Table 3.
Summary of findings from studies that evaluated the benefits, harms and the balance of benefits versus harms of screening mammography in older women
| Source | Subgroups (years) | Outcomes reported | |||||
|---|---|---|---|---|---|---|---|
| Benefits | |||||||
| McPherson et al63 | RR of death and 95% CI | ||||||
| Screening groups: Mammographic vs clinical (palpation) diagnosis | Comorbidity | No comorbidity | Moderate | Severe | |||
| Ages: 65–69 | 0.44 (0.32–0.59) | 0.32 (0.15–0.69) | 0.41 (0.11–1.48) | ||||
| Ages: 70–74 | 0.32 (0.23–0.44) | 0.45 (0.22–0.91) | 0.30 (0.11–0.79) | ||||
| Ages: 75–79 | 0.36 (0.26–0.49) | 0.47 (0.25–0.88) | 0.53 (0.20–1.36) | ||||
| Ages: ≥80 | 0.66 (0.52–0.83) | 0.52 (0.33–0.80) | 0.64 (0.30–1.87) | ||||
| Fleming et al62 | OR (and P-value) of late-stage (regional and distant) vs early stage (in situ and local) disease, under comorbid conditions | ||||||
| Screening groups: All patients were screened | Comorbidity OR (P-value) | Cardiovascular disease | Pulmonary disease, mild/moderate | Gastrointestinal disease, severe | |||
| 0.87 (P<0.01) | 1.08 (P>0.05) | 0.94 (P>0.05) | |||||
| Diabetes | Genital-urinary disease | Rheumatologic disease | |||||
| 1.19 (P<0.01) | 0.91 (P>0.05) | 1.02 (P>0.05) | |||||
| Musculoskeletal disease | Renal disease | Other vascular disease | |||||
| 0.93 (P<0.01) | 1.15 (P>0.05) | 1.04 (P>0.05) | |||||
| Benign breast disease, nonmalignant | Osteoporosis | Psychiatric disease | |||||
| 0.76 (P<0.01) | 1.16 (P>0.05) | 1.2 (P<0.01) | |||||
| Cerebrovascular disease | Malignant hypertension | Gastrointestinal disease | |||||
| 1.03 (P>0.05) | 1.02 (P>0.05) | 0.86 (P<0.01) | |||||
| Osteoarthritis | Neurological disease | AIDS | |||||
| 0.96 (P>0.05) | 1 (P>0.05) | 1.41 (P>0.05) | |||||
| Benign hypertension | Pulmonary disease, severe | Hematologic disease | |||||
| 0.98 (P>0.05) | 0.99 (P>0.05) | 1.19 (P<0.01) | |||||
| Endocrine disease | Obesity | Other cancers | |||||
| 1.11 (P<0.05) | 1.18 (P>0.05) | 1.04 (P>0.05) | |||||
| Braithwaite et al61 | OR and 95% CI for invasive breast cancer vs DCIS | ||||||
| Screening groups: 2- vs 1-year interval | 2- vs 1-year interval | ||||||
| Comorbidity | Charlson score =0 | Charlson score ≥1 | |||||
| Ages: 66–74 | 0.83 (0.59–1.17) | 0.92 (0.54–1.56) | |||||
| Ages: 75–89 | 1.07 (0.71–1.60) | 1.02 (0.51–2.03) | |||||
| OR and 95% CI for advanced stage (stages IIB–IV) vs early stage (stages I–IIA) | |||||||
| Comorbidity | Charlson score =0 | Charlson score ≥1 | |||||
| Ages: 66–74 | 0.75 (0.46–1.22) | 0.99 (0.48–2.04) | |||||
| Ages: 75–89 | 1.27 (0.72–2.25) | 0.37 (0.13–1.04) | |||||
| OR and 95% CI for large size tumors (>20 mm) vs small (≤20 mm) | |||||||
| Comorbidity | Charlson score =0 | Charlson score ≥1 | |||||
| Ages: 66–74 | 0.83 (0.55–1.24) | 0.91 (0.50–1.65) | |||||
| Ages: 75–89 | 1.30 (0.83–2.05) | 1.38 (0.70–2.73) | |||||
| OR and 95% CI for positive lymph node involvement | |||||||
| Comorbidity | Charlson score =0 | Charlson score ≥1 | |||||
| Ages: 66–74 | 0.84 (0.57–1.23) | 0.76 (0.41–1.43) | |||||
| Ages:75–89 | 0.83 (0.51–1.33) | 0.62 (0.29–1.34) | |||||
| Mandelblatt et al64 | Long-term quality-adjusted marginal savings in life-expectancy (in days) and 95% CI | ||||||
| Screening groups: Screening vs no screening | Comorbidity | Average health | Mild hypertension | Congestive heart failure | Average health (black) | ||
| Ages: 65–69 | 2.19 (1.97, 2.41) | 1.97 (1.77, 2.16) | 1.17 (1.06, 1.28) | 2.17 (1.95, 2.39) | |||
| Ages: 70–74 | 1.85 (1.67, 2.03) | 1.68 (1.51, 1.84) | 1.08 (0.98, 1.18) | 2.22 (1.99, 2.44) | |||
| Ages: 75–79 | 1.43 (1.30, 1.57) | 1.32 (1.20, 1.44) | 0.91 (0.83, 0.98) | 1.76 (1.59, 1.94) | |||
| Ages: 80–84 | 1.08 (0.98, 1.18) | 1.01 (0.92, 1.10) | 0.76 (0.69, 0.82) | 1.65 (1.49, 1.80) | |||
| Ages: ≥85 | 0.80 (0.73, 0.87) | 0.76 (0.69, 0.83) | 0.59 (0.54, 0.65) | 1.16 (1.05, 1.27) | |||
| Long- and short-term quality-adjusted marginal savings in life-expectancy (in days) and 95% CI | |||||||
| Comorbidity | Average health | Mild hypertension | Congestive heart failure | Average health (black) | |||
| Ages: 65–69 | 1.44 (1.22, 1.66) | 1.22 (1.03, 1.42) | 0.43 (0.31, 0.54) | 1.42 (1.20, 1.64) | |||
| Ages: 70–74 | 1.10 (0.92, 1.28) | 0.93 (0.77, 1.09) | 0.33 (0.23, 0.44) | 1.47 (1.25, 1.69) | |||
| Ages: 75–79 | 0.69 (0.55, 0.82) | 0.57 (0.45, 0.70) | 0.16 (0.08, 0.24) | 1.01 (0.84, 1.19) | |||
| Ages: 80–84 | 0.34 (0.24, 0.44) | 0.27 (0.17, 0.36) | 0.01 (−0.06, 0.07) | 0.90 (0.74, 1.06) | |||
| Ages: ≥85 | 0.05 (−0.02, 0.12) | 0.01 (−0.06, 0.08) | −0.15 (−0.20, −0.10) | 0.42 (0.31, 0.56) | |||
| Messecar66 | Quality-adjusted savings in life-expectancy, quality-adjusted life-years (in days) | ||||||
| Screening groups: One additional screening following biennial screening vs no prior screening | Subgroups | Following regular biennial screening | No prior screening | ||||
| Comorbidity | Cognitive impairment | Healthy | Cognitive impairment | Healthy | |||
| Ages: 75–79 | 0.004 (1.5) | 0.009 (3.3) | 0.055 (20) | 0.119 (43.4) | |||
| Ages: 80–84 | 0.002 (0.7) | 0.007 (2.5) | 0.025 (9.1) | 0.089 (32.5) | |||
| Ages: ≥85 | 0.001 (0.4) | 0.006 (2.2) | 0.015 (5.5) | 0.071 (25.9) | |||
| Lansdorp-Vogelaar et al65 | Incremental LYG per 1,000 individuals screened according to guidelines since 50 years of age in populations with average comorbidity, by model, and age of screening cessation | ||||||
| Screening groups:Age of screening cessation | Comorbidity | Average comorbidity | |||||
| Model | MISCAN-Fadiaa | SPECTRUMb | |||||
| Age of cessation =74 (vs 72) | 7.6 | 5.8 | |||||
| Age of cessation =76 (vs 74) | 6.9 | 5.1 | |||||
| Deaths prevented per 1,000 individuals screened according to guidelines since 50 years of age in populations with average comorbidity, by model, and age of screening cessation | |||||||
| Comorbidity | Average comorbidity | ||||||
| Model | MISCAN-Fadiaa | SPECTRUMb | |||||
| Age of cessation =74 (vs 72) | 0.9 | 0.7 | |||||
| Age of cessation =76 (vs 74) | 0.9 | 0.7 | |||||
| Harms | |||||||
| Braithwaite et al61 | % of false-positive recalls at first mammography | ||||||
| Screening Group: First mammography for all | Comorbidity | Charlson score =0 | Charlson score ≥1 | ||||
| Ages: 66–74 | 8.6 (8.3–8.8) | 8.9 (8.5–9.3) | |||||
| Ages: 75–89 | 8.0 (7.6–8.4) | 8.8 (8.2–9.4) | |||||
| Screening groups: Annual screening vs biennial screening | % of women with at least one false-positive recall after 10 years of subsequent mammography, by screening interval | ||||||
| Annual | Biennial | ||||||
| Comorbidity | Charlson score =0 | Charlson score ≥1 | Charlson score =0 | Charlson score ≥1 | |||
| Ages: 66–74 | 49.7 (47.8–51.5) | 48.0 (46.1–49.9) | 30.2 (29.4–31.1) | 29.0 (28.1–29.9) | |||
| Ages: 75–89 | 47.2 (44.9–49.5) | 48.4 (46.1–50.8) | 26.6 (25.7–27.5) | 27.4 (26.5–28.4) | |||
| Screening group: First mammography for all | % of false-positive biopsy recommendations at first mammography | ||||||
| Comorbidity | Charlson score =0 | Charlson score ≥1 | |||||
| Ages: 66–74 | 1.2 (1.1–1.3) | 1.7 (1.5–1.9) | |||||
| Ages: 75–89 | 1.2 (1.1–1.4) | 1.7 (1.4–2.0) | |||||
| Screening groups: Annual screening vs biennial screening | % of women with at least one false-positive biopsy recommendation after 10 years of subsequent mammography, by screening interval | ||||||
| Annual | Biennial | ||||||
| Comorbidity | Charlson score =0 | Charlson score ≥1 | Charlson score =0 | Charlson score ≥1 | |||
| Ages: 66–74 | 9.8 (8.4–11.3) | 11.8 (10.1–13.8) | 4.6 (4.2–5.1) | 5.6 (5.1–6.2) | |||
| Ages: 75–89 | 9.2 (7.5–11.2) | 11.3 (9.3–13.6) | 4.1 (3.7–4.6) | 5.1 (4.5–5.7) | |||
| Lansdorp-Vogelaar et al65 | False-positive tests per 1,000 individuals screened according to guidelines since 50 years of age in populations with average comorbidity, by model, and age of screening cessation | ||||||
| Screening groups: Age of screening cessation | Comorbidity | Average comorbidity | |||||
| Model | MISCAN-Fadiaa | SPECTRUMb | |||||
| Age of cessation 74(vs 72) | 79 | 96 | |||||
| Age of cessation 76(vs 74) | 77 | 96 | |||||
| Overdiagnosed cases per 1,000 individuals screened according to guidelines since 50 years of age in populations with average comorbidity, by model, and age of screening cessation | |||||||
| Comorbidity | Average comorbidity | ||||||
| Model | MISCAN-Fadiaa | SPECTRUMb | |||||
| Age of cessation 74(vs 72) | 0.8 | 0.5 | |||||
| Age of cessation 76(vs 74) | 1 | 0.6 | |||||
| Balance of benefits vs harms | |||||||
| Landsdorp-Vogelaar et al65 | Number needed to screen to gain 1 life-year (NNS/LYG), by model and age of screening cessation | ||||||
| Screening groups: Age of screening cessation | Comorbidity | Average comorbidity | |||||
| Model | MISCAN-Fadiaa | SPECTRUMb | |||||
| Age of cessation =74(vs 72) | 132 | 173 | |||||
| Age of cessation =76(vs 74) | 146 | 198 | |||||
Notes:
a
MISCAN-Fadia: the MISCAN-Fadia model is a computer simulation program which incorporates information on the natural history of the disease as described by tumor stages and fatal tumor diameter (the size at which cancer becomes fatal) to construct models that compare the (cost-) effectiveness of different screening policies. It consists of four major components that simulate the demography and breast cancer incidence in the population, the natural history of a breast cancer tumor, the dissemination of screening mammography and its effects, and the dissemination of adjuvant treatment and its effects. bSPECTRUM: SPECTRUM is an event-driven continuous-time state model, which uses population-based estimates of breast cancer incidence and distribution of stage and other breast cancer characteristics (such as estrogen receptor status, response to treatment, and mortality) to estimate the efficacy of screening programs.
Abbreviations: CI, confidence interval; DCIS, ductal carcinoma in situ; LYG, life-years gained; NNS, number needed to screen; OR, odds ratio; RR, relative risk.