The Background Review for the USPSTF Recommendation on Screening for Breast Cancer
Authors: Karsten J. Jørgensen
Journal: Annals of Internal Medicine (2010)

Letters20 April 2010The Background Review for the USPSTF Recommendation on Screening for Breast CancerFREEKarsten J. Jørgensen, MD and Peter C. Gøtzsche, DrMedSciKarsten J. Jørgensen, MDFrom The Nordic Cochrane Centre, 2100 Copenhagen, Denmark.Search for more papers by this author and Peter C. Gøtzsche, DrMedSciFrom The Nordic Cochrane Centre, 2100 Copenhagen, Denmark.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-152-8-201004200-00198 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:Nelson and colleagues calculate the reduction in breast cancer mortality on the basis of randomized trials (1) but present no calculations for the most important harm: overdiagnosis. They quote a mixture of observational studies and results from statistical models with unverifiable and doubtful assumptions. Only for the Malmö trial do they quote real data, but these data were obtained 15 years after the trial ended, when many additional cases of cancer had occurred in both groups. When we corrected for this dilution and for the 24% of the women in the control group who were also screened during the trial, we found a 25% overdiagnosis rate (2), rather than the 10% reported by the authors.It is indefensible that Nelson and colleagues base their estimate of overdiagnosis on flawed studies when data from about 600 000 randomly assigned women are available, which we pooled in our Cochrane systematic review in 2009 (3) and before that in 2006 and 2001. We found 31% more lumpectomies and mastectomies. In July, we reported an overdiagnosis rate of 52% in a systematic review of publicly organized mammography screening programs, without using assumptions or statistical modeling (4). It is also curious that Nelson and colleagues do not quote our Cochrane review, as they searched the Cochrane Library.Nelson and colleagues reported that most studies found an overdiagnosis rate between 1% and 10%. However, systematic reviewing is not a consensus conference—it is a scientific discipline—and Nelson and colleagues overlook that the small estimates of overdiagnosis are based on poor science, mostly produced by researchers with vested interests in screening. If one opens one's eyes, unaided by any statistical tricks, one cannot escape seeing a huge amount of overdiagnosis, such as in the United Kingdom (4, 5).The Task Force now recommends against breast screening in women aged 40 to 49 years, but the harms may outweigh the benefits in all age groups. An effect of 15% and an overdiagnosis rate of 30% mean that for every 2000 women invited for screening throughout 10 years, 1 woman will have her life prolonged and 10 healthy women, who would not have breast cancer diagnosed if there had not been screening, will be treated unnecessarily (3). Furthermore, about 1000 women in the United States will have had a false-positive diagnosis (3). The psychological strain until one knows whether it was cancer can be severe. The harms caused by overdiagnosis are lifelong.Karsten J. Jørgensen, MDPeter C. Gøtzsche, DrMedSciThe Nordic Cochrane Centre2100 Copenhagen, DenmarkReferences1. Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L; 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 Scholar2. Gøtzsche PC, Jørgensen KJ. Estimate of harm/benefit ratio of mammography screening was five times too optimistic [Rapid response]. BMJ. Published 27 March 2006. Accessed at bmj.bmjjournals.com/cgi/eletters/332/7543/691 on 3 February 2009. Google Scholar3. Gøtzsche PC, Nielsen M. Screening for breast cancer with mammography. Cochrane Database Syst Rev. 2009;:CD001877. [PMID: 19821284] MedlineGoogle Scholar4. Jørgensen KJ, Gøtzsche PC. Overdiagnosis in publicly organised mammography screening programmes: systematic review of incidence trends. BMJ. 2009;339:b2587. [PMID: 19589821] CrossrefMedlineGoogle Scholar5. Jørgensen KJ, Gøtzsche PC. It is time for a new paradigm for overdiagnosis with screening mammography [Rapid response]. BMJ. Published 20 August 2009. Accessed at www.bmj.com/cgi/eletters/339/jul09_1/b2587 on 3 February 2009. Google Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Karsten J. Jørgensen, MD; Peter C. Gøtzsche, DrMedSciAffiliations: From The Nordic Cochrane Centre, 2100 Copenhagen, Denmark.Disclosures: None disclosed. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoScreening 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 When Evidence Collides With Anecdote, Politics, and Emotion: Breast Cancer ScreeningThe EditorsThe Background Review for the USPSTF Recommendation on Screening for Breast Cancer Heidi D. Nelson , Arpana Naik , Linda Humphrey , and Kari Tyne The Background Review for the USPSTF Recommendation on Screening for Breast Cancer Kay Dickersin , David Tovey , Nicholas Wilcken , and Davina Ghersi The Background Review for the USPSTF Recommendation on Screening for Breast Cancer Jessica T. DeFrank and Noel T. Brewer Metrics Cited byQuality varies across clinical practice guidelines for mammography screening in women aged 40–49 years as assessed by AGREE and AMSTAR instrumentsWhen Evidence Collides With Anecdote, Politics, and Emotion: Breast Cancer ScreeningThe Editors 20 April 2010Volume 152, Issue 8Page: 538KeywordsBreast cancerLibrariesLumpectomyMammographyMastectomyMortalityObservational studiesRandomized trialsStatistical modelsSystematic reviews ePublished: 20 April 2010 Issue Published: 20 April 2010 Copyright & PermissionsCopyright © 2010 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...