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In the Balance |

Clinical Strategies for Breast Cancer Screening: Weighing and Using the Evidence

Russell Harris, MD, MPH; and Linda Leininger, MD, MPH
[+] Article and Author Information

From the Department of Medicine and the UNC-Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina. Requests for Reprints: Russell Harris, MD, MPH, Cancer Control Program, University of North Carolina at Chapel Hill, CB#7300, Trailer L, Chapel Hill, NC 27599-7300. Acknowledgments: The authors thank Eric Feuer, PhD, and Martin Brown, PhD, at the National Cancer Institute for discussion and for sharing data; Anthony Miller, MB, FRCP, for further analysis of the data from the Canadian National Breast Screening Study; William Black, MD, Tim Carey, MD, Suzanne Fletcher, MD, Michael O'Malley, MSPH, Bruce McCarthy, MD, Alvin Mushlin, MD, David Ransohoff, MD, and Ann Chamberlin, MPH, for suggestions on an earlier draft of the manuscript; and Kevin Squires and Laura Philpot for developing tables and figures and for manuscript preparation. Grant Support: In part by National Cancer Institute grant CA5434-02.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1995;122(7):539-547. doi:10.7326/0003-4819-122-7-199504010-00011
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When balancing the benefits of screening women for breast cancer against the harms and costs of such screening, one needs to consider the risk for dying of breast cancer, the relative reduction in that risk that will result from screening women in different age groups, and the harms and costs associated with screening.Seven randomized, controlled trials provide evidence of the relative risk reduction that results from screening women in different age groups; other studies estimate the harms and costs of screening. These studies indicate that the benefit of screening, expressed as the absolute number of lives extended per 1000 women screened, increases with age and that the harm of screening, expressed as the number of follow-up procedures per cancer detected, decreases with age. Thus, the tradeoff between the benefits and the harms and costs of screening is better for older than for younger women. Because there is no clear cut-point for determining when benefits outweigh harms and costs, it is important to involve women in discussions of breast cancer screening. The women who most need to be involved are those for whom the benefits of screening clearly outweigh the harms and costs and those for whom the benefits and the harms and costs constitute a “close call.” For women in both groups, the physician should routinely raise the issue of screening, first eliciting the patient's perceptions and then providing information and discussion about the risk for breast cancer and about the benefits and the harms and costs of screening. Furthermore, the physician should encourage the patient to use her own values to weigh the benefits against the harms and costs, pointing out biases in reasoning and minimizing socioeconomic barriers. Finally, when the benefits obviously outweigh the harms and costs, the physician should make a clear recommendation for screening.

Figures

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Figure 1.
Breast cancer incidence (■) and mortality (○) for women in different age groups.

Rates are per 100 000 population. Data from the Surveillance, Epidemiology, and End Results (SEER) program.

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Figure 2.
Estimated consequences of a single screening mammogram for 10 000 women 50 to 70 years of age who participate in a program of regular annual screening.
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Figure 3.
Estimated consequences of a single screening mammogram for 10 000 women 40 to 49 years of age who participate in a program of regular annual screening.
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