van Ravesteyn NT, Miglioretti DL, Stout NK, Lee SJ, Schechter CB, Buist DSM, Huang H, Heijnsdijk EAM, Trentham-Dietz A, Alagoz O, Near AM, Kerlikowske K, Nelson HD, Mandelblatt JS, de Koning HJ. Tipping the balance of benefits and harms to favor screening mammography starting at age 40 years: a comparative modeling study of risk.
Ann Intern Med 2012;
156:609-17. [PMID:
22547470 PMCID:
PMC3520058 DOI:
10.7326/0003-4819-156-9-201205010-00002]
[Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND
Timing of initiation of screening for breast cancer is controversial in the United States.
OBJECTIVE
To determine the threshold relative risk (RR) at which the harm-benefit ratio of screening women aged 40 to 49 years equals that of biennial screening for women aged 50 to 74 years.
DESIGN
Comparative modeling study.
DATA SOURCES
Surveillance, Epidemiology, and End Results program, Breast Cancer Surveillance Consortium, and medical literature.
TARGET POPULATION
A contemporary cohort of women eligible for routine screening.
TIME HORIZON
Lifetime.
PERSPECTIVE
Societal.
INTERVENTION
Mammography screening starting at age 40 versus 50 years with different screening methods (film, digital) and screening intervals (annual, biennial).
BENEFITS
life-years gained, breast cancer deaths averted; harms: false-positive mammography findings; harm-benefit ratios: false-positive findings/life-years gained, false-positive findings/deaths averted.
RESULTS OF BASE-CASE ANALYSIS
Screening average-risk women aged 50 to 74 years biennially yields the same false-positive findings/life-years gained as biennial screening with digital mammography starting at age 40 years for women with a 2-fold increased risk above average (median threshold RR, 1.9 [range across models, 1.5 to 4.4]). The threshold RRs are higher for annual screening with digital mammography (median, 4.3 [range, 3.3 to 10]) and when false-positive findings/deaths averted is used as an outcome measure instead of false-positive findings/life-years gained. The harm-benefit ratio for film mammography is more favorable than for digital mammography because film has a lower false-positive rate.
RESULTS OF SENSITIVITY ANALYSIS
The threshold RRs changed slightly when a more comprehensive measure of harm was used and were relatively insensitive to lower adherence assumptions.
LIMITATION
Risk was assumed to influence onset of disease without influencing screening performance.
CONCLUSION
Women aged 40 to 49 years with a 2-fold increased risk have similar harm-benefit ratios for biennial screening mammography as average-risk women aged 50 to 74 years. Threshold RRs required for favorable harm-benefit ratios vary by screening method, interval, and outcome measure.
PRIMARY FUNDING SOURCE
National Cancer Institute.
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