Effects of Mammography Screening Under Different Screening Schedules: Model Estimates of Potential Benefits and Harms

  1. Jeanne S. Mandelblatt, MD, MPH;
  2. Kathleen A. Cronin, PhD;
  3. Stephanie Bailey, PhD;
  4. Donald A. Berry, PhD;
  5. Harry J. de Koning, MD, PhD;
  6. Gerrit Draisma, PhD;
  7. Hui Huang, MS;
  8. Sandra J. Lee, DSc;
  9. Mark Munsell, MS;
  10. Sylvia K. Plevritis, PhD;
  11. Peter Ravdin, MD, PhD;
  12. Clyde B. Schechter, MD, MA;
  13. Bronislava Sigal, PhD;
  14. Michael A. Stoto, PhD;
  15. Natasha K. Stout, PhD;
  16. Nicolien T. van Ravesteyn, MSc;
  17. John Venier, MS;
  18. Marvin Zelen, PhD;
  19. Eric J. Feuer, PhD; and
  20. for the Breast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET)*
  1. From the Georgetown University Medical Center and Lombardi Comprehensive Cancer Center, Washington, DC; National Institutes of Health, Bethesda, Maryland; University of Texas M.D. Anderson Cancer Center, Houston, Texas; Erasmus University Medical Center, Rotterdam, the Netherlands; Dana-Farber Cancer Institute, Harvard School of Public Health, Harvard Medical School, and Harvard Pilgrim Health Care, Boston, Massachusetts; Stanford University, Palo Alto, California; and Albert Einstein College of Medicine, New York, New York.

Abstract

Background: Despite trials of mammography and widespread use, optimal screening policy is controversial.

Objective: To evaluate U.S. breast cancer screening strategies.

Design: 6 models using common data elements.

Data Sources: National data on age-specific incidence, competing mortality, mammography characteristics, and treatment effects.

Target Population: A contemporary population cohort.

Time Horizon: Lifetime.

Perspective: Societal.

Interventions: 20 screening strategies with varying initiation and cessation ages applied annually or biennially.

Outcome Measures: Number of mammograms, reduction in deaths from breast cancer or life-years gained (vs. no screening), false-positive results, unnecessary biopsies, and overdiagnosis.

Results of Base-Case Analysis: The 6 models produced consistent rankings of screening strategies. Screening biennially maintained an average of 81% (range across strategies and models, 67% to 99%) of the benefit of annual screening with almost half the number of false-positive results. Screening biennially from ages 50 to 69 years achieved a median 16.5% (range, 15% to 23%) reduction in breast cancer deaths versus no screening. Initiating biennial screening at age 40 years (vs. 50 years) reduced mortality by an additional 3% (range, 1% to 6%), consumed more resources, and yielded more false-positive results. Biennial screening after age 69 years yielded some additional mortality reduction in all models, but overdiagnosis increased most substantially at older ages.

Results of Sensitivity Analysis: Varying test sensitivity or treatment patterns did not change conclusions.

Limitation: Results do not include morbidity from false-positive results, patient knowledge of earlier diagnosis, or unnecessary treatment.

Conclusion: Biennial screening achieves most of the benefit of annual screening with less harm. Decisions about the best strategy depend on program and individual objectives and the weight placed on benefits, harms, and resource considerations.

Primary Funding Source: National Cancer Institute.

Article and Author Information

  • Acknowledgment: The authors thank the BCSC investigators, participating mammography facilities, and radiologists for the data they provided that were used to inform some of our model data input variables. A list of the BCSC investigators and procedures for requesting BCSC data for research purposes is at http://breastscreening.cancer.gov/. The authors also thank Mary Barton, MD, MPP, and William Lawrence, MD, MSc, from AHRQ; members of the U.S. Preventive Services Task Force; the Oregon Evidence-based Practice Center; Ann Zauber, PhD; and Karla Kerlikowske, MD, for helpful comments and review of earlier versions of this article. The authors thank Jackie Ford and Aimee Near for manuscript preparation.

  • Grant Support: By NCI cooperative agreements (2U01CA088270, 2U01CA088283, 2U01CA088248, and F32 CA125984). Portions of this work were performed under contract HHSN261200800769P. Data collection in the BCSC was supported by NCI-funded BCSC cooperative agreements (U01CA63740, U01CA86076, U01CA86082, U01CA63736, U01CA70013, U01CA69976, U01CA63731, and U01CA70040) and several U.S. state public health departments and cancer registries. CISNET data management and Web site support were provided by Cornerstone Systems Northwest (NCI contract HHSN261200800002C).

  • Potential Conflicts of Interest: None disclosed.

  • Requests for Single Reprints: Jeannes S. Mandelblatt, MD, MPH, Lombardi Comprehensive Cancer Center, 3300 Whitehaven Street, Northwest, Suite 4100, Washington, DC 20007; e-mail, mandelbj{at}georgetown.edu.

  • Current Author Addresses: Dr. Mandelblatt: Lombardi Comprehensive Cancer Center, 3300 Whitehaven Street, Northwest, Suite 4100, Washington, DC 20007.

  • Dr. Cronin: National Cancer Institute, 6116 Executive Boulevard, Suite 504, Bethesda, MD 20892.

  • Dr. Bailey: 8666 Macawa Avenue, San Diego, CA 92123.

  • Dr. Berry: The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1409, Houston, TX 77030.

  • Dr. de Koning: Erasmus University Medical Center, Dr. Molewaterplein 50, Rotterdam 3015 GE, the Netherlands.

  • Dr. Draisma: Department of Public Health, Room AE-235, Erasmus University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands.

  • Mr. Huang: Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 01720.

  • Dr. Lee: Dana-Farber Cancer Institute, 3 Blackfan Circle, Boston, MA 02115.

  • Mr. Munsell and Mr. Venier: The University of Texas M.D. Anderson Cancer Center, PO Box 301402, Houston, TX 77230-1402.

  • Dr. Plevritis: Stanford Univeristy, 1201 Welch Road, Room P267, Stanford, CA 94305-5488.

  • Dr. Ravdin: 19931 Encino Royale, San Antonio, TX 78259.

  • Dr. Schechter: Albert Einstein College of Medicine of Yeshiva University, 1300 Morris Park Avenue, Mazer Building 110, Bronx, NY 10461.

  • Dr. Sigal: Department of Radiology, Stanford University, Lucas Center for Imaging, 1201 Welch Road, Stanford, CA 94305-5488.

  • Dr. Stoto: Georgetown University School of Nursing & Health Studies, 3700 Reservoir Road, Northwest, Room 235, Washington, DC 20057-1107.

  • Dr. Stout: Harvard Medical School, 133 Brookline Avenue, 6th Floor, Boston, MA 02215.

  • Mr. van Ravesteyn: Erasmus University Medical Center, PO Box 2040, Rotterdam 3000 CA, the Netherlands.

  • Dr. Zelen: Dana-Farber Cancer Institute, 3 Blackfan Circle, 11th Floor, Center for Life Sciences B, Boston, MA 02115.

  • Dr. Feuer: National Cancer Institute, 6116 Executive Boulevard, Room 5041, Mail, Stop Code 8317, Bethesda, MD 20892-8317.

  • Author Contributions: Conception and design: J.S. Mandelblatt, K.A. Cronin, D.A. Berry, H.J. de Koning, S.J. Lee, S.K. Plevritis, C.B. Schechter, M.A. Stoto, N.K. Stout, M. Zelen, E.J. Feuer.

  • Analysis and interpretation of the data: J.S. Mandelblatt, K.A. Cronin, S. Bailey, D.A. Berry, H.J. de Koning, G. Draisma, H. Huang, S.J. Lee, M. Munsell, S.K. Plevritis, C.B. Schechter, B. Sigal, M.A. Stoto, N.K. Stout, N.T. van Ravesteyn, M. Zelen, E.J. Feuer.

  • Drafting of the article: J.S. Mandelblatt, H.J. de Koning, C.B. Schechter.

  • Critical revision of the article for important intellectual content: J.S. Mandelblatt, K.A. Cronin, S. Bailey, D.A. Berry, H.J. de Koning, G. Draisma, S.K. Plevritis, C.B. Schechter, M.A. Stoto, N.K. Stout, N.T. van Ravesteyn, M. Zelen, E.J. Feuer.

  • Final approval of the article: J.S. Mandelblatt, K.A. Cronin, S. Bailey, D.A. Berry, H.J. de Koning, G. Draisma, S.J. Lee, M. Munsell, S.K. Plevritis, C.B. Schechter, B. Sigal, M.A. Stoto, N.K. Stout, N.T. van Ravesteyn, M. Zelen, E.J. Feuer.

  • Statistical expertise: D.A. Berry, G. Draisma, S.J. Lee, M. Munsell, S.K. Plevritis, C.B. Schechter, B. Sigal, M.A. Stoto, M. Zelen, E.J. Feuer.

  • Obtaining of funding: J.S. Mandelblatt, D.A. Berry, S.K. Plevritis.

  • Administrative, technical, or logistic support: J.S. Mandelblatt, K.A. Cronin, S.K. Plevritis, J. Venier, E.J. Feuer.

  • Collection and assembly of data: K.A. Cronin, S. Bailey, D.A. Berry, H.J. de Koning, M. Munsell, S.K. Plevritis, C.B. Schechter, N.K. Stout, J. Venier.

  • ↵* This work was done by 6 independent modeling teams from Dana-Farber Cancer Institute (Dr. Lee, principal investigator); Erasmus University (Dr. de Koning, principal investigator); Georgetown University Medical Center, Lombardi Comprehensive Cancer Center (Dr. Mandelblatt, principal investigator); Harvard School of Public Health, Harvard Medical School, Harvard Pilgrim Health Care/University of Wisconsin (Dr. Stout, principal investigator); M.D. Anderson Comprehensive Cancer Center (Dr. Berry, principal investigator); and Stanford University (Dr. Plevritis, principal investigator). Drs. Mandelblatt and Cronin were the writing and coordinating committee for the project; all other collaborators are listed in alphabetical order. Dr. Feuer was responsible for overall CISNET project direction.

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    Ann Intern Med published online November 20, 2009

Summary for Patients

  • Summaries for Patients:Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendations Ann Intern Med November 17, 2009 151:I-44; doi:10.1059/0003-4819-151-10-200911170-00002
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