Breast cancer screening associated with substantial overdiagnosis

1. Breast cancer screening associated with substantial overdiagnosis in Danish study
Screening was not associated with a reduction in advanced tumors
Abstract: http://annals.org/aim/article/doi/10.7326/M16-0270
Free Summary for Patients: http://annals.org/aim/article/doi/10.7326/P16-9029
Editorial: http://annals.org/aim/article/doi/10.7326/M16-2850
URLs go live when the embargo lifts

Breast cancer screening in Denmark was associated with a substantial increase in the incidence of nonadvanced tumors and DCIS but not with a reduction in the incidence of advanced tumors. The rate of overdiagnosis was also substantial. The findings of a cohort study are published in Annals of Internal Medicine.

Effective breast cancer screening should detect early-stage cancer and prevent advanced disease. Overdiagnosis occurs when mammography detects small tumors that may never affect the patient's health during a lifetime. The problem with overdiagnosis is that it exposes patients to the potential harms of treatment, such as surgery, chemotherapy, and radiation, without a clinical benefit. Whether screening reduces the incidence of advanced tumors has important treatment implications.

Using data from two comprehensive Danish cancer registries, researchers sought to examine the association of screening with a reduction in the incidence of advanced cancer and estimate the level of overdiagnosis in the country's breast screening program, which offered biennial mammography for women aged 50 - 69 years beginning in different regions at different times. The authors measured the incidence of advanced and nonadvanced breast cancer tumors in screened and unscreened women. To examine trends in overdiagnosis, the authors compared the incidence of advanced tumors in women aged 50 to 84 in screening and nonscreening areas and compared the incidence for nonadvanced tumors among women aged 35 to 49, 50 to 69, and 70 to 84 years in both screening and nonscreening areas. They concluded that screening was not associated with lower incidence of advanced tumors and approximately 1 in 3 invasive tumors and cases of DCIS diagnosed in screened women represent overdiagnosis.

In an accompanying editorial, Otis Brawley, MD, MACP, Chief Medical Officer of the American Cancer Society says that it's time to accept that overdiagnosis is real and that the benefits of breast screening have been overstated. He writes that "considering all small breast cancer lesions to be deadly aggressive cancer is the "pathology equivalent of racial profiling." This does not mean that screening should be abandoned, but we should try to recognize its limitations, use it in the most effective way possible, and try to improve it. Dr. Brawley suggests that more emphasis should be focused on preventing breast cancer through diet, weight control, and exercise.

Note: For an embargoed PDF, please contact Cara Graeff. To reach the lead author, please contact Dina Muscat Meng at dmm@cochrane.dk or +45 35 45 71 45. To interview Dr. Otis Brawley of the American Cancer Society, please contact David Sampson at david.sampson@cancer.org or 213-407-9950.

2. Physicians should reject repeal and 'demand a plan' to replace the ACA
Abstract: http://annals.org/aim/article/doi/10.7326/M16-2935
URLs go live when the embargo lifts

In an Ideas and Opinions piece published in Annals of Internal Medicine, Susan Dentzer, BA, President and Chief Executive Officer of The Network for Excellence in Health Innovation in Cambridge, Mass., says that America's physicians resist the plans of the incoming Trump administration and Republican-controlled Congress to repeal and replace the Patient Protection and Affordable Care Act (ACA). According to the author, any plan presented by the Republicans is likely to strip coverage from poorer patients and those with pre-existing conditions, which could result in an unprecedented public health crisis. She urges physicians to resist repeal and demand to see a full-blown replacement plan first with the same "cold-eyed rigor they would apply to any claim that the latest snake oil offering on the market was a better cure for patients."

Note: For an embargoed PDF, please contact Cara Graeff. For an interview with Susan Dentzer, please contact Sarah Carroll at scarroll@nehi.net or Sanja Mutabdzija at sanjam@nehi.net.

Also new in this issue:
The Effects of Pay-for-Performance Programs on Health, Health Care Use, and Processes of Care: A Systematic Review
Aaron Mendelson, BA; Karli Kondo, PhD; Cheryl Damberg, PhD; Allison Low, BA; Makalapua Motu´ apuaka, BA; Michele Freeman, MPH; Maya O'Neil, PhD; Rose Relevo, MLIS, MS; and Devan Kansagara, MD, MCR

Review
Abstract: http://annals.org/aim/article/doi/10.7326/M16-1881
Editorial: http://annals.org/aim/article/doi/10.7326/M16-2947

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