Breast Cancer Screening: A 35-Year Perspective

Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, 6th Floor, Boston, MA 02215, USA.
Epidemiologic Reviews (Impact Factor: 6.67). 06/2011; 33(1):165-75. DOI: 10.1093/epirev/mxr003
Source: PubMed


Screening for breast cancer has been evaluated by 9 randomized trials over 5 decades and recommended by major guideline groups for more than 3 decades. Successes and lessons for cancer screening from this history include development of scientific methods to evaluate screening, by the Canadian Task Force on the Periodic Health Examination and the U.S. Preventive Services Task Force; the importance of randomized trials in the past, and the increasing need to develop new methods to evaluate cancer screening in the future; the challenge of assessing new technologies that are replacing originally evaluated screening tests; the need to measure false-positive screening test results and the difficulty in reducing their frequency; the unexpected emergence of overdiagnosis due to cancer screening; the difficulty in stratifying individuals according to breast cancer risk; women's fear of breast cancer and the public outrage over changing guidelines for breast cancer screening; the need for population scientists to better communicate with the public if evidence-based recommendations are to be heeded by clinicians, patients, and insurers; new developments in the primary prevention of cancers; and the interaction between improved treatment and screening, which, over time, and together with primary prevention, may decrease the need for cancer screening.

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    • "The level of dispute also reveals the entrenched positions that various experts and commentators occupy in their reading of the scientific results from the trials. A recent review by Fletcher (2011) problematizes the changed landscape of screening, arguing that while it had its place as a secondary prevention measure, it is an 'imperfect tool' and that with progress in primary prevention and treatment, the need for screening should decrease. Such a message may be difficult to reconcile with the 'early detection is your best protection' message that forms part of the dominant discourse about breast cancer screening. "

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    Preview · Article · Jun 2011 · American journal of epidemiology
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    ABSTRACT: This volume of Epidemiologic Reviews continues a discussion about screening within the evidence community that has been going on for many years. From various perspectives, the authors of these reviews consider the benefits and harms of screening for multiple conditions; the balance between benefits and harms (and costs) is often not clear. With few exceptions, the contribution of screening to improving the health of the public is small, yet it has become a popular and growing form of prevention. It may be that we are learning that the magnitude of benefit from screening is less than we hoped, and the harms may be greater than we thought. Perhaps we should not think of screening as our primary prevention strategy but rather use screening to make a real, but limited contribution to population health for a few conditions. We might target screening to smaller subpopulations with the highest potential benefit and the lowest potential harm. The payoff for population health could be greater if we shifted some resources we now devote to screening to developing, testing, and implementing alternative approaches to preventing the important threats to population health. There needs to be a wider discussion about these issues with the public.
    Preview · Article · Jun 2011 · Epidemiologic Reviews
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