UCSF

Background

Controversy persists about optimal mammography screening strategies.

Objective

To evaluate screening outcomes, taking into account advances in mammography and treatment of breast cancer.

Design

Collaboration of 6 simulation models using national data on incidence, digital mammography performance, treatment effects, and other-cause mortality.

Setting

United States.

Patients

Average-risk U.S. female population and subgroups with varying risk, breast density, or comorbidity.

Intervention

Eight strategies differing by age at which screening starts (40, 45, or 50 years) and screening interval (annual, biennial, and hybrid [annual for women in their 40s and biennial thereafter]). All strategies assumed 100% adherence and stopped at age 74 years.

Measurements

Benefits (breast cancer-specific mortality reduction, breast cancer deaths averted, life-years, and quality-adjusted life-years); number of mammograms used; harms (false-positive results, benign biopsies, and overdiagnosis); and ratios of harms (or use) and benefits (efficiency) per 1000 screens.

Results

Biennial strategies were consistently the most efficient for average-risk women. Biennial screening from age 50 to 74 years avoided a median of 7 breast cancer deaths versus no screening; annual screening from age 40 to 74 years avoided an additional 3 deaths, but yielded 1988 more false-positive results and 11 more overdiagnoses per 1000 women screened. Annual screening from age 50 to 74 years was inefficient (similar benefits, but more harms than other strategies). For groups with a 2- to 4-fold increased risk, annual screening from age 40 years had similar harms and benefits as screening average-risk women biennially from 50 to 74 years. For groups with moderate or severe comorbidity, screening could stop at age 66 to 68 years.

Limitation

Other imaging technologies, polygenic risk, and nonadherence were not considered.

Conclusion

Biennial screening for breast cancer is efficient for average-risk populations. Decisions about starting ages and intervals will depend on population characteristics and the decision makers' weight given to the harms and benefits of screening.

Primary funding source

National Institutes of Health.