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No Mammography If Life Expectancy Is Short?

January 10, 2013
Written by: , Filed in: Breast Imaging, Medical Ethics
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The headlines say that a new study published online Tuesday in BMJ recommends no breast cancer screening (or colorectal cancer screening) unless the patient has a life expectancy of at least 10 years. But that’s not exactly what the study says.

Researchers from the University of California, San Francisco, conducted meta-analyses of five large, randomized, population-based clinical trials of breast cancer screening, four carried out in Sweden and one in the United States. It found that 10.7 years elapsed before one death was prevented for every 1,000 women screened.

Because serious harms of screening (overdiagnosis, unnecessary treatment, complications from unnecessary biopsies resulting from false positives, etc.) also occur at a rate of about one per every 1,000 women screened, the researchers concluded:

Therefore, patients with a life expectancy greater than 10 years should be encouraged to undergo screening for colorectal cancer and breast cancer.

Patients with a life expectancy of less than three to five years “probably should be discouraged from screening, since the potential risks probably outweigh the small probability of benefit.”

However, the authors continue, “Between these extremes is an intermediate zone of small or unclear benefit, in which patient preferences and values should have the dominant role in deciding whether screening is appropriate.” So, they wrote:

Therefore, our results should not be used to deny screening for patients with limited life expectancy.

Instead, they suggest, doctors and patients should used the information to help in “individualized decision making, which aims to account for patient preferences and values while maximizing benefits and minimizing risks.”

The authors also mention some significant limitations to their study:

  • “Avoiding symptoms related to cancer is also important.” Because debilitating cancer symptoms normally precede cancer-related death by months or years, “our results could have overestimated the time lag to benefit for avoiding cancer symptoms.”
  • Because of advances in technology and training, mammography may be better at early detection of dangerous cancers than the study reflects. “We relied on older studies of cancer screening that could have limited our ability to address current strategies of cancer screening. For breast cancer screening, modern mammography machines could be more accurate, and radiologists might now receive better training.”

Nobody with patients’ best interests at heart thinks giving mammograms to women with a life expectancy of just three years is a good idea. But “no screening for anyone with less than 10 years to live” isn’t a hard and fast rule either. That nuance is likely to be lost in the general coverage of this study. Radiologists and other responsible health care professionals should work to disseminate the full story.

Related seminar: Breast & Women’s Imaging Seminar


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