Hanging in the Balance: Making Decisions About the Benefits and Harms of Breast Cancer Screening Among the Oldest Old Without a Safety Net of Scientific Evidence

Lombardi Comprehensive Cancer Center, Cancer Control Program, Georgetown University Medical Center, Washington, DC.
Journal of Clinical Oncology (Impact Factor: 18.43). 02/2009; 27(4):487-90. DOI: 10.1200/JCO.2008.19.4928
Source: PubMed
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    ABSTRACT: Despite trials of mammography and widespread use, optimal screening policy is controversial. To evaluate U.S. breast cancer screening strategies. 6 models using common data elements. National data on age-specific incidence, competing mortality, mammography characteristics, and treatment effects. A contemporary population cohort. Lifetime. Societal. 20 screening strategies with varying initiation and cessation ages applied annually or biennially. Number of mammograms, reduction in deaths from breast cancer or life-years gained (vs. no screening), false-positive results, unnecessary biopsies, and overdiagnosis. 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. Varying test sensitivity or treatment patterns did not change conclusions. Results do not include morbidity from false-positive results, patient knowledge of earlier diagnosis, or unnecessary treatment. 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.
    Annals of internal medicine 11/2009; 151(10):738-47. DOI:10.1059/0003-4819-151-10-200911170-00010 · 17.81 Impact Factor

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    ABSTRACT: Four hundred thirty-seven patients with solid tumor cancer, undergoing chemotherapy, were enrolled, interviewed, and randomized to receive either a six-contact, eight-week, nurse-directed intervention or an automated telephone symptom management intervention. Patients were assessed at 10 and 16 weeks. Patients were queried at intake and at 10 and 16 weeks to determine the severity of their symptoms and if they had been hospitalized-if hospitalized, the number of hospitalizations and location of the hospital. The fixed and variable costs associated with the production of each arm were identified. Both total fixed and variable costs were greater for the nurse arm; total costs per patient were $69 and $167 for the automated and nurse arms, respectively. The overall symptom severity declined significantly over baseline and equally between the groups at 10 and 16 weeks. The relationship between reductions in symptom severity and the number of hospitalizations and days in the hospital was investigated using zero-inflated Poisson regression model. The cost of a hospitalization was estimated at $1,800 per day in 2004. At 16 weeks, those with 50% or greater reductions in severity had an adjusted mean of 1.1 days in the hospital, whereas those with increased symptom severity had a mean of 2.23. Reductions in hospitalizations related to lower severity suggest that the telephone arm could produce a net saving over cost of its development and implementation. Although promising, the links between reductions in severity of symptoms and fewer hospitalizations remain difficult to isolate.
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