Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer
Authors: Colin B. Begg
Journal: Annals of Internal Medicine (2010)

Letters20 April 2010Comments and Response on the USPSTF Recommendation on Screening for Breast CancerFREEColin B. Begg, PhDColin B. Begg, PhDFrom Memorial Sloan-Kettering Cancer Center, New York, NY 10065.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-152-8-201004200-00203 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:In its evaluation of mammography, the USPSTF (1) recommends screening for breast cancer biennially starting at age 50 years. The USPSTF has stressed that this recommendation depends solely on the tradeoff between medical benefits and harms, with no consideration of costs. Editorials in the Wall Street Journal(2) and New England Journal of Medicine(3), however, suggest that the recommendation was in fact motivated by cost considerations. A careful examination of the data analyses by Mandelblatt and colleagues (4), presented in support of the recommendations, seems to confirm the view that costs were indeed pivotal in informing the USPSTF recommendation.The USPSTF states that its recommendation involves trading off the mortality benefit of screening against medical “harms,” such as provoked anxiety, the adverse consequences of false-positive results (such as unnecessary biopsies and treatment), and the adverse effects of overdiagnosis. But how did the Task Force use the evidence about these effects to reach its recommendation? No analyses in the report or supporting articles (4, 5) simultaneously consider both benefits and harms and lead directly to the specific recommendation to begin screening at age 50 years and to do it biennially. Only the Figure in Mandelblatt and colleagues' article (4) includes an analysis that aligns clearly with the USPSTF recommendation.This figure shows the results of independent analyses by 6 investigative groups of the projected mortality reduction for a range of screening strategies, covering various starting ages, and including options to screen annually or biennially. The critical feature of these analyses is that the population mortality benefit is contrasted solely with the number of mammograms required, a surrogate for resource utilization and thus for costs. The authors do not use the term harms. These analyses search for an optimum strategy at the point where the graphs plateau, representing a point of diminishing returns from additional screening. Biennial screening strategies starting at age 50 years are close to the optimum inflection point in all 6 of these analyses, which seems to be the crucial finding that motivated the USPSTF recommendation.The number of mammograms in these analyses does not represent “harm.” Rather, it is a measure of the societal investment in mammography (that is, the societal cost). In other words, this is, in effect, a thinly disguised assessment of cost relative to effectiveness, something most experts would label a cost-effectiveness analysis.Colin B. Begg, PhDMemorial Sloan-Kettering Cancer CenterNew York, NY 10065References1. U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151:716-26, W-236. [PMID: 19920272] MedlineGoogle Scholar2. Editorial. Liberals and mammography: Rationing? What rationing? Wall Street Journal. 24 November 2009. Accessed at online.wsj.com/article/SB10001424052748704779704574552320222125990.html on 3 February 2010. Google Scholar3. Truog RD. Screening mammography and the “r” word. N Engl J Med. 2009;361:2501-3. [PMID: 19940292] CrossrefMedlineGoogle Scholar4. Mandelblatt JS, Cronin KA, Bailey S, Berry DA, de Koning HJ, Draisma G, et al; Breast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network. Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms. Ann Intern Med. 2009;151:738-47. [PMID: 19920274] LinkGoogle Scholar5. U.S. Preventive Services Task Force. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 2009;151:727-37, W237-42. [PMID: 19920273] LinkGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Memorial Sloan-Kettering Cancer Center, New York, NY 10065.Disclosures: None disclosed. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoScreening for Breast Cancer: U.S. Preventive Services Task Force Recommendation StatementScreening for Breast Cancer: An Update for the U.S. Preventive Services Task Force Heidi D. Nelson , Kari Tyne , Arpana Naik , Christina Bougatsos , Benjamin K. Chan , and Linda Humphrey Effects of Mammography Screening Under Different Screening Schedules: Model Estimates of Potential Benefits and Harms Jeanne S. Mandelblatt , Kathleen A. Cronin , Stephanie Bailey , Donald A. Berry , Harry J. de Koning , Gerrit Draisma , Hui Huang , Sandra J. Lee , Mark Munsell , Sylvia K. Plevritis , Peter Ravdin , Clyde B. Schechter , Bronislava Sigal , Michael A. Stoto , Natasha K. Stout , Nicolien T. van Ravesteyn , John Venier , Marvin Zelen , Eric J. Feuer , and When Evidence Collides With Anecdote, Politics, and Emotion: Breast Cancer ScreeningComments and Response on the USPSTF Recommendation on Screening for Breast Cancer Richard Yoast Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer Victoria L. Seewaldt Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer Nananda F. Col , Moritz H. Hansen , Baruch Fischhoff , and Steven G. Pauker Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer Anita Ho Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer Diana Pettiti and Ned Calonge Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer Peter B. Dean Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer R. Scott Braithwaite Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer Mitchell H. Gail and Catherine Schairer Metrics Cited ByPersonalizing Age of Cancer Screening Cessation Based on Comorbid Conditions: Model Estimates of Harms and BenefitsIris Lansdorp-Vogelaar, PhD, Roman Gulati, MS, Angela B. Mariotto, PhD, Clyde B. Schechter, MD, MA, Tiago M. de Carvalho, MSc, Amy B. Knudsen, PhD, Nicolien T. van Ravesteyn, PhD, Eveline A.M. Heijnsdijk, PhD, Chester Pabiniak, MSc, Marjolein van Ballegooijen, MD, PhD, Carolyn M. Rutter, PhD, Karen M. Kuntz, ScD, Eric J. Feuer, PhD, Ruth Etzioni, PhD, Harry J. de Koning, MD, PhD, Ann G. Zauber, PhD, and Jeanne S. Mandelblatt, MD, MPHTrends in mammography screening rates after publication of the 2009 US Preventive Services Task Force recommendationsQuality varies across clinical practice guidelines for mammography screening in women aged 40–49 years as assessed by AGREE and AMSTAR instrumentsScreening women aged 40–49yearsWhen Evidence Collides With Anecdote, Politics, and Emotion: Breast Cancer ScreeningThe Editors 20 April 2010Volume 152, Issue 8Page: 540-541KeywordsAnxietyBiopsyBreast cancerCancer screeningConflicts of interestMammography ePublished: 20 April 2010 Issue Published: 20 April 2010 CopyrightCopyright © 2010 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...