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Editorials | 
Albert L. Siu, MD, MSPH; Kirsten Bibbins-Domingo, PhD, MD, MAS; David C. Grossman, MD, MPH; Michael L. LeFevre, MD, MSPH, on behalf of the U.S. Preventive Services Task Force
This issue includes updated recommendations from the U.S. Preventive Services Task Force on screening mammography for breast cancer. Task Force members discuss the recommendation statement and the strong emerging convergence among groups who have recently issued evidence-based guidelines, which should give the public confidence in the science that supports mammography screening.
Topics: breast neoplasm screening
Original Research | 
Jeanette Birnbaum, PhD, MPH; Vijayakrishna K. Gadi, MD, PhD; Elan Markowitz; and Ruth Etzioni, PhD
Background:Mammography trials, which are the primary sources of evidence for screening benefit, were conducted decades ago. Whether advances in systemic therapies have rendered previously observed benefits of screening less significant is unknown. Objective:To compare the outcomes of breast cancer screening trials had they been conducted using contemporary systemic treatments with outcomes of trials conducted with previously used treatments. Design:Computer simulation model of 3 virtual screening trials with similar reductions in advanced-stage cancer cases but reflecting treatment patterns in 1975 (prechemotherapy era), 1999, or 2015 (treatment according to receptor status). Data Sources:Meta-analyses of screening and treatment trials; study of dissemination of primary systemic treatments; SEER (Surveillance, Epidemiology, and End Results) registry. Target Population:U.S. women aged 50 to 74 years. Time Horizon:10 and 25 years. Perspective:Population. Intervention:Mammography, chemotherapy, tamoxifen, aromatase inhibitors, and trastuzumab. Outcome Measures:Breast cancer mortality rate ratio (MRR) and absolute risk reduction (ARR) obtained by the difference in cumulative breast cancer mortality between control and screening groups. Results of Base-Case Analysis:At 10 years, screening in a 1975 trial yielded an MRR of 90% and an ARR of 5 deaths per 10 000 women. A 2015 screening trial yielded a 10-year MRR of 90% and an ARR of 3 deaths per 10 000 women. Results of Sensitivity Analysis:Greater reductions in advanced-stage disease yielded a greater screening effect, but MRRs remained similar across trials. However, ARRs were consistently lower under contemporary treatments. When contemporary treatments were available only for early-stage cases, the MRR was 88%. Limitation:Disease models simplify reality and cannot capture all breast cancer subtypes. Conclusion:Advances in systemic therapies for breast cancer have not substantively reduced the relative benefits of screening but have likely reduced the absolute benefits because of their positive effect on breast cancer survival. Primary Funding Source:University of Washington and National Cancer Institute.
Topics: mortality, breast cancer, breast neoplasm screening, mammography, sensitivity analysis, chemotherapy regimen
Original Research | 
Diana L. Miglioretti, PhD; Jane Lange, PhD; Jeroen J. van den Broek, MSc; Christoph I. Lee, MD, MSHS; Nicolien T. van Ravesteyn, PhD; Dominique Ritley, MPH; Karla Kerlikowske, MD; Joshua J. Fenton, MD, MPH; Joy Melnikow, MD, MPH; Harry J. de Koning, PhD; and Rebecca A. Hubbard, PhD
Includes: Supplemental Content
Background:Estimates of risk for radiation-induced breast cancer from mammography screening have not considered variation in dose exposure or diagnostic work-up after abnormal screening results. Objective:To estimate distributions of radiation-induced breast cancer incidence and mortality from digital mammography screening while considering exposure from screening and diagnostic mammography and dose variation among women. Design:2 simulation-modeling approaches. Setting:U.S. population. Patients:Women aged 40 to 74 years. Intervention:Annual or biennial digital mammography screening from age 40, 45, or 50 years until age 74 years. Measurements:Lifetime breast cancer deaths averted (benefits) and radiation-induced breast cancer incidence and mortality (harms) per 100 000 women screened. Results:Annual screening of 100 000 women aged 40 to 74 years was projected to induce 125 breast cancer cases (95% CI, 88 to 178) leading to 16 deaths (CI, 11 to 23), relative to 968 breast cancer deaths averted by early detection from screening. Women exposed at the 95th percentile were projected to develop 246 cases of radiation-induced breast cancer leading to 32 deaths per 100 000 women. Women with large breasts requiring extra views for complete examination (8% of population) were projected to have greater radiation-induced breast cancer risk (266 cancer cases and 35 deaths per 100 000 women) than other women (113 cancer cases and 15 deaths per 100 000 women). Biennial screening starting at age 50 years reduced risk for radiation-induced cancer 5-fold. Limitation:Life-years lost from radiation-induced breast cancer could not be estimated. Conclusion:Radiation-induced breast cancer incidence and mortality from digital mammography screening are affected by dose variability from screening, resultant diagnostic work-up, initiation age, and screening frequency. Women with large breasts may have a greater risk for radiation-induced breast cancer. Primary Funding Source:Agency for Healthcare Research and Quality, U.S. Preventive Services Task Force, National Cancer Institute.
Topics: breast cancer, mammography, digital, breast, mortality
Original Research | 
Jeanne S. Mandelblatt, MD, MPH; Natasha K. Stout, PhD; Clyde B. Schechter, MA, MD; Jeroen J. van den Broek, MS; Diana L. Miglioretti, PhD; Martin Krapcho, BS; Amy Trentham-Dietz, PhD, MS; Diego Munoz, PhD, MS; Sandra J. Lee, ScD; Donald A. Berry, PhD; Nicolien T. van Ravesteyn, PhD; Oguzhan Alagoz, PhD; Karla Kerlikowske, MD; Anna N.A. Tosteson, ScD; Aimee M. Near, MPH; Amanda Hoeffken, MPH; Yaojen Chang, DrPH, MS, MPH; Eveline A. Heijnsdijk, PhD; Gary Chisholm, MS; Xuelin Huang, PhD; Hui Huang, MS; Mehmet Ali Ergun, MSc; Ronald Gangnon, PhD; Brian L. Sprague, PhD; Sylvia Plevritis, PhD; Eric Feuer, PhD; Harry J. de Koning, MD, PhD; and Kathleen A. Cronin, PhD, MPH
Background:Controversy persists about optimal mammography screening strategies. Objective:To evaluate screening outcomes, taking into account advances in mammography and treatment of breast cancer. Design:Collaboration of 6 simulation models using national data on incidence, digital mammography performance, treatment effects, and other-cause mortality. Setting:United States. Patients:Average-risk US female population and subgroups with varying risk, breast density, or comorbidity. Intervention:Eight strategies differing by age at which screening starts (40, 45, or 50 years) and screening interval (annual, biennial, and hybrid [annual for women in their 40s and biennial thereafter]). All strategies assumed 100% adherence and stopped at age 74 years. Measurements:Benefits (breast cancer–specific mortality reduction, breast cancer deaths averted, life-years, and quality-adjusted life-years); number of mammograms used; harms (false-positive results, benign biopsies, and overdiagnosis); and ratios of harms (or use) and benefits (efficiency) per 1000 screens. Results:Biennial strategies were consistently the most efficient for average-risk women. Biennial screening from age 50 to 74 years avoided a median of 7 breast cancer deaths versus no screening; annual screening from age 40 to 74 years avoided an additional 3 deaths, but yielded 1988 more false-positive results and 11 more overdiagnoses per 1000 women screened. Annual screening from age 50 to 74 years was inefficient (similar benefits, but more harms than other strategies). For groups with a 2- to 4-fold increased risk, annual screening from age 40 years had similar harms and benefits as screening average-risk women biennially from 50 to 74 years. For groups with moderate or severe comorbidity, screening could stop at age 66 to 68 years. Limitation:Other imaging technologies, polygenic risk, and nonadherence were not considered. Conclusion:Biennial screening for breast cancer is efficient for average-risk populations. Decisions about starting ages and intervals will depend on population characteristics and the decision makers' weight given to the harms and benefits of screening. Primary Funding Source:National Institutes of Health.
Topics: mammography, breast cancer, breast neoplasm screening, breast density, mammography, digital, cancer, mortality, comorbidity
In this issue, Birnbaum and colleagues evaluate whether the availability of efficient adjuvant and chemotherapy treatments would have changed reductions in the risk for breast cancer death reported by randomized trials on breast cancer screening. The editorialist discusses these results and the implications for women having breast cancer screening.
Topics: breast neoplasm screening, breast cancer
Topics: breast neoplasm screening
Ideas and Opinions | 
Mosoka Fallah, PhD, MPH; Bernice Dahn, MD, MPH; Tolbert G. Nyenswah, Esq, MPH; Moses Massaquoi, MD, MPH; Laura A. Skrip, MPH; Dan Yamin, PhD; Martial Ndeffo Mbah, PhD; Netty Joe, MD; Siedoh Freeman, MD; Thomas Harris, BA; Zinnah Benson, BBA; and Alison P. Galvani, PhD
In Liberia, programs based on community engagement were effective in controlling the Ebola virus disease epidemic.
Topics: ebola virus disease, liberia, community
Ideas and Opinions | 
David U. Himmelstein, MD; and Russell S. Phillips, MD
Should asymptomatic patients schedule annual visits with their physicians? Many experts and some professional organizations say no and cite evidence-based studies as the reason why. This article examines those studies and reaches more nuanced conclusions.
Topics: primary care physicians, health evaluation, primary health care, elderly, evidence-based practice, cochrane collaboration, health disparity, professional organizations, multiphasic screening, add-on code, physician-patient relations, mortality, angiotensin-converting enzyme inhibitors, screening test, inspection, laboratory test finding, asymptomatic diseases, breast cancer, manual pelvic examination, visual acuity testing, exertional dyspnea, sexually transmitted diseases, spirometry, tonometry, urinalysis, vaginal smears, audiometry, follow-up, laboratory techniques and procedures, mammography, melanoma, myopia, pain, electrocardiogram, statins, edema, diagnostic radiologic examination, chest pain, blood test, headache
Letters | 
Eirion Slade, MPhys; Henry Drysdale, BSc; Ben Goldacre, MBBS, on behalf of the COMPare Team
Members of the Centre for Evidence-Based Medicine Outcome Monitoring Project (COMPare) express their concerns about switched or incompletely reported outcomes in 2 trials published in Annals. In the accompanying response, the Editors describe their procedures for reviewing reports of clinical trials and potential reasons for the discrepancies noted by COMPare.
Letters | 
The Editors
Members of the Centre for Evidence-Based Medicine Outcome Monitoring Project (COMPare) express their concerns about switched or incompletely reported outcomes in 2 trials published in Annals. In the accompanying response, the Editors describe their procedures for reviewing reports of clinical trials and potential reasons for the discrepancies noted by COMPare.
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