in the Medical Journals A Commentary. AJR 2005,; 185:176-177 accompanies Kopans DB. Informed Decision Making: age of 50 is arbitrary and has no demonstrated influence on breast cancer screening in women. Am J Roentgenology 2005;185:177-82
2. Kopans DB, Moore RH, McCarthy KA, Hall DA, Hulka C, Whitman GJ, Slanetz PJ, Halpern EF. Biasing the Interpretation of Mammography Screening Data By Age Grouping: Nothing Changes Abruptly at Age 50. The Breast Journal 1998;4:139-145.
3. Kopans DB. The Breast Cancer Screening Controversy: Lessons to be Learned. J Surg Onc 1998;67:143-150.
4. Kopans DB, Halpern E, Hulka CA. Statistical Power in Breast Cancer Screening Trials and Mortality Reduction Among Women 40-49 with Particular Emphasis on The National Breast Screening Study of Canada. Cancer 1994;74:1196-1203.
5. Kopans DB, Feig SA. The Canadian National Breast Screening Study: A Critical Review. AJR 1993;161:755-760.
6. Tarone RE. The Excess of Patients with Advanced Breast Cancers in Young Women Screened with Mammography in the Canadian National Breast Screening Study. Cancer 1995;75:997-1003.
I am an expert in screening mammography
Breast Cancer Action Germany
May 5, 2007
Number needed to screen and preventable risk factors missing
Unfortunately the guideline do not quantify any relation. How many women in the age group 40 - 49 years must be screened to prevent dying of breast cancer for one women? A guideline should include this figure. And how are those figures in proportion to the risks? How many biopsies, false -positive results etc. are to be expected in that group of women? Concerning the basically welcome communication of risks it must be remarked that the individual risk reduction can also be discussed. Especially mentionable issues are
- intake of hormones, e.g. HRT, hormonal contraception - possible contact with pesticides - physical activities, sports - obesity / overweight - diet / intake of fat from foodstuffs.
See your report too: http://bcag.twoday.net/
Gudrun Kemper Breast Cancer Action Germany www.bcaction.de
Peter C GÃ¸tzsche
Nordic Cochrane Centre
May 25, 2007
Mammography screening leads to an increase in mastectomies, not a decrease
In an otherwise balanced guideline (1), the authors unfortunately quoted a very small and misleading study without a control group from Florence in Italy (2), when they claimed that screening is associated with a decrease in the absolute risk of mastectomy. This study builds on the false assumption that if screening increases the number of mastectomies, populations in which screening has been introduced should see a subsequent increase (3). The authors should have quoted the much more reliable evidence that exists, which was quoted by the authors of the systematic review in the same issue of Annals (4).
We have discussed this issue at length in our updated Cochrane review of mammography screening (5). The randomised trials showed a 20% increase in mastectomies, which could be overestimated as there has been a policy change towards more lumpectomies. However, the policy change has occurred much too slowly to explain such a large increase, and because of opportunistic screening in the control group, which was reported to have occurred for 24% of the women in the MalmÃ¶ trial (6), this rate could also be underestimated. In Southeast Netherlands, for example, where screening was introduced from 1990 to 1998, the rate of breast-conserving surgery increased by 71% while the rate of mastectomy increased by 84% (7), despite the fact that this study did not include carcinoma in situ, which is often treated by mastectomy as the cell changes are often diffuse.
Because of the substantial overdiagnosis, about 30% (5), screening leads to more surgery and also to more mastectomies.
1. Qaseem A, Snow V, Sherif K, Aronson M, Weiss KB, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Screening mammography for women 40 to 49 years of age: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2007; 146:511-5.
2. Paci E,Duffy SW,Giorgi D,ZappaM,Crocetti E,VezzosiV, et al. Are breast cancer screening programmes increasing rates of mastectomy? Observational study. BMJ 2002; 325:418.
3. GÃ¸tzsche PC. Misleading paper on mastectomy rates in a screening programme. http://bmj.com/cgi/eletters/325/7361/418#24972, 26 Aug 2002.
4. Armstrong K, Moye E, Williams S, Berlin JA, Reynolds EE. Screening mammography in women 40 to 49 years of age: a systematic review for the American College of Physicians. Ann Intern Med 2007; 146:516-26.
5. GÃ¸tzsche PC, Nielsen M. Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD001877.
6. Andersson I, Aspegren K, Janzon L et al. Mammographic screening and mortality from breast cancer: the Malmo mammographic screening trial. BMJ 1988;297:943"“48.
7. GÃ¸tzsche PC. Trends in breast-conserving surgery in the Southeast Netherlands: Comment on article by Ernst and colleagues Eur J Cancer 2001, 37, 2435-2440. Eur J Cancer 2002; 38:1288.
I have authored a Cochrane review that questions the value of mammography screening
June 19, 2007
Our recommendations are based on thorough review of high quality scientific evidence for both the benefits and risks of screening mammography. We are recommending that all women between the age 40 to 49 have an opportunity to participate in the decision whether to screen or not with full information about the benefits and risks from screening mammography. The individualized decision about screening mammography should be tailored to each individual woman and include an assessment of a woman's risk for breast cancer, a discussion of the benefits and risk of screening mammography, and a discussion of a woman's concerns about breast cancer or risk associated with screening mammography. We support women getting screening mammograms as long as they are fully informed. If a woman decides to defer screening mammography, we recommend that the decision should be revisited every one to two years.
Qaseem A, Snow V, Sherif K, Aronson M, Weiss KB, Owens DK, et al. Screening Mammography for Women 40 to 49 Years of Age: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2007;146:511–515. doi: 10.7326/0003-4819-146-7-200704030-00007
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Published: Ann Intern Med. 2007;146(7):511-515.
Breast Cancer, Cancer Screening/Prevention, Guidelines, Hematology/Oncology, Prevention/Screening.
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