JOURNAL ARTICLE

Tipping the balance of benefits and harms to favor screening mammography starting at age 40 years: a comparative modeling study of risk

Nicolien T van Ravesteyn, Diana L Miglioretti, Natasha K Stout, Sandra J Lee, Clyde B Schechter, Diana S M Buist, Hui Huang, Eveline A M Heijnsdijk, Amy Trentham-Dietz, Oguzhan Alagoz, Aimee M Near, Karla Kerlikowske, Heidi D Nelson, Jeanne S Mandelblatt, Harry J de Koning
Annals of Internal Medicine 2012 May 1, 156 (9): 609-17
22547470

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).

OUTCOME MEASURES:

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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