Access to this full-text is provided by Springer Nature.
Content available from Systematic Reviews
This content is subject to copyright. Terms and conditions apply.
R E S E A R C H Open Access
Conclusions in systematic reviews of
mammography for breast cancer screening
and associations with review design and
author characteristics
Smriti Raichand
1,2
, Adam G. Dunn
1*
, Mei-Sing Ong
1,3,5
, Florence T. Bourgeois
3,4
, Enrico Coiera
1
and Kenneth D. Mandl
3,5
Abstract
Background: Debates about the benefits and harms of mammography continue despite the accumulation of
evidence. We sought to quantify the disagreement across systematic reviews of mammography and determine
whether author or design characteristics were associated with conclusions that were favourable to the use of
mammography for routine breast cancer screening.
Methods: We identified systematic reviews of mammography published between January 2000 and November
2015, and extracted information about the selection of evidence, age groups, the use of meta-analysis, and authors’
professions and financial competing interest disclosures. Conclusions about specific age groups were graded as
favourable if they stated that there were meaningful benefits, that benefits of mammography outweighed harms,
or that harms were inconsequential. The main outcome measures were the proportions of favourable conclusions
relative to review design and author characteristics.
Results: From 59 conclusions identified in 50 reviews, 42% (25/59) were graded as favourable by two investigators.
Among the conclusions produced by clinicians, 63% (12/19) were graded as favourable compared to 32% (13/40)
from other authors. In the 50–69 age group where the largest proportion of systematic reviews were focused,
conclusions drawn by authors without financial competing interests (odds ratio 0.06; 95% CI 0.07–0.56) and non-
clinicians (odds ratio 0.11; 95% CI 0.01–0.84) were less likely to be graded as favourable. There was no trend in the
proportion of favourable conclusions over the period, and we found no significant association between review
design characteristics and favourable conclusions.
Conclusions: Differences in the conclusions of systematic reviews of the evidence for mammography have
persisted for 15 years. We found no strong evidence that design characteristics were associated with greater
support for the benefits of mammography in routine breast cancer screening. Instead, the results suggested that
the specific expertise and competing interests of the authors influenced the conclusions of systematic reviews.
Keywords: Mammography screening, Systematic reviews as topic, Competing interests, Bias, Breast cancer
* Correspondence: adam.dunn@mq.edu.au
1
Centre for Health Informatics, Australian Institute of Health Innovation,
Macquarie University, Sydney, NSW 2109, Australia
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Raichand et al. Systematic Reviews (2017) 6:105
DOI 10.1186/s13643-017-0495-6
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Mammography is the most widely used screening technol-
ogy for detecting breast cancers in asymptomatic women.
Since its introduction, the relative harms and benefits of
mammography have been the subject of ongoing debate.
Both the age at which to begin breast cancer screening
and the frequency of screening have been disputed.
Conflicting recommendations persist despite decades of
interventional and observational studies that are used as
the basis for making recommendations [1–4], and cancer
screening guidelines generally fail to quantify benefits and
harms in a balanced way [5]. For mammography, the de-
bate was renewed in 2009 when the US Preventive
Services Task Force (USPSTF) revised their guidelines to
initiate biennial screening at 50 years of age instead of 40
[6]. In 2012, the National Health Services (NHS) in the
UK recommended mammography once in 3 years to
women aged 47–73 years [7]. In late 2015, the American
Cancer Society (ACS) updated their guidelines to initiate
annual screening at 45 and reduce the frequency to
biennial screening at 55 [8]. In early 2016, the USPSTF
again examined the evidence and recommended biennial
screening for women between the ages of 50 and 74 [9].
Conflicting recommendations about breast cancer screen-
ing make it difficult for clinicians and patients to make
informed choices about when to start and how often to re-
peat mammography for women at average risk.
Inconsistencies in the conclusions produced across
systematic reviews may reflect the manner in which the
reviews were designed and undertaken, or may be
related to the expertise and competing interests held by
the reviewers. Analyses in other domains have found
that financial conflicts of interest can be associated
with differences in the interpretation of the results
when drawing conclusions and making recommenda-
tions [10–12]. Specific to mammography, an analysis
of mostly primary studies showed that authors who
worked directly in mammography screening were
more likely to downplay or reject over-diagnosis than
other authors [13]. Another study examining 12 clinical
practice guidelines showed that guidelines authored by ra-
diologists or where lead authors had recent publications
on diagnosis and treatment were more likely to recom-
mend routine screening [14].
By measuring review design and author characteristics
associated with certain conclusions in systematic reviews
of mammography, we may be able to identify factors
that are associated with inconsistent conclusions. Our
aim was to quantify the degree of disagreement in the
conclusions of systematic reviews of mammography for
breast cancer screening and then measure associations
between the conclusions, design characteristics of the
reviews, and the professions and financial competing
interests of the authors.
Methods
Search strategy
We examined systematic reviews of mammography for
breast cancer screening published between January 2000
and November 2015. The PubMed database was
searched to identify relevant studies using the following
search strategy: “(((((guideline*[Text Word]) OR recom-
mend*[Text Word]) OR review[Publication Type]))
AND (((((“mass screening”[MeSH Terms]) OR (“early
detection of cancer”[MeSH Terms]) OR screen*[Text
Word])))) AND (((mammogr*[Text Word]) OR (breast
cancer screening[MeSH terms]) OR (mammography[-
MeSH Terms])))”. We additionally hand-searched the
citations of included reviews after screening to identify
any other relevant literature.
Selection of reviews
Review articles were included in the analysis if they met
all four of the following inclusion criteria: (a) the re-
viewers specified a search criteria and the databases in
which the search was conducted; (b) the review was fo-
cused on mammography for breast cancer screening; (c)
at least two primary studies addressing the harms or
benefits of mammography were cited; and (d) the
reviewers made conclusions about the harms or benefits
of mammography for breast cancer screening in relation
to the evidence. Outcomes related to benefits included
breast cancer survival (mortality reduction), and cost-
effectiveness of screening for quality-of-life. Outcomes
related to harms included over-diagnosis, false positives,
unnecessary treatments, radiation cancers, anxiety or
worry, and pain or discomfort. Reviews that examined
only diagnosis endpoints without considering survival or
harms were excluded, as were reviews that only consid-
ered high-risk populations or populations of women
who had previously been diagnosed with breast cancer.
Articles were also excluded if they were guidelines, no
longer archived or accessible online, not peer reviewed,
or were in a language other than English.
Screening and data extraction
Two investigators independently screened article titles
and abstracts against the inclusion criteria, and then
examined the full text of articles against the inclusion
and exclusion criteria. Discrepancies were resolved by
discussion at both stages.
The review design characteristics extracted included
patient age ranges covered in the evidence, the types of
primary studies analysed, the set of outcome measures
examined, the presence or absence of a meta-analysis,
and the year the systematic review was published. Pa-
tient age ranges were assigned to one of four categories:
49 or under, 50 to 69 years, 70 years or older, and one
other group for reviews that considered all ages or did
Raichand et al. Systematic Reviews (2017) 6:105 Page 2 of 8
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
not specify an age range. These age groups were selected
to correspond with the common age ranges used in the
most recent guidelines. The age group for women aged
between 50 and 69 in particular is where there has been
substantial disagreement about how often women should
undergo mammography, and this was a focus of our
study. Where age ranges differed from the four
groups, we identified the group with the largest over-
lap (see Additional file 1). The types of studies in-
cluded in the review were classified into controlled
trials, observational studies, both forms of primary
studies, or cost-effectiveness analyses.
We recorded the professional role or specialty of all
individual authors and categorised them as clinicians or
non-clinicians. Professional role was determined by the
affiliation listed on the article, employment history, qual-
ifications, and listed research interests. These elements
were identified and interpreted from the systematic re-
view and biographies on institutional webpages where
available. Qualifications for clinicians included MD or
equivalent degrees, and non-clinical qualifications in-
cluded PhD and MPH. Where corresponding authors
had both clinical and non-clinical qualifications, we
assigned them to the clinician group if we identified a
clinical affiliation on institutional webpages or recent
publications, and to the non-clinician group if we could
find no such evidence. Where authors were all clinicians
or all non-clinicians, we labelled the review as such, and
where the authors had a mix of the two types of profes-
sional roles, we labelled the review according to the
professional role of the corresponding author, under the
assumption that the corresponding author takes primary
responsibility for the conclusions drawn in the review
(Additional file 2).
A financial competing interest disclosure may have
described research funding, ownership, or fees from a
developer of mammography systems or software. Finan-
cial competing interests were determined from disclos-
ure statements in the article. If a competing interest was
identified and was financial in nature, we assumed it to
be relevant and labelled all conclusions in the systematic
review as associated with a financial competing interest.
We also noted the presence or absence of a disclosure
statement in the systematic reviews and labelled system-
atic reviews without a disclosure separately.
Two investigators read each included systematic
review in its entirety to evaluate the mammography
recommendations contained in the conclusions. Each
conclusion was judged as favourable or non-favourable
by assigning it to one of eight types. Four types were
considered to be favourable (evidence of benefits, benefits
outweigh harms, the practice is cost-effective, no evidence
of harms), and four were labelled as non-favourable (evi-
dence of harms, harms outweigh benefits, the practice is
not cost-effective, no evidence of benefits). A third investi-
gator read any reviews for which there was a disagreement
to produce a final grading. For each conclusion, we also
extracted supporting conclusion statements from the
systematic reviews, as well as any statements that made
recommendations about who should undergo screening
by mammography and how often it should be done.
Some of systematic reviews examined evidence for dif-
ferent age ranges or frequency of screening separately,
producing conclusions for each. These conclusions were
considered separately. This means that systematic
reviews may be represented in the analysis with more
than one conclusion and those conclusions may differ.
Analysis
A linear regression was used to check whether favourable
conclusions became more or less common over the period
of study, testing whether changes in the primary evidence
influenced the likelihood of a favourable conclusion in
systematic reviews. Where appropriate, we performed chi-
square tests to test the association between favourable
conclusions and each of the review design (evidence selec-
tion, age groups, outcomes, or the use of meta-analysis)
and author (professional roles and financial competing in-
terests) characteristics extracted from the systematic
reviews.
Results
The search returned 2726 publications, from which 50
systematic reviews met the inclusion criteria (Fig. 1).
Five systematic reviews included separate conclusions
for two or more age groups, yielding a set of 59
conclusions and 42 corresponding authors.
Summary systematic review characteristics
Among the 59 conclusions, 42% (25/59) were graded as
favourable. The statements that best characterised the
grading are provided as Additional files 3 and 4).
The greatest number of conclusions were for women
aged between 50 and 69 (22 conclusions), and for which
there was no restriction on age range in the evidence
cited or where no age range was specified (also 22 con-
clusions). Of the remainder, 17% (10/59) considered
women under 49, and 8% (5/59) considered women aged
70 and older (see Additional file 5).
Evidence selection also varied across the conclusions.
Conclusions based entirely on randomised controlled
trials comprised 20% (12/59). Another 41% (24/59)
considered both randomised controlled trials and obser-
vational studies, 34% (20/59) considered only observa-
tional studies, and 5% (3/59) were based on cost-
effectiveness studies. Mortality outcomes were used in
64% (38/59) of the conclusions. Meta-analyses supported
27% (16/59) of the conclusions.
Raichand et al. Systematic Reviews (2017) 6:105 Page 3 of 8
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Most conclusions were associated with author groups
that had a public health, epidemiology, or biostatistics
(68%; 40/59) background. Among the 32% (19/59) of
corresponding authors from clinical specialties, 6 were
from oncology, 4 from radiology, and 10 from other
medical specialties (see Additional file 6). Disclosures of
relevant financial competing interests were present in
14% (8/59) of conclusions.
The number of systematic review conclusions pro-
duced over the period peaked between 2004 and 2007,
and increased again from 2010 (Fig. 2). Fitting a linear
regression to the proportion of favourable conclusions
per year revealed no clear increase or decrease in the
proportion of favourable conclusions over time (r
2
=
9.73 × 10
−3
;p= 0.716).
Associations between systematic review characteristics
and conclusions
Of the conclusions written by corresponding authors
from clinical specialties, 63% (12/19) were graded as
Fig. 1 From a search identifying 2726 articles, 59 conclusions from 50 systematic reviews were included in the analysis
Fig. 2 The number of systematic review conclusions by publication years during the period, including favourable conclusions (orange) and
non-favourable conclusions (cyan)
Raichand et al. Systematic Reviews (2017) 6:105 Page 4 of 8
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
favourable (Table 1). A greater proportion of the conclu-
sions made in systematic reviews written by clinicians
were favourable compared to conclusions by corre-
sponding authors from a public health and epidemiology
profession, for which 32% (13/40) of conclusions were
graded as favourable. Among the conclusions associated
with a disclosed financial competing interest, 75% (6/8)
were favourable. In comparison, 47% (9/19) were graded
as favourable when there was no disclosure, and 31%
(10/32) were graded as favourable when there was an ex-
plicit declaration of no financial competing interests.
The proportions of favourable conclusions relative to
combinations of clinical profession and financial com-
peting interest disclosures revealed a consistent pattern
in which corresponding authors who were clinicians or
had financial competing interests more often produced
favourable conclusions (Fig. 2).
Among the conclusions drawn from reviews of rando-
mised controlled trials, 42% (5/12) were graded as
favourable; compared to 29% (7/24) of conclusions based
on studies of both controlled trials and observational
studies; 55% (11/20) of conclusions based only on obser-
vational studies; and 67% (2/3) of conclusions based on
cost-effectiveness studies (Table 1). For conclusions
about women under 50, 40% (4/10) were favourable,
45% (10/22) were graded as favourable for women aged
50–69, 80% (4/5) for women aged 70 and over, and for
women of all ages (or where age was not specified), 32%
(7/22) were graded as favourable. Among the conclusions
drawn in systematic reviews that used a meta-analysis,
25% (4/16) were graded as favourable, compared to 49%
(21/43) of those with no meta-analysis (Fig. 3).
For the subset of conclusions relating to women aged
50–69 (corresponding to the age group for which mam-
mography is recommended by several current guide-
lines), the 20 conclusions were produced by different
authors and we were able to more reliably test the associ-
ation between the observed characteristics and favourable
conclusions (Table 2). In this subset, 27% (3/9) of
conclusions from non-clinicians were favourable com-
pared to 78% (7/9) from clinicians (OR 0.11; 95% CI
0.01–0.84; p=0.025; χ
2
= 5.05). When corresponding
authors declared no financial competing interests,
20% (2/10) of the conclusions were graded as
favourable compared to 80% (8/10) when authors declared
a financial competing interest or did not include a disclos-
ure statement (OR 0.06; 95% CI 0.07–0.56; p=0.007;χ
2
=
7.20). Analyses in other age groups did not indicate a
significant difference (see Additional files 5, 7, and 8). We
found no clear evidence that the types of primary
studies included in the analysis, choice of outcomes,
or the use of meta-analysis were associated with
favourable conclusions.
Discussion
As evidence accumulates, systematic reviews addressing
the same clinical question should converge toward a
common conclusion. In the last 15 years, 50 systematic
reviews on the use of routine mammography for breast
cancer screening in asymptomatic women have been
published but a consistent conclusion has not emerged.
While we did not find strong evidence to suggest that
these differences were associated with the types of stud-
ies or outcomes included, or the use of meta-analysis,
we did find that authors from certain professions were
more likely to produce favourable conclusions for
women aged between 50 and 69. There were too few
conclusions published in systematic reviews for women
under 50 and women 70 or older to reliably identify
Table 1 Characteristics of the review and author characteristics
relative to the conclusions
Characteristics Number of
conclusions
Favourable
conclusions
(% of type)
Non-favourable
conclusions
(% of type)
Corresponding author
Non-clinical 40 13 (32%) 27 (68%)
Clinical 19 12 (63%) 7 (37%)
Competing interests
Declared none 32 10 (31%) 22 (69%)
Declared 8 6 (75%) 2 (25%)
No statement 19 9 (47%) 10 (53%)
Type of evidence
Both 24 7 (29%) 17 (71%)
RCT only 12 5 (42%) 7 (58%)
Non-RCT only 20 11 (55%) 9 (45%)
Cost effectiveness 3 2 (67%) 1 (33%)
Age groups
Not specified/all ages 22 7 (32%) 15 (68%)
Up to 49 10 4 (40%) 6 (60%)
50–69 22 10 (45%) 12 (55%)
70 and over 5 4 (80%) 1 (20%)
Outcome measures
a
Mortality 38 19 (50%) 19 (50%)
Over-diagnosis 25 8 (32%) 17 (68%)
Specific harms 28 9 (32%) 19 (68%)
Cost effectiveness 8 5 (62%) 3 (38%)
Meta-analysis
No 43 21 (49%) 22 (51%)
Yes 16 4 (25%) 12 (75%)
Total 59 25 (42%) 34 (58%)
a
Totals for outcome measures sum to more than the total because systematic
review conclusions may have considered more than one outcome
Raichand et al. Systematic Reviews (2017) 6:105 Page 5 of 8
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
factors associated with favourable conclusions. The re-
sults suggest that the expertise and experience of the au-
thors of systematic reviews may have influenced the
conclusions in ways that could not be easily identified as
differences in the designs of the reviews.
Author professions or specialties have also been asso-
ciated with conclusions in primary studies and clinical
practice guidelines for mammography. For clinical
practice guidelines, both author specialty and competing
interests were associated with a recommendation of
routine screening [14]. In an analysis of mostly primary
studies, authors who worked in screening less often
included over-diagnosis as an outcome or minimised it
as a harm [13]. We found similar results for systematic
reviews on the same topic. Together, the results from
these studies suggest that one of the reasons why we
continue to see ongoing debate about the harms and
benefits of mammography may be because the expertise
and experiences of the researchers who report the
evidence have influenced both the manner in which it is
reported and the conclusions and recommendations that
have been made.
Previous studies examining differences in systematic
reviews on other topics have demonstrated associations
between the characteristics of authors and the conclu-
sions they have drawn. These studies have often
examined financial and non-financial competing inter-
ests [10, 11, 15]. In each case, the analyses demonstrated
that authors of systematic reviews may introduce biases
in the design and reporting of systematic review to pro-
duce conclusions that are aligned with their interests.
The introduction of biases into the design and reporting
of systematic reviews may be subtle [16, 17], so it may
be difficult to quantify where biases are introduced in
the systematic review process.
Limitations
There were several limitations to the analysis we
performed. Non-systematic reviews were not considered
in the analysis, and it is likely that reviewers with affilia-
tions other than public health and epidemiology would
be more commonly represented in non-systematic re-
views. Similarly, we did not consider systematic reviews
that were focused on the performance of mammography
for diagnosis, and practitioners may have been more
commonly represented in these systematic reviews. We
did not use any formal tools—such as AMSTAR or the
PRISMA checklist [18, 19]—to assess the quality of the
reviews or the reporting of the reviews on mammog-
raphy screening, which may have also been associated
with differences in the conclusions. However, prior re-
search has found that there were differences in quality
among clinical practice guidelines for mammography
[20]. We did not investigate financial competing inter-
ests beyond what was disclosed by the authors—for
some journals, the authors may not have been required
to disclose their financial competing interests, which
means that we may have under-reported the true rate of
financial competing interests. Finally, because some au-
thors were present in more than one review and some
reviews included more than one conclusion, certain
characteristics may have been over-represented in the
sample, so we were limited in what we could conclude
from the statistical analyses.
Fig. 3 The proportions of systematic review conclusions that were favourable relative to review design and corresponding author differences
illustrating some consistent patterns. Line widths correspond to the number of conclusions
Raichand et al. Systematic Reviews (2017) 6:105 Page 6 of 8
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Conclusions
Analysing 15 years of systematic reviews examining the
benefits and harms of mammography for routine breast
cancer screening in asymptomatic women, we found that
there is still no consensus across systematic reviews
about when and how often mammography should be
used. Despite the volume of evidence available for
women aged 50 to 69, disagreements between guidelines
about frequency are common. For this age group, the
results suggest that favourable conclusions were more
common in systematic reviews written by authors who
were clinicians. The results were generally consistent
with studies examining primary studies and clinical prac-
tice guidelines about mammography for routine breast
cancer screening. The results provide further evidence
to suggest that conclusions in systematic reviews may be
influenced by the expertise and experiences of the
authors who write them rather than when they were
published, the evidence included, or the designs of the
reviews.
Additional files
Additional file 1: Age group ranges. Age group ranges identified in the
systematic reviews and their classification in the analysis. Shaded regions
represent the age groups used in the analysis (orange rectangles) and
the set of all age groups identified in the systematic reviews are labelled
by their reference number and age range (grey rectangles). (PDF 374 kb)
Additional file 2: Table S5. Authors’professional roles; (C: clinican;
N: non-clinician; G: group; triangles indicate the corresponding author).
(PDF 602 kb)
Additional file 3: Table S6. Systematic review conclusion and
recommendation statements. (PDF 433 kb)
Additional file 4: Included systematic reviews. References for all
included systematic reviews. (PDF 229 kb)
Additional file 5: Table S3. Associations between systematic review
characteristics and conclusions in 5 conclusions of studies that included
women aged 70 years and older. (PDF 193 kb)
Additional file 6: Table S4. Included systematic review conclusions in
detail. (PDF 774 kb)
Additional file 7: Table S1. Associations between systematic review
characteristics and conclusions in 22 conclusions of studies that did not
specify age group or specified all ages. (PDF 193 kb)
Additional file 8: Table S2. Associations between systematic review
characteristics and conclusions in 10 conclusions of studies that included
women aged up to 49 years. (PDF 193 kb)
Abbreviations
AMSTAR: Assessment of Multiple Systematic Reviews; MD: Medical doctor;
NHS: National Health Service; PRISMA: Preferred Reporting Items for
Systematic Reviews and Meta-Analyses; USPSTF: US Preventive Services
Task Force
Acknowledgements
Not applicable.
Funding
MSO is supported by a grant from the National Health and Medical Research
Council, Australia (APP1052871), and the National Institutes of Health
(T15LM007092).
Availability of data and materials
All data generated or analysed during this study are included in this
published article and its additional files.
Authors’contributions
SR designed the study, prepared and analysed the data, drafted the
manuscript, and revised the manuscript. AGD designed the study, analysed
the data, drafted the manuscript, and revised the manuscript. MSO
contributed to the design of the study, supported the data analysis,
provided domain expertise, and revised the manuscript. FTB contributed to
the design of the study and revised the manuscript. EC contributed to the
design of the study and revised the manuscript. KDM designed the study,
drafted the manuscript, and revised the manuscript. All authors read and
approved the final manuscript.
Authors’information
Not applicable.
Table 2 Associations between systematic review characteristics
and conclusions for women aged 50–69
Characteristics Number of
conclusions
Proportion of
favourable
conclusions (%)
pvalue
(chi-square test)
Corresponding author
Non-clinical 11 3 (27%)
Clinical 9 7 (78%)
p= 0.025;
χ
2
= 5.05
Competing interests
Declared none 10 2 (20%)
No statement 6 4 (67%)
Declared 4 4 (100%)
p= 0.016;
χ
2
= 8.27
Type of evidence
RCT only 5 1 (20%)
RCT and non-RCT 8 4 (50%)
Non-RCT only 6 4 (67%)
Cost-effectiveness 1 1 (100%)
p= 0.325;
χ
2
= 3.47
Outcome measures
Did not include
harms
9 6 (67%)
Included harms or
over-diagnosis
11 4 (36%)
p= 0.178;
χ
2
= 1.81
Meta-analysis
Yes 7 2 (29%)
No 13 8 (62%)
p= 0.160;
χ
2
= 1.98
Equivalent conclusions and characteristics for reviews separately considering
age groups 50–59 and 60–69 were combined
RCT randomised controlled trial
Raichand et al. Systematic Reviews (2017) 6:105 Page 7 of 8
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
Not applicable.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Centre for Health Informatics, Australian Institute of Health Innovation,
Macquarie University, Sydney, NSW 2109, Australia.
2
Centre for Big Data
Research in Health, University of New South Wales, Sydney, NSW, Australia.
3
Computational Health Informatics Program, Boston Children’s Hospital,
Boston, MA, USA.
4
Department of Pediatrics, Harvard Medical School, Boston,
MA, USA.
5
Department of Biomedical Informatics, Harvard Medical School,
Boston, MA, USA.
Received: 14 September 2016 Accepted: 5 May 2017
References
1. Perry N, Broeders M, de Wolf C, Tornberg S, Holland R, von Karsa L.
European guidelines for quality assurance in breast cancer screening and
diagnosis. Fourth edition—summary document. Ann Oncol.
2008;19(4):614–22. http://dx.doi.org/10.1093/annonc/mdm481.
2. World Health Organisation (WHO). WHO position paper on mammography
screening. Switzerland: WHO; 2014.
3. The American College of Obstetricians and Gynecologists (ACOG). Practice
bulletin no. 122: breast cancer screening. Obstet Gynecol. 2011;118(2):372–82.
4. Nattinger AB, Mitchell JL. Breast cancer screening and prevention. Ann
Intern Med. 2016;164(11):81–96. http://dx.doi.org/10.1097/AOG.
0b013e31822c98e5.
5. Caverly TJ, Hayward RA, Reamer E, Zikmund-Fisher BJ, Connochie D, Heisler
M, et al. Presentation of benefits and harms in US cancer screening and
prevention guidelines: systematic review. J Natl Cancer Inst. 2016;108(6):
djv436. doi:10.1093/jnci/djv436.
6. U.S. Preventive Services Task Force. Screening for breast cancer: U.S.
Preventive Services Task Force recommendation statement. Ann Intern Med.
2009;151(10):716–26. doi:10.7326/0003-4819-151-10-200911170-00008.
7. The Independent UK Panel on Breast Cancer Screening. The benefits and
harms of breast cancer screening: an independent review. Lancet. 2012;
380(9855):1778–86. doi:10.1016/S0140-6736(12)61611-0.
8. Oeffinger KC, Fontham ET, Etzioni R, Herzig A, Michaelson JS, Shih YC, et al.
Breast cancer screening for women at average risk: 2015 guideline update
from the American Cancer Society. JAMA. 2015;314(15):1599–614. http://dx.
doi.org/10.1001/jama.2015.12783.
9. Siu AL. Screening for breast cancer: U.S. Preventive Services Task Force
recommendation statement. Ann Intern Med. 2016;164(4):279–96.
http://dx.doi.org/10.7326/M15-2886.
10. Dunn AG, Arachi D, Hudgins J, Tsafnat G, Coiera E, Bourgeois FT. Financial
conflicts of interest and conclusions about neuraminidase inhibitors for
influenza: an analysis of systematic reviews. Ann Intern Med.
2014;161(7):513–18. http://dx.doi.org/10.7326/M14-0933.
11. Bes-Rastrollo M, Schulze MB, Ruiz-Canela M, Martinez-Gonzalez MA. Financial
conflicts of interest and reporting bias regarding the association between
sugar-sweetened beverages and weight gain: a systematic review of
systematic reviews. PLoS Med. 2013;10(12):e1001578. http://dx.doi.org/10.
1371/journal.pmed.1001578.
12. Yank V, Rennie D, Bero LA. Financial ties and concordance between results
and conclusions in meta-analyses: retrospective cohort study. BMJ. 2007;
335(7631):1202–05. http://dx.doi.org/10.1136/bmj.39376.447211.BE.
13. Jorgensen KJ, Klahn A, Gotzsche PC. Are benefits and harms in
mammography screening given equal attention in scientific articles? A
cross-sectional study. BMC Med. 2007;5:12. doi:http://dx.doi.org/10.1186/
1741-7015-5-12.
14. Norris SL, Burda BU, Holmer HK, Ogden LA, Fu R, Bero L, et al. Author’s
specialty and conflicts of interest contribute to conflicting guidelines for
screening mammography. J Clin Epidemiol. 2012;65(7):725–33.
http://dx.doi.org/10.1016/j.jclinepi.2011.12.011.
15. Lieb K, Osten-Sacken J, Stoffers-Winterling J, Reiss N, Barth J. Conflicts of
interest and spin in reviews of psychological therapies: a systematic review.
BMJ Open. 2016;6(4):e010606. doi:10.1136/bmjopen-2015-010606.
16. Bero L. Industry sponsorship and research outcome: a cochrane review.
JAMA Intern Med. 2013;173(7):580–1. http://dx.doi.org/10.1001/
jamainternmed.2013.4190.
17. Lundh A, Sismondo S, Lexchin J, Busuioc OA, Bero L. Industry sponsorship
and research outcome. Cochrane Database Syst Rev. 2012;12:MR000033.
http://dx.doi.org/10.1002/14651858.MR000033.pub2.
18. Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al.
Development of AMSTAR: a measurement tool to assess the
methodological quality of systematic reviews. BMC Med Res Methodol.
2007;7(1):1. http://dx.doi.org/10.1186/1471-2288-7-10.
19. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for
systematic reviews and meta-analyses: the PRISMA statement. Ann Intern
Med. 2009;151(4):264–69. http://dx.doi.org/10.7326/0003-4819-151-4-
200908180-00135 .
20. Burda BU, Norris SL, Holmer HK, Ogden LA, Smith ME. Quality varies across
clinical practice guidelines for mammography screening in women aged
40-49 years as assessed by AGREE and AMSTAR instruments. J Clin
Epidemiol. 2011;64(9):968–76. http://dx.doi.org/10.1016/j.jclinepi.2010.12.005.
• We accept pre-submission inquiries
• Our selector tool helps you to find the most relevant journal
• We provide round the clock customer support
• Convenient online submission
• Thorough peer review
• Inclusion in PubMed and all major indexing services
• Maximum visibility for your research
Submit your manuscript at
www.biomedcentral.com/submit
Submit your next manuscript to BioMed Central
and we will help you at every step:
Raichand et al. Systematic Reviews (2017) 6:105 Page 8 of 8
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com
Available via license: CC BY 4.0
Content may be subject to copyright.
